**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview, and review of medication information from Medscape, the facility failed to administer seizure medications for a resident who was admitted to the facility from the hospital with a new onset of seizure disorder resulting in significant medication errors. This affected one (Resident #30) of three residents reviewed for medication administration. The facility census was 29. Findings include: Review of the medical record of Resident #30 revealed an admission date of 09/12/24, a transfer to the hospital on [DATE] and then discharged home on [DATE], with a return to the facility on [DATE] after retruning to the hosptial on 09/29/2024. Diagnoses included unspecified convulsions, Parkinson's disease with dyskinesia without mention of fluctuations, repeated falls, wedge compression fracture of T5-T6 vertebra (on admission), and type II diabetes mellitus. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #30 was cognitively intact and required supervision assistance for toileting, bathing, and dressing. Review of the progress note dated 09/25/24 at 8:21 A.M. LPN #100 documented Resident #30 was nonresponsive and shaking all over with seizure-like activity. Resident #30 was sent to the emergency room. Further review of the medical record revealed Resident #30 returned to the facility from the hospital on [DATE] at approximately 4:15 P.M. with a new diagnosis of new onset seizures. Review of the hospital discharge paperwork dated 10/10/24 revealed new orders for Keppra (anticonvulsant medication) 1000 milligrams by mouth twice daily for convulsions and Vimpat (anticonvulsant medication) 100 mg by mouth twice daily for convulsions. Review of the document titled, Electronically Transmitted Prescription, dated 10/10/24 at 8:19 P.M. revealed the pharmacy was advised of the admission medications for Resident #30. The form did not indicate if the medications were ordered as stat. Review of the Medication Administration Record (MAR) revealed the Keppra and Vimpat were not administered on 10/10/24. Further review of the medical record revealed no documentation the physician was notified Keppra and Vimpat were not administered. Review of the progress note dated 10/10/24 at 11:23 P.M. documented by Licensed Practical Nurse (LPN) #106, revealed Resident #30 was alert and oriented to person, place, time, and event, pleasant and cooperative. Her speech was clear. Focal seizure-like activity had been noted during supper lasting 10 minutes. Seizure precautions were in place and Resident #30 had been able to answer questions during the active episode. Blood pressure, heart rate, and respiratory rate were within normal limits. Resident #30 remained continent of bowel and bladder with minimal intermittent urinary incontinence. The documentation is absent of any family or physician notification. Review of the progress note dated 10/11/24 at 9:01 A.M. documented by Registered Nurse (RN) #128, revealed the nurse was alerted to Resident #30's room by son-in-law. Upon entry to the room, RN #128 noted Resident #30 lying in bed, her body was shaking, her eyes were fixed open and pupils dilated. Resident #30 was not responsive to verbal or tactile stimuli. Resident #30's respirations varied but the partial oxygen saturation remained between 89 to 97% (percent) on room air. The episode occurred for an extended period with the convulsions slowly subsiding. The Director of Nursing (DON) arrived at the room and the son-in-law refused to have Resident #30 transported to the emergency room stating ,what good would it do? She will end back up in a larger hospital and she does not want to be there. The DON notified the physician of the interaction. Review of the progress note at 9:45 A.M., documented by RN #166, revealed a late entry: received orders from Nurse Practitioner to administer two mg of Ativan twice to help control the seizures and a one time dose to administer Keppra 1000 mg liquid orally. A progress note, on 10/11/24 at 4:21 P.M. documented by RN #128 revealed an order to begin Diastat (anticonvulsant) rectally as needed. Review of the MAR revealed Levetiracetam (Keppra) 100 mg per milliliters (ml), 10 ml was administered 10/11/24 at 9:34 A.M. Review of the pharmacy, Delivery Sheet, dated 10/11/24 and time stamped 12:22 P.M. revealed six tablets of Keppra 1000 mg was delivered, along with 11 other medications for Resident #30. Interview on 10/22/24 at 8:40 A.M. with the Director of Nursing (DON) revealed Resident #30 arrived at the facility on 10/10/24 at a little after 4:00 P.M. without the transferring hospital having given any report. The facility did not have some of her medications. Interview on 10/22/24 at 3:00 P.M. with Pharmacist #500 revealed medications were delivered on 10/11/24 between 1:00 P.M. and 1:30 P.M. which included Keppra 1000 mg six tablets, among others. Interview on 10/31/24 at 9:34 A.M. with LPN #101 revealed she had been on duty when Resident #30 arrived back to the facility from the hospital on [DATE]. LPN #101 stated she had put the medication orders into the computer. She stated she normally will also print out a copy of the orders and fax them to the pharmacy but could not be certain she had done that. The facility does not keep a record of fax transactions. Telephone interview on 10/31/24 at 9:39 A.M. with Certified Nurse Practitioner (CNP) #500 revealed she had not been contacted related to the unavailability of the Keppra and Vimpat. CNP #500 stated if she would have been notified, she would have called the pharmacy herself or called a local pharmacy to have an emergency supply drop shipped and also given an order for an as needed medication the facility does have in the emergency box. She further reported having been called on 10/11/24 of the active seizure occurring and had given the Ativan order and added the Diastat order. CNP #500 stated she had attempted to have Resident #30 returned to the hospital numerous times and the family refused. Interview on 10/31/24 at 10:30 A.M. with the DON revealed the Keppra liquid was borrowed from another resident. Telephone interview on 10/31/24 at 11:02 A.M. with RN #128 revealed she guessed Resident #30's seizure began on 10/11/24 a little after 8:00 A.M. RN #128 stated she remained with Resident #30 for the duration and had sent a State Tested Nursing Assistant (STNA) to get another nurse. RN #128 stated the DON came and assisted and got the order for the Ativan. Interview on 10/31/24 at 11:54 A.M. with the DON revealed there was no documentation in the medical record indicating the physician was made aware of Keppra and Vimpat not being available for Resident #30. The DON further verified the medications were not administered timely. Review of medication information from Medscape at https://reference.medscape.com/drug/keppra-spritam-levetiracetam-343013#91 revealed Vimpat and Keppra are used for seizure disorder. Further review revealed, Do not stop taking this medication without consulting your doctor. Your seizures may become worse when the drug is suddenly stopped. This deficiency represents non-compliance investigated under Complaint Number OH00159061.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a dependent resident received timely personal hygiene care. This affected one resident (#11) out of two residents reviewed for activities of daily living (ADL). The facility identified all 24 residents required assistance from staff with bathing and dressing. The facility census was 24. Findings include: Review of the medical record for Resident #11 revealed an admission date of 01/31/20. Diagnoses included Alzheimer's disease, restlessness and agitation, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition and required extensive assistance of one person for personal hygiene. Review of the current care plan for Resident #11 revealed an ADL self-care deficit related to chronic pain, osteoarthritis, Alzheimer's, dementia, and need for limited assistance in ADL function. Interventions included extensive assistance of one person for personal hygiene. Review of the bathing schedule revealed Resident #11 received a shower on 01/16/23. Observations on 01/17/23 at 9:45 A.M. revealed Resident #11 was dressed and sitting on her bed playing cards. Resident #11 had several long, white hairs coming from her chin. Subsequent observation on 01/18/23 at 8:54 A.M. revealed Resident #11 sitting in her recliner and playing cards. Resident #11 remained with several long, white hairs coming from her chin. Observation and interview on 01/19/23 at 8:08 A.M. with the Director of Nursing (DON) revealed Resident #11 was in her room and Resident #11 had long white hairs coming from her chin. The DON verified the hairs were present and visible. The DON said the State Tested Nurse Aides (STNAs) were expected to provide shaving for residents. Interview on 01/19/23 at 8:12 A.M., with STNA #342 verified she had shaved Resident #11 in the past and Resident #11 had not resisted care. Interview on 01/19/23 at 10:44 A.M., with STNA #358 verified Resident #11 had some hairs coming from her chin which were long enough to shave. Review of the facility policy titled Activities of Daily Living AM/PM Care, undated revealed residents were assisted at appropriate level for mouth care, hair care, and shaving, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected one (#21) of one resident reviewed for hospitalizations. The facility census was 22. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, congestive heart failure, stage three chronic kidney disease, atrial fibrillation, urinary tract infection, alkalosis, overactive bladder, hypothyroidism, history of venous thrombosis and embolism, gastroesophageal reflux disease, chronic pain, headache, muscle weakness, difficulty walking, cataract, major depressive disorder, morbid obesity, fracture of left toes, nonspecific abnormal finding of lung field, low back pain, anemia and constipation. Review of the medical record for Resident #21 revealed the resident was transferred to the hospital by ambulance on 07/15/19 at 12:14 P.M. Resiident #21 returned to the facility on [DATE] at 4:32 P.M. Additional review of Resident #21's medical record revealed the resident was also transferred to the hospital by ambulance on 07/23/19 at 2:37 P.M. Resident #21 had not returned to the facility as of 08/20/19. The medical record had no evidence of the written notifications being provided to the resident and/or resident representative at the 07/15/19 or 07/23/19 discharge. Interview on 08/20/19 at 2:27 P.M. with Social Services Manager (SSM) #100 confirmed Resident #21's medical record had no documented written notifications being provided to the resident and/or resident representative. Review of a facility policy titled Transfer and Discharge, dated 11/2017, revealed notice will be provided to the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing in a language and manner they understand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interview, the facility failed to issue written notice of the bed hold policy to a resident's representative. This affected one (#21) of one resident reviewed for hospitalizations. The total facility census was 22. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, congestive heart failure, stage three chronic kidney disease, atrial fibrillation, urinary tract infection, alkalosis, overactive bladder, hypothyroidism, history of venous thrombosis and embolism, gastroesophageal reflux disease, chronic pain, headache, muscle weakness, difficulty walking, cataract, major depressive disorder, morbid obesity, fracture of left toes, nonspecific abnormal finding of lung field, low back pain, anemia and constipation. Review of the medical record for Resident #21 revealed the resident was transferred to the hospital by ambulance on 07/15/19 at 12:14 P.M. Additional review of Resident #21's medical record revealed the resident was also transferred to the hospital by ambulance on 07/23/19 at 2:37 P.M. The medical record had no evidence of the resident representative being notified of the bed hold policy or bed hold days for the 07/15/19 and 07/23/19 transfers. Interview with Social Services Manager (SSM) #100 on 08/20/19 on 2:27 P.M. confirmed the facility did not issue a written notice of the bed hold policy to the resident or representative related to the resident's discharges to the hospital on [DATE] and 07/23/19. SSM #100 confirmed the facility was only providing the bed hold policy upon initial admission to the facility.