**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facilty failed to ensure new mental illness diagnoses were reported to the OHCA for one (#6) of one sampled resident reviewed for PASARR. The administrator reported 52 residents resided in the facility. Findings: A Preadmission Screening and Annual Resident Review policy, revised 06/25/21, read in part, [Name withheld] will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative. Resident #6 was admitted to the facility on [DATE]. A level I PASARR screen, dated 08/22/23, documented primary diagnoses of chronic obstructive pulmonary disease and secondary of acute on chronic systolic heart failure. The level I PASARR screen documented no level II screening was required. Resident #6's face sheet documented the following diagnoses dates: anxiety disorder on 09/24/20, recurrent depressive disorder on 12/01/23, hallucinations on 12/14/23, and psychosis on 02/02/24. A comprehensive assessment, dated 08/14/24, documented resident #6's cognition was intact. The assessment documented diagnoses of anxiety, depression, and psychotic disorder. On 11/20/24 at 1:29 p.m., the DON reported the OHCA was contacted on 11/18/24. The DON reported a level II screen was not required. The DON reported they were not aware if the new mental illness diagnoses had been reported to the OHCA previously. The DON reported they were not aware until recently that new mental health diagnoses needed to be reported to the OHCA.

Based on record review and interview, the facility failed to include hospice services on a care plan for one (#9) of one sampled resident reviewed for hospice. The administrator reported 52 residents resided in the facility. Findings: A Care Plans policy, dated 10/12/17, read in part, Comprehensive care plans will be revised and updated upon any new changes in a resident's condition within 7 days .Care Plans will address all areas pertinent to providing care to that resident. Resident #9 had diagnoses which included congestive heart failure and chronic obstructive pulmonary disease. A physician order for Resident #9, dated 06/27/24, documented the resident was admitted to hospice with the diagnosis of hypertensive heart disease with heart failure. A comprehensive assessment for Resident #9, dated 10/02/24, documented the resident's cognition was intact. The assessment documented the resident received hospice services. A care plan for Resident #9, dated 10/02/24, did not address hospice or document the resident received hospice services. On 11/20/24 at 12:33 p.m., MDS coordinator #1 reported hospice services should be included on the resident's care plan under its own care area.

Based on observation, record review, and interview the facility failed to administer physician ordered medications for one (#14) of five sampled residents reviewed for medications. The administrator reported 52 residents resided in the facility. Findings: A Medication Administration and General Guidelines policy, dated 07/10/23, read in part, Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. Resident #14 had diagnoses which included senile degeneration of brain, anxiety disorder, and polyarthritis. Resident #14's physician order, dated 11/06/24, read in part, Give 0.5 mg PLO gel q 4 hours. A drug label for Resident #14, dated 11/06/24, documented, apply 0.5 ml (0.5 mg) to the inside of one wrist and rub in well with the other wrist every four hours. lorazepam (benzodiazepine) 1 mg/1 ml-PLO. Resident #14's physician order list, dated November 2024, documented, (lorazepam 1 ml) PLO transdermal external cream (transdermal base) apply to wrist or neck topically four times a day related to anxiety. The order was not transcribed correctly per the physician's order of 11/06/24. A November 2024 Controlled Narcotic Administration Record, documented lorazepam 1 mg/1 ml-PLO, frequency 0.5 ml every 4 hours. The controlled narcotic administration record documented an accurate count for 53 pre-filled syringes measuring 0.5 ml of medication and documented the medication was administered four times a day and not every four hours as ordered. A Medication Error Report, dated 11/06/24, documented the order on the prescription label did not match the order in the chart and no clarification was made. On 11/18/24 at 1:05 p.m., CMA #2 was observed to administer Lorazepam topical medication to Resident #14's wrist. On 11/19/24 at 1:25 p.m., the DON reported there was a discrepancy between the medication label and the physician's order. The DON reported they would need to contact the physician for clarification of the order.

3. Resident #44 had diagnoses which included congestive heart failure and atrial fibrillation. A comprehensive assessment, dated 09/06/24, documented, Resident #44's cognition was severly impaired and was dependent on staff for most activities of daily living. A physician order, dated 08/02/24, read in part, Piperacillin sodium-Tazobactam sodium solution reconstituted 4-0.5 gram, use 4.5 gram intravenously every 8 hours for infection related to abscess of liver and cholangitis (severe infection of the liver's bile ducts) until 08/30/24. On 11/20/24 at 3:44 p.m., the ADON reported the infection preventionist should be completing the Mcgreer criteria for infection surveillance of residents receiving antibiotics. On 11/20/24 at 3:44 p.m., the infection preventionist reported no Mcgreer criteria checklist had not been completed on Residents #17, #39, or #44 with the prescribed antibiotics. The infection preventionist reported not being aware that Mcgreer criteria checklist should have been completed with antibiotics use. On 11/20/24 3:55 p.m., the DON reported due to a change in staff, the Mcgreer criteria had not been completed for residents prescribed antibiotics. The DON reported Mcgreer criteria should be used for residents prescribed antibiotics and a pip would be done to correct this. Based on record review and interview, it was determined the facility failed to implement an antibiotic stewardship program for three (#17, 39. and #44) of five residents sampled for medication review. The DON identified 52 residents resided in the facility. Findings: 1. Resident #17 had diagnoses which included chronic systolic congestive heart failure, permanent A-Fib, and recurrent depressive disorders. Resident #17's care plan, dated 07/31/24, documented frequently incontinent of bowel and occasional incontinent of urine. A Culture Urine for resident #17, dated 08/17/24, read in part, Culture Colony count > 100,000 CFU/ml Escherichia Coli (Abnormal). Resident #17's physician order, dated 08/19/24, documented to give Macrobid oral capsule 100 mg (Nitrofurantoin), 100 mg by mouth, two times a day for five days, related to urinary tract infection. 2. Resident #39 had diagnoses which included chronic obstructive pulmonary disease, acute kidney disease, and senile degeneration of the brain. Resident #39's care plan, dated 01/02/24, documented the resident was frequently incontinent of bowel and bladder. A physician order for Resident #39, dated 08/02/24, documented to give Cephalexin 500 mg tablet, one (500 mg) by mouth, three times per day. A Culture Urine for Resident #39, dated 08/03/24, read in part, Culture Colony count 10,000-50,000 CFU/ml Escherichia Coli (Abnormal). On 11/21/24 at 10:19 a.m., the DON was interviewed regarding the facility's infection control program. The DON reported the facility was not conducting antibiotic stewardship.

Based on observation and interview, the facility failed to ensure incontinent care was provided to dependent residents at least every two hours for three (#2, 3, and #4) of three dependent residents observed for receiving incontinent care. The DON identified 61 residents resided in the facility. RN #1 identified 27 residents that were totally dependent on staff for incontinent care. Findings: 1. A 'Functional Abilities & Goals' assessment for Resident #2, dated 05/16/24, documented they had impaired ROM to both upper and both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. 2. A 'Functional Abilities & Goals' assessment for Resident #3, dated 07/02/24, documented they had impaired ROM to both upper and both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. 3. A 'Functional Abilities & Goals' assessment for Resident #4, dated 07/29/24, documented they had impaired ROM to both upper and both lower extremities, was incontinent of bowel and bladder, and was dependent on staff for all ADL's. On 07/30/24 at 10:32 a.m., Resident #2, Resident #3, and Resident #4 were observed sitting in the facility common area outside of the main dining room. On 07/30/24 at 11:57 a.m., after uninterrupted observation from 10:32 a.m. to this time, Residents #2, #3, and #4 were observed being escorted to the dining room by facility staff. On 07/30/24 at 1:00 p.m., after uninterrupted observation from 11:57 a.m. to this time, Residents #2, #3, and #4 were observed being escorted to the activity area adjacent to the common area outside of the dining room by facility staff. On 07/30/24 at 1:15 p.m., Resident #3 was observed being taken from the activity area and provided incontinent care by CNA #1 and CNA #3. Resident #3's brief and padding were observed to be grossly saturated when removed. On 07/30/24 at 1:22 p.m., Resident #4 was observed being taken from the activity area and provided incontinent care by CNA #2 and Rehab Aide. Resident #4's brief and padding were observed to be grossly saturated when removed. On 07/30/24 at 1:32 p.m., Resident #2 was observed being taken from the activity area and provided incontinent care by CNA #2 and CNA #6. Resident #2 was observed to have a small BM and be grossly saturated when brief was removed. On 07/30/24 at 2:01 p.m., CNA #6 was asked how often dependent residents received incontinent care. They stated every two hours. After informing CNA #6 of my observations, they acknowledged incontinent care had not been provided at least every two hours to Resident #2, Resident #3, nor Resident #4. On 07/30/24 at 3:23 p.m., RN #1 was asked the facility policy regarding incontinent care for dependent residents. They reported dependent residents should be checked at least every two hours and acknowledged facility policy had not been followed for the above residents.

Based on record review and interview, the facility failed to ensure dietary staff received training in safe food handling practices for the prevention of foodborne illness for eight (Cook #1, [NAME] #2, [NAME] #3, [NAME] #4, Dietary Aide #1, Dietary Aide #2, Dietary Aide #3, Dietary Aide #4) of nineteen dietary staff. The DON identified 61 residents resided in the facility. All residents received meals prepared in the facility dietary department. Findings: On 08/01/24 at 9:00 a.m., the Administrator was asked for verification of Food Handlers training for all dietary staff. On 08/01/24 at 9:08 a.m., the Administrator submitted a copy of in-service training for eleven of nineteen dietary staff and acknowledged [NAME] #1, [NAME] #2, [NAME] #3, [NAME] #4, Dietary Aide #1, Dietary Aide #2, Dietary Aide #3, and Dietary Aide #4 had not received the required training.

2. Resident #48 was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease. The resident's Care Plan, dated 08/17/22, documented, . Resident has chronic obstructive pulmonary disease, wheezing, and cough as per her PCP's orders .Resident has orders for to wear her CPAP nightly, staff to observe that it is functioning properly when worn .Resident is not able to self-administer her own breathing treatment .Resident may use oxygen as prescribed by her PCP . The resident's Quarterly MDS Assessment, dated 08/17/22, documented the resident's cognition to be intact. The resident's Monthly Physician Orders, dated 09/01/22, read in parts, .May have O2 @1-2 LPM/NC for SAT's =or> 92% every shift for SAT'S BELOW 89% .Clean oxygen concentrator every night shift starting on the 15th and ending on the 15th every month for maintenance .Albuterol Sulfate Nebulization Solution 2.5 MG/0.5ml 1 unit inhale orally via nebulizer every 4 hours as needed for shortness of breath .CPAP 1 time daily at bedtime related .Change oxygen tubing every 2 weeks every night shift every 15 days for O2/nebulizer therapy .Clean oxygen concentrator every night shift starting on the 15th and ending on the 15th every month for maintenance . On 09/20/22 at 10:41 a.m., resident #48 reported she wore oxygen at night and as-needed for shortness of breath. The resident's oxygen tubing and nebulizer tubing was observed and was not labeled with the date and staff initials of when it had been changed. On 09/21/22 at 11:42 a.m., LPN #2 reported O2 tubing and nebulizer tubing was changed monthly and she was not aware the tubing should be dated when changed out. The LPN reported night shift was responsible for that task and stated she did not work the night shift. On 09/21/22 at 11:44 a.m., the DON reported the facility's policy was to label the oxygen/nebulizer tubing with the date and staff initials when changed. The DON verified resident #48's oxygen/nebulizer tubing was not labeled. 3. Resident #71 was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease. The resident's Monthly Physician Orders, dated 09/01/22, read in part, .May have oxygen 1-4 LPM to maintain SATs >89%; .Apply oxygen via NC if Sp02 is below 90% every shift . The resident's Care Plan, dated 09/07/22, documented, .Oxygen settings: O2 via nasal prongs @ 1-4 LPM to maintain oxygen saturation greater than 89%. Obtain SpO2 routinely and maintain oxygen/nebulizer machine and tubing . The resident's Quarterly MDS Assessment, dated 09/07/22, documented the resident had severely impaired cognition. On 09/20/22 at 10:31 a.m., resident #71 was observed to be up in a chair wearing oxygen. The oxygen/nebulizer tubing was not labeled to indicate when it was last changed. On 09/21/22 at 11:45 a.m., the DON verified resident #71's oxygen tubing was not properly labeled. The DON reported the facility's policy was to change oxygen/nebulizer tubing every two weeks and should be labeled with the date and staff initial of when it was changed. Based on record review, observation, and interview, the facility failed to adhere to the facility's policy and procedure to label and date oxygen tubing for three (#49, 48, and #71) of three residents sampled for oxygen therapy. The Resident Census and Condition of Residents, report, dated 09/19/22, documented 80 residents resided in the facility. Findings: The Oxygen System Change Out Policy, revised on 10/11/17, read in parts, .It is the policy of Corn Heritage Village and Rehab that the oxygen setups including the nasal cannula, any extension tubing, and humidifier bottle will be changed out every 2 weeks for infection control purposes. Each new oxygen set will be labeled with the date of change and the nurses initials . 1. Resident #49 was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease. Physician Orders, dated 07/30/20, read in parts, . may have oxygen 2 L. Do NOT increase oxygen without discussing with PCP first. as needed for shortness of breath related to DYSPNEA [Shortness of breath] .May have NC PRN for SHOB. May keep at bedside. Do NOT increase oxygen without discussing with PCP first . Physician Orders, dated 07/30/20, read in parts, .change nebulizer/oxygen tubing every evening shift every 2 weeks on Sun for O2/Nebulizer Therapy Date and initial . The resident's Quarterly MDS Assessment, dated 08/18/22, documented the resident's cognition to be intact. The resident's Plan of Care, dated 08/23/22, read in parts, .Congestive Obstructive Pulmonary Disease/Cough: Res #49 has the diagnosis of COPD. She also has a cough from time to time. Res #49 receives medication to combat these issues as prescribed by her PCP. She does not like to have cleaning agents or chemicals that can cause fumes used in her room. She also chooses to have a humidifier going in her room. She often refuses to take Prednisone stating, It makes me lose my mind. Res #49 was treated for bronchitis on 8/4/21 . On 09/19/22 at 1:08 p.m., the tape wrapped around Res #49's oxygen tubing was observed to be dated 07/03/22 and without staff initials. On 09/21/22 at 9:27 a.m., Res #49 reported she usually wore her oxygen at night and when needed.

Based on observation, record review, and interview, the facility failed to ensure emergency call lights were accessible and/or in working order for eight (#1, 3, 5, 6, 7, 10, 11, and #54) of eight residents reviewed for an emergency call light system. The Administrator reported 80 residents resided in the facility. Findings: On 09/19/22 at 10:00 a.m., a tour of the facility was conducted. Resident bathrooms on the E Unit, for residents #1, 3, 5, 6, 7, 10, and #11, were observed to have missing pull cords, short pull cords, or cords wrapped around the hand bar. On 09/19/22 at 10:10 a.m., resident #54 reported utilizing the bathroom during the daytime. The resident's bathroom call light was observed to be missing a cord. The maintenance log was reviewed and documented no reported issues with bathroom call light repairs. The facility reported no policy and procedure related to the call light system. On 09/22/22 at 10:14 a.m., an interview with the DON was conducted. She was asked to review the September 2022 work log for maintenance issues. The DON stated there had been no reports of missing or out-of-reach call light cords for the E unit. The DON toured the E unit and viewed the emergency call light in the identified resident bathrooms. She reported she would educate her staff and report the call light issues to the maintenance department.