**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of hospital records, facility policy review and interview the facility failed to ensure Resident #91 was free from a significant medication error when the facility administered Resident #91's diuretic (medication to increase the production of urine) when it should have been on hold. Actual Harm occurred on 03/29/24 when the facility failed to hold Resident #91's diuretic medication resulting in a significant change in the resident's condition resulting in an unplanned hospitalization. On 03/29/24 Primary Care Physician (PCP) #615 ordered to hold Resident #91's Torsemide (diuretic medication) due to abnormal lab work including an increase in the resident's creatinine level (a test that measured how well the kidneys filter waste from the blood) to 3.3 mg/ deciliter (dl) indicating worsening of her kidney function, repeat the lab work on 04/01/24 and to notify Nephrologist #614 of the results. On 04/01/24 Resident #91's creatinine increased to 5.4 mg/dl; however, the facility restarted the Torsemide medication on this date without a physician order. The facility was unable to contact Nephrologist #614 regarding the increase in creatinine level until 04/03/24 without PCP #615 knowledge. The facility continued to administer Resident #91's Torsemide until 04/03/23 at 4:25 P.M. when the resident was sent to the hospital. Hospital Internal Medicine Physician #900 noted per his history and physical Resident #91 looked remarkedly dry and he suspected uremia (like threatening condition caused by kidney failure and waste build up in the blood). The note also revealed her labs were consistent with over diuresis (excessive production of urine usually caused by diuretics) and if no improvement the resident would require dialysis. This affected one resident (#91) of three residents reviewed for medication administration. The facility census was 87. Findings included: Review of closed medical record for Resident #91 revealed an admission date of 03/09/24. The resident was transferred to the hospital on [DATE] and she did not return to the facility. Resident #91 had diagnoses including partial amputation of her right foot, diabetes, chronic kidney disease, lymphedema, osteomyelitis, and hypertension. Review of March 2024 physician orders revealed Resident #91 had an order dated 03/20/24 for the diuretic medication, Torsemide 20 milligram (mg) one tablet by mouth two times a day for edema. She also had an order to have weekly lab work, a Completed Blood Count (CBC), Basic Metabolic Panel (BMP) and Renal Function Panel (RFP) with the order indicating to fax the results to Nephrologist #614. Resident #91 was on a 1500 milliliter (ml) fluid restriction per day. Review of an After Visit Summary dated 03/09/24 revealed hospital discharge instructions included start diuretics when approved by nephrology. The summary revealed the resident had chronic kidney disease with chronic edema to her bilateral legs. Her Lasix (diuretic) was discontinued in the hospital due to worsening of renal function. There was nothing in the medical record the nephrologist was aware Resident #91 started the diuretic on 03/20/24. Review of lab work dated 03/15/24 for Resident #91 revealed a BMP that indicated the resident's potassium was 3.6 milliequivalent (mEq)/ liter (l), sodium 146 mEq/l, chloride 100 mEq/l , and creatinine 1.1 mg/dl which were all within normal limits. Review of a care plan dated 03/15/24 revealed Resident #91 was at nutritional risk related to diabetes, chronic kidney disease, hypertension, and lymphedema. The resident was on a fluid restriction. Interventions included administering medications as ordered, encourage compliance with fluid restriction as tolerated, and monitor lab values as available. Review of lab work dated 03/20/24 for Resident #91 revealed a BMP that indicated the resident's potassium was 3.6 mEq/l, sodium was 144 mEq/l, and chloride 101 mEq/l which were all within normal limits. The resident's creatinine was slightly elevated at 1.9 mg/dl (Normal was .6 to 1.2). Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 had impaired cognition. The assessment revealed the resident required set up help with eating. Review of lab work dated 03/22/24 for Resident #91 revealed a BMP that indicated a sodium level was high at 147 mEq/l (normal was 136 to 145), potassium was low at 3.3 mEq/l (normal was 3.5 to 5.3), and her creatinine increased to 2 mg/dl. The resident's chloride level continued to be 100 mEq/l within normal limits. Review of lab work dated 03/29/24 for Resident #91 revealed a BMP that indicated the resident's sodium had increased to 149 mEq/l, potassium had now decreased to 2.5 mEq/l, chloride decreased to 95 mEq/l, and her creatine now as at 3.3 mg/dl. The lab results showed signs of dehydration and renal failure. Review of a physician progress note dated 03/29/24 at 4:06 P.M. completed by Primary Care Physician (PCP) #615 revealed Resident #91's creatinine had jumped to three and her lab work was getting faxed to nephrology. He revealed under his assessment and plan a diagnosis of acute kidney injury, to hold diuretics, and check lab work on 04/01/24. Review of a nursing note dated 03/29/24 at 5:50 P.M. completed by Licensed Practical Nurse (LPN) #616 revealed PCP #615 was in to see Resident #91 and placed Torsemide on hold until Monday, 04/01/24 after BMP and encourage oral fluids. Review of April 2024 Medication Administration Record (MAR) revealed Resident #91 received the Torsemide 20 mg tablet by mouth after it was supposed to remain on hold on 04/01/24 4:00 P.M. to 6:00 P.M. dose, 04/02/24 both the early morning dose and the 4:00 P.M. to 6:00 P.M. dose, and on 04/03/24 the early morning dose until she was sent to the hospital. Review of lab work dated 04/01/24 for Resident #91 revealed a BMP that indicated the resident's sodium continued to be elevated at 146 mEq/l, potassium was still low at 3.4 mEq/l and her creatinine was now at 5.4 mg/dl. Review of nursing note dated 04/02/24 at 2:31 A.M. and completed by LPN #617 revealed Resident #91's lab work was sent to PCP #615, and he was also sent a message. Review of a nursing note dated 04/02/24 at 8:16 A.M. and completed by Registered Nurse (RN) #618 revealed the resident's lab work was faxed to Nephrologist #614. Review of a nursing note dated 04/02/24 at 10:58 A.M. and completed by RN/ Assistant director of Nursing (ADON) #620 revealed she received a phone call from Nephrologist #614's office stating Resident #91's husband had called the office regarding Resident #91's lab work. The lab work was re-faxed to the office at 10:55 A.M. and no new orders were received as of this nursing entry. Review of a nursing note dated 04/03/24 at 11:30 A.M. completed by RN/ ADON #620 revealed she spoke with Resident #91's husband in the morning as he had questions regarding the resident's current medications and if Nephrologist #614 had called back with any order changes. She informed Resident #91's husband that the lab work was faxed to the Nephrologist #614's office and that she would follow up with the office. Review of a nursing note dated 04/03/24 at 4:25 P.M. completed by RN #601 revealed Resident #91 was sent to the hospital by a rescue squad. There was no other documentation regarding the resident assessment, the condition of the resident, who had ordered her to go to the hospital and the reason why she was sent. Review of the hospital History and Physical dated 04/03/24 and completed per Hospital Internal Medicine Physician #900 revealed Resident #91 looked remarkedly dry and that he suspected uremia (life threatening condition caused by kidney failure and waste build up in the blood). The note revealed her labs show alkalosis consistent with over diuresis (excessive production of urine usually caused by diuretics). Internal Medicine Physician #900 discussed in detail her status with Nephrologist #614 and if no improvement she would require dialysis. Review of Clinical Note from the hospital dated 04/04/24 and completed by Nephrologist #614 revealed he had sent Resident #91 to the emergency room as he was sent lab work which he just became aware of for the first time yesterday afternoon, 04/03/24. The note revealed Resident #91's husband was concerned as his wife was displaying change in mental status including eyes rolling back in her head. The note revealed notably another provider had checked her lab work and stopped her Torsemide (the note does not reference how the facility had restarted the Torsemide on 04/01/24). The note revealed her creatine was 6.7 mg/dl, high sodium level at 149 and she was encephalopathic (disorder that affect the brain including confusion, memory loss and mental changes). The note revealed the resident appeared very dry and showed signs of significant dehydration. He recommended to continue to hold all diuretics. He diagnosed Resident #91 with acute kidney injury, and hypernatremia (low sodium) secondary to significant dehydration. He recommended if by the next morning, 04/05/24 her renal function had not improved, he would have her start dialysis. Interview on 05/06/24 at 4:42 P.M. with RN #601 revealed she was the nurse on duty on 04/03/24 caring for Resident #91. She revealed she could not remember why Resident #91 went to the hospital, who had ordered her to go to the hospital, and/ or her status at the time she was sent to the hospital. She revealed after reviewing the medical record, I cannot believe I did not write anything about it including documenting an assessment. Interview on 05/07/24 at 11:08 A.M. with PCP #615 revealed he thought Resident #91's husband had requested her to start on the Torsemide 20 mg twice a day on 03/19/24 but was unsure. He revealed he then ordered it as he knew she was getting weekly lab work that was being reviewed by Nephrologist #614. He revealed he was at the facility on 03/29/24 and was notified of Resident #91's lab work indicating her creatinine had increased to above three. He revealed he was told Nephrologist #614 was not in the office and since it was a Friday he handled the abnormal lab work. He revealed he placed her Torsemide on hold as residents displaying renal failure signs and dehydration should not continue a diuretic. He revealed he assumed then that the facility would have Nephrologist #614 address her lab work on 04/01/24 and continue to hold the Torsemide until then. He verified that he never gave the order to restart the Torsemide as this needed continued to be held especially since her creatinine on 04/01/24 increased to 5.4 as this medication would affect her kidney function. He revealed he was not informed she had received the Torsemide on 04/1/24 through 04/3/24 (date she was sent to the hospital). He stated, no she should not have. He revealed he was not aware the facility was not able to get a hold of Nephrologist #614 until 04/03/24 and that her lab work had not been addressed. Interview on 05/07/24 at 11:30 A.M. with Resident #91's husband revealed Resident #91 should have never been receiving a diuretic as this was what caused her renal failure to deteriorate. He revealed on 03/29/24 he had expressed concern that his wife was severely dehydrated as her lips/ mouth were severely dry and she was confused with mental status changes. He revealed he was told that they placed Torsemide on hold on 03/29/24 as her creatine level had increased. He revealed he found out that the level continued to rise as the facility kept giving her the Torsemide instead of holding it as it should have been. He revealed he continued to question the facility as she continued to not look well but they seemed to ignore her symptoms especially that she was severely dehydrated, and in renal failure. He revealed on 04/03/24 that since the facility was not doing anything he contacted Nephrologist #614's secretary who had called the facility to have her sent out by 911- emergency rescue services. He revealed at the hospital the resident's creatinine had increased further and that she required emergency dialysis to get her kidneys functioning again. He revealed she now was doing a lot better and no longer required dialysis. Interview on 05/07/24 at 1:41 P.M. with the Director of Nursing verified she had nothing in the medical record to support Nephrologist #614 was aware Resident #91 had started on a diuretic. She also verified Resident #91 had received the following doses of Torsemide when it should have continued to be on hold: on 04/01/24 4:00 P.M. to 6:00 P.M. dose, 04/02/24 both the early morning dose and the 4:00 P.M. to 6:00 P.M. dose, and on 04/03/24. She revealed PCP #615 had contacted her after the interview with this surveyor and had stated the Torsemide should never had been restarted especially because of how high the resident's creatinine level was and that he was not aware that they were having difficulty contacting Nephrologist #614 and that they should have contacted him. Review of facility policy labeled, Administering Medications dated April 2019 revealed medications were to be administered in a safe and timely manner as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00152934 and Complaint Number OH00152981.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview, the facility failed to provide comprehensive, individualized and sufficient wound care for Resident #28 and Resident #95. This affected two residents (#28 and #95) of three residents reviewed for non-pressure related wound care. The facility census was 90. Actual harm occurred on 03/21/24 when Resident #28, who was incontinent and admitted for wound care, was directly admitted to the hospital with a foul smelling, pus draining, painful wound and diagnosed with cellulitis/infection due to a lack of monitoring and adequate wound care following the resident's admission on [DATE]. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 03/12/24. Diagnoses included polyneuropathy, diabetes mellitus type II, congestive heart failure, hidradenitis suppurativa (chronic skin condition which involve lesions from inflammation and infection of sweat glands), pain in hip, dorsalgia (back pain), cervicalgia (neck pain), acute kidney failure, and sciatica (pain down leg from back). Resident #28 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had no cognitive impairment, was occasionally incontinent of urine and frequently incontinent of bowel. Review of the hospital discharge information dated 03/11/24 revealed Resident #28 was treated for a hidradenitis suppurativa (HS) flare of the buttocks with left hip and buttock pain and received antibiotic treatment and zinc oxide paste (medicated paste that treats or prevents skin irritation like cuts, burns, or diaper rash) to the area. The wound care consultant recommended zinc oxide 20 percent ointment applied three times daily. Review of Resident #28's admission assessment dated [DATE] revealed a wound to the left buttock with no description or treatment documented. A weekly skin review dated 03/12/24 also reflected the left buttock wound with no documented description or treatment. In addition, the baseline care plan indicated open areas to the left buttocks. Review of the nursing progress notes dated 03/12/24 revealed Resident #28 was admitted to the facility for wound care. A message was left with the physician to review the admission, but there was no documented evidence the physician verified the admission orders. Review of the wound nurse practitioner progress note dated 03/14/24 revealed Resident #28's left buttocks HS measured 10.0 centimeters (cm) length by 12.0 cm width and 0.1 cm depth. Treatment was indicated to cleanse with normal saline, apply silver alginate (dressing to facilitate wound healing) to the base of the wound and secure with bordered foam twice daily. The nurse practitioner requested this order on 03/14/24 after examination, but the order was not initiated. Review of the skilled nursing note dated 03/14/24 indicated Resident #28 had two areas covered by bandages without a location or further information related to the areas. Review of the nursing progress note dated 03/16/24 revealed Resident #28 called emergency services and indicated not feeling well, wanting narcotics and to be taken to the hospital. Emergency services provided transfer but there was no additional documentation related to Resident #28's complaint. Review of the hospital visit summary dated 03/16/24 revealed Resident #28 was treated at the emergency room for a musculoskeletal problem and returned to the facility. Diagnoses included rib pain and muscle strain of chest wall, initial encounter. Orders were given for Robaxin (muscle spasms and pain) 750 milligrams (mg) every six hours as needed up to three days, and Lidocaine four percent patch (relieves minor pain including nerve pain) daily for five days and remove after 12 hours. Review of Resident #28's physician orders dated 03/17/24 revealed a left buttocks treatment to cleanse with normal saline, dry, apply silver alginate and cover with a foam border dressing twice daily and as needed. There were no treatment orders initiated to the left buttocks prior to 03/17/24. Review of Resident #28's physician orders and medication administration record (MAR) for March 2024 revealed the hospital ordered Robaxin and Lidocaine patches were not ordered or made available to Resident #28 until 03/18/24. These orders should have started on 03/16/24 following the residents return from the emergency room. Review of the wound nurse practitioner progress note dated 03/21/24 revealed Resident #28's left buttocks HS had worsened, measuring 4.0 cm length by 24.0 cm width and 0.1 cm depth, and had a malodourous (foul smelling) odor after cleansing was completed. The wound had a heavy amount of seropurulent exudate (yellow to tan colored secretions). There was a high concern for infection and escalation of care to the hospital was recommended. Arrangements were made for hospital transfer. Review of the nursing progress note dated 03/21/24 revealed Resident #28 was direct admitted to the hospital using emergency services. Resident #28 complained of pain and was medicated with Oxycodone, an opioid pain medication. The progress note was void of the location of the pain. Review of the hospital discharge information dated 03/25/24 revealed Resident #28 was admitted for diagnosis of left hip cellulitis. Resident #28 was presented to the hospital with a left hip infection and had a history of HS of the buttock and received treatment for it at the facility. (The buttock and hip were used interchangeably because the area was large and encompassed both the buttock and hip). Resident #28 reported to the hospital staff the dressing was supposed to be changed twice daily but the facility staff were not doing it, indicating four dressing changes in ten days. Resident #28 developed pain in the left buttock which gradually got worse which required an emergency room visit due to difficulty sitting and standing due to the pain. Intravenous (IV) antibiotic treatment was administered, and wound orders were to wash daily with soap and water, cover with Xeroform (non-adherent dressing) and apply Mepilex (absorbent foam dressing). Review of Resident #28's physician orders dated 03/25/24 revealed the left buttocks treatment order was changed to wash daily with soap and water, cover with Xeroform and cover with Mepilex daily at bedtime. Review of the wound nurse practitioner progress note dated 03/28/24 at 12:59 P.M. indicated the left buttocks HS was a full thickness wound with a mild odor and ordered a new treatment plan to cleanse with normal saline, apply silver alginate to the base of the wound, and secure with an abdominal dressing pad daily. Review of Resident #28's treatment administration records from March 2024 to April 2024 revealed there was no evidence of wound care provided to the left buttock from admission on [DATE] until initiated on 03/17/24. The left buttocks wound treatment ordered on 03/17/24 was not signed as completed on 03/19/24 but was signed as completed on 03/22/24 day shift when Resident #28 was no longer in the facility. Additional treatments effective March 2024 including vital signs every shift and laboratory testing were signed as completed on 03/22/24 day shift when Resident #28 was not in the facility. The left buttock wound treatment dated 03/25/24 was administered from 03/25/24 through 04/03/24 and was not changed on 03/28/24 as requested by the wound nurse practitioner. On 04/02/24 at 11:47 A.M. interview with Resident #28 revealed complaints of left hip dressing changes not being completed by facility staff and indicated the dressing was changed four times in the last 11 days which caused an infection. Resident #28 reported trying to talk to the nurses, and no one did anything about it. Pain in the wound area increased so he called emergency services to get help. Then the wound became infected, and Resident #28 was admitted to the hospital. Attempts to observe wound care three times throughout the survey were unsuccessful because Resident #28 refused to allow the surveyor to observe the area. Interview on 04/04/24 at 1:17 P.M. with Director of Nursing (DON) verified the above findings. The DON stated Resident #28's wound was not treated after admission until 03/17/24 but remembered placing a dressing on it on 03/14/24 when Resident #28 complained about treatments not being completed. Despite the complaint, wound treatment orders were not initiated until 03/17/24 when the DON audited the wound notes. The DON notified the physician but did not document it. The DON confirmed Resident #28 contacted emergency services for increased pain and upon return on 03/16/24 was not offered treatment intervention until 03/18/24. The DON indicated a phone call was received at some time by the hospital case manager regarding Resident #28's complaint of no wound care and verified Resident #28 was ultimately admitted with a wound infection. Review of the facility policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, revealed the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions, and the physician will order pertinent wound treatments. Review of the facility policy, Pain - Clinical Protocol, revised October 2022, revealed the physician and staff will identify pain, and provide non-pharmacologic and medication interventions to address the pain. 2. Review of the medical record for Resident #95 revealed an admission date of 01/25/24. Diagnoses included diabetes, neuropathy, cellulitis of the right lower limb, and localized edema. Review of the admission MDS assessment dated [DATE] revealed Resident #95 had intact cognition. Review of physician orders for April 2024 identified orders to cleanse the left shin with normal saline solution, pad dry, cover with form dressing daily and as needed dated 03/01/24. Review of the Treatment Administration Record (TAR) for March and April 2024 revealed ordered wound care was not completed as ordered on 03/12/24, 03/13/24, 03/19/24, and 03/22/24. Interview on 04/04/24 at 3:56 P.M. the DON verified Resident #95 did not receive wound care on the dates noted. This deficiency represents non-compliance investigated under Complaint Number OH00152133 and Complaint Number OH00152075.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure Resident #62 received nutritional supplements as ordered, failed to develop and implement a comprehensive and effective nutrition program, and failed to obtain re-weights and/or weekly weights when a severe weight loss was noted. This affected one resident (#62) of three residents reviewed for nutrition. The facility census was 90. Actual harm occurred when Resident #62, who weighed 11.0 pounds on 01/04/24, experienced a severe 6.2% weight loss from 01/04/24 to 02/01/24, continued to lose an additional 8.4% from 02/01/24 to 03/01/24, and the weight loss was not addressed until 02/28/24. Resident #62 did not receive nutritional supplements as ordered. Resident #62's weight of 95.4 pounds on 03/01/24 reflected a severe weight loss of 14.5% over 56 days. Findings include: Review of the medical record for Resident #62 revealed an admission date of 07/10/23. Diagnoses included rheumatoid arthritis (RA), diabetes, lupus, emphysema, Bell's palsy, hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLD), schizophrenia, hypothyroidism, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had intact cognition. The assessment indicated the resident was 63 inches tall and weighed 111 pounds. Weight loss was marked as no or unknown. Review of the physician's orders for diet and nutritional supplements revealed: • Consistent Carbohydrate Diet, Mechanical Soft texture, thin consistency Diet was ordered on 07/13/23. • Super Cereal (high calorie, nutritious, and fortified cereal) in the morning with breakfast was ordered on 07/28/23. • Boost Glucose Control (supplement) every morning and at bedtime eight (8) ounces (oz) between meals from nursing was ordered 09/27/23 and discontinued on 02/28/24. • House Supplement with meals four (4) oz No Sugar Added Health Shake (supplement) three times a day with meals. Document percent consumed was ordered on 02/28/24. • Regular diet, Mechanical Soft texture, thin consistency was ordered 02/29/24. • Weekly weights for four weeks in the morning every Monday until 04/15/24 was ordered on 03/25/24. Review of weights revealed Resident #62 weighed 104.1 pounds on 02/05/24 (a 6% weight loss in one month). Review of the Medication Administration Record (MAR) for February 2024 for the Boost Glucose Control every morning and evening 8 oz between meals from nursing revealed morning intake was 0% (per staff, the 0% was when the resident did not receive the supplement) on 02/05/24, 02/06/24,02/ 07/24, 02/08/24, 02/09/24, 02/10/24, 02/11/24, 02/15/24, 02/16/24, 02/19/24, 02/20/24, 02/21/24, 02/22/24, 02/23/24, 02/24/24, 02/24/24, 02/25/24, and 02/26/24. Evening intake was 0% on 01/03/23, 02/04/24, 02/0524, 02/06/24, 02/07/24, 02/08/24, 02/09/24, 02/14/24, 02/15/24, 02/16/24, 02/18/24, 02/19/24, 02/20/24, 02/22/24, 02/24/24, and 02/25/24. Review of the nutrition note dated 02/28/24 at 1:40 P.M. authored by Registered Dietitian (RD) #282 revealed Resident #62 received a regular diet and liquids, mechanical soft meats, and protein. The resident had a pork intolerance. Meal intakes 50-100% consumption which is adequate, accepts fluids well. No skin issues or edema noted at this time per skin assessments. Recommended DC Boost Glucose Control due to corporate formulary update, recommending a four ounce No Sugar Added Health Shake three times daily with meals for 600 calories and 24 grams of protein daily; document percent consumed on the medication administration record (MAR). Continue Super Cereal as ordered. Will monitor upcoming March weight. The physician was notified of the significant weight loss. Review of weights revealed Resident #62 weighed 95.4 pounds on 03/01/24 (an additional 8% weight loss). Review of the medical record revealed no documented evidence a re-weight was obtained. Review of the medical record revealed no re-weight or weekly weight was documented after 03/01/24. Review of the nutritional care plan (initiated 07/13/23), last revised 03/21/24, revealed the resident was at risk for altered nutrition and dehydration related to multiple medical conditions including HTN, RA, lupus, emphysema, DM, HLD, schizophrenia, hypothyroidism, anxiety. The care plan reflected the resident had a pork intolerance and use of a mechanically altered diet. Therapeutic diet (supplement with meals). The resident's March (2024) weight indicated serious weight loss trend and underweight status. The resident was at risk for malnutrition related to serious weight loss and underweight status as evidenced by a body mass index (BMI) less than 18.5 and chronic disease. The interventions included supplements with meals three times a day, super cereal, and weekly weights. Review of the nutrition note dated 03/21/24 authored by RD #282 revealed Resident #62 received No Added Sugar Health Shakes three times daily with meals. Meal intake average 75-100% most meals per intake records. Dietary caters to food preferences and offers Super Cereal in the morning with breakfast. No chewing or swallowing difficulty reported. Weight history reviewed, noted September 2023 to January 2024 weights between 111 - 115 pounds. February weight was 104.1 pounds. Resident #62 remains at risk for altered nutrition and dehydration related to multiple medical conditions including hypertension, rheumatoid arthritis, lupus, emphysema, diabetes mellitus, hyperlipidemia, schizophrenia, hypothyroidism, anxiety, pork intolerance, mechanically altered diet, therapeutic diet (supplement with meals), significant weight loss and underweight status. Resident #62 is at risk for malnutrition related to significant weight loss as evidenced by body mass index less than 18.5, and chronic disease. Requests re-weight to confirm current body weight. Requests weekly weights times four weeks to monitor for trends. On 03/21/24 a request for diagnosis of at risk for malnutrition form was completed for Resident #62 based on the following criteria: Involuntary loss of 10% or more of usual body weight within six months, or involuntary loss of greater than or 5% or more of usual body weight in one month. BMI less than 18.5 (weight in kilograms divided by the square of height in meters (kg/m2) or greater than 25 kg/m2 and chronic disease. It was signed by the dietitian on 03/21/24 and approved by the physician on 03/21/24. Review of the medical record revealed no physician notes regarding nutrition or weight status in the medical record. Review of the MAR for March 2024 for the No Sugar Added House supplement revealed Resident #62 drank 100% or 0%. The 0% was when the resident did not receive the supplement. Breakfast was 0% on 03/03/24, 03/14/24, 03/15/24, 03/16/24, 03/20/24, 03/24/24, 03/27/24, 03/28/24, and 03/31/24. Lunch was 0% on 03/04/24, 03/14/24, 03/15/24, 03/17/24, 03/20/24, 03/24/24, 03/28/24, 03/29/24, and 03/31/24. Dinner was 0% on 03/02/24, 03/09/24, 03/11/24, 03/13/24, 03/14/24, 03/15/24, 03/20/24, 03/24/24, 03/27/24, 03/28/24, 03/29/24, and 03/31/24. Interview on 04/03/24 at 12:46 P.M. with Resident #62 revealed the resident stated she often didn't receive her sugar free supplement. She thought maybe the facility had been out of the sugar free ones. Observation on 04/03/24 at 12:12 P.M. and 12:46 P.M. of the lunch meal revealed Resident #62 did not have a supplement on her lunch tray. Interview on 04/03/24 at 1:16 P.M. with Dietary Manager, #285 revealed the facility had ginger ale per request. For supplements the facility carried Mighty Shakes, Sugar Free Mighty Shakes, boost pudding for medication administration, and Gelato magic cups. The Sugar Free Mighty Shakes had just come in and might have still been frozen. The Dietary Manager revealed the facility did not have a problem getting supplements. The dietary aide was responsible to place the supplements on the resident meal trays. Interview 04/03/24 at 1:40 PM. RD #282 revealed the RDs run a monthly report on weight loss. When they see weight loss, they try to figure out the cause. If the weight loss was unplanned, the RDs see if the resident was eating. The kitchen could offer extra portions, health shake mighty. The facility carried a protein supplement and a high protein pudding. Interview on 04/04/24 at 3:56 P.M. the Director of Nursing (DON) verified the above dates/meals a nutritional supplement was not received by Resident #62. Review of the MAR for April 2024 for the No Sugar Added House supplement revealed Resident #62 drank 100% or 0%. The 0% was when the resident did not receive the supplement. Breakfast was 0% on 04/15/24. Lunch was 0% on 04/17/24 and dinner was 0% on 04/13/17/24, 04/17/24, and 04/18/24. Interview on 04/19/24/ at 9:27 A.M. with the DON revealed weight loss was followed up on at the weekly risk management meetings. RD #282 sent an email at least weekly regarding resident's nutritional concerns. Interview on 04/19/24/ a 9:43 A.M. with Licensed Practical Nurse (LPN) /Unit Manager #247 revealed nursing did not notify the RD of weight loss. The RD reviewed weights and contacted the facility. The RD notified the physician of nutritional concerns. The unit manager and the nurses were responsible for making sure weekly weights were completed as ordered. LPN /Unit Manager #247 verified no weights were documented in the medical record for Resident #62 after 03/01/24. Interview on 04/19/24 at 10:58 A.M. with the DON verified no weights were documented in the medical record for Resident #62 after 03/01/24, and there had been no new orders due to the resident's weight loss. Interview on 04/19/24 at 11:12 A.M. with RD #282 revealed nursing did not notify the RD of residents with weight loss, the RD tracked it. The RD verified there was no nutrition note documented until 02/28/24 after the resident's weight loss documented 02/05/24, 23 days earlier. Weight loss residents were normally monitored weekly. The RD stated they might not write a note if there was no new information. RD #282 revealed Resident #62 was originally offered Boost, due to formulary changes made 02/28/24, the only option was to provide the house supplement. RD #282 did not usually recommend an appetite stimulant because she avoided adding additional medication. The physician or nurse practitioner sometimes ordered an appetite stimulant. RD #282 notified the physician of all resident nutritional concerns weekly on one form. Review of the Weight Assessment and Intervention policy, dated 03/2022, revealed residents were weighed upon admission and at intervals established by the interdisciplinary team. Weights were recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment was retaken the next day for confirmation. If the weight was verified, nursing would immediately notify the dietitian in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. This deficiency represents non-compliance investigated under Complaint Number OH00152036.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient tracheostomy care for Residents #19 and #29. This affected two residents (#19 and #29) of three residents reviewed for tracheostomy care. The facility census was 90. Actual harm occurred on [DATE] and on [DATE] when Resident #19, who was cognitively impaired and was dependent on staff for tracheostomy care, was admitted to the hospital with acute on chronic respiratory failure with hypoxia, recurrent infection, and need for mechanical ventilation. On [DATE] there was concern for mucus plugging prior to the hospital stay which contributed to the respiratory failure. From admission on [DATE] through [DATE], there was no evidence Resident #19 received routine ordered tracheostomy care including administering oxygen, continuous monitoring of oxygenation levels, suctioning, changing the cannula, and cleaning the tracheostomy site outside of when the respiratory therapist was in the facility. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of [DATE]. Diagnoses included diabetes mellitus type II, acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, tracheostomy status, encephalopathy, and chronic kidney disease stage four, severe. Resident #19 was discharged to the hospital on [DATE], re-entered the facility on [DATE], was discharged to the hospital on [DATE], re-entered the facility on [DATE], and was discharged to the hospital on [DATE]. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #19 was rarely or never understood. The plan of care dated [DATE] indicated a need for tracheostomy care. Interventions included oxygen as ordered, monitor oxygenation levels as ordered, and suction tracheostomy as ordered. Review of Resident #19's physician orders for tracheostomy care revealed effective from [DATE] to [DATE] to change trach circuit every week and as needed; continuous pulse oximeter monitoring; maintain oxygenation greater or equal to 92 percent; suction as needed to clear secretions; oxygen via humidified trach collar on FIO2 (fraction of inspired oxygen) 28 percent two liters per minute (LPM) continuous; speaking valve as tolerated and maintain oxygenation of 92 percent or greater; and trach tube #6 Shiley every 30 to 45 days per respiratory therapy (RT). Effective from [DATE] to [DATE] were orders to suction via trach as needed and may use saline if needed every two hours, and trach care every shift and as needed. Review of Resident #19's medication administration records (MARs) and treatment administration records (TARs) for [DATE] to [DATE] revealed tracheostomy care every shift and as needed was completed. There was no documented evidence the additional effective tracheostomy care orders were completed. Review of the progress notes from [DATE] to [DATE] revealed Resident #19 received varied tracheostomy care less than daily from a respiratory therapist during a scheduled shift in the facility. The care included tracheostomy care, changing of the cannula, suctioning, monitoring of oxygenation levels and respiratory assessment. The documented dates of completed tracheostomy type care were [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]. There was no documented evidence nursing provided routine ordered tracheostomy care on dates when a respiratory therapist was not working in the facility. On [DATE] at 8:55 P.M. the primary care physician (PCP) examined Resident #19 and indicated coarse lung sounds were present with upper airway secretions observed. On [DATE] at 3:22 P.M. the PCP examined Resident #19 and indicated rhonchi was present with a copious (abundant) amounts of secretions observed. On [DATE] Resident #19 had bloody sputum and was transferred to the hospital for evaluation and treatment. On [DATE], Resident #19 was sent to the hospital after pulse oxygenation decreased to 78 percent and heart rate was decreasing. Suctioning was performed until all secretions were cleared, but the heart rate still decreased. CPR (cardio-pulmonary resuscitation) was started until emergency services arrived. Resident #19's spouse reported to facility staff of Resident #19 being back on a ventilator. Resident #19 returned to the facility on [DATE]. On [DATE], the PCP examined Resident #19 and indicated rhonchi was present. Resident #19 was taken to the hospital for cardiac arrest, but it appeared it was respiratory failure and infection. On [DATE], Resident #19 had low oxygen saturation. Suctioning was performed and the inner cannula was changed but saturation kept decreasing. Staff bagged for ventilation until emergency services arrived. Review of hospital information from [DATE] to [DATE] revealed Resident #19 was previously admitted on [DATE] for tracheal bleeding and pneumonia with tracheal aspirate positive for multiple organisms which required antibiotic treatment. On [DATE], Resident #19 presented to the hospital post cardiac arrest with acute on chronic hypoxic respiratory failure. CPR was started at the facility and upon emergency services arrival had a heart rate in the 20s. Resident #19 was bagged and upon arrival to the hospital had a heart rate in the 80s and was placed on a ventilator. Resident #19 had decreased breath sounds, wheezing and rhonchi (coarse and loud sound in the larger airways). There was concern for mucus plugging prior to hospital arrival that caused the episode, and concern for pneumonia with sputum culture growing mixed bacteria. Antibiotic treatment was provided. Review of Resident #19's MAR and TAR for [DATE] revealed tracheostomy care every shift and as needed was completed. The suction via trach as needed and may use saline if needed every two hours effective from [DATE] to [DATE] was signed as completed on [DATE] at 10:29 A.M. and 3:00 P.M. There was no documented evidence the additional effective tracheostomy care orders were completed. Review of hospital information dated [DATE] revealed Resident #19 presented to the hospital with hypoxia and respiratory distress. After emergency services suctioned and bagged for ventilation, Resident #19 returned to normal oxygen saturation levels. Resident #19 was unable to respond to questions due to aphasia (difficulty with communication). Diagnoses was acute one chronic respiratory failure with hypoxia due to recurrent aspiration pneumonia, and sepsis. During an interview on [DATE] at 1:52 P.M. with Resident #19's family, the family voiced concerns Resident #19 did not receive adequate tracheostomy care which caused hospital stays and reported the hospital staff indicated Resident #19's trach was filthy. Interview on [DATE] at 9:31 A.M. with the Director of Nursing (DON) indicated Resident #19 was admitted to the hospital on [DATE] due to low pulse oxygenation and possible pneumonia. Interview on [DATE] at 12:22 P.M. with Respiratory Therapist (RT) #281 revealed a lack of routine or adequate suctioning could contribute to infection but was more likely to cause shortness of breath, difficulty breathing or desaturation (decreased oxygenation levels). Interview on [DATE] at 1:42 P.M. with the DON verified the above findings and indicated the respiratory care orders were in place but not visible to the nursing staff so there was no evidence the required care was provided as ordered or outside of when respiratory therapy was present in the facility. 2. Review of the medical record for Resident #29 revealed an admission date of [DATE] and re-entry date of [DATE]. Diagnoses included acute respiratory failure with hypoxia, metabolic encephalopathy, tracheostomy status, and dependence on respiratory ventilator status. Review of the quarterly MDS assessment dated [DATE] revealed Resident #29 had no cognitive impairment. The plan of care dated [DATE] indicated a need for tracheostomy care. Interventions included oxygen as ordered, monitor oxygenation levels as ordered, and suction tracheostomy as ordered. Review of the hospital information for facility re-entry on [DATE] indicated Resident #29 had a tracheostomy and collar without mechanical ventilation. Orders included continuous pulse oximetry, oxygen at ten liters per minute and suctioning. Review of Resident #29's active physician orders for tracheostomy care from [DATE] through [DATE] revealed to change trach circuit every week and as needed; change tracheostomy tube every 30 to 45 days and as needed; maintain oxygenation levels greater than 92 percent and respiratory rate less than 30 by continuous pulse oxygenation monitoring every shift; oxygen via humidified trach collar at FIO2 40 percent during daytime hours when respiratory therapy present; suction as needed; and trach care every shift. Review of Resident #29's MARs and TARs for [DATE] to [DATE] revealed no evidence of tracheostomy care orders completed after re-entry to facility on [DATE]. Review of the progress notes from [DATE] to [DATE] revealed Resident #29 received varied tracheostomy care less than daily from a respiratory therapist during a scheduled shift in the facility. The care included tracheostomy care, changing of the cannula, suctioning, monitoring of oxygenation levels and respiratory assessment. The documented dates of completed tracheostomy type care were [DATE] to [DATE], and [DATE] to [DATE]. There was no documented evidence nursing provided routine ordered tracheostomy care on dates when a respiratory therapist was not working in the facility. Interview on [DATE] at 2:03 P.M. with Resident #29 revealed the resident believed tracheostomy care was provided but was not sure if it was completed or how it was supposed to be. Resident #29 indicated calling staff if help with the tracheostomy was needed. Interview on [DATE] at 2:46 P.M. with RT #281 and Licensed Practical Nurse (LPN) #238 while reviewing the electronic medical records verified there were no visible tracheostomy care orders for Resident #29. LPN #238 stated a reliance on RT #281 to perform tracheostomy related care when in the facility, but there was not anything visible for the nurses to follow or sign as completed when RT #281 was not in the facility. RT #281 stated the tracheostomy care orders must not have been put back in place when Resident #29 re-entered the facility on [DATE]. Interview on [DATE] at 3:30 P.M. with the DON verified the above findings. This deficiency represents non-compliance investigated under Complaint Number OH00152226.