**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital document review, staff interview, policy review, and sit-to-stand lift instructions, the facility failed to ensure sufficient fall interventions were put into place to promote resident safety and prevent falls. This resulted in actual harm when Resident #1 fell on [DATE] and sustained a fracture to her right ankle and had a subsequent fall on 01/02/24 and sustained a head laceration which required two staples with no immediate interventions implemented. In addition, the facility failed to ensure transfer equipment was utilized in a safe manner for one (#8) resident. This affected two (#1 and #8) of four residents reviewed for accidents. The facility census was 52. Findings Include: 1. Review of Resident #1's medical record revealed an admission date of 05/03/18. Diagnoses included dementia, emphysema, cerebral infarction, hemiplegia and hemiparesis, seizures, anxiety disorder, major depressive disorder, insomnia, and spinal stenosis. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 indicating Resident #1 was moderately cognitively impaired. Resident #1 required limited assistance of one person for transfers and toilet use. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10 indicating Resident #1 continued to be moderately cognitively impaired. Resident #1 required set up only with one person assistance for toilet use. Resident #1 required extensive assistance with transfer. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10 indicating Resident #1 continued to be moderately cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, eating, and toilet use. Resident #1 displayed no behaviors during the review period. Resident #1 was on hospice at the time of the review and used a wheelchair for mobility. Review of Resident #1's care plan revised 01/24/24 revealed supports and interventions for impaired cognitive function, fall with injury including an ankle fracture on 01/02/24, hospice services for terminal diagnosis of cerebral disease, used antipsychotic medications with risk for adverse reactions, chronic pain, seizure disorder, self-care deficit, and risk for falls. Fall interventions included to anticipate Resident #1's needs, ensure the call light was in reach, provide a safe environment including the bed in low position and personal items in reach, encourage to participate in activities, and ensure the resident wore appropriate footwear. Review of Resident #1's progress notes and fall investigation reports revealed on Saturday, 12/30/23 at 7:27 P.M., it was documented Resident #1 was lowered to the ground by a nurse aide while using the bathroom. Resident #1 had asked for help to the bathroom, and the nurse aide was helping Resident #1 to stand when the resident's legs were shaky, and she could not support herself. The nurse aide lowered Resident #1 to the ground. Resident #1 was assessed with no skin abnormalities were found. Resident #1 reported no pain. Resident #1's physician, family, and management were notified. Further review of the progress notes and fall investigation revealed on Saturday, 12/30/23 at 8:30 P.M., it was noted Resident #1 had an unwitnessed fall in her room. The resident was found lying on her back on the floor in front of her recliner. Resident #1 was unable to bear weight and fell during an unsupervised transfer. Resident #1 denied pain at the time. Resident #1 was assessed with no injuries were found. Neurological checks were initiated. Resident #1 was assisted off the floor, assisted to the toilet, and returned to the recliner. Resident #1 was educated on using the call light for assistance. A fall assessment was completed, and Resident #1 was determined to be a high risk for falls with a score of 12. Review of the previous fall risk assessment from 03/05/23 revealed the resident was assessed at low risk for falls. The interdisciplinary team (IDT) reviewed the fall and it was determined Resident #1 was ambulating on her own and did not ask for assistance. No injuries were found at the time. The new intervention was to refer Resident #1 to occupational therapy (OT) for a toileting program. A moderately cognitively impaired resident was educated on using the call light and no additional immediate interventions were added though Resident #1 had been identified as needing to use the bathroom for both instances. Review of Resident #1's entire medical record revealed the intervention of OT for a toileting program was never initiated for the resident. Review of progress notes and fall investigation revealed on Monday, 01/01/24, it was noted Resident #1 was found on the floor in her room at 7:28 A.M. by a nurse aide. The fall was not witnessed. Resident #1 was assessed, and an injury was noted on assessment. Notifications were made to Resident's family and physician. Resident #1 was noted to be confused at the time and had a strong odor to her urine. Resident #1 complained of right hip pain, her right foot was observed to be swollen and she had redness to the ankle. In addition, the middle of the right side of her back also had redness and Resident #1 also had a bump to the right side of her head. It was documented Resident #1 was confused, lethargic, had a bruise, and reported pain. Emergency medical service (EMS) was called at 7:33 A.M. and Resident #1 was transferred to the hospital. The IDT team discussed Resident #1's fall from 01/01/24 and it was determined the root cause of the fall was Resident #1 attempted to ambulate on her own, and she lost her balance and had a fall. Notifications were made and Resident #1 was sent to the emergency room (ER) for evaluation. Resident #1 returned from the hospital and Resident #1 was diagnosed with a fracture to the right ankle. Resident #1 was provided a soft cast and was to follow up with orthopedic as soon as possible to have a hard cast put on. Resident #1 was to elevate her right lower leg and be non-weight bearing. Resident #1 was also diagnosed with a urinary tract infection (UTI) and had a new order for the antibiotic Keflex 500 milligrams (mg) three times a day for ten days. Resident #1 received her first dose at the hospital. The noted intervention was sending her to the ER. A fall risk assessment was completed, and Resident #1 was assessed to be at moderate risk for falls with a score of 9. The noted intervention was to send Resident #1 to the ER for evaluation and treatment. In addition, the intervention was to continue Resident #1 on the prescribed the antibiotic. There were no interventions implemented for increased supervision or additional interventions to reduce Resident #1's risk for falls. Review of Resident #1's hospital Discharge summary dated [DATE] revealed Resident #1 was seen following a fall for hip pain and altered mental status. Resident #1 was diagnosed with a closed fracture of her right ankle and a urinary tract infection. A new order for Keflex 500 mg one capsule three times a day for 10 days was ordered. The resident's last dosage was at 12:54 P.M. at the hospital. Resident #1 was also provided an occlusal splint (plaster splint roll) for her right ankle. Review of progress notes and fall investigation revealed on 01/02/24, Resident #1 had another unwitnessed fall in her room. Resident #1 was found on her right side up against her bed. Resident #1 was assessed with an injury was noted. Resident #1 was on the floor on her right side with bleeding noted from the back of her head on the right side. Pressure was applied to Resident #1's head to stop the bleeding, and EMS was called. Resident #1's physician and family were notified. Resident #1 could not explain what happened. Resident #1 was sent to the hospital for evaluation and treatment. Resident #1 was noted in her bed prior to the fall and was alert but not completely orientated at the time of the fall. There were no witnesses to the fall. A fall risk assessment was completed, and Resident #1 was found to be at high risk for falls with a score of 16. The IDT met and discussed Resident #1 falls. It was determined the root cause of the fall was due to Resident #1's cognitive decline related to a UTI and weakness. Resident #1 was attempting to get up on her own and lost her balance. The interventions put in place were to send Resident #1 to the emergency room to be evaluate, refer to physical therapy (PT) for strengthening, place the bed in the lowest position when she was in it along with a fall mat next to the bed. On 01/04/24, Resident #1 returned from the hospital and was noted to have had a scalp laceration which required two staples. Review of Resident #1's hospital Discharge summary dated [DATE] revealed Resident #1 was admitted to the hospital on [DATE]. Resident #1 was admitted with recurrent falls with mild delirium secondary to a UTI and neurological disorder along with a laceration in the back of the head and scalp which required staples. Resident #1 reported she was trying to transfer from her bed into her wheelchair when she fell and hit her head. At the time of Resident #1's discharge from the hospital on [DATE] to return to the nursing home with recommendations for physical therapy. Resident #1 was determined to be a high fall risk and had the barrier to learning of dementia. Resident #1 was orientated to person only. Review of Resident #1's medical record and nurse aide tasks revealed no documentation of two-hour checks completed for toileting, and documentation of two-hour checks for repositioning was not consistent during the review period. Interview on 01/29/24 with Resident #1 found her alert and able to answer basic questions. Resident #1 was not aware she had any falls. Interview on 01/30/24 at 8:31 A.M. with State Tested Nurse Aide (STNA) #471 reported Resident #1 was able to make her basic needs known and required extensive assistance with transfer and toilet use. STNA #471 reported Resident #1 knew when she needed to use the bathroom but was not safe in transferring herself. STNA #471 stated the staff made sure Resident #1 had her call light in reach at all times, but she did not always use it. STNA #471 verified Resident #1 had had a couple falls that resulted in injuries. STNA #471 reported Resident #1 had no other falls since she fell and had to have staples in her head from falling and hitting her head on the bed. STNA #471 reported Resident #1 was declining since the end of December 2023 and was now on hospice. STNA #471 was not sure of the exact day Resident #1 began on hospice, but it was earlier in the month shortly after the resident returned from her hospital stay following her fall. Interview on 02/01/24 at 1:49 P.M. with the Director of Nursing (DON) revealed she was familiar with Resident #1 and her falls. The DON reported in March 2023, Resident #1 was evaluated and determined to be low risk for falls. On 12/30/23, Resident #1 was found on the floor in front of her recliner when the resident attempted to transfer herself. Resident #1 was assessed, and no injury was found. Neurological checks were initiated, and notifications were made. The DON verified the only intervention implemented at the time was education with Resident #1 to use her call light. The DON reported Resident #1 then had another fall on 01/01/24 at 7:28 A.M. when the resident was found by a nurse aide on the floor of her room. Resident #1 was confused, complained of pain, and her right foot was swollen and red. Resident #1 also had a bump on the back of her head. EMS was called and Resident #1 was sent to the hospital. Notifications were made and Resident #1 returned to the facility with a soft cast to her right ankle for a closed fracture, and an order for follow up for a hard cast and an antibiotic for a UTI. The DON reported the interventions put into place included to send Resident #1 to the ER, and when the resident returned to complete the antibiotic for the UTI and refer Resident #1 to OT for a toileting program. The DON verified they were not able to implement the referral to OT prior to Resident #1's fall on 01/02/24 and verified no other fall interventions were implemented. The DON stated on 01/02/24 Resident #1 had another unwitnessed fall in her room when she was found on her right side up against her bed. Resident #1 had a laceration to her head and was complaining of right-sided hip pain. Notifications were made to Resident #1's son and physician and Resident #1 was sent out to the hospital. The DON stated when the resident returned to the facility, she had staples in place to the laceration and they updated her interventions to include having her bed in the lowest position and a fall mat next to her low bed. The DON reported Resident #1 had no subsequent falls and completed the ordered antibiotic on 01/10/24. A follow up interview on 02/01/24 at 4:10 P.M. with the DON and Assistant Director of Nursing (ADON) reiterated the interventions implemented for Resident #1 following her falls. They verified Resident #1 had been on two-hour checks with toileting assistance provided prior to her falls and there had been no increases or changes to the checks or toileting assistance following the falls. Review of the facility policy titled, Falls and Fall Risk, Managing, revised March 2018, revealed based on previous evaluations and current data the staff would identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try and minimize complications from falling. Review of the facility policy titled, Fall Prevention Program, revised 10/20/22, revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized risk to minimize the likelihood of falls. 2. Review of the medical record revealed Resident #8 admitted to the facility on [DATE] with the diagnoses including, generalized osteoarthritis, cerebral infarction, sprain ligaments lumbar spine, wedge compression fracture lumbar vertebra, collapsed vertebra thoracic region, low back pain, displaced fracture of left femur, and osteoporosis. Review of the MDS assessment dated [DATE] assessed Resident #8 with intact cognition, and revealed the resident utilized a wheelchair for mobility propelled by staff and was dependent on staff for activities of daily living (ADL) including sit to stand and chair to bed transfer. On 05/04/23, a nursing plan of care was implemented addressing Resident #8's ADLs deficit related to limited mobility and joint pain due to history of cerebral vascular accident and diagnoses of arthritis and osteoporosis. Further review revealed an updated intervention for staff to utilize a mechanical lift (Hoyer) lift with two staff assistance for transfers. Observation on 01/30/24 at 6:13 A.M. revealed STNA #461 with Resident #8 suspended in a stand-up lift. The resident was unable to stand up right and was slumping to the right while resting on the sling. STNA #461 proceeded to propel Resident #8 in the lift approximately 60 feet down the common hall to the shower room. At 6:20 A.M., an interview with STNA #461 revealed Resident #8 required two staff to assist with transfers and uses a mechanical (Hoyer) lift. STNA #461 confirmed Resident #8 was not safely placed in the stand-up lift and the stand-up lift was not to be used for transporting residents outside their rooms. On 01/30/24 at 6:43 A.M., an interview with the DON verified the stand-up lift was not to be utilized for transferring distances. The DON verified Resident #8 was unable to bear weight and required the use of a Hoyer lift with two staff present for transfers. Review of the Using a Mechanical Lifting Machine policy, revised July 2017, noted at least two nursing assistants are needed to safely move a resident with a mechanical lift. Review of the Sit and Stand Lift ([NAME] Flex) instructions for use, dated 2022, revealed the resident must be able to bear weight on at least one leg and have some trunk stability, be able to sit on the edge of the bed to meet criteria for use. Alternative equipment or system shall be used if criteria is not meet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident, family, and staff interview, pharmacy interview, review of pharmacy delivery manifest, review of facility policy, and review of hospital neurology notes, the facility failed to ensure Resident #01 was free of significant medication errors when Resident #01 had not received physician ordered anti-anxiety medication (Klonopin) for three days. Actual Harm occurred to Resident #01 when the facility failed to ensure medications were available for administration resulting in the resident experiencing a seizure attributed to medication withdrawal requiring hospitalization with additional testing, monitoring, and restarting of the ordered medication as a result of the medication error. This affected one (Resident #01) of three residents reviewed for medications. The facility census was 54. Findings include: Review of Resident #01's medical record revealed an admission date of 01/23/21 and a re-admission date of 02/02/21. Diagnoses included major depressive disorder, dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact and received anti-anxiety medications seven of the seven days of the look-back period. Review of the plan of care, initiated 05/25/23, revealed Resident #01 used anti-anxiety medications. Interventions included to administer anti-anxiety medications as ordered by physician. Review of the physician orders revealed Resident #01 was prescribed Klonopin oral tablet 0.5 milligrams (mg) two times daily for anxiety. Review of the Medication Administration Record (MAR) from 09/01/23 through 09/30/23 revealed Klonopin 0.5 mg was documented as 9 on 09/08/23 evening dose, 09/09/23 morning dose, 09/10/23 evening dose, and 09/11/23 morning dose. Further review of the MAR revealed 9 indicated to see nurses notes. Review of the nursing progress notes revealed on 09/08/23, Klonopin was on order; on 09/09/23 the facility was waiting on delivery; on 09/10/23 awaiting supply; and 09/11/23, Klonopin was not available and waiting on pharmacy. Further review of the medical record from 09/08/23 through 09/11/23 revealed no evidence of communication with the physician or pharmacy regarding Klonopin being unavailable for administration to Resident #01. Review of the nursing progress note dated 09/11/23 at 4:20 P.M. revealed Resident #01 was with her daughter in her room and the daughter stated she was shaking a little like she does and then all of a sudden her head went back and started shaking harder and foaming at the mouth. Daughter yelled for help and aide found writer. Resident #01 was in a safe position and was watched until it was over. Emergency 9-1-1 service was called and Resident #01 was transported to the hospital. Review of a hospital neurology progress note, dated 09/12/23, revealed Resident #01 presented to the Emergency Department (ED) for complaints of seizure of two minutes, witnessed by family who described resident's eyes rolling back, followed by jerking, non-responsive, foaming at the mouth, while seated. Resident #01 had some facial twitching, jerking hand movements, stuttering, small seizure examined by bedside nurse that lasted five to ten seconds, and a incontinent episode. Resident #01 was brought to the hospital because of an apparent witnessed seizure. The description was of generalized convulsive activity lasting several minutes and she was confused afterwards. She had a normal Computed Tomography Scan (CT) of the brain. Per the history, she had been on Klonopin and was apparently off of this for three days. The impression was Resident #01 had a new onset seizure and given the available history, this was likely benzodiazepine (Klonopin is in this medication class) withdrawal. Anticonvulsant therapy was deferred and recommended the resident follow-up in the physician's office post-discharge. Review of a Pharmacy Delivery Manifest (PDM) revealed on 08/07/23, there were 60 - 0.5 mg clonazepam (Klonopin) tablets delivered to the facility for Resident #01. On 09/12/23, the next order of clonazepam was delivered to the facility for Resident #01. Interview on 10/11/23 at 8:15 A.M. with Resident #01 revealed she had a seizure and was in the hospital. Resident #01 stated Evidently for three days I could not get my pills and I had a seizure. That was kind of scary. Resident #01 stated she had no recollection of the seizure and had no prior history of seizures. Resident #01 confirmed she was currently receiving her medications as ordered and had no further concerns. Interview on 10/11/12 at 8:47 A.M. with Resident #01's family member revealed the facility did not have the resident's Klonopin for three days. The family member was visiting when Resident #01 had a seizure at the facility and was taken to the ED. The family member stated Resident #01 had no prior history of seizures and the hospital said the seizure was due to Klonopin withdrawal. Interview on 10/11/23 at 10:47 A.M. with the Director of Nursing (DON) verified the facility did not have Klonopin available for administration to Resident #01 from the evening dose on 09/08/23 through the morning dose on 09/11/23, for a total of six missed doses. Additionally, Resident #01 had a seizure the afternoon of 09/11/23 and was transferred to the hospital. The DON stated she investigated the incident and learned the resident's Klonopin was not delivered by the pharmacy as a new controlled substance form was needed by the pharmacy. Nursing staff had e-mailed the document to the physician on Friday, 09/08/23, but failed to follow-up with the physician to ensure he received, signed, and returned the document. Over the weekend, including 09/09/23 and 09/10/23, none of the nursing staff who worked with Resident #01 contacted the physician or the pharmacy regarding the medication. The DON confirmed Klonopin was in the facility's contingency medication box (c-box), however, since it was a controlled substance, nursing would have needed to call the pharmacy to be given an authorization code in order to pull the medication. The DON verified nursing staff did not contact the pharmacy to get authorization to pull the medication for administration to the resident. On Monday, 09/11/23, the physician was contacted and the controlled substance form was signed and returned to the pharmacy in order for the medication to be delivered to the facility. The DON verified Resident #01 had seizure-like activity that afternoon, was sent to the ED, and the treating neurologist at the hospital believed the seizure was likely the result of benzodiazepine withdrawal. The DON stated every licensed nurse who worked with Resident #01 from 09/08/23 through 09/11/23 was disciplined and all licensed nursing staff were re-educated on the process for ordering medications, follow-up with the physician and pharmacy, and accurate and complete documentation related to medication administration. Telephone interview on 10/11/23 at 12:39 P.M. with Quality Assurance Pharmacist (QAP) #200 confirmed the pharmacy had filled Resident #01's Klonopin order on 08/07/23 and stated it made sense the facility did not have any medication to administer to the resident from 09/08/23 through 09/11/23. QAP #200 stated the pharmacy did not have a valid controlled substance form for Resident #01 and a new one was needed before any additional medication could be delivered. QAP #200 verified the facility was responsible for obtaining the controlled substance form. QAP #200 verified the facility had Klonopin in their c-box and, had the facility contacted the pharmacy indicating a need for the medication, the pharmacy would have paged the physician to obtain a verbal order and provided an authorization code for the facility to pull the medication for Resident #01. QAP #200 confirmed there was no record anyone from the facility had contacted the pharmacy regarding Resident #01's Klonopin from 09/08/23 through 09/11/23. Interview on 10/11/23 at 1:50 P.M. with the Administrator verified Resident #01 did not have Klonopin available for administration from 09/08/23 through 09/11/23. The Administrator stated when administration learned of the medication error on 09/11/23, a plan of correction was developed and implemented to prevent any further significant medication errors. Review of the facility policy titled Administering Medications, revised April 2019, revealed medications are administered in accordance with prescriber orders. The deficient practice was corrected on 09/30/23 when the facility implemented the following corrective actions: • On 09/11/23, the DON followed-up with the physician and received the controlled substance form in order to obtain Resident #01's medication. • On 09/11/23, Resident #01 was transferred to the ED for assessment following a seizure. Resident #01 was restarted on her medication. • On 09/12/23, the DON completed an audit of all residents on benzodiazepine medications and found no other concerns related to medications being available or administered per physician orders. • On 09/12/23, the pharmacy delivered Resident #01's medication to the facility. • From 09/13/23 through 09/21/23, the DON met with each of the four licensed nursing staff (Licensed Practical Nurses (LPN) #100, #105, #110, and #115) who were responsible for medication administration during the time Resident #01 did not receive her medication and provided re-education and disciplinary action related to the medication not being available, administered, and lack of follow-up with the physician and/or pharmacy. • From 09/13/23 through 09/30/23, the DON re-educated all licensed nursing staff on re-ordering medications, medication administration, follow-up with the physician and/or pharmacy, and complete and accurate documentation. • On 09/13/23, the Administrator provided education to the Medical Director on the process of ordering medications, signing controlled substance forms timely, and being in compliance with timely ordering of medications. • On 09/13/23, Assistant Director of Nursing (ADON) #150 audited all residents to ensure all ordered medications were available for administration, were administered as ordered, and accurately documented in the medical record. Additional audits conducted on 09/19/23, 10/02/23, and 10/10/23 revealed no additional concerns related to medications administration and documentation. Audits will continue for a total of six weeks and any additional concerns will be presented to the Quality Assurance and Performance Improvement (QAPI) team members. • On 09/28/23, an ad hoc QAPI meeting was held to review the audits that had been completed to ensure medications were administered correctly and free of error. This deficiency represents non-compliance investigated under Complaint Number OH00146724.