**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to notify Resident #12's physician that he had an active infection and was currently being isolated before sending him to an appointment at the physician's office. This affected one resident (#12) of three residents reviewed for infection control. The facility census was 23. Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/19/24. Diagnoses included congestive heart failure, type two diabetes mellitus, and diarrhea unspecified. Review of the hospital information sent to the facility on admission, printed on 03/19/24 revealed Resident #12 had a positive stool for clostridioides difficile (c-diff) on 03/14/24. Resident #12 was started on oral vancomycin 250 milligrams (mg) (antibiotic) four times daily on 03/19/24. Review of the physician's order dated 03/20/24 and discontinued on 04/02/24 revealed Resident #12 was to remain in contact isolation for c-diff. Review of the physician's order dated 03/20/24 and ended on 04/02/24 revealed an order to administer vancomycin 250 mg by mouth to Resident #12 four times a day for c-diff. Review of the care plan for Resident #12 dated 03/20/24 revealed he had an infection. Interventions included to administer medications as ordered and to provide perineal care after each incontinent episode. Review of the transfer for Resident #12 dated 03/21/24 revealed he was leaving for an appointment at a physician's office. No diagnoses were listed on the form, just emergency contact information. At the bottom of the form where the physician writes a response, the physician left a note questioning the facility for sending a patient to his office with an active c-diff diagnosis. The form was signed by the physician. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Resident #12 required some help of another person for self-care and was independent for ambulation with or without a device. Resident #12 was occasionally incontinent of urine and bowel. He had also received an antibiotic in the past seven days. Interview on 04/12/24 at 10:00 A.M. with the Director of Nursing (DON) confirmed Resident #12 was admitted to the facility late on 03/19/24. He had been diagnosed with c-diff in the hospital and began vancomycin treatment on 03/17/24. The DON confirmed Resident #12 was in contact isolation from the time of admission until the order was discontinued on 04/02/24. She reported Resident #12 did go to an outside physician's appointment on 03/21/24 but at the time Resident #12 was not having any loose stools and had no fever. She confirmed the facility sent Resident #12 but did not notify the physician of the diagnosis or his current condition prior to sending him to the appointment. Review of the undated facility policy titled isolation of a resident with infectious disease revealed residents are transported as follows, appropriate barriers such as masks and impervious dressing are used to prevent transmission of organisms when isolated residents leave their rooms, the facility is to notify personnel in the area to which the resident is to be taken if precautions are to be used, and if the transport vehicle is contaminated with infectious material, do not remove the vehicle from the room until disinfected by environmental services. This deficiency represents non-compliance investigated under Complaint Number OH00152318.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure Resident #7's discharge assessment was submitted within 14 days after completion. This affected one resident (#7) of one resident reviewed for assessments. The facility census was 17. Findings include: Review of the medical record for Resident #7 revealed an admission date of 12/06/22 and a discharge date of 12/27/22. Medical diagnoses included diverticulitis (the inflammation or infection of small pouches) of large intestine, influenza, osteoarthritis of the right knee, moderate protein-calorie malnutrition, obsessive compulsive disorder, anxiety, gastro-esophageal reflux disease (stomach acid repeatedly flows back up into the esophagus), and hypercholesterolemia (high cholesterol levels in the blood). The Discharge Return Not Anticipated Minimum Data Set (MDS) assessment was completed with an assessment reference date of 12/27/22. Review of the facility batch status report dated 05/23/23 revealed Resident #7's Discharge Return Not Anticipated MDS assessment dated [DATE] was submitted and accepted on 05/23/23. Interview on 05/23/23 at 9:02 A.M. with Registered Nurse #504 verified Resident #7's Discharge Return Not Anticipated MDS assessment dated [DATE] was not submitted until 05/23/23, which was not within the required timeframe. Review of the facility policy titled Minimum Data Set , dated May 2015, revealed the MDS coordinator would transmit all completed assessments to the appropriate state agency in a timely manner in compliance with federal regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to administer all doses of an antibiotic to treat a urinary tract infection for Resident #81. This affected one resident (#81) of three residents who were all receiving antibiotics for a urinary tract infection. Findings include: Review of the medical record for Resident #81 revealed an admission date of 05/12/23. Diagnoses included acute cystitis with hematuria, acute kidney failure, urinary tract infection (UTI), and cerebral infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had mild cognitive impairment. Resident #81 required limited one-person assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; and supervision with set up help only for eating. Resident #81 was always continent of urine and bowel. Review of the admission physician's order dated 05/12/23 revealed an order to administer Keflex (antibiotic) 250 milligrams every eight hours for infection for 20 administrations. Review of the initial care plan for Resident #81 dated 05/12/23 revealed she had a urinary tract infection and to administer her antibiotic as ordered. Review of nursing note dated 05/21/22 at 9:14 A.M. revealed Resident #81 was experiencing increased weakness and requiring more assistance with transfers and urinary frequency. Resident #81's antibiotics were discontinued on 05/19/23 for a urinary tract infection. Resident #81's physician was notified and a new order for stat lab work and urinalysis with culture and sensitivity. The nurse collected the urine sample via straight catheterization. Review of physician's order dated 05/21/23 for Resident #81 revealed an order for stat complete blood count and complete metabolic panel (lab work) and a urinalysis with culture and sensitivity. Review of the Medication Administration Record (MAR) for Resident #81 from 05/12/23 to 05/22/23 revealed Resident #81 received the Keflex three times a day from 05/13/23 to 05/18/23 and only one morning dose on 05/19/23. The total number of doses received was equal to 19. Interview on 05/21/23 at 10:04 A.M. with Resident #81 revealed she was admitted with a urinary tract infection and today she is feeling very weak. She reported she had finished her antibiotics, but she feels the infection was not completely treated. Interview on 05/22/23 at 10:00 A.M. with the Director of Nursing (DON) confirmed the Keflex for Resident #81 was only administered 19 times not the 20 doses that were ordered. She also confirmed Resident #81 became symptomatic again on 05/21/23. Review of the facility policy titled Medication Administration, effective May 2015, revealed the purpose is to ensure that all medications are administered safely and appropriately to aid residents to overcome illness, relieve pain, and prevent symptoms and help in diagnosis. A physician's order that indicates dosage, route, frequency, duration, and other required considerations are required for administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to provide residents and/or resident representatives of bed hold notice and/or bed hold policy upon discharge to the hospital. This affected four residents (#3, #11, #14, and #26) of four residents reviewed for hospitalizations. The facility census was 17. Findings include: 1. Review of the medical record for Resident #3 revealed admission date of 03/17/23 and a discharge date of 05/22/23 with diagnoses including pleural effusion (accumulation of excess fluid around the lungs), cystitis (inflammation of the urinary bladder), cerebral infarction (stroke), hemiplegia (paralysis) affecting left nondominant side and right dominant side, dysphagia (difficulty swallowing), diabetes mellitus, chronic kidney disease stage three, and systolic congestive heart failure, and depressive disorder. Review of the progress notes for Resident #3 revealed on 04/08/23 Resident #3 had increased edema to thighs and abdomen, and family had expressed concerns regarding the increase edema. The nurse practitioner was notified and gave an order to send Resident #3 to the emergency department. On 04/09/23, Resident #3 was admitted to the hospital with a diagnosis of pleural effusion. On 04/14/23, Resident #3 was readmitted to the facility from the hospital. A progress note dated 04/19/23 revealed Resident #3 felt an increase in shortness of breath and wanted to be sent to the emergency department. On 04/20/23, Resident #3 was admitted to the hospital with pleural effusion. Further review of the medical record for Resident #3 revealed no documented evidence of a bed hold notification and/or bed hold policy was provided to Resident #3 and/or Resident #3's representative when the resident was sent to the hospital on [DATE] and 04/19/23. 2. Review of the medical record for Resident #11 revealed an admission date of 02/23/23 and a discharge date of 05/05/23 with diagnoses including gross hematuria (blood in urine), long term use of anticoagulants (blood thinners), permanent atrial fibrillation (abnormal heart rhythm), and cirrhosis (impaired function caused by formation of scar tissue) of liver. Review of the progress notes for Resident #11 revealed on 04/11/23 Resident #11 was complaining of abdominal pain, the Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine) was noted to have blood-tinged urine in the bag, the Foley catheter was unable to be flushed, and the Foley catheter was removed. The doctor was notified and ordered Resident #11 sent to the emergency room. On 04/12/23, Resident #11 was admitted to the hospital for acute hematuria. Further review of the medical record for Resident #11 revealed no documented evidence of a bed hold notification and/or bed hold policy was provided to Resident #11 and/or Resident #11's representative when the resident was sent to the hospital on [DATE]. 3. Review of the medical record for Resident #14 revealed admission date of 03/18/23 and a discharge date of 05/19/23 with diagnoses including anxiety, atrial fibrillation (abnormal heart rhythm), congestive heart disease (heart failure), hypertension (high blood pressure), hyperlipidemia (high levels of lipids in the blood), and hyponatremia (low sodium levels in the blood). Review of the progress notes for Resident #14 revealed on 05/10/23 according to the lab report, Resident #14 had a low sodium level, and the nurse practitioner ordered Resident #14 be sent out to the emergency room for evaluation and treatment. Resident #14 was admitted to the hospital on [DATE] with a diagnosis of hyponatremia. Further review of the medical record for Resident #14 revealed no documented evidence a bed hold notification and/or bed hold policy was provided to Resident #14 and/or Resident #14's representative when the resident was sent to the hospital on [DATE]. 4. Review of the medical record for Resident #26 revealed an initial admission date of 06/1/22 and a discharge date of 07/17/22 with diagnoses including urinary tract infection, cognitive communication deficit, type two diabetes mellitus with hyperglycemia (high blood sugars) , hypertension, hyperlipidemia, chronic kidney disease stage three, and multiple fractures of pelvis. Review of the progress notes for Resident #26 revealed on 02/25/23 Resident #26 was observed in bed with a large coffee ground emesis and had a temperature of 104.3 degrees Fahrenheit. The doctor was notified and ordered Resident #26 sent to the emergency room for evaluation. On 02/26/23, Resident #26 was admitted to the hospital with a diagnosis of sepsis. Further review of the medical record for Resident #26 revealed no documented evidence of a bed hold notification and/or bed hold policy was provided to Resident #26 and/or Resident #26's representative when the resident was sent to the hospital on [DATE]. Interview on 05/22/23 at 4:31 P.M. with the Administrator confirmed the facility did not send bed hold notification and/or bed hold policy upon transfer to the hospital since most residents would not be able to pay the bed hold cost, and the facility would normally hold the bed for them without charging them. Interview on 05/24/23 at 8:20 A.M. with the Administrator and Director of Nursing confirmed bed hold notices had not been sent as required when Residents #3, #11, #14, and #26 were sent to the hospital. Review of the undated facility policy titled Woodlands Bed Holds & Leave of Absence revealed the facility charged on a per day basis for each day the resident resided in the facility. If a resident were to leave the facility on an overnight basis, which included hospital stays, it would be considered a voluntary discharge, unless the resident elected to have the facility hold the bed so the resident may return to it. The routine per day basic rate would be charged for every day the resident was absent from the facility and if bed hold payments were not made, then a bed would not be held.