**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to notify a physician of the facility's failure to administer ordered medications in a timely manner to three (Residents #46, #107, and #199) of four residents reviewed for notification of changes. Additionally, the facility failed to notify the Infectious Disease specialist of the addition of an antifungal medication for Resident #107. The facility census was 50. Findings included:1. Review of Resident Face Sheet revealed the facility admitted Resident #199 on 02/08/2025 with diagnoses of cellulitis of the right and left lower limbs and methicillin-resistant Staphylococcus aureus (MRSA) infection. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2025, revealed Resident #199 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated Resident #199 did not reject care during the assessment's lookback period. The MDS revealed the resident had intravenous (IV) access on admission and while a resident. The MDS indicated Resident #199 admitted from a short-term general hospital. Revie of Resident #199's Care Plan History, included a problem statement dated 02/19/2025, that indicated the resident required enhanced barrier precautions (EBP) during high-contact care related to the presence of a wound with dressing changes. Interventions directed staff to observe for and report any new or worsened signs/symptoms of infection. Review of Resident #199's Out-patient antibiotic therapy ([NAME])/Antibiotic Infusion orders, dated 02/07/2025, indicated the resident was to receive IV meropenem (an antibiotic) 1 gram (g) every eight hours and linezolid (an antibiotic), 600 milligrams (mg) by mouth every 12 hours, to complete 02/21/2025. The [NAME]/Antibiotic Infusion orders, indicated Resident #199 had bilateral leg wounds with a polymicrobial infection including MRSA infection. Review of Resident #199's View Prescription Order, received 02/09/2025 and started 02/10/2025, revealed a written physician's order for meropenem 1 g IV every eight hours, first administration time 12:00 A.M. Review of Resident #199's Physician Order Report, dated from 02/01/2025 through 07/02/2025, included an order for meropenem 1 g IV every eight hours at 12:00 A.M., 8:00 A.M., and 4:00 P.M., started on 02/10/2025. The Physician Order Report included an order for linezolid 600 mg by mouth every 12 hours for 14 days, started on 02/09/2025. Review of Resident #199's 02/2025 Medication Administration History revealed meropenem was not administered as scheduled on 02/10/2025 at 12:00 AM or 8:00 A.M. The Medication Administration History revealed staff documented that they administered the meropenem late on 02/10/2025 at 12:57 P.M. Further review revealed linezolid was not administered as scheduled on 02/09/2025 and 02/10/2025 from 7:00 A.M. to 11:00 A.M. The Medication Administration History revealed staff documented that they administered linezolid late on 02/10/2025 at 12:57 P.M. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated he was unaware that Resident #199's IV antibiotics were not started on admission but two days after admission. The MD stated he expected medications to be available to be administered as ordered and to be notified if medications could not be administered so the orders could be potentially modified or to provide further instructions, because when antibiotics were missed it resulted in a delay in treatment. On 07/11/2025 at 7:28 A.M., interview with the Director of Health Services (DHS) revealed they would call the doctor to see what they could do if they were not able to get the resident's medications right away. The DHS stated they should have gotten an order from the doctor as to when they wanted them to start medications for Resident #199. 2. Review of the Resident Face Sheet revealed the facility admitted Resident #107 on 03/20/2025 at 6:55 PM. with diagnoses of cellulitis of the right upper and lower limb, gangrene, Group B Streptococcus (a bacteria), aftercare following a surgical amputation, and acquired absence of the right finger. Review of the admission Minimum Data Set (MDS), with an admission Reference Date (ARD) of 03/24/2025, revealed Resident #107 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also indicated that the resident did not reject care during the assessment's lookback period. The MDS revealed the resident received intravenous (IV) medications while a resident. The MDS indicated Resident #107 admitted from a short-term general hospital. Review of Resident #107's Care Plan History, included a problem statement dated 03/24/2025, that indicated the resident required enhanced barrier precautions (EBP) during high-contact care related to the presence of a wound with dressing changes and a central line. Interventions directed staff to observe for and report any new or worsened signs/symptoms of infection. Review of a physician's ID [Infectious Disease] progress note, dated 03/20/2025 and electronically signed on 03/20/2025 at 9:26 AM, indicated Resident #107 had a right index finger infection, bacteremia, and a diabetic foot infection. The ID progress note indicated the illness posed a threat to life or bodily function. The ID progress note indicated recommendations included: continue daptomycin (an IV antibiotic) 6 mg/kg (milligrams/kilogram) IV every 24 hours; continue meropenem (an IV antibiotic) 1 g (gram) IV every 12 hours in house and at discharge transition to ertapenem 1 g IV every 24 hours; and continue daptomycin and ertapenem four weeks from the last surgical debridement. Review of Resident #107's Physician Discharge Summary, dated 03/20/2025 at 10:52 AM, indicated a discharge diagnosis of gangrene of the right hand. The Physician Discharge Summary indicated, Start taking these medications, and included daptomycin 400 mg IV daily; ertapenem 1 g every 24 hours; and 5,000 units of heparin subcutaneously every 12 hours. Review of Resident #107's hospital Discharge Summary, dated 03/20/2025 at 4:20 P.M., included discharge instructions dated 03/19/2025 at 2:58 PM that revealed a discharge medication list that included doxycycline 100 mg twice daily; ertapenem 1 g every 24 hours; and heparin 5000 units/ml subcutaneously every 12 hours. The Discharge Summary did not include instructions to start daptomycin. Review of Resident #107's Progress Notes included an IDT [Interdisciplinary Team] Infection note, dated 03/20/205 at 10:56 P.M., written by the Director of Health Services (DHS), that indicated Resident #107 admitted to the facility with an amputated right finger related to gangrene and bacteremia. The note indicated Resident #107 was on IV ertapenem and received doxycycline by mouth. The note revealed the resident was being followed by an infectious disease provider. Review of Resident #107's Physician Order Report, for the timeframe from 03/20/2025 through 04/04/2025, included orders for:- Doxycycline monohydrate (an antibiotic),100 mg capsule twice a day for cellulitis, started and ended on 03/21/2025.- Doxycycline monohydrate 100 mg capsule twice a day for cellulitis, started on 03/22/2025.- Ertapenem (an injectable antibiotic) 1 g IV for cellulitis, started and ended on 03/21/2025.- Ertapenem 1 g IV once a day for cellulitis, started on 03/22/2025.- Heparin, 5,000 unit/ml (milliliter) injected twice a day for deep vein thrombosis (DVT) prevention, started and ended on 03/21/2025.- Heparin, 5,000 unit/ml injected twice a day for deep vein thrombosis (DVT) prevention, started on 03/22/2025.- Micafungin (an antifungal medication), 100 mg IV once a day, started on 03/27/2025.The Physician Order Report did not include an order for daptomycin. Review of Resident #107's 03/2025 Medication Administration History revealed staff documented that Resident #107 received initial doses of heparin, doxycycline monohydrate, and IV ertapenem on 03/22/2025. The Medication Administration History revealed staff documented that heparin and doxycycline monohydrate were not available on 03/21/2025. The Medication Administration History did not include the transcription of an order for daptomycin. During an interview on 07/07/2025 at 1:26 P.M., the Assistant Director of Health Services (ADHS) reviewed Resident #107's discharge summary and verified the resident should have started daptomycin IV. The ADHS reviewed Resident #107's orders and stated it appeared the order was omitted. During a follow-up interview on 07/08/2025 at 9:55 A.M., the ADHS stated she had reviewed Resident #107's medical chart and the staff entered orders from an after-visit summary (AVS) record when Resident #107 was admitted , which did not include daptomycin. The ADHS stated the AVS was completed after the discharge summary and infection disease note, so there was no need to contact a provider to question it. During an interview on 07/08/2025 at 10:36 A.M., the Infectious Disease (ID) Nurse Practice Manager reviewed Resident #107's medical record and stated the ID provider cared for the resident during their hospital admission from 03/11/2025 to 03/20/2025. The ID Nurse Practice Manager stated the ID provider wrote orders for Resident #107 to discharge to the skilled nursing facility (SNF) on daptomycin and ertapenem daily until 04/15/2025. The ID Nurse Practice Manager stated she did not see where the ID provider changed Resident #107's order from daptomycin to doxycycline. The ID Nurse Practice Manager stated Resident #107 was seen in the office for a follow-up visit on 04/03/2025, and the provider was unaware the resident was not receiving both daptomycin and ertapenem and was unaware of the addition of micafungin. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated he expected medications to be available to be administered as ordered. The MD stated he expected to be notified if medications could not be administered so the orders could be potentially modified or to provide further instructions, because when antibiotics were missed it resulted in a delay in treatment. During an interview on 07/10/2025 at 3:00 P.M., the ADHS stated nurses should contact the doctor to confirm orders were correct. On 07/11/2025 at 7:28 AM, interview with the Director of Health Services (DHS) revealed the doctor was called if the facility could not get resident medications right away. The DHS stated Resident #107 was admitted with orders for heparin, doxycycline, and ertapenem that should have been administered and the doctor notified if they were not available. 3. Review of the Resident Face Sheet revealed the facility admitted Resident #46 on 04/12/2025 at 5:19 P.M. with diagnoses of of aftercare following surgery for neoplasm, acute respiratory failure with hypoxia, pneumonia due to Pseudomonas (a bacteria), pulmonary fibrosis, interstitial lung disease, systemic stenosis with lung involvement, malignant neoplasm of upper lobe, left bronchus, or lung, and pulmonary hypertension. Review of the 5-day Minimum Data Set (MDS) with an admission Reference Date (ARD) of 04/17/2025 revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #107 did not reject care during the assessment's lookback period. The MDS revealed the resident received intravenous (IV) medications while a resident. The MDS indicated Resident #107 admitted from a short-term general hospital. Review of Resident #46's Care Plan History, included a problem statement dated 04/14/2025, that indicated the resident required IV medications related to pneumonia. Interventions directed staff to administer IV medications as ordered. Review of Resident #46's hospital Inpatient Discharge Summary, dated 04/12/2025, indicated the resident's discharge medications included a new prescription for cefepime (an antibiotic), 2 grams (g) IV every eight hours for four days. Review of Resident #46's Physician Order Report, dated from 04/01/2025 through 07/01/2025, included an order for cefepime, 2 g IV every eight hours for four days, started on 04/12/2025 and ended on 04/15/2025. Review of Resident #46's 04/2025 Medication Administration History, revealed staff documented that they administered cefepime 2 g on 04/13/2025 at 4:00 PM, and the medication was discontinued after the resident received six doses. The Medication Administration History revealed staff documented that cefepime was awaiting on 04/12/2025 at 10:17 P.M.; none on 04/13/2025 at 3:04 A.M., and drug/item unavailable on 04/13/2025 at 12:04 P.M. During an interview on 07/01/2025 at 3:04 P.M., Registered Nurse (RN) #9 stated she did not contact the pharmacy to find out when the medication would arrive or contact the medical provider that the medication was unavailable to administer on 04/13/2025 at 4:00 A.M. because she thought the medication would arrive later that day. During an interview on 07/01/2025 at 3:36 P.M., Licensed Practical Nurse (LPN) #5 stated she did not recall contacting the provider about the antibiotic's unavailability because she thought it would start later that day. During an interview on 07/01/2025 at 3:58 P.M., LPN #10 revealed she was on duty on 04/12/2025 when Resident #46's 8:00 P.M. dose of IV cefepime was due; however, it had not arrived from the pharmacy. LPN #10 revealed she did not contact the pharmacy or the medical provider to notify them that the medication was unavailable to be administered because she thought the medication would arrive the next day for administration. During an interview on 07/02/2025 at 9:25 A.M., the Director of Assisted Living (DAL) stated anytime a medication was not available nurses were to call the pharmacy and notify the physician of the unavailability of the medication unless the medication arrived before the end of the medication administration pass. On 07/11/2025 at 7:28 A.M., interview with the Director of Health Services (DHS) revealed the doctor was called if the facility could not get resident medications right away. Review of the facility policy titled, Physician-Provider Notification Guidelines, last reviewed by the facility on 12/17/2024, revealed, The purpose of this policy is to: To [sic] ensure the resident's physician or practitioner (may include NP [nurse practitioner], PA [physician assistant], or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment by failing to ensure an intravenous (IV) pole utilized for tube feeding was clean for one (Resident #27) of two residents reviewed for tube feeding. The facility census was 50. Findings included:Review of Resident Face Sheet revealed the facility admitted Resident #27 on 01/17/2025 with diagnoses of cerebral palsy and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #27 had moderate impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment for Mental Status (SAMS). The MDS indicated that the resident required substantial to maximal assistance with eating and indicated the resident had a feeding tube. The MDS indicated the resident received greater than 51% of their total calories via feeding tube. Review of Resident #27's Care Plan included a problem statement, dated 06/30/2025, that indicated the resident required tube feeding related to dysphagia and cerebral palsy, which placed the resident at risk for complications. Interventions directed staff to administer eternal feedings per physician's orders (initiated 06/30/2025) and provide water flushes per physician's orders (initiated 06/30/2025). Review of Resident #27's Physician Order Report, for the timeframe from 01/01/2025 through 07/02/2025, included an active order for enteral feeding formula at a rate of 65 milliliters (ml) per hour for 12 hours a day, from 5:00 P.M. to 5:00 A.M., with an order date of 06/03/2025. During an observation on 06/30/2025 at 10:14 A.M. in Resident #27's room, an IV pole utilized to attach a pump for eternal feedings for Resident #27 had brown spots of a sticky liquid on the legs of the pole. During an observation on 07/03/2025 at 9:06 A.M. in Resident #27's room, the IV pole appeared dirty with the lower legs of the pole containing brown spots of a sticky substance. During an observation on 07/07/2025 at 4:12 A.M. in Resident #27's room, the IV pole's legs were dirty. During an interview on 07/07/2025 at 1:18 P.M., the Assistant Director of Health Services (ADHS) observed the IV pole in Resident #27's room and stated the legs appeared to have tube feeding contents which had dripped down the pole. She stated that it was dirty and should be cleaned. During an interview on 07/11/2025 at 9:10 A.M., the Executive Director stated she expected the equipment to be cleaned appropriately. She stated that the facility did not have a cleaning schedule or a policy regarding cleaning multi-use equipment. This deficiency represents non-compliance investigated under Complaint Number OH00163512.

Based on record review, interview, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed timely, which affected one (Resident #103) of 13 sampled residents. Specifically, the facility failed to ensure Resident #103's admission assessment was completed timely. The facility census was 50. Findings included:Review of Resident Face Sheet revealed the facility admitted Resident #103 on 06/23/2025 with a diagnosis of encephalopathy.Review of Resident #103's admission Minimum Data Set (MDS), with an admission Reference Date (ARD) of 06/30/2025, revealed the entry date (A1600), was entered as 06/23/2025. Per the MDS, the completion date (Z0500B), was dated 07/08/2025, 15 days after the entry date.During an interview on 07/08/2025 at 12:26 P.M., the MDS Coordinator stated that she had been trained that the admission MDS assessment was to be completed by the fourteenth day of the resident's stay, which would have been 07/06/2025 for Resident #103. She stated that the facility did not have a policy regarding MDS assessments and stated that she used the most recent version of the Resident Assessment Instrument (RAI) manual for completion date requirements.During an interview on 07/10/2025 at 3:00 P.M., the Assistant Director of Health Services (ADHS) stated she was unfamiliar with the MDS assessments completion date requirements. During an interview with the Executive Director on 07/11/2025 at 9:10 A.M., in regard to the timing of the completion of admission MDS assessments, the Executive Director stated staff should refer to the RAI manual to determine when admission MDSs should be completed. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed the section titled, 5.2 Timeliness Criteria, included, In accordance with the requirements at 42 CFR [Code of Federal Regulations] S483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions, which included Completion Timing. The manual revealed, For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600).

Based on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed for one (Resident #11) of one resident reviewed as part of the resident assessment task. The facility census was 50.Findings included:Review of Resident Face Sheet indicated the facility originally admitted Resident #11 on 02/24/2021 and most recently readmitted the resident on 08/05/2024.Review of Resident #11's MDS 3.0 Resident Assessments revealed a quarterly MDS with an ARD of 01/14/2025 and an annual MDS with an ARD of 06/12/2025 were completed; however, there was no indication any additional MDS assessments were completed between 01/14/2025 and 06/12/2025. During an interview on 07/03/2025 at 1:02 P.M., the MDS Coordinator stated she was responsible for completing all MDS assessments. She stated quarterly MDS assessments should be completed every three months. The MDS Coordinator stated that Resident #11 was not out of the facility when their quarterly MDS was due. She stated Resident #11's should have had a quarterly MDS completed around 04/15/2025. The MDS Coordinator confirmed Resident #11 did not have a quarterly assessment completed in 04/2025, but she did not know why. She stated it was important to complete MDS assessments accurately and timely to get a clear picture of what was going on with a resident and what care they needed. During an interview on 07/03/2025 at 1:15 P.M., the Assistant Director of Health Services (ADHS) stated she was not involved in the completion or submission of MDS assessments. She stated she expected all MDS assessments to be completed on time.During an interview on 07/03/2025 at 1:20 P.M., the Executive Director (ED) stated she was not involved in the MDS process, but she expected MDS assessments to be completed within the timeframes required. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated 10/2024 indicated, The ARD [Assessment Reference Date] of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA [Omnibus Budget Reconciliation Act] assessment (ARD of previous OBRA assessment - Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment - + 92 calendar days). The manual further specified, The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.

Based on observation, interview, and record review, the facility failed to ensure a tube feeding formula bag was labeled and dated for one (Resident #27) of two residents reviewed for tube feedings. The facility census was 50. Findings included:Review of Resident Face sheet revealed the facility originally admitted Resident #27 on 01/17/2025 and most recently admitted the resident on 05/28/2025. Resident #27 had a medical history that included diagnoses of cerebral palsy, pneumonitis due to inhalation of food or vomitus, gastrointestinal hemorrhage, encounter of attention to gastrostomy, gastrostomy malfunction, and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #27 had moderately impaired cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment for Mental Status (SAMS). The MDS indicated that the resident required substantial to maximal assistance with eating and indicated the resident had a feeding tube. The MDS indicated the resident received greater than 51% of their total calories via feeding tube. Review of Resident #27's Care Plan included a problem statement, dated 06/30/2025, that indicated the resident required tube feeding related to dysphagia and cerebral palsy, which placed the resident at risk for complications. Interventions directed staff to administer eternal feedings per physician's orders (initiated 06/30/2025) and to provide water flushes per physician's orders (initiated 06/30/2025). Review of Resident #27's Physician Order Report, for the timeframe from 01/01/2025 through 07/02/2025, included an active order for enteral feeding formula at a rate of 65 milliliters (ml) per hour for 12 hours a day, from 5:00 P.M. to 5:00 A.M., with an order date of 06/03/2025. An observation on 07/07/2025 at 4:12 A.M. revealed Resident #27 was in bed with tubing attached to an unlabeled bag of a tan-colored substance, which was running via a pump at 65 ml per hour. The tube feeding formula bag was not labeled with the resident's name, room number, date the feeding was hung, the time the bag was hung, the type/brand of the tube feeding formula, or the rate of infusion. During an observation on 07/07/2025 at 4:43 A.M., Licensed Practical Nurse (LPN) #1 entered the resident's room to flush Resident #27's feeding tube with water. After completing the water flush, LPN #1 removed the unlabeled bag of tube feeding formula and associated supplies and exited the resident's room. During a concurrent observation and interview on 07/07/2025 at 4:49 A.M., LPN #1 observed the tube feeding formula bag she removed from Resident #27's room and acknowledged it was not labeled. She stated she could not determine what type/brand of tube feeding had been provided to Resident #27 (because the bag was not labeled). She stated she knew that the tube feeding bag should be labeled to identify the ordered type/brand of tube feeding and when it was started. LPN #1 stated the tube feeding formula bag was hung by the nurse on day shift on 07/06/2025, and she had not noticed the bag was not labeled when she had been in to care for the resident during her shift. During an interview on 07/08/2025 at 7:45 A.M., LPN #2 stated she worked on day shift (7:00 A.M. to 7:00 P.M.) on 07/06/2025. She verified she hung and started Resident #27's tube feeding formula around 5:00 PM (on 07/06/2025). She said that because the pumps used in the facility and the original container of the ordered tube feeding formula were not compatible, she emptied the contents of the feeding formula into a disposable tube feeding bag before hanging it to be infused. She said she usually put the date and time the bag of feeding formula was hung on a sticker affixed to the bag. LPN #2 stated the stickers she used to label the tube feeding formula bags were known to fall off because they did not adhere well and could have fallen off. LPN #2 further stated she did not attempt to reinforce the sticker; she stated in the past, she had written the required information directly on the bag, but had not done that when she hung Resident #27's feeding formula on 07/06/2025. During an interview on 07/10/2025 at 2:44 P.M., the Assistant Director of Health Services (ADHS) stated feeding formula bags were to be labeled with the resident's name, room number, date and time the feeding was hung, the type/brand of the feeding formula, and the rate of infusion.

Based on observation, interview, record review, and facility standard operating procedure review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) during close-contact activities for residents on enhanced barrier precautions (EBP), which affected one (Resident #27) of two residents reviewed for tube feeding and one (Resident #26) of two residents reviewed for non-pressure related skin conditions. The facility census was 50.Findings included: 1. Review of Resident Face Sheet revealed the facility admitted Resident #27 on 01/17/2025. The resident had a medical history that included diagnoses of cerebral palsy and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #27 had moderate impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment for Mental Status (SAMS). The MDS indicated that the resident required substantial to maximal assistance with eating. The MDS indicated the resident had a feeding tube and received greater than 51% of their total calories via feeding tube. Review of Resident #27's Care Plan, included a problem statement dated 06/30/2025, that indicated the resident required tube feeding related to dysphagia and cerebral palsy, which placed the resident at risk for complications. Interventions directed staff to administer eternal feedings per physician's orders (initiated 06/30/2025) and provide water flushes per physician's orders (initiated 06/30/2025). Review of Resident #27's Physician Order Report, for the timeframe from 01/01/2025 through 07/02/2025, included an active order dated 06/03/2025 for enteral feeding formula at a rate of 65 milliliters (ml) per hour for 12 hours a day, from 5:00 P.M. to 5:00 A.M. The Physician Order Report also included an order dated 05/28/2025 for staff to use EBP, wearing a gown and gloves at minimum during high contact activities. During an observation on 07/07/2025 at 4:43 A.M., License Practical Nurse (LPN) #1 entered Resident #27's resident's room, where there was signage posted on the door that indicated Resident #27 was on EBP. LPN #1 entered the room, carrying a pair of gloves and two partially filled glasses of water in hand. LPN #1 donned a pair of gloves and turned off Resident #27's tube feeding pump. LPN #1 placed a plunger barrel into Resident #27's feeding tube and allowed water to flow by gravity to flush the tube before capping off the tube. LPN #1 then removed the used syringe, the bag of unused water, and the bag of unused, tan-colored liquid from the feeding pump and took it from Resident #27's room. LPN #1 did not don a gown during the observation. During an interview on 07/07/2025 at 4:49 A.M., LPN #1 stated that she was aware Resident #27 was on EBP, and she had been taught to don a gown and gloves when completing care of the feeding tube. She stated she forgot to don a gown when she completed the care of Resident #27's feeding tube. During an interview on 07/07/2025 at 9:13 A.M., the Assistant Director of Health Services stated Resident #27 was on EBP and that she expected LPN #1 to don a gown and gloves when providing care of the feeding tube. During an interview on 07/11/2025 at 7:28 A.M., the Director of Health Services stated a resident on EBP had signage on their door indicating the resident was on EBP, and a PPE cart outside their room. She stated staff should wear standard EBP PPE, such as a gown, gloves, and goggles. 2. Review of Resident Face Sheet revealed the facility admitted Resident #26 on 06/07/2025. The resident had a medical history that included diagnoses of cellulitis of right and left lower extremities, open wound of the left and right lower extremities, methicillin resistant staphylococcus aureus (MRSA), and diabetic peripheral angiopathy without gangrene other bacterial infections of unspecified site. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2025, revealed Resident #26 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident was at risk for developing pressure ulcers/injuries, and indicated the resident had moisture associated skin breakdown present. Review of Resident #26's Care Plan, included a problem statement dated 06/20/2025, that indicated the resident was at risk for skin breakdown related to cellulitis of the bilateral lower extremities. Interventions directed staff to provide treatments/preventative treatments as ordered (initiated 06/20/2025). Review of Resident #26's Physician Order Report, for the timeframe from 06/02/2025 through 07/02/2025, revealed an active order dated 06/30/2025 to cleanse open area to left lateral shin with normal saline, pat dry, apply a dressing, and cover with rolled gauze, then compression wrap daily for wound management. The Physician Order Report also revealed an order dated 06/12/2025 that indicated staff were to use EBP, wearing a gown and gloves at minimum during high-contact activities. During an observation on 07/03/2025 at 1:35 P.M., Registered Nurse (RN) #3 was wearing gloves and provided wound care to Resident #26's left leg. RN #3 did not don a gown before providing the wound care. During an interview on 07/03/2025 at 2:13 P.M., RN #3 stated she had been trained that when providing wound care for a resident on EBP, staff were to wear a gown and gloves, and she knew when residents were on EBP because a sign would be on the door. RN #3 looked at Resident #26's room door and acknowledged the resident was on EBP. She stated she forgot to don a gown before beginning wound care for the resident. During an interview on 07/10/2025 at 2:44 P.M., the Assistant Director of Health Services stated that RN #3 should have donned a gown and gloves before providing wound care to Resident #26. During an interview on 07/11/2025 at 7:28 A.M., the Director of Health Services stated residents on EBP had signage on their door indicating the resident was on EBP, and a PPE cart outside their room. She stated staff should wear standard EBP PPE, such as a gown, gloves, and goggles when they provided wound care. During an interview on 07/11/2025 at 9:10 A.M., the Executive Director stated she referred questions related to EBP to clinical staff. Review of the facility standard operating procedure titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, revised 04/02/2024, revealed, Guidance for enhanced barrier precautions (EBP) to decrease risk of becoming colonized and developing infections with multidrug-resistant organism (MDRO) status. EBP does not replace existing guidance regarding the use of Contact precautions for other pathogens (ie [id est, that is]: Cdiff [clotridoides difficile colitis], scabies, norovirus etc [et cetera, and so forth]. The policy revealed, 1. Enhanced Barrier Precautions (EBP) will be in place during high-contact activities for residents with the following conditions, including Residents at an increased risk of MDRO acquisition which include: i. All residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. ii. All Residents with indwelling medical devices, which included feeding tubes. The policy revealed, 2) Personal Protective Equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. a) At minimum, staff shall wear gloves and gowns during high-contact care activities. The policy revealed, 3. High-contact care activities include but are not limited to: morning ADL [activity of daily living] care, toileting, and showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility document review the facility failed to ensure residents were free of significant medication errors for four (Residents #46, #103, #107, and #199) of four sampled residents reviewed for medication errors. The facility census was 50.Findings included: 1. Review of Resident Face Sheet revealed the facility admitted Resident #199 on 02/08/2025. The resident had a medical history that included diagnoses of cellulitis of the right and left lower limbs and methicillin-resistant Staphylococcus aureus (MRSA) infection. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2025, revealed Resident #199 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated Resident #199 did not reject care during the assessment's lookback period. The MDS revealed the resident had intravenous (IV) access on admission and while a resident. The MDS indicated Resident #199 admitted from a short-term general hospital. Review of Resident #199's Care Plan History, included a problem statement dated 02/19/2025, that indicated the resident required enhanced barrier precautions (EBP) during high-contact care related to the presence of a wound with dressing changes. Interventions directed staff to observe for and report any new or worsened signs/symptoms of infection. Review of Resident #199's Out-patient antibiotic therapy ([NAME])/Antibiotic Infusion orders, dated 02/07/2025, indicated the resident was to receive IV meropenem (an antibiotic) 1 gram (g) every eight hours and linezolid (an antibiotic), 600 milligrams (mg) by mouth every 12 hours, to complete 02/21/2025. The [NAME]/Antibiotic Infusion orders, indicated Resident #199 had bilateral leg wounds with a polymicrobial infection including MRSA infection. Review of Resident #199's View Prescription Order, received 02/09/2025 and started 02/10/2025, revealed a written physician's order for meropenem 1 g IV every eight hours, first administration time 12:00 A.M. Review of Resident #199's Physician Order Report, dated from 02/01/2025 through 07/02/2025, included an order for meropenem 1 g IV every eight hours at 12:00 A.M., 8:00 A.M., and 4:00 P.M., started on 02/10/2025. The Physician Order Report included an order for linezolid 600 mg by mouth every 12 hours for 14 days, started on 02/09/2025. Review of Resident #199's 02/2025 Medication Administration History revealed meropenem was not administered as scheduled on 02/10/2025 at 12:00 A.M. or 8:00 A.M. The Medication Administration History revealed staff documented that they administered the meropenem late on 02/10/2025 at 12:57 P.M. Further review revealed linezolid was not administered as scheduled on 02/09/2025 and 02/10/2025 from 7:00 A.M. to 11:00 A.M. The Medication Administration History revealed staff documented that they administered linezolid late on 02/10/2025 at 12:57 P.M. During an interview on 07/05/2025 at 12:37 P.M., Family Member #4, Resident #199's family member, stated Resident #199 was admitted to the facility to receive intravenous medications, but the antibiotics did not get started immediately after admission to the facility. During an interview on 07/08/2025 at 1:32 P.M., Licensed Practical Nurse (LPN) #5 indicated she could not recall transcribing the resident's admission orders and was unsure why Resident #199's antibiotic orders were not started immediately as ordered. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated he was unaware that Resident #199's IV antibiotics were not started on admission but two days after admission. The MD stated he expected medications to be available to be administered as ordered and to be notified if medications could not be administered so the orders could be potentially modified or to provide further instructions, because when antibiotics were missed it resulted in a delay in treatment. During an interview on 07/09/2025 at 3:56 P.M., the Pharmacist revealed medication orders were received from the facility through an electronic medical record submission. The Pharmacist stated the pharmacy relied on the facility to transcribe all orders from a hospital discharge into the medical record. The Pharmacist stated the cut-off time for filling new admission orders for the standard delivery was 7:00 P.M.; however, the facility could contact the pharmacy to request medication be sent stat ( immediately, at once) or drop shipment which would allow medication to be sent in as little as four hours. The Pharmacist stated anytime a nurse did not have a medication that was needed to be administered, they should contact the pharmacy to request a delivery time and request either a drop shipment or stat delivery of the item. The Pharmacist stated the pharmacy received the IV meropenem order on 02/09/2025 at 3:40 P.M., it was requested to be delivered stat, and it was received in the facility on 02/09/2025 at 10:00 P.M. During an interview on 07/10/2025 at 3:00 P.M., the Assistant Director of Health Services (ADHS) stated she expected residents to receive their medication when it was delivered and not have to wait until the next day. The ADHS stated she expected nurses to call the pharmacy to drop-ship any medications they did not have. On 07/11/2025 at 7:28 A.M. the Director of Health Services (DHS) stated when they received orders for a resident, they sometimes received an after-visit summary (AVS), a discharge summary, and/or continuation of care documents. The DHS stated staff entered the orders, tried to have another nurse look at the order if it was a high risk medication, called the doctor to confirm the orders and make any changes, faxed the orders to the pharmacy, called the pharmacy to confirm the orders were received, and had the medications drop-shipped to the facility if the medications were not available in the facility's backup medication inventory. The DHS stated nurses had a list of the available medications. The DHS stated normally antibiotics were started within 24 hours, and staff confirmed the hospital had given the resident a dose before discharge. The DHS stated they would call the doctor to see what they could do if they were not able to get the resident's medications right away. The DHS stated they should have gotten an order from the doctor as to when they wanted them to start medications for Resident #199. 2. Review of Resident Face Sheet revealed the facility admitted Resident #107 on 03/20/2025 at 6:55 P.M. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of cellulitis of the right upper and lower limb, gangrene, Group B Streptococcus (a bacteria), aftercare following a surgical amputation, and acquired absence of the right finger. Review of the admission Minimum Data Set (MDS), with an admission Reference Date (ARD) of 03/24/2025, revealed Resident #107 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS also indicated that the resident did not reject care during the assessment's lookback period. The MDS revealed the resident received intravenous (IV) medications while a resident. The MDS indicated Resident #107 admitted from a short-term general hospital. Review of Resident #107's Care Plan History, included a problem statement dated 03/24/2025, that indicated the resident required enhanced barrier precautions (EBP) during high-contact care related to the presence of a wound with dressing changes and a central line. Interventions directed staff to observe for and report any new or worsened signs/symptoms of infection. Review of the physician's ID [Infectious Disease] progress note, dated 03/20/2025 and electronically signed on 03/20/2025 at 9:26 A.M., indicated Resident #107 had a right index finger infection, bacteremia, and a diabetic foot infection. The ID progress note indicated the illness posed a threat to life or bodily function. The ID progress note indicated recommendations included: continue daptomycin (an IV antibiotic) 6 mg/kg (milligrams/kilogram) IV every 24 hours; continue meropenem (an IV antibiotic) 1 g (gram) IV every 12 hours in house and at discharge transition to ertapenem 1 g IV every 24 hours; and continue daptomycin and ertapenem four weeks from the last surgical debridement. Review of Resident #107's Physician Discharge Summary, dated 03/20/2025 at 10:52 A.M., indicated a discharge diagnosis of gangrene of the right hand. The Physician Discharge Summary indicated, Start taking these medications, and included daptomycin 400 mg IV daily; ertapenem 1 g every 24 hours; and 5,000 units of heparin subcutaneously every 12 hours. Review of Resident #107's hospital Discharge Summary, dated 03/20/2025 at 4:20 P.M., included discharge instructions dated 03/19/2025 at 2:58 P.M. that revealed a discharge medication list that included doxycycline 100 mg twice daily; ertapenem 1 g every 24 hours; and heparin 5000 units/ml subcutaneously every 12 hours. The Discharge Summary did not include instructions to start daptomycin. Review of Resident #107's Progress Notes included an IDT [Interdisciplinary Team] Infection note, dated 03/20/205 at 10:56 P.M., written by the Director of Health Services (DHS), that indicated Resident #107 admitted to the facility with an amputated right finger related to gangrene and bacteremia. The note indicated Resident #107 was on IV ertapenem and received doxycycline by mouth. The note revealed the resident was being followed by an infectious disease provider. Resident #107's Physician Order Report, for the timeframe from 03/20/2025 through 04/04/2025, included orders for:- Doxycycline monohydrate (an antibiotic),100 mg capsule twice a day for cellulitis, started and ended on 03/21/2025.- Doxycycline monohydrate 100 mg capsule twice a day for cellulitis, started on 03/22/2025.- Ertapenem (an injectable antibiotic) 1 g IV for cellulitis, started and ended on 03/21/2025.- Ertapenem 1 g IV once a day for cellulitis, started on 03/22/2025.- Heparin, 5,000 unit/ml (milliliter) injected twice a day for deep vein thrombosis (DVT) prevention, started and ended on 03/21/2025.- Heparin, 5,000 unit/ml injected twice a day for deep vein thrombosis (DVT) prevention, started on 03/22/2025. - Micafungin (an antifungal medication), 100 mg IV once a day, started on 03/27/2025.The Physician Order Report did not include an order for daptomycin. Review of Resident #107's 03/2025 Medication Administration History revealed staff documented that Resident #107 received initial doses of heparin, doxycycline monohydrate, and IV ertapenem on 03/22/2025. The Medication Administration History revealed staff documented that heparin and doxycycline monohydrate were not available on 03/21/2025. The Medication Administration History did not include the transcription of an order for daptomycin. During an interview on 07/07/2025 at 1:26 P.M., the Assistant Director of Health Services (ADHS) reviewed Resident #107's discharge summary and verified the resident should have started daptomycin IV. The ADHS reviewed Resident #107's orders and stated it appeared the order was omitted. The ADHS stated orders were entered from the discharge summary and verified by the provider. During a follow-up interview on 07/08/2025 at 9:55 A.M., the ADHS stated she had reviewed Resident #107's medical chart and the staff entered orders from an after-visit summary (AVS) record when Resident #107 was admitted , which did not include daptomycin. The ADHS stated the AVS was completed after the discharge summary and infection disease note, so there was no need to contact a provider to question it. During an interview on 07/08/2025 at 10:36 A.M., the Infectious Disease (ID) Nurse Practice Manager reviewed Resident #107's medical record and stated the ID provider cared for the resident during their hospital admission from 03/11/2025 to 03/20/2025. The ID Nurse Practice Manager stated the ID provider wrote orders for Resident #107 to discharge to the skilled nursing facility (SNF) on daptomycin and ertapenem daily until 04/15/2025. The ID Nurse Practice Manager stated that discharge orders were inadvertently cancelled then immediately reinstated to continue at discharge. The ID Nurse Practice Manager stated she did not know if the provider who dictated the discharge summary missed the daptomycin order but included the ertapenem order. The ID Nurse Practice Manager stated she did not see where the ID provider changed Resident #107's order from daptomycin to doxycycline. The ID Nurse Practice Manager stated Resident #107 was seen in the office for a follow-up visit on 04/03/2025, and the provider was unaware the resident was not receiving both daptomycin and ertapenem and was unaware of the addition of micafungin. The ID Nurse Practice Manager stated the ID provider did not dictate the discharge summary and the daptomycin could have possibly been left off the summary when it was transcribed by a hospitalist. The ID Nurse Practice Manager stated the facility should have reconciled the orders for all documents upon admission, Resident #107 was supposed to receive the medications for their serious infection, and she considered not receiving an IV medication a major medication error. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated he expected medications to be available to be administered as ordered. The MD stated he expected to be notified if medications could not be administered so the orders could be potentially modified or to provide further instructions, because when antibiotics were missed it resulted in a delay in treatment. During an interview on 07/08/2025 at 4:16 P.M., Licensed Practical Nurse (LPN) #7 indicated she only worked at the facility about one month, never learned to put in orders, so she did not think she was given Resident #107's admission packet with orders to enter but thought an administrative nurse entered the orders. LPN #7 stated she was told Resident #107's orders were in the electronic medical record, and she was told to verify the orders with the on-call provider. LPN #7 stated she did not need the paperwork to verify what was in the electronic medical record with the provider or to get medications from the pharmacy. LPN #7 stated because she never received the paperwork, she was unsure of Resident #107's orders or what was transcribed on admission. During an interview on 07/09/2025 at 3:56 P.M., the Pharmacist revealed medication orders were received from the facility through an electronic medical record submission. The Pharmacist stated the pharmacy relied on the facility to transcribe all orders from a hospital discharge into the medical record. The Pharmacist stated the cut-off time for filling new admission orders for the standard delivery was 7:00 P.M.; however, the facility could contact the pharmacy to request medication be sent stat immediately, at once) or drop shipment which would allow medication to be sent in as little as four hours. The Pharmacist stated anytime a nurse did not have a medication that was needed to be administered, they should contact the pharmacy to request a delivery time and request either a drop shipment or stat delivery of the item. The Pharmacist stated the pharmacy received the order for the ertapenem on 03/20/2025, the medication was dispensed by the pharmacy on 03/21/2025, and the medication was delivered as a routine order on 03/22/2025 at 5:12 A.M. The Pharmacist stated Resident #107's medications were not requested to be delivered stat or by drop-shipment services upon the resident's admission. During an interview on 07/10/2025 at 3:00 P.M., the ADHS stated it was the responsibility of the admitting nurses to ensure that reconciliation of the resident's medications was accurate, especially if there were differences between the AVS, continuity of care documents, and/or discharge summary. The ADHS stated a nurses should contact the doctor to confirm orders were correct. The ADHS stated Resident #107 should have received their first dose of medication the following day after admission on [DATE]. The ADHS stated doxycycline was prescribed to be given twice per day, and because the resident was admitted at 6:00 P.M., she would have expected Resident #107 to receive the first dose on the night shift on the day of admission. The ADHS stated if the facility did not have the medication available, then they should have obtained it from their backup medication inventory system. On 07/11/2025 at 7:28 A.M., the DHS stated when they received orders for a resident, they sometimes received an AVS, a discharge summary, and/or continuation of care documents. The DHS stated staff entered the orders, tried to have another nurse look at the order if it was a high risk medication, called the doctor to confirm the orders and make any changes, faxed the orders to the pharmacy, called the pharmacy to confirm the orders were received, and had the medications drop-shipped to the facility if the medications were not available in the facility's backup medication inventory. The DHS stated nurses had a list of the available medications. The DHS stated normally antibiotics were started within 24 hours, and they would confirm the hospital had given the resident a dose before discharge. The DHS stated the doctor was called if the facility could not get resident medications right away. The DHS stated anticoagulants were available in the backup medication inventory including heparin and Eliquis, and she expected them to be administered as ordered. The DHS stated she expected any resident to receive their insulin as ordered as a stock of insulin including Lantus, Novolog, and Humalog were in the backup medication inventory. The DHS stated Resident #107 had several antibiotics, including two IV antibiotics and one to be taken by mouth, ordered that needed to be clarified to ensure the resident received the correct one. The DHS stated she called the hospital and spoke with a doctor about Resident #107's antibiotics, and she stated she wrote the clarification in the IDT notes. The DHS stated Resident #107 was admitted with orders for heparin, doxycycline, and ertapenem that should have been administered and the doctor notified if they were not available. 3. Review of Resident Face Sheet revealed the facility admitted Resident #46 on 04/12/2025. The resident had a medical history that included diagnoses of aftercare following surgery for neoplasm, acute respiratory failure with hypoxia, pneumonia due to Pseudomonas (a bacteria), pulmonary fibrosis, interstitial lung disease, systemic stenosis with lung involvement, malignant neoplasm of upper lobe, left bronchus, or lung, and pulmonary hypertension. Review of the 5-day Minimum Data Set (MDS) with an admission Reference Date (ARD) of 04/17/2025 revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #107 did not reject care during the assessment's lookback period. The MDS revealed the resident received intravenous (IV) medications while a resident. The MDS indicated Resident #107 admitted from a short-term general hospital. Review of Resident #46's Care Plan History, included a problem statement dated 04/14/2025, that indicated the resident required IV medications related to pneumonia. Interventions directed staff to administer IV medications as ordered. Review of Resident #46's hospital Inpatient Discharge Summary, dated 04/12/2025, indicated the resident's discharge medications included a new prescription for cefepime (an antibiotic), 2 grams (g) IV every eight hours for four days. The Inpatient Discharge Summary indicated Resident #46 was admitted to the hospital after hypoxia (low oxygen) likely due to pneumonia following a left upper lobe lung wedge resection. Review of Resident #46's Physician Order Report, dated from 04/01/2025 through 07/01/2025, included an order for cefepime, 2 g IV every eight hours for four days, started on 04/12/2025 and ended on 04/15/2025. Review of Resident #46's 04/2025 Medication Administration History, revealed staff documented that they administered cefepime 2 g on 04/13/2025 at 4:00 P.M., and the medication was discontinued after the resident received six doses. The Medication Administration History revealed staff documented that cefepime was awaiting on 04/12/2025 at 10:17 P.M.; none on 04/13/2025 at 3:04 A.M., and drug/item unavailable on 04/13/2025 at 12:04 P.M. During an interview on 07/01/2025 at 10:50 A.M., Resident #46 stated they did not get their IV antibiotics on several occasions. During an interview on 07/01/2025 at 12:09 P.M., Family Member #8, Resident #46's family member, revealed when Resident #46 first arrived at the facility they had to wait a day or so to get most of their medications. Family Member #8 stated they were at the facility almost daily and Resident #46 was upset several times that medications were not provided as ordered, and the resident was told the medications could not be found or the facility did not have them. During an interview on 07/01/2025 at 3:04 P.M., Registered Nurse (RN) #9 stated nurses were to enter all medications into the medical record upon admission if the nurse management team had left the facility for the day. RN #9 stated after the orders were entered in the electronic record the pharmacy was immediately notified to ship the medications to the facility. RN #9 stated some IV medications were available to be used from the facility's backup medication inventory system, but some had to be shipped from the pharmacy. RN #9 indicated she could not recall caring for Resident #46; however, she documented the medication was unavailable then the medication was not available from the backup system and had not arrived from the pharmacy. RN #9 stated she did not contact the pharmacy to find out when the medication would arrive or contact the medical provider that the medication was unavailable to administer on 04/13/2025 at 4:00 A.M. because she thought the medication would arrive later that day. During an interview on 07/01/2025 at 3:36 P.M., LPN #5 stated she occasionally admitted residents to the facility and had been trained to enter orders for new admissions from the discharge summary into the electronic medical record, and the orders were sent electronically to the pharmacy. LPN #5 stated if a medication was not available, she contacted the pharmacy to see if it could be pulled from the backup medication inventory system. LPN #5 stated some IV medications were available in the backup system and some had to be shipped to the facility. LPN #5 stated she was on duty when Resident #46 was to receive the IV cefepime on 04/13/2025 at 8:00 A.M., but the medication was unavailable. LPN #5 stated she did not recall contacting the pharmacy to have the medication drop-shipped or to determine why the medication had not arrived as she thought it had been ordered and would arrive later that day. LPN #5 stated she did not recall contacting the provider about the antibiotic's unavailability because she thought it would start later that day. During an interview on 07/01/2025 at 3:58 P.M., LPN #10 revealed she was on duty on 04/12/2025 when Resident #46's 8:00 P.M. dose of IV cefepime was due; however, it had not arrived from the pharmacy. LPN #10 revealed she did not contact the pharmacy or the medical provider to notify them the medication was unavailable to be administered because she thought the medication would arrive the next day for administration. During an interview on 07/02/2025 at 9:25 A.M., the Director of Assisted Living (DAL) stated she was on duty on 04/12/2025 and assisted the skilled nursing facility side by entering Resident #46's pending orders, the orders entered from the discharge summary prior to the orders being verified by the facility admitting nurse with the provider, into the electronic medical record. The DAL stated depending on the time a resident arrived medications may need to be pulled from the backup system, drop-shipped from another pharmacy within two hours, or sent on the routine nightly delivery from the pharmacy. The DAL stated anytime a medication was not available nurses were to call the pharmacy and notify the physician of the unavailability of the medication unless the medication arrived before the end of the medication administration pass. The DAL stated unless specified to be daily or instructed not to be started immediately on admission all antibiotics were started immediately within a couple of hours after the resident arrived at the facility. The DAL stated an RN must start the first dose of IV medications; however, there was always an RN available in the building to start the medication for the resident. During an interview on 07/09/2025 at 3:56 P.M., the Pharmacist revealed medication orders were received from the facility through an electronic medical record submission. The Pharmacist stated the pharmacy relied on the facility to transcribe all orders from a hospital discharge into the medical record. The Pharmacist stated the cut-off time for filling new admission orders for the standard delivery was 7:00 PM; however, the facility could contact the pharmacy to request medication be sent stat ( immediately, at once) or drop shipment which would allow medication to be sent in as little as four hours. The Pharmacist stated anytime a nurse did not have a medication that was needed to be administered, they should contact the pharmacy to request a delivery time and request either a drop shipment or stat delivery of the item. He stated the pharmacy received the order for cefepime on 04/12/2025 at 6:26 PM, the cefepime was dispensed on 04/12/2025, and it was delivered to the facility on [DATE] at 1:59 A.M. During an interview on 07/10/2025 at 3:00 P.M., the Assistant Director of Health Services (ADHS) stated she expected a nurse to call the pharmacy to have any medications they did not have drop-shipped. The ADHS stated it was the nurses' responsibility to ensure reconciliation of residents' medications. On 07/11/2025 at 7:28 A.M., the Director of Health Services (DHS) stated when they received orders for a resident, they sometimes received an after-visit summary (AVS), a discharge summary, and/or continuation of care documents. The DHS stated staff entered the orders, tried to have another nurse look at the order if it was a high risk medication, called the doctor to confirm the orders and make any changes, faxed the orders to the pharmacy, called the pharmacy to confirm the orders were received, and had the medications drop-shipped to the facility if the medications were not available in the facility's backup medication inventory. The DHS stated nurses had a list of the available medications. The DHS stated normally antibiotics were started within 24 hours, and they would confirm the hospital had given the resident a dose before discharge. The DHS stated the doctor was called if the facility could not get resident medications right away. 4. Review of Resident Face Sheet revealed the facility admitted Resident #103 on 06/23/2025. The resident had a medical history that included diagnoses of encephalopathy, pneumonia due to methicillin susceptible Staphylococcus aureus (a bacteria) (MRSA), coronary artery bypass graft (CABG), acute pulmonary insufficiency following thoracic surgery, acute posthemorrhagic anemia, atrial fibrillation, and diabetes mellitus type 2. Review of the admission Minimum Data Set (MDS), with an admission Reference Date (ARD) of 06/30/2025, revealed Resident #103 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS also indicated Resident #103 did not reject care during the assessment's lookback period. The MDS revealed the resident received insulin. The MDS indicated Resident #103 was admitted from a short-term general hospital. Review of Resident #103's Care Plan History, included a problem statement started 06/30/2025, that indicated the resident was at risk for excessive bleeding and bruising related to medications. Interventions directed staff to administer medications per physician's orders; obtain laboratory specimens as ordered and notify the provider of abnormal results; and to notify the provider of abnormal bruising or bleeding. Review of Resident #103's Care Plan History, included a problem statement started 07/07/2025, that indicated the resident was at risk for hypo/hyperglycemia related to diabetes mellitus. Interventions directed staff to provide medications and to monitor blood glucose levels per orders. Review of Resident #103's Cardiothoracic Surgery Discharge Summary, dated 06/23/2025, indicated, Continue these medications which have changed and included Eliquis (used to prevent clots), 2.5 milligrams (mg) two times daily for 30 days due to a blockage of a blood vessel to the lung by a particle; insulin lispro (a rapid-acting insulin) 2 units under the skin three times daily before meals; and insulin aspart (a rapid-acting insulin) according to a sliding scale (a chart of insulin dosages based on blood glucose level levels). Review of Resident #103's 06/2025 Medication Administration History, dated 06/2025 revealed the following:- A transcription of an order for insulin lispro to be administered per a sliding scale before meals, started on 06/24/2025. The Medication Administration History revealed staff documented that on 06/24/2025 for the timeframe from 6:30 through 9:00 A.M. the residents blood sugar level was 568 mg/dL (milligrams per deciliter) and for the timeframe from 10:00 A.M. through 12:30 P.M. the residents blood sugar level was 212 mg/dL. The sliding scale revealed that if the resident blood sugar level was greater than 400, they were to call the medical doctor and if the resident's blood sugar was 181 to 220 to administer 6 units of the insulin. The Medication Administration History revealed staff documented that the first dose of sliding scale lispro was administered on 06/24/2025 for the timeframe from 3:30 P.M. to 6:30 P.M. - A transcription of an order for insulin lispro, 2 units subcutaneously before meals with a blood glucose level greater than 99 mg/dL, started on 06/24/2025. The Medication Administration History revealed staff documented that on 06/24/2025 for the timeframe from 6:30 through 9:00 A.M. the residents blood sugar level was 568 mg/dL and for the timeframe from 10:00 A.M. through 12:30 P.M. the residents blood sugar level was 212 mg/dL. The Medication Administration History revealed staff documented that the first dose of lispro was administered on 06/24/2025 for the timeframe from 3:30 P.M. to 6:30 P.M. - A transcription of an order for Semglee (insulin glargine, a long-acting insulin) 40 units at bedtime, started on 06/23/2025. The Medication Administration History revealed staff documented that the first dose of Semglee was administered on 06/24/2025.The Medication Administration History revealed no transcription of an order for Eliquis. An observation on 07/08/2025 at 8:58 A.M. revealed Resident #103 was delivered a breakfast meal tray including apple juice, pancakes, and bacon. An observation on 07/08/2025 at 9:10 A.M. revealed Resident #103 completed eating the entire breakfast meal and pushed the overhead table with the meal tray away from their bed. An observation on 07/08/2025 at 9:28 A.M. revealed a nurse entered the room with a cup of pills and vital sign equipment. The observation revealed Resident #103's blood glucose level reading was 121 mg/dL and insulin was administered to the resident's right upper quadrant of the abdomen. During an interview on 07/08/2025 at 9:38 A.M., Licensed Practical Nurse (LPN) #14 stated she had been educated to obtain blood glucose level readings prior to the resident eating a meal, and she should have taken Resident #103's blood glucose level reading and provided the resident with their insulin prior to their meal that morning. During an interview on 07/08/2025 at 2:06 P.M., the Medical Director (MD) stated resident blood glucose levels should be obtained before meals. During an interview on 07/09/2025 at 3:56 P.M., the Pharmacist revealed medication orders were received from the facility through an electronic medical record submission. The Pharmacist stated the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and policy review, the facility failed to ensure documentation was completed regarding a resident's meal/dietary intake. This affected one (#45) out of three residents reviewed for meal service. The facility census was 43. Findings include: Medical record review for Resident #45 revealed an admission on [DATE] and a discharge on [DATE]. Diagnoses include acute kidney failure, asthma, and cerebral infarction without deficits. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 was not completed due to discharge from the facility. Review of the baseline plan of care dated 04/16/24 for Resident #45 revealed the resident was on a regular diet, mechanical soft with thin liquids. Review of the active physicians' orders for Resident #45 revealed an order dated 04/16/24 stating regular diet, mechanical soft with thin liquids. Review of the electronic health record for Resident #45 for dietary intake revealed there was no documentation the resident consumed any meals during her stay at the facility. Interview on 05/28/24 at 2:10 P.M. with the Director of Nursing (DON) verified the facility did not have any documentation for Resident #45's meal intake during the resident's stay. DON stated the staff should be documenting the percentage of food consumed at each meal in the electronic health record. Review of the facility policy titled Meal Service, dated 01/2024 revealed if an individual is not accepting of their food an appropriate an alternate is offered and the staff will assist the individual as needed. This deficiency represents non-compliance investigated under Complaint Number OH00153301.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff utilized proper hand hygiene during wound dressing change procedures. This affected one (#06) resident of three residents reviewed for wound care. The facility census was 47. Findings include: Review of the medical record for Resident #06 revealed an admission on [DATE] with diagnoses including, but not limited to, fracture of lower end of left radius, encephalopathy, rhabdomyolysis, atherosclerotic heart disease, peripheral vascular disease, chronic obstructive pulmonary disease, and stroke. Review of the admission Minimum Data Set (MDS) assessment for Resident #06 dated 02/06/24 revealed the assessment was still in progress. Review of the plan of care dated 02/13/24 for Resident #06 revealed the resident had a pressure ulcer. Interventions include medications as ordered, assess, and record the condition of skin, observe and report signs of infection, observe for and report signs of pain related to pressure, pressure cushion to chair and mattress, diet as ordered, and weekly skin assessments. Review of the physician orders dated 02/13/24 for Resident #06 revealed the resident was ordered to have the pressure ulcer on the left hip cleansed with normal saline and apply nickel thick layer of Santyl ointment 250 units/gram, cover with alginate pad and secure with a foam dressing every other day and as needed (PRN) for soiling or dislodgement. Observations of wound care for Resident #06 on 02/15/24 at 10:00 A.M. with Licensed Practical Nurse (LPN) #86 revealed the residents bed side table was wiped down with sani-wipes and draped with a towel. The wound supplies were placed on the towel and pulled close to the resident's bedside. LPN #86 completed hand hygiene with soap and water, then donned gloves. The dressing to resident's left hip was removed and placed into the plastic trash bag. LPN #86 proceeded to cleanse the wound with normal saline and four by four gauze pads. LPN #86 then removed her gloves, completed hand hygiene, donned gloves, and applied Santyl ointment to the wound bed. LPN #86 applied collagen alginate to wound bed and covered with foam bordered dressing. Interview with LPN #86 n 02/15/24 at 10:15 A.M. revealed she was unsure of what the policy stated regarding hand hygiene and confirmed she removed old dressing from left hip and cleanse the wound without changing her gloves. Interview with the Director of Nursing (DON)on 02/15/24 at 11:00 A.M. revealed LPN #86 should have removed her gloves after removing the old wound dressing and completed hand hygiene prior to the application of the new dressing. Review of the facility policy titled Dressing Changes, dated 12/31/23 revealed to ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize and control contamination. The staff would remove soiled dressing and discard it in plastic bag or trash can, remove and dispose of gloves and wash hands with soap and water. Then apply a second pair of disposable gloves and follow physician orders for application of treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and resident interviews and policy review, the facility failed to maintain an effective pest control program. This had affected two (#10 and #36) out of two residents reviewed for pest control. The facility census was 52. Findings include: 1. Record review for Resident #10 revealed she was admitted to the facility on [DATE]. Diagnoses include acute and chronic respiratory failure with hypoxia, heart failure, chronic respiratory failure with hypoxia, cerebrovascular disease, atherosclerotic heart, old myocardial infarction, chronic obstructive pulmonary disease, asthma, polyneuropathy, diabetes mellitus two, diverticulosis of intestine, major depressive disorder, obesity, sleep apnea, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had intact cognition. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 required limited assistance from staff with eating. 2. Record review for Resident #36 revealed an admission date of 10/29/21. Diagnoses included arthropathy, hypertensive urgency, asthma, hypothyroidism, diabetes mellitus two, depression, osteoarthritis, insomnia, dysphagia, hypertension, gastro-esophageal reflux disease without esophagitis, and myocardial infarction. Review of the quarterly MDS assessment, dated 07/13/22, revealed Resident #36 had impaired cognition. Further review of the MDS assessment revealed she required supervision from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Observation on 08/16/22 at 9:51 A.M. during an interview with Resident #36 revealed the resident was sitting on the side of the bed. Observation of the wall next to her bed revealed a large colony of ants crawling all over the wall, over the bedside chair, and along the carpet. Interview on 08/16/22 at 10:07 A.M. with Licensed Practical Nurse (LPN) #53 confirmed ants were crawling all over the chair, up the wall and all over the floor in Resident #36's room. Interview on 08/16/22 at 12:38 P.M. with Resident #10 stated she has had an ongoing issue with ants in her room. Interview on 08/17/22 at 8:48 A.M. with Maintenance Supervisor (MS) #68 revealed the facility utilizes a professional pest control company to spray for pest monthly. MS #68 stated the facility is treated monthly, however, if pest are identified in a resident's room the facility maintenance staff will treat until the next monthly visit from the professional pest control program. MS #68 confirmed Resident #36 had an infestation of ants in her room and the issue should have been referred to the professional pest control company for treatment. Follow up interview on 08/17/22 at 3:42 P.M. with the MS #68 confirmed the facility has never had Resident #10 or Resident #36's room treated by the professional pest control company utilized by the facility. MS #68 confirmed each room had ant infestation. Review of the facility policy tiled Pest Control dated 08/07/2018, revealed the facility will maintain an ongoing pest control program to ensure the building is kept free of insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, the facility failed to ensure the accuracy of assessments regarding dental status and catheter use. This affected two residents (#41 and #45) of 16 residents sampled. The census was 45. Findings include: 1. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including diabetes, hypertension, and osteoarthritis. Review of progress note for Resident #41 dated 05/29/19 revealed the resident's indwelling urinary catheter was removed. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively impaired and was coded as having an indwelling urinary catheter. Interview with Registered Nurse (RN) #400 on 07/01/19 at 4:29 P.M., confirmed Resident #41 did not have an indwelling urinary catheter in place during the assessment window for the MDS dated [DATE], and the MDS had been coded in error. 2. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with an admitting diagnosis of chronic kidney disease. Review of MDS assessment dated [DATE] revealed Resident #45 was cognitively intact and was not coded as being edentulous (no natural teeth or teeth fragments). Review of Care Area Assessment report for the MDS dated [DATE] for Resident #45 revealed the section regarding dental status was not triggered or completed. Interview and observation with Resident #45 on 07/01/19 at 12:35 P.M., confirmed the resident was edentulous. Interview with RN #400 on 07/01/19 at 5:30 P.M., confirmed Resident #45 was edentulous and had been so upon admission to the facility. Further interview with RN #400 confirmed the MDS section L dated 01/01/19 for Resident #45 was not coded for resident being edentulous and had been coded in error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to include the resident's dental status. This affected one resident (#45) of two residents investigated for dental concerns. The census was 45. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with an admitting diagnosis of chronic kidney disease. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 revealed the resident was cognitively intact and was not coded as being edentulous (no natural teeth or teeth fragments). Review of Care Area Assessment report for the MDS dated [DATE] for Resident #45 revealed the section regarding dental status was not triggered or completed. Review of the comprehensive care plan for Resident #45 revealed the care plan was silent regarding resident's dental status and/or dental concerns. Interview and observation with Resident #45 on 07/01/19 at 11:50 A.M., confirmed the resident was edentulous. Further interview with Resident #45 confirmed the resident had full dentures she had brought with her upon admission to the facility, however they were old and resident felt they needed to be replaced. Interview with RN #400 on 07/01/19 at 4:15 P.M., confirmed Resident #45's comprehensive care plan was silent regarding resident's dental status and/or dental concerns.

Based upon record review and staff interview, the facility failed to ensure the services of a registered nurse were in place for at least 8 consecutive hours per day, seven days per week. This had the potential to affect all 45 residents residing in the facility. Findings include: Review of staffing schedule for 06/21/19 revealed a registered nurse was present in the facility for only four hours on this date. Review of punch detail for RN #400 for 06/21/19 revealed nurse clocked in at 8:00 A.M. and clocked out at 12:00 P.M. Interview with Administrator on 07/03/19 at 8:50 A.M., confirmed the facility only had a RN present in the facility for four hours on 06/21/19.

Based on medical record review, observation, resident interview, staff interview, and review of the facility's medication storage policy, the facility failed to ensure medications were properly labeled with dates and stored. This affected two of two residents (#16 and #45) medications reviewed for proper labels. The facility census was 45. Findings include: 1. Review of Resident #16's physician orders dated 04/01/19, revealed active orders for Latanoprost drops 0.05 percent; administer one drop into both eyes once daily for glaucoma. Physicians orders dated 04/18/19 revealed active orders for Brimonidine drops 0.2 percent; administer one drop into left eye twice daily for glaucoma. Physician orders for same date revealed active orders for Dorzolamide-timolol drops 22.3-6.8 milligrams per milliliter (mg/mL); administer one drop into left eye twice daily for glaucoma. Observation of the top drawer in the medication cart for 300-hall on 06/25/19 at 8:12 A.M. revealed three opened and undated bottles of eye drops for Resident #16. Interview with Licensed Practical Nurse (LPN) #20 on 07/02/19 at 8:15 A.M., verified one bottle of Latanoprost drops 0.05 percent, one bottle Brimonidine drops 0.2 percent and one bottle Dorzolamide-timolol drops 22.3-6.8 milligrams per milliliter (mg/mL) were opened and undated. 2. Observation and interview with Resident #45 on 07/01/19 at 11:50 A.M., revealed a container of topical medication on the resident's bedside table. The medication had a pharmacy label indicating the contents were a topical cream for pain relief containing Gabapentin (for nerve pain) and Lidocaine. The name of the on the prescription label was not Resident #45's name. Resident #45 confirmed the topical prescription medication belonged to her daughter and her daughter had brought the medication to the resident about a month ago. Further interview with Resident #45 confirmed she used the topical medication almost daily for pain relief. Interview on 07/01/19 at 12:00 P.M. with Licensed Practical Nurse (LPN) #57 confirmed Resident #45 did not have a physician's order for a topical cream and the name on the prescription was not Resident #45's name. LPN #57 confirmed the medication was not properly labeled or stored. Review of facility policy titled Medication Storage in the Facility dated 01/01/17 revealed medications should be individually labeled for resident use and should be stored properly. The policy also revealed when a container is opened, a date-opened sticker shall be placed on the medication with expiration of 30-days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical record review, observation, resident and staff interview, the facility failed to ensure a resident received routine dental services. This affected one resident (#45) of two residents investigated for dental concerns. The facility census was 45. Findings include: Medical record review revealed Resident #45 was admitted to the facility on [DATE] with an admitting diagnosis of chronic kidney disease. Review of the comprehensive care plan for Resident #45 revealed the care plan was silent regarding resident's dental status and/or dental concerns. Review of the dental consultation notes for Resident #45 dated 12/13/17 revealed the resident was edentulous and desired to have new dentures made. There was no evidence the resident had been seen by the dentist or had any dentures made since 12/13/17. Review of Minimum Data Set (MDS) dated [DATE] for Resident #45 revealed resident was cognitively intact and was not coded as being edentulous (no natural teeth or teeth fragments.) Interview and observation with Resident #45 on 07/01/19 at 11:50 A.M., confirmed the resident was edentulous. She revealed she had full dentures she had brought with her upon admission to the facility, however they were old and felt they needed replaced. Resident #45 confirmed it had been over a year since she had been seen by the dentist. Interview with the Director of Nursing (DON) on 07/02/19 at 5:20 P.M., confirmed the resident had not been examined by the facility dentist since 12/13/17.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, medical record review, observation, staff interview and facilty policy review, the facility failed to follow their tuberculosis control plan when a new employee, a Dietary Services Assistant (DSA) #9 of six reviewed did not receive a two step Mantoux (PPD) test. This had the potential to affect all 45 residents of the facility. Additionally, the facility failed to ensure oxygen tubing was labeled and kept in a sanitary manner. This affected one resident (#37) of 16 reveiwed for oxygen therapy. Findings include: 1. Review of DSA #9's personnel file revealed a hire date of 05/02/19. There was no evidence the DSA received a two step tuberculosis skin test (PPD) being completed. Interview with Corporate Support #300 on 07/03/19 at 2:09 P.M., verified DSA #9 did not have a two step PPD test completed prior to 07/03/19. Corporate Support #300 confirmed Dietary Services Assistant #9 was hired on 05/02/19. Review of the facility's policy Guidelines for Tuberculosis Results Summary Documentation dated 05/11/16 revealed upon hire each employee shall receive a two step Mantoux PPD test to ensure they are free from tuberculosis. 2. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of hypertension and glaucoma. Review of physician orders for Resident #37 for June 2019 revealed an order to administer oxygen via nasal cannula at one liter continuously from 11:00 P.M. to 7:00 A.M., and to change the oxygen tubing once monthly. Observation with Licensed Practical Nurse (LPN) #57 of Resident #37 on 07/01/19 at 10:10 A.M., revealed the oxygen tubing was not labeled with the date it was initiated, and the tubing was observed laying directly on the floor. LPN #57 confirmed the oxygen tubing for Resident #37 was uncovered and observed laying directly on the floor. LPN #57 further confirmed the tubing should be labeled with the date it was initiated and it should not be stored in direct contact with the floor. Review of policy titled Guidelines for the Administration of Oxygen dated 09/17/18 revealed oxygen tubing should be changed monthly, as needed, and should be labeled with the date it was initiated.