**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview, and hospital record review, the facility failed to provide treatment and care in accordance with professional standards of practice when they failed to monitor Resident #2 who was on Eliquis (an anticoagulant medication) and had a decreasing hemoglobin and did not complete a Physician recommended complete blood count (CBC) lab test. This resulted in harm when Resident #2 had bloody tarry stool and was admitted to the hospital for three days with a hemoglobin lab value (a test to detect anemia with a normal range of 11.5 to 15.4 g/dl) of 4.5 grams per dececiliter (g/dl) upon hospital admission. Resident #2 had to receive three units of packed red blood cells and was found to have a gastric ulcer that required clamping. This affected one (Resident #2) of three residents reviewed on anticoagulant medication. The facility census was 88. Findings include: Record review of Resident #2 revealed an admission date of 03/04/22 with pertinent diagnoses of: morbid obesity, macular degeneration, retinal hemorrhage left eye, vascular dementia with psychotic disturbance, gait abnormalities, major depressive disorder, low back pain, insomnia, type two diabetes mellitus with diabetic polyneuropathy, hypertensive chronic kidney disease, arthropathy, congestive heart failure, gastroesophageal reflux disease, sleep apnea, atrial fibrillation, anemia, functional urinary incontinence, and chronic kidney disease stage four. Review of the 09/30/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #2 is moderately cognitively impaired and uses a wheelchair to aid in mobility. Resident #2 is noted to be taking an anticoagulant medication. Review of Resident #2's plan of care dated 02/10/24 revealed a goal of being free from signs or symptoms of bruising or bleeding with a target date of 11/22/24. The care planned interventions included: Resident is at risk for bleeding/bruising related to platelet aggregated/anticoagulant therapy. Resident will free from signs or symptoms of bruising or bleeding, Contact Physician with any signs or symptoms of bleeding. Labs per order. Medications as ordered. Monitor for signs or symptoms of bruising or bleeding every shift. Review of a Physician Order dated 10/05/24 revealed Eliquis (Apixaban) oral tablet five milligrams (mgs) Give one tablet by mouth two times a day related to paroxysmal atrial fibrillation the order was discontinued on 10/10/24. Review of a complete blood count (CBC) lab collected on 08/05/24 and reported the same day revealed a low Hemoglobin value of 10.3 g/dl with a normal value of 11.5-15.4 g/dl. Review of a complete blood count lab collected on 08/13/24 and reported the same day revealed a low Hemoglobin value of 7.3 g/dl with a normal value of 11.5-15.4 g/dl. Review of Nurse Practitioner (NP) #15 written Progress note dated 08/14/24 at 11:59 P.M. revealed an acute visit and Resident #2 is a [AGE] year old female who presents today with anemia, diabetes, and hypothyroidism. Resident #2 had a recent CBC result showing hemoglobin of 7.3 and hematocrit of 22.4, indicating anemia. Resident is currently taking ferrous sulfate 325 mg once a day for anemia management. The patient's vital signs include blood pressure of 133/64, heart rate of 70, respirations of 18, Oxygen saturation of 96%, and temperature of 97.7. The healthcare provider plans to increase the ferrous sulfate dose to twice a day, pending the patient's tolerance and absorption, and will continue to monitor CBC levels in one month for effectiveness. The assessment and plan for Iron deficiency anemia was the resident's CBC results indicated iron deficiency anemia with a hemoglobin level of 7.3 and hematocrit of 22.4. The resident is currently on ferrous sulfate 325 mg once a day. Plan: The dose of ferrous sulfate will be increased to twice a day, pending the patient's tolerance and absorption. CBC levels will be monitored in one month to assess the effectiveness of the increased dosage. Review of progress note dated 8/14/24 at 7:00 P.M. revealed Licensed Practical Nurse (LPN) #22 received an order from NP #15 to give iron twice a day due to hemoglobin level from recent labs. Review of Physician order dated 08/14/24 revealed Ferrous sulfate oral Tablet 325 (65 iron) mg give one tablet by mouth two times a day related to anemia. Review of the medical record for 08/14/24 revealed no order was written for a CBC laboratory value to be drawn in a month as per the NP progress notes. Review of Nurse Practitioner (NP) #15 written Progress Note dated 09/19/24 at 11:59 P.M. revealed and acute visit and the reason for the visit: Resident #2 is a [AGE] year-old female, with a history of diabetes mellitus managed with insulin, atrial fibrillation managed with aspirin, and neuropathy managed with gabapentin, seen today for blood glucose concerns. The patient also reports nausea for the past three weeks, which she attributes to food intake. The nausea occurs both before and after eating, leading her to reduce her food intake. She suspects that an ulcer, diagnosed several years ago, may be contributing to her symptoms. She requested Tums yesterday but did not receive them. Additionally, she reports constipation, with no bowel movement in the past 3 days. Review of a nurse note dated 10/06/24 at 6:30 P.M. revealed Resident #2 received milk of magnesium for complaints of stomachache. Resident's stool appeared black although this is normal with the resident. Resident noted to be pale in color. Family and nurse discussed sending her to emergency room. Resident was alert and oriented,blood pressure was 164/48, heart rate 80 beats per minute and respiration rate 16 per minute, Oxygen saturation 92%. Squad arrived and resident left without incident. Review of Emergency Department Provider notes dated 10/07/24 revealed Resident #2 presents on 10/06/24 with complaints of abdominal pain and concern for dark stools. Resident had a critically low hemoglobin of 4.5 g/dl. She received three units of packed red blood cells and is being sent to another hospital. Review of Hospital record dated 10/07/24 revealed Resident #2 transferred in from another hospital due to dark tarry stool and had an esophagogastroduodenoscopy (EGD) procedure done and she had three linear mucosal gastric erosions/ulcerations and one principal area in the fundus with the potential for a visible vessel which was endoclipped to maintain hemostasis. Review of Nurse Practitioner (NP) #15 written Progress Note dated 10/14/24 at 11:59 P.M. revealed Resident #2 is a [AGE] year old female who presents for a post-acute care visit following a recent hospitalization for anemia and a gastrointestinal bleed. The resident was hospitalized last week due to black, tarry stools and was diagnosed with a gastrointestinal bleed. Resident reports during the hospital stay, she had two large ulcers in her stomach that were bleeding and required clamping. Resident's blood count dropped to four, necessitating several blood transfusions. Resident #2 returned to the care facility on 10/10/24 and started on Protonix 40 mg twice a day. A follow-up with a gastrointestinal (GI) doctor is planned. Resident reports feeling better since returning from the hospital but expresses frustration with the care facility staff for not addressing her stomach pain complaints earlier. She mentioned having complained about stomach pain for weeks prior to the hospitalization. Currently, the resident's stomach is a little sore, and they feel the need to have a bowel movement. Interview with the Director of Nursing (DON) on 11/04/24 at 3:52 P.M. verified there was never an order written on 08/14/24 for Resident #2 CBC and a CBC lab was not completed. Telephone Interview with NP #15 on 11/04/24 at 4:14 P.M. revealed the note from 08/14/24 was read to her and she stated she meant for Resident #2 to have a follow up CBC lab done in a month due to the hemoglobin dropping and the increase of the ferrous sulfate medication. NP #15 was unsure of why it was not completed. NP #15 was informed there was not an order written and she stated her intention was for the lab to be drawn and she is not sure if she gave a verbal order for the CBC or wrote the order out. She stated when she comes in the facility she usually writes out the order but sometimes they do not have the slips. NP #15 could not recollect if she wrote a paper order for the CBC or gave a verbal order to the nurse. NP #15 stated the standard of practice would be to draw a CBC lab in a month to monitor the medication change and the hemoglobin level since the resident was on Eliquis and had the hemoglobin decrease. Interview with LPN #22 on 11/04/24 at 4:35 P.M. revealed she worked 08/14/24 and put the order in the electronic record to increase the ferrous sulfate for Resident #2. LPN #22 was unable to recollect whether she received a verbal order from NP #15 or if NP #15 wrote the order. LPN #22 stated she input the order in the electronic medical record as it was prescriber written so it should of been on paper. The Prescriber Order paper order was unable to be located in the medical record and LPN #22 stated she might of marked that in error and it could of been a verbal order. LPN #22 stated NP #15 usually writes her own paper orders and the nurse will put them in the computer. Review of Resident #2's paper medical record on 11/05/24 revealed no evidence of a telephone order being written for ferrous sulfate to be increased, or the CBC lab to be drawn in a month. Interview with Director of Nursing (DON) on 11/05/24 at 12:50 P.M. revealed Resident #2 had two gastric ulcers on 10/06/24 and they clamped them. This deficiency represents non-compliance investigated under Complaint Number OH00158854.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, observation, staff interview and facility policy review, the facility failed to ensure Resident #33's fall interventions were implemented to prevent falls in accordance with the resident's fall risk care plan. This resulted in actual harm when Resident #33's bilateral side rails were not in place and the resident experienced a fall resulting in a laceration to the head and bruising. The resident was subsequently sent to the hospital and required staples. In addition, the facility failed to ensure staff implemented a second resident's (Resident #32) fall interventions in accordance with the care plan. This affected two (Resident #32 and Resident #33) of four residents reviewed for falls. The facility census was 89. Findings include: 1. Review Resident #33's medical record revealed an admission date of 12/13/17 with diagnoses including unspecified pain, unilateral primary osteoarthritis to the left knee, muscle weakness, difficulty in walking, and cerebral infarction due to embolism of unspecified cerebral artery (stroke). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact and had one fall since admission. The MDS further revealed the resident required supervision and one-person assistance with mobility, transferring, dressing and hygiene. The resident utilized a walker for ambulating. Review of Resident #33's progress note and fall investigation dated 08/19/19 revealed the resident rolled out of bed and was found sitting up at the bedside. Resident #33 got herself off the floor. A new intervention was added to encourage the use of a pillow to define bed perimeters and to utilize 1/2 side rails on both sides on the bed for safe independent bed mobility. Review of Resident #33's physicians order dated 08/19/19 revealed an order for 1/2 side rails on both sides of the bed to encourage safe independent bed mobility. Review of Resident #33's care plan dated 08/19/19 revealed the resident was at risk for falls and an intervention was added to utilize half side rails for independent bed mobility. Review of Resident #33's progress note dated 08/24/19 revealed an aide notified the nurse Resident #33 was found on the floor with blood observed on her as well as on the floor. The resident stated she fell out of the bed. The resident had fallen within the last week. Review of Resident #33's fall investigation dated 08/24/19 at 10:50 P.M., revealed the resident was on the floor and was bleeding from her head. She was sent to the hospital. Further review of the fall investigation revealed the location of the injury was at the back of the head and the resident was alert and oriented. Review of Resident #33's hospital documentation dated 08/24/19 at 11:10 P.M., revealed the resident was transferred from the nursing home due to a head injury. The laceration was a 2.5 centimeters (cm) subcutaneous laceration to the left temporal area and was closed with staples. The hospital documentation revealed the resident had a moderate left frontal scalp hematoma and probable mild ecchymosis in the left posterior parietal scalp. Further review of Resident #33's nursing progress note dated 08/25/19 at 1:30 A.M., revealed the resident arrived back to the facility and had three staples in the back of her head. Nursing progress note dated 08/30/19 revealed bruising was noted to several areas of the resident's body due to fall on 08/24/19. Observation of Resident #33 on 09/10/19 at 9:48 A.M. revealed the resident had a large bruise on her face which started on her forehead and ran down to the middle of her chest. Interview with Resident #33 on 09/10/19 at 9:48 A.M. revealed she had fallen onto the floor two times in two weeks while turning over in bed. Resident #33 stated the facility was supposed to install bed rails on her bed after she fell out of the bed the first time, but they were not put in place until after the second fall. Interview with the Director of Nursing (DON) on 09/11/19 at 12:33 P.M., confirmed the bed rails for Resident #33 were ordered on 08/19/19 but were not put in place until 08/25/19 following the second fall. 2. Review of Resident #32's medical record revealed an admission date of 09/12/14 with diagnoses including dementia, anxiety, depression, insomnia, and right leg above knee amputee. Review of physical therapy evaluation dated 07/16/19 revealed Resident #32 required the assistance of two staff members for transfers without falling. Review of physical therapy note dated 08/13/19 revealed they recommended two-person assistance for transfers and positioning for safety. Review of Resident #32's care plan revealed the resident was at high risk for falls related to a right above the knee amputation with balance issues, muscle weakness, and dementia. Interventions dated 10/08/18 revealed to utilize two staff assistance when applying the prosthetic leg, with transfers, ambulation, etc. Review of the quarterly MDS assessment dated [DATE] revealed he had moderate cognitive deficits and received extensive assistance of two staff for transfers. Review of change in condition note dated 09/07/19 revealed an aide alerted the nurse that Resident #32 fell to the floor during a transfer to a wheelchair. He was face down next to the bed with a moderate amount of blood pooled under his face when the nurse entered the room. Resident #32 stated he fell when the wheelchair moved, and his face hit the floor. The aide stated during the transfer from the bed to the wheel chair, Resident #32 leaned toward the glider in the room. The wheelchair moved to one side which caused the transfer to be unstable and Resident #32 fell face forward onto the floor. Resident #32 had a laceration to the bridge of his nose and abrasions to the right side of his face and was sent to the hospital. Interventions added included to check the wheel chair brakes for proper function. Review of the emergency room report dated 09/07/19 revealed Resident #32 presented with complaints of a fall injury with laceration to the nose. Wound care was provided with steri-strip application and a Computed Tomography (CT) scan which was negative for any injury. Observation was conducted of Resident #32 on 09/09/19 at 11:02 A.M. and noted he was sitting in the dining room in a wheel chair. The resident had bruising under both eyes and across the bridge of the nose. Interview was conducted on 09/10/19 at 9:16 A.M., with Resident #32. He stated the aide did not tighten up the lock on the wheel chair, he started to get into it, it pushed away, and he fell. He stated he was sent to hospital and nothing was broken. Interview was conducted on 09/11/19 at 7:05 A.M., with State Tested Nursing Assistant (STNA) #158. STNA #158 verified she was the aide that was transferring Resident #32 when he fell. She verified she was the only staff member present and she was not sure what his care plan stated as to whether he was a two person assist. She stated she pulled the wheel chair up next to the bed and locked the brakes. When she stood him up, he put out his hand onto the glider next to his bed and he lost his balance. STNA #158 stated she tried to catch him, but he went down. Interview was conducted on 09/11/19 at 7:24 A.M., with the DON verifying Resident #32's care plan intervention included the use of two-person assistance from a fall he had back in October of 2018. She stated his level of assistance with transfers varied due to his mental capacity and that some days were better than others. Interview was conducted on 09/11/19 at 9:21 A.M., with Resident #32 and he stated he usually gets transferred per two staff and occasionally one staff will do the transfer. He stated staff used a mechanical lift to get him up yesterday. Review of the facility policy titled Restraint Policy dated 11/02/16 revealed goals of a restraint are to maintain a resident's independence and highest level of physical and psychosocial function. The restraint policy was the policy provided by the facility for falls during the survey.