Every finding on record at Bel Air Care Center

Based on record review and interview, the facility failed to ensure resident funds in excess of $100 were maintained in an interest-bearing account. This affected eight residents (#1, #15, #19, #21, #22, #23, #29, and #33) of ten residents reviewed for personal funds. The facility identified ten residents with personal funds managed by the facility. The facility census was 32. Findings include: a. Review of Resident #1's personal fund account statements for January 2025 and Feburary 2025 revealed a balance of $1,193.96 and no evidence any interest had been earned. b. Review of Resident #15's personal fund account statements for January 2025 and Feburary 2025 revealed a balance of $126.00 and no evidence any interest had been earned. c. Review of Resident #19's personal fund account statements for January 2025 and Feburary 2025 revealed a balance of $725.57 and no evidence any interest had been earned. d. Review of Resident #21's personal fund account statements for January 2025 and Feburary 2025 revealed a balance of $305.18 and no evidence any interest had been earned. e. Review of Resident #22's personal fund account statements for January 2025 and Feburary 2025 revealed a balance of $145.39 and no evidence any interest had been earned. f. Review of Resident #23's personal fund account statements for January 2025 and Feburary 2025 revealed a balance of $750.18 and no evidence any interest had been earned. g. Review of Resident #29's personal fund account statements for January 2025 and Feburary 2025 revealed a balance of $418.36 and no evidence any interest had been earned. h. Review of Resident #33's personal fund account statements for January 2025 and Feburary 2025 revealed a balance of $573.91 and no evidence any interest had been earned. Interview on 03/13/25 at 10:00 A.M. with Social Service Designee/Multi-Media Specialist confirmed resident funds were not maintained in an interest-bearing account. Residents' funds were in a simple checking account that was not interest-bearing. Review of the facility policy, Resident Accounts (Resident Trust Funds), dated 06/01/22 revealed a key requirement was that if a resident's balance was more than $50, the facility must place those funds in an interest-bearing account.

Based on record review, observation, resident interview, staff interview, and review of facility correspondence, and facility policy review, the facility failed to maintain the upper level shower in proper working order which resulted in Residents #5 and #6 not being able to receive showers per their preferences and had the potential to affect all 13 residents (#1, #5, #6, #8, #11, #13, #18, #20, #21, #24, #27, #35, and #140) residing on the upper level. Additionally, the facility failed to maintain comfortable temperatures in the bathrooms of Residents #2 and #14. The facility census was 32. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including age-related osteoporosis, fibromyalgia, and multiple sclerosis. Review of the Minimum Data Set (MDS) annual assessment, dated 08/15/24, revealed Resident #5 reported it was very important to her to be able to choose between a tub bath, shower, bed bath, and sponge bath. Review of the quarterly MDS assessment, dated 01/23/25, revealed Resident #5 was cognitively intact, was dependent for tub and shower transfers, and required substantial or maximal assistance for showering or bathing self. Review of the activities of daily living (ADLs) care plan, revised 02/09/25, revealed Resident #5 had a self-care deficit related to weakness, decreased mobility, balance/gait problems, decreased safety awareness, right sided rigidity, and incontinence. Interventions included provide bathing/hygiene with substantial assistance of one staff, maintain resident privacy during care, and Resident #5 had a preference for showers twice per week on day shift. Review of the nurse aide documentation for bathing revealed Resident #5 received a shower on one day (02/11/25 at 9:59 P.M.) out of the previous 30 days. No other showers were documented. Interview on 03/10/25 at 10:10 A.M., interview with Resident #5 stated the upper level shower had been broken for two months and the facility was not fixing it. Resident #5 said it had been brought up in Resident Council and the facility's solution was to use the shower on the lower level. She stated that was too much because staff would undress her in her room, then transport her down the elevator to the lower level, give her a shower, and then transport her back up the elevator to the upper level while she was soaking wet. Resident #5 said the facility needed to fix the upstairs shower instead of putting residents through all that. 2. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including cerebral infarction, transient cerebral ischemic attack, dementia, and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. Review of the annual MDS assessment, dated 01/02/25, revealed Resident #6 reported it was very important to her to be able to choose between a tub bath, shower, bed bath, and sponge bath. Review of the quarterly MDS assessment, dated 01/24/25, revealed Resident #6 had moderate cognitive impairment and required substantial or maximal assist for transfers to the tub or shower and for showering or bathing self. Review of the activities of daily living (ADLs) care plan, revised 02/06/25, revealed Resident #6 had a self-care deficit related to weakness, decreased mobility, balance/gait problems, decreased safety awareness, confusion, and decreased autonomy with ADLs. Interventions included provide bathing/hygiene with partial assistance of one staff, maintain resident privacy during care, and Resident #6 had a preference for showers three times weekly in the mornings. Review of the nurse aide documentation for bathing revealed Resident #6 received showers on five days (02/14/25 at 9:44 P.M., 02/17/25 at 7:50 P.M., 02/21/25 at 3:13 P.M., 02/24/25 at 3:42 P.M., and 03/03/25 at 9:59 P.M.) out of the previous 30 days. No other showers were documented. Review of the text message quote from a contractor, dated 01/03/25 at 12:26 P.M., revealed the facility was quoted $7,500 to $8,500 to replace the upper level shower with an estimated completion time of two days. Interview on 03/10/25 at 11:24 A.M. with Resident #6 said the upper level shower had not worked in months. On 03/10/25 at 11:40 A.M., interview with Maintenance Director #200 confirmed the facility had to shut off the upper level shower because it was leaking into the lower level bathroom. He further stated he had a contractor come and give an estimate for replacement, the quote was too expensive, and he was working with the Administrator to figure out a plan for fixing it. On 03/10/25 at 12:05 P.M., interview with Maintenance Director #200 verified they got the quote for the shower replacement via text message on 01/03/25 at 12:26 P.M., the estimate was not approved by the Administrator because it was too expensive. Maintenance Director #200 said the facility's solution was for upper level residents to use the lower level shower. On 03/11/25 at 8:42 A.M., observation of upper level shower room with Maintenance Director #200 revealed the shower had a gray rubber flexible raised border along bottom edge. Maintenance Director #200 said they don't use the shower because the bottom edge of the shower doesn't seal properly and he pointed along edge where gray rubber border was. He said none of the sealant products they had tried worked to correct the issue and the shower was not used due to continued leaking. Maintenance Director #200 said the Administrator wanted to get a seamless shower installed and that's what they got the quote for, but it was too expensive. Review of the Resident Council meeting minutes, dated 01/27/25, revealed Residents expressed concerns about the upstairs shower being broken and they did not want to go downstairs to shower. The facility's response was that the quote for replacing the shower was too high and Maintenance Director #200 and the Administrator agreed to have residents use the downstairs shower until a resolution was found for the upstairs shower (despite residents voicing they did not want to use the downstairs shower). Review of the facility's policy titled Resident Bathing or Showering, dated 01/01/17, revealed the facility would provide an individualized and resident-centered approach to bathing, residents could request a bed bath or shower per their choice, and efforts would be made to schedule bed baths or showers at a time of the resident's choosing. 51514 3. Record review revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses include spinal stenosis of lumbar region (spine disease of the lower back), congestive heart failure, atherosclerotic heart disease (plaque build up in heart arteries), chronic pain syndrome, and chest pain. Interview on 03/10/25 at 12:42 P.M. with Resident #2 revealed they felt the room temperature was continuously too cold. The resident stated they had mentioned to facility staff the room temperature being uncomfortable. The resident stated the bathroom was even colder. 4. Record review revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses include malignant neoplasm of tongue (tongue cancer), major depressive disorder, malignant neoplasm of floor of mouth (mouth cancer), heart failure, alcoholic cirrhosis of liver without ascites (liver disease), Type II diabetes, anxiety disorder, chronic kidney disease stage 3, and chronic obstructive pulmonary disease (lung and airway disease that restricts breathing). Interview on 03/10/25 at 12:50 P.M. with Resident #14 revealed they felt the room was too cold. The resident stated they had mentioned to facility staff the room temperature being uncomfortable. The resident stated the bathroom was even colder. On 03/13/25 at 10:00 A.M. observation with Maintenance Assistant #150 for room temperature checks revealed the shared bathroom for Resident #2 and Resident #14 read 69.9 degrees Fahrenheit. Maintenance Assistant #150 confirmed the bathroom felt cold. On 03/13/25 at 10:08 A.M. interview with Maintenance Assistant #150 confirmed the temperature read outs and verified the thermometer was the one used for room temperature spot checks. Review of the resident handbook, undated, included in the resident admission packet revealed the following statement: Our Maintenance personnel ensure that resident rooms and the entire facility are in good repair at all times. Their goal is to provide an environment that is safe and functional for our residents.

Based on record review, observation, resident interview, staff interview, and review of the activity participation logs, the facility failed to provide activities on all days, including evenings and weekends, to meet the needs and preferences of residents. This affected five residents (#2, #5, #6, #30, and #36) of six residents reviewed for activities. The facility census was 32. Findings include: 1. Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including congestive heart failure, chronic pain syndrome, major depressive disorder, and hypertension. 2. Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including age-related osteoporosis, fibromyalgia, and multiple sclerosis. 3. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including cerebral infarction, transient cerebral ischemic attack, dementia, and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. 4. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including occlusion and stenosis of bilateral carotid arteries, anxiety disorder, dementia, major depressive disorder, and schizoaffective disorder. 5. Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including major depressive disorder, anxiety, dementia, and hypertension. Review of the facility's activity participation records for November 2024 through March 2025 revealed there was no documentation for any group activities on Saturday 11/02/24, Sunday 11/03/24, Saturday 11/09/24, Sunday 11/10/24, Saturday 11/16/24, Sunday 11/17/24, Sunday 11/24/24, Thursday 11/28/24 (Thanksgiving Day), Friday 11/29/24, Saturday 11/30/24, Sunday 12/01/24, Saturday 12/07/24, Sunday 12/08/24, Saturday 12/14/24, Sunday 12/15/24, Saturday 12/21/24, Sunday 12/22/24, Tuesday 12/24/24 (Christmas Eve), Wednesday 12/25/24 (Christmas Day), Saturday 12/28/24, Sunday 12/29/24, Wednesday 01/01/25 (New Year's Day), Saturday 01/04/25, Sunday 01/05/25, Saturday 01/11/25, Sunday 01/12/25, Saturday 01/18/25, Sunday 01/19/25, Saturday 01/25/25, Sunday 01/26/25, Saturday 02/01/25, Sunday 02/02/25, Saturday 02/08/25, Sunday 02/09/25, Saturday 02/15/25, Sunday 02/16/25, Saturday 02/22/25, Sunday 02/23/25, Saturday 03/01/25, Sunday 03/02/25, Saturday 03/08/25, and Sunday 03/09/25. Review of the posted activities calendars for November 2024 through March 2025 revealed there were no activities scheduled after 4:00 P.M. daily, there were no activities scheduled on Sundays, there were only one to two activities scheduled between 1:00 P.M. and 2:30 P.M. on Saturdays in November 2024 and December 2024, and there were no weekend activities scheduled in January 2025, February 2025, and March 2025. Review of the schedules for activities staff revealed all activities staff were scheduled to work Monday through Friday from 8:00 A.M. to 4:00 P.M. There was no activities staff scheduled to work after 4:00 P.M. or on Saturdays and Sundays. On 03/10/25 at 10:05 A.M., interview with Activities Assistant confirmed activities staff left daily at 4:00 P.M. and there were no activities scheduled for the evenings. She also confirmed the scheduled activity for 03/10/25 at 4:00 P.M. was take a nap. On 03/10/25 at 10:13 A.M., interview with Resident #5 stated there were no activities on the weekends because the activities staff did not work on the weekends. On 03/10/25 at 10:39 A.M., interview with Resident #36 stated there were no activities on the weekends. On 03/10/25 at 10:41 A.M., interview with Resident #30 stated there were no weekend activities and said the facility did not offer alternate activities when she was unable to participate due to the function in her hands. On 03/10/25 at 11:22 A.M., interview with Resident #6 stated there were no activities in the evenings or on the weekends. On 03/10/25 at 12:32 P.M., interview with Resident #2 stated activities could be better because they only have bingo once per week and sometimes had no activities at all. On 03/11/25 at 2:08 P.M., interview with Activities Director confirmed there was a lack of activities, and stated she had recently taken over the role of Activities Director. On 03/11/25 at 2:26 P.M., interview with Activities Director confirmed activities staff worked daily until 4:00 P.M. and there were no activities planned for after 4:00 P.M. The facility was unable to provide a policy for the activities program.

Based on record review and interview, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) at least two days in advance for Residents #28, #91, and #92. This affected three residents (#28, #91, and #92) of five residents reviewed for beneficiary notices. The facility census was 32. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including schizoaffective disorder bipolar type, night terrors, atrial fibrillation, anxiety, and post-traumatic stress disorder. Resident #28 was discharged on [DATE]. Review of the NOMNC for Resident #28 revealed the last covered day of 03/03/25. The NOMNC and ABN were signed by Resident #28 on 03/03/25. 2. Review of the medical record for Resident #91 revealed an admitted [DATE] with diagnoses including spinal stenosis, prostate cancer, hyperlipidemia, dementia, schizoaffective disorder, and hypertension. Resident #91 was discharged on [DATE]. Review of the NOMNC for Resident #91 revealed the last covered day of 01/06/25. The NOMNC and ABN were signed by Resident #91 on 01/07/25. 3. Review of the medical record for Resident #92 revealed an admitted [DATE] with diagnoses including cerebral infarction, chronic kidney disease stage four, hyperlipidemia, and hypertension. Resident #92 was discharged on [DATE]. Review of the NOMNC for Resident #92 revealed the last covered day of 11/13/24. The NOMNC and ABN were signed by Resident #92 on 11/13/24. On 03/10/25 at 5:32 P.M., interview with Social Services Designee (SSD) verified the NOMNC and ABN forms were not provided at least two days in advance for Residents #28, #91, and #92. SSD said she had only been in her position for one week and she did not know NOMNC and ABN forms had to be provided two days in advance.

Based on personnel file review and staff interview, the facility failed to ensure the Activities Director was qualified for the position. This had the potential to affect all 32 residents residing in the facility. Findings include: Review of the personnel file for Activities Director revealed no evidence of training or certification to be an Activities Director. Review of the receipt for Modular Education Program for Activities Professionals revealed registration for an upcoming training course was completed on 03/12/25. On 03/11/25 at 2:26 P.M., interview with Activities Director confirmed she was new to her position as Activities Director and was still learning the role. On 03/12/25 at 11:17 A.M., interview with Human Resources (HR) Director confirmed Activities Director did not have any formal training or education to be an Activities Director. HR Director further stated it was planned for Activities Director to complete the training but it had not been completed yet. On 03/12/25 at 3:21 P.M., interview with the Director of Nursing (DON) verified Activities Director enrolled in the training course on 03/12/25.

Based on observation, interview, and record review, the facility failed to ensure all staff wore appropriate personal protective equipment (PPE) during a COVID-19 outbreak. This had the potential to affect all 38 residents residing in the facility. Findings include: Review of the facility COVID-19 testing logs revealed a dietary staff member tested positive for COVID-19 on 06/27/22 and the facility went into outbreak status at that time. On 07/06/22 at 4:13 P.M., observation of the kitchen revealed Dietary Aid #519, Cook #543, Dietary Aid #554, and Dietary Manager #570 were not wearing face masks while working in the kitchen. On 07/06/22 at 4:58 P.M., interview with Dietary Manager #570 verified face masks were not worn by dietary staff. She stated they were not required to wear masks while working in the kitchen. Review of an email, dated 11/24/20, sent to the facility from the Stark County Health Department indicated dietary staff working in the kitchen were not required to wear N95 masks while working in the kitchen. The email did not indicate staff could work with no face covering. On 07/07/22 at 12:03 P.M., interview with the Stark County Health Department revealed the facility was to follow the guidance of the Alliance City Health Department regarding wearing face masks during the COVID-19 pandemic. On 07/07/22 at 12:55 P.M., interview with the Alliance City Health Department revealed the facility was to follow the Centers for Disease Control and Prevention (CDC) guidance for wearing face masks during the COVID-19 pandemic. Review of the CDC's Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2, updated 01/21/22, revealed the following: Healthcare personnel with prolonged close contact with any patient, visitor, or healthcare personnel with confirmed [CONDITION(S)]-CoV-2 infection while not wearing a facemask should follow all recommended infection prevention and control practices including wearing well-fitting source control.

Based on observation and interview, the facility failed to ensure foods and chemicals were stored separately in the kitchen. This had the potential to affect all 38 residents receiving food from the facility kitchen. The facility census was 38. Findings include: On 07/06/22 at 4:22 P.M., observation of the kitchen revealed two carts with ready to eat foods and beverages were stored in the same area as chemical products. At the time of observation, interview with Dietary Manager #570 confirmed the snack carts were stored alongside chemical products. On 07/07/22 at 8:23 A.M., observation of the kitchen revealed one cart with ready to eat foods and beverages was stored in the same area as chemical products. At the time of observation, interview with Cook #556 verified the snack cart was stored alongside chemical products. Cook #556 stated the kitchen staff usually pushed the snack carts to the chemical storage area when they needed to move the carts out of the way.

Based on record review and interview, the facility failed to ensure residents provided written authorization for management of resident accounts. This affected all 18 (Residents #1, #2, #4, #7, #11, #12, #14, #17, #18, #19, #22, #23, #27, #28, #29, #30, #31, and #33) with funds managed by the facility. The facility census was 38. Findings include: Review of the resident agreements for fund management revealed residents (Residents #1, #2, #4, #7, #11, #12, #14, #17, #18, #19, #22, #23, #27, #28, #29, #30, #31, and #33) did not provide written authorization for the facility to manage their funds. On 07/07/22 at 10:32 A.M., interview with Social Services Designee (SSD) #536 verified residents did not provide written authorization for the facility to manage their funds. On 07/07/22 at 3:17 P.M., an email from the Administrator confirmed no signatures were obtained from residents because the process of making the facility the representative payee was completed through the Social Security Administration and not the facility itself.

Based on medical record review and staff interview, the facility failed to provide written notification of transfer to the hospital to the resident and/or the resident's representative. This affected two (Resident's #9 and #37) of two residents reviewed for hospitalization . The facility census was 38. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognitive impairment. Resident #37 required extensive assistance of one staff member for bed mobility, dressing, toilet use, and person hygiene. She was frequently incontinent of bowel and bladder. Review of the nursing progress note dated 04/17/22 revealed Resident #37 was transferred to the hospital via ambulance. Upon request, the facility did not provide evidence of written notification of transfer to the hospital to Resident #37's representative. On 07/06/22 at 9:52 A.M., interview with the Social Service Designee #536 verified no written notification of transfer to the hospital was given to Resident #37's representative. 2. Review of Resident #9's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS 3.0 assessment dated [DATE] indicated Resident #9 was cognitively intact and required extensive assistance for toilet use and personal hygiene. A nursing note dated 12/03/21 at 1:30 P.M. indicated the nurse spoke to someone from a clinic who reported Resident #9 was transferred to the emergency room for evaluation and treatment. Resident #9 was lethargic (abnormally drowsy) and his blood pressure was low (82/54). A nursing note dated 12/03/21 at 6:47 P.M. indicated the hospital reported Resident #9 was being admitted with a urinary tract infection [CONDITION(S)]. No transfer notice information was able to be located. Resident #9 returned to the facility 12/17/21. On 07/06/22 at 9:55 A.M., SSD #536 revealed she was unaware the facility was required to provide transfer notices when residents were sent to the hospital. SSD #536 verified Resident #9 was at the hospital from 12/03/22 to 12/17/22.

Based on record review and interview, the facility failed to ensure an accurate Pre-Admission Screening and Record Review (PASRR) was completed prior to admission. This affected one (Resident #23) of four residents reviewed for PASRR. The facility census was 38. Findings include: Review of Resident #23's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a PASRR record dated 12/09/14 revealed dementia nor any of the mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 07/06/22 at 9:10 A.M., Registered Nurse (RN) #505 stated when Resident #23 was admitted he had a PASRR from the previous facility which came with him. When it was discussed the PASRR from 2014 did not reflect mental illness diagnoses, no explanation was provided as to why Resident #23 was not reassessed to determine if he could benefit from specialized services. On 07/06/22 at 12:03 P.M., the Administrator stated Resident #23 had been in a different facility between the one who provided the PASRR and this facility. The Administrator stated Resident #23 had been a long-term resident at the first facility and had no psychiatric diagnoses. The Administrator indicated he was not sure why Resident #23 had multiple psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on staff interview, record review, and policy review the facility failed to complete pre-[MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] assessments for one resident (Resident #15) of two residents reviewed for [MEDICAL TREATMENT] care. The facility census was 42. Findings Include: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 quarterly comprehensive assessment dated [DATE] revealed the resident was moderately cognitively impaired, needed extensive assistance for all personal care, and required [MEDICAL TREATMENT] treatments three times a week. Review of the progress notes from 06/01/19 through 07/02/19 revealed no documentation regarding Resident #15's [MEDICAL TREATMENT] port, if any bleeding was noted at the site, where the site was located, or assessments completed both before and after the resident returned from [MEDICAL TREATMENT]. Interview with the Assistant Director of Nursing (ADON) on 07/01/19 at 4:30 P.M. revealed Resident #15's [MEDICAL TREATMENT] provider did not provide the facility with updates regarding the resident's [MEDICAL TREATMENT] treatments on a routine basis. They submitted them to the facility approximately every six months. The facility requested monthly updates from the provider without success. Review of the facility's Policy # RC-30.0 [MEDICAL TREATMENT] Therapy, dated 01/01/17, revealed no documentation requirements for nurses to complete with each [MEDICAL TREATMENT] treatment. Interview with the Director of Nursing on 07/02/19 at 10:25 A.M. confirmed nursing has not been assessing Resident #15 either prior to leaving for [MEDICAL TREATMENT] or upon return to the facility after [MEDICAL TREATMENT] treatment had been completed.

Based on record review, interview, and policy review, the facility failed to ensure Foley (urinary) catheter orders were in place for one resident (Resident #193) of two residents in the facility with Foley catheters. Findings include: Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #193's hospital discharge orders and instructions revealed an order for [REDACTED]. Interview on 07/01/19 at 2:58 P.M. with the Director of Nursing (DON) verified Resident #193 did not have any Foley catheter orders since admission on 06/25/19. Review of the facility policy titled Urinary Catheter Insertion, Maintenance and Removal, dated (MONTH) (YEAR), revealed physician orders must be obtained for and to maintain Foley catheters.

Based on observation, record review and interview the facility failed to ensure proper infection control measures for respiratory equipment for two residents (Resident #22 and Resident #1) of eight receiving respiratory treatments. Findings include: 1. Record review revealed Resident #22 was admitted on [DATE] with [DIAGNOSES REDACTED]. There was a physician order [REDACTED]. Observation on 06/30/19 at 10:35 P.M. of Resident's #22's room revealed a nebulizer machine (device used to deliver breathing treatments) on the floor next to the bed. The mask through which the medicated mist was inhaled was covered in a plastic bag. Interview on 06/30/19 with Licensed Practical Nurse (LPN) #586 revealed the nebulizer machine was usually kept on the tray table, someone removed the table and set the machine on the floor. 2. Record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident had a [DIAGNOSES REDACTED]. Observation of Resident #1's room on 06/30/19 at 10:35 P.M. and on 07/01/19 at 10:45 A.M. revealed a portable ventilator device attached to a pole with a wire basket underneath that contained an uncovered full-face mask. Interview with Assistant Director of Nursing # 514 on 07/01/19 at 10:50 A.M. verified that no protective covering was around the ventilator face mask.

Based on interview and record review the facility failed to notify residents or their responsible party of the facility's bed hold policy. This affected one resident (Resident #42) of two reviewed for hospitalization . The facility census was 43. Findings include: Record review revealed Resident #42 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #42's progress notes revealed on 05/25/19 the resident was sent to the hospital via emergency medical services (911) per physician order [REDACTED]. Interview on 07/01/19 at 12:05 P.M. with Social Service Director (SSD) #559 verified there was no evidence of bed hold policy notification for Resident #42 when he was admitted to the hospital 05/25/19. SSD #559 revealed the facility had not been notifying family representatives of the bed hold policy. Review of facility's undated bed hold policy revealed the responsible party of the resident would be notified by certified mail on the day of the transfer or the day after the transfer. Notification would inform responsible parties of the transfer, the bed hold restriction and number of available bed hold days.

Based on observations, review of the medical record, facility investigation report, staff witness statements, facility policy and staff, resident, and family interviews, the facility failed to provide adequate supervision to prevent elopement of one cognitively impaired resident (Resident #1) with exit seeking behaviors. This resulted in Immediate Jeopardy when Resident #1 eloped from the facility. The likelihood of serious harm or injury occurred when the resident was picked up by a passer-by and taken to her previous residence. Resident #1's son was called by the family living in the home and he returned her to the facility on [DATE] at approximately 8:15 P.M. This affected one of one resident reviewed for elopement and one of two residents identified as at risk for elopement, (Resident #1 and #2). The facility census was 39. On 08/21/18 at 11:45 A.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) #107 were notified that Immediate Jeopardy began on 08/08/18 at approximately 6:30 P.M., when Resident #1, who had previously exhibited exit seeking behaviors was last seen and exited the facility without staff knowledge. The Immediate Jeopardy was removed on 08/10/18 when the facility implemented the following corrective actions: · On 08/08/18 at 8:15 P.M. Resident #1 was found and returned to the facility unharmed. Registered Nurse (RN) #108 assessed Resident #1 and no injuries were found. Resident #1 was wearing walking shoes, slacks, a shirt and light jacket and was sweaty but not short of breath. Resident #1 of was placed on every fifteen-minute observation checks until 08/11/18. · On 08/09/18, Resident #1 was placed on the Purple Star program, a program to alert staff a resident is at risk for elopement by placing a purple bracelet on the resident and placing a purple star on the wall next to their room door. · On 08/09/18, all facility doors were modified to alarm when anyone entered or exited, 24 hours a day except for the front door. The front door alarm is not on while the receptionist is on duty from 8:30 A.M. to 4:30 P.M., Monday through Friday. · On 08/09/18 and 08/10/18, elopement drills and in-services were conducted with all 26 staff members by the DON and ADON #107. On 08/22/18, at 4:30 P.M. the ADON indicated they were in the process of in-servicing, by telephone, the 25 staff who work on an as needed basis prior to them returning to work in the facility. · On 08/20/18, between 1:04 P.M. and 1:45 P.M. staff interviews with Licensed Practical Nurses (LPN) #100 and #104, State tested Nursing Assistants (STNA) #101, #102, #103 and Receptionist #105 indicated they were educated on the elopement policy and had participated in elopement drills. · On 08/20/18 at 1:29 PM, a physician order [REDACTED].#1 to have a wanderguard applied (a device which alarms to alert staff when an individual nears an exit door). · On 08/20/18 between 3:09 P.M. and 6:40 P.M., staff interviews with LPN #106, ADON #107, the DON, RN #108, and LPN #109 revealed staff members had knowledge on reassessing residents if exit seeking behaviors were exhibited, knowledge on the implementation of door alarms and the wander guard system and were knowledgeable on preventing resident elopement. The staff confirmed they had participated in elopement drills. · On 08/21/18 at 9:35 A.M., staff interview with LPN #110 confirmed staff were educated on reassessment, the elopement policy and had participated in elopement drills. · On 08/22/18 at 2:10 P.M., ADON #107 verified LPN #110 was verbally counseled and in-serviced on timeliness of reporting and reassessing residents who exhibit exit seeking behaviors. · On 08/22/18 at 3:25 P.M., ADON #107 confirmed all facility residents were reassessed for elopement risk and two residents (Resident #1 and Resident #2) were identified as being high risk for elopement. Care plans for elopement risk were in place for these two residents. · On 08/22/18 at 3:25 P.M., ADON #107 confirmed both Resident #1 and Resident #2 were on the Purple Star program. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan including conducting in services for as needed staff and monitoring to ensure on-going compliance. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set (MDS) 3.0 assessment with an Assessment Reference Date (ARD) of 08/03/18 revealed Resident #1 had severe cognitive impairment. The assessment indicated Resident #1 required limited assistance of one person for ambulation. Review of an elopement risk assessment dated [DATE] revealed Resident #1 was at moderate risk for elopement due to being mobile with a [DIAGNOSES REDACTED]. Resident #1's care plan, initiated on 07/27/18, indicated Resident #1 was at risk for elopement due to decreased memory and recall. Interventions in place included staff to discuss safety concerns with administration and/or physician as per policy and as needed, observe the resident frequently and complete wander risk/elopement assessments as per policy. A nursing progress note dated 08/01/18 at 4:12 A.M., authored by LPN #110, indicated Resident #1 was exit seeking at the beginning of the shift, however she was easily redirected. Record review revealed no notification to the DON or other administrative staff or the physician that Resident #1 exhibited exit seeking behavior. Resident #1's care plan was not updated to reflect the exit seeking behavior. A nursing progress note dated 08/08/18 at 8:25 P.M., authored by Registered Nurse (RN) #108, revealed at 8:00 P.M. STNA #111 was unable to locate Resident #1 in the facility after the 6:30 P.M. activity concluded. RN #108 initiated a facility search on the interior and exterior. At approximately 8:15 P.M. Resident #1 and her son were observed standing at the nurse's station. RN #108's progress notes stated the son reported Resident #1 had walked towards her previous residence, a concerned citizen had found her and had driven her to her previous home. The current homeowners knew the family and called Resident #1's son. The son picked Resident #1 up and brought her back to the facility. RN #108 documented Resident #1 was wearing walking shoes, slacks, a light jacket, was sweaty, but had no injuries. Her vital signs were normal with a blood pressure of 126/76, heart rate of 64, respirations of 16, temperature of 98.4 and an oxygen level of 95%. According to Acu-Weather.com the outdoor temperature was 80 degrees on 08/08/18. Review of the facility Self-Reported Incident (SRI), # 6, dated 08/08/18 revealed the following time line: Resident #1 participated in activities at 3:00 P.M. and 4:00 P.M. and was seen at dinner at 6:02 P.M. and 6:15 P.M. STNA #111 documented in a witness statement Resident #1 was in a group of residents gathered to attend the quarter bingo activity at 6:30 P.M. in the downstairs activity area. At the end of quarter bingo at 8:00 P.M., STNA #111 documented Resident #1 was not in the group of residents who returned to the second floor. STNA #111 informed the charge nurse, RN #108, that Resident #1 was unable to be located and a facility search was initiated which included RN #108 assigning staff members to different locations of the facility. Per her witness statement, LPN #106 saw Resident #1 and her son returning to the facility during the perimeter search at approximately 8:15 P.M. Staff interview with the DON and ADON #107 on 08/21/18 at 9:28 A.M. revealed they were not notified by LPN #110 when Resident #1 had exhibited exit seeking behaviors on 08/01/18. Telephone interview with LPN #110 on 08/21/18 at 9:35 A.M. revealed on 08/01/18, Resident #1 had attempted to walk out of the facility with another family member. LPN #110 stated Resident #1 was stopped before the lobby area. Resident #1 told staff she wanted to walk home and said it was not far away. LPN #110 stated Resident #1 was redirected back to her room by informing her of her son's wishes for her to remain in the facility. LPN #110 stated every fifteen-minute observation checks were initiated after this incident to monitor her whereabouts until 08/03/18. LPN #110 verified she did not notify the DON or the physician of this incident in order to reassess her and implement appropriate safety interventions. Review of the fifteen-minute observation checks revealed they were only completed during the 6:00 P.M. to 6:00 A.M. shift from 08/01/18 through 08/03/18. On 08/21/18, a wander guard was ordered for Resident #1 to alert staff if she was in the vicinity of an exit. Interview with Resident #1's son, on 08/22/18 at 9:26 A.M., revealed he was telephoned and told his mother was at her childhood home, which the family sold approximately one month ago. The son stated it was approximately a one-mile walk to their old home and she had to cross a busy four lane road in town which has one additional turn lane. Resident #1 was found sitting on the steps of a home and a concerned citizen asked Resident #1 where she was going. Resident #1 gave her old home address to the citizen, who then drove Resident #1 to her previous home. Resident #1 walked into the home and asked the new homeowners what they were doing in her home. The son stated the new homeowners contacted him by phone at 7:49 P.M. and he returned Resident #1 to the facility at approximately 8:05 P.M. with no injuries. Resident #1's son also confirmed Resident #1 had been placed on the Purple Star program and the facility doors are now alarmed. This deficiency substantiates Complaint Number OH 528.

Based on record review and interview, the facility failed to ensure one resident (Resident #1) of two residents reviewed for exit seeking/wandering/elopement were coded accurately on the Minimum Data Set (MDS) 3.0 assessment. This affected one of three residents reviewed for assessments. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's record review revealed a nurse's progress note, written by Licensed Practical Nurse (LPN) #110, dated 08/01/18 at 4:12 A.M. which stated Resident #1 had been exit seeking at the beginning of her shift. Phone interview with LPN #110 on 08/21/18 at 9:35 A.M. confirmed the progress note dated 08/01/18 and LPN #110 explained Resident #1 had attempted to leave the facility during the evening of 07/31/18 with another resident's visitors, however was easily redirected back to her room. Review of the comprehensive Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/03/18, revealed Resident #1 had impaired cognition scoring a seven out of 15 on the BIMS. Scores of zero to seven indicate severe cognitive impairment. The assessment was silent as to Resident #1 having behaviors of wandering. Staff interview on 08/22/18 at 11:25 A.M. with Assistant Director of Nursing (ADON) #107, who also completed the MDS assessments, verified the 08/03/18 was marked incorrectly regarding Resident #1's wandering behavior.

Based on record review and interview, the facility failed to revise the comprehensive care plan for Resident #1 related to exit seeking/wandering behaviors. This affected one of three residents reviewed for care plans. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's record review revealed a nurse's progress note, written by Licensed Practical Nurse (LPN) #110, dated 08/01/18 at 4:12 A.M. which stated Resident #1 had been exit seeking at the beginning of the shift. Phone interview with LPN #110 on 08/21/18 at 9:35 A.M. confirmed the progress note dated 08/01/18 and LPN #110 further stated Resident #1 had attempted to leave the facility during the evening of 07/31/18 with another resident's visitors, however was easily redirected back to her room. Review of the comprehensive care plan, initially dated 07/27/18 with a revision on 08/09/18, revealed the resident was at risk for falls/impaired safety/elopement secondary to decreased cognition. Interventions included ongoing assessment for resident needs, wander risk/elopement assessment as per policy, and to discuss safety concerns with administration and/or physician as per policy as needed. The care plan was not updated to address Resident #1's wandering or exit seeking behaviors which occurred 07/31/18. Staff interview on 08/22/18 at 11:25 A.M. with the Assistant Director of Nursing (ADON) #107, who also completed the care plans, verified the care plan was not revised and did not accurately reflect Resident #1's exit seeking/wandering behaviors.

Based on observation, interview and review of the facility sanitation policy the facility failed to ensure that food was prepared, stored and served under sanitary conditions. This affected 39 resident who received their meals from the kitchen and excluded one resident, Resident # 27 who did not eat by mouth. Findings include: 1. Observation on 05/29/18 from 9:31 A.M. to 10:05 A.M. in the kitchen revealed two small brown stained dishcloths laying under the spout to the coffee container and sitting on the work space next to the coffer container. A clean rack of dishes was drying on top of a large towel next to the dishwasher machine. Four glasses were inverted and air drying on top of a large towel. The oven door was covered with dried splattered white substance. The backsplash behind the stove was covered with a layer of splattered grease. The garbage container was filled to the top and the cover was laying on floor next to the container along with along with three cardboard boxed that were broken down. The floor was sticky and a layer of black debris covered the baseboard along the floor. The refrigerator contained an unlabeled open bag of carrots with an expiration date of 05/21/18, an opened unlabeled bag of celery had an expiration date of 05/28/18 , and there were three unopened, undated bags of salad mix. Interview on 05/29/18 at 10:05 with the head dietary cook and assistant dietary manager verified the findings. 2. Observation on 05/30/18 at 12:10 P.M. of the ice machine located in employee lounge revealed a layer of dark black debris located on the internal rim of the ice dispenser. Interview on 05/30/18 at 12:10 P.M. with Dietary Supervisor verified the observation and stated dietary did not serve any ice to residents. Observation on 5/30/18 at 12:56 P.M. revealed a pitcher of water with ice sitting on top of the medication cart on the second floor. Observation on 5/30/18 at 1:05 P.M. revealed a pitcher of water with ice sitting on top of the medication cart located on the first floor. Interview with Registered Nurse #50 revealed ice was used in the water for medication pass. In addition, one resident requested ice and it was provided from the only ice machine located in the employee lounge. Interview on 05/30/18 at 1:07 P.M. with the Assistant Director of Nursing verified nursing used ice water for medication passes and hydration for residents. The ice was provided from the ice machine located in the employee lounge. Review of the facility's ice policy dated (YEAR) revealed ice machines would be maintained in a clean and sanitary condition to prevent ice contamination. Review of undated food and nutrition services general sanitation of kitchen revealed an outlined specific cleaning schedule for kitchen. Review of food safety and sanitation policy dated (YEAR) revealed food items should be labeled and dated. Review of cleaning dish/dish machine policy dated (YEAR) revealed dishes should be air dried on dish racks.

Based on staff interview, resident interview, record review, and self-reported incident review the facility failed to ensure Resident #17 was free from non consensual sexual contact. This affected one of 39 residents residing in the facility. Findings Include: Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS quarterly comprehensive assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance for all personal care. Medical record review revealed Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS quarterly comprehensive assessment dated [DATE] revealed the resident was cognitively intact, needed assistance for all personal care, and took an antidepressant daily. The resident was discharged on [DATE] due to an escalation of inappropriate behaviors and transferred to a psychiatric center for treatment. Review of the nursing notes for Resident #190 from admission to discharge revealed the resident demonstrated inappropriate behaviors including tearing decorations off the walls, spitting on the floor, entering female resident rooms without permission when personal care was being provided, making sexually inappropriate remarks to staff and residents, and touching staff and other residents inappropriately. Resident #190's behaviors escalated throughout his stay. The resident's daughter, felt her father was acting out so he would be discharged and go back to living with her; however she was no longer able to care for him at home. Review of SRI # 5 dated 02/10/18 revealed Resident #190 attempted to kiss Resident #17 as he touched her breast. Staff intervened and escorted Resident #190 to his room. Resident #190 was placed on 1:1 observation while up and every 15 minute checks when in bed. The other residents on the unit were interviewed and they indicated they had not been bothered by any other resident. Resident #17 was checked every 30 minutes to determine how her well being was. Interview with Resident #17 on 05/30/18 at 10:34 A.M. revealed there had been a resident at the facility who did terrible things and made a lot of girls cry. She was happy he was gone. Interview with the Administrator and the Assistant Director of Nursing (ADON) on 05/30/18 at 4:45 P.M. revealed the facility substantiated SRI # 5 for sexual abuse. Resident #17 was severely cognitively impaired and not able to give informed consent for Resident #190 to touch her in a sexual manner.

Based on staff interview, resident interview, record review, policy review, and self-reported incident review the facility failed to ensure their abuse policy and procedure was implemented to protect Resident #17 from non consensual sexual contact. This affected one of 39 residents in the facility. Findings Include: Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly comprehensive assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance for all personal care. Medical record review revealed Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS quarterly comprehensive assessment dated [DATE] revealed the resident was cognitively intact, needed assistance for all personal care, and took an antidepressant daily. The resident was discharged on [DATE] due to an escalation of inappropriate behaviors and transferred to a psychiatric center for treatment. Review of the nursing notes for Resident #190 from admission to discharge revealed the resident demonstrated inappropriate behaviors including tearing decorations off the walls, spitting on the floor, entering female resident rooms without permission when personal care was being provided, making sexually inappropriate remarks to staff and residents, and touching staff and other residents inappropriately. Resident #190's behaviors escalated throughout his stay. The resident was not under psychiatric care. The resident's daughter felt her father was acting out so he would be discharged and go back to living with her; however she said she was no longer able to care for him at home. Review of SRI # 5 dated 02/10/18 revealed Resident #190 attempted to kiss Resident #17 and touched her breast. Staff intervened and escorted Resident #190 to his room. Resident #190 was placed on 1:1 observation while up and every 15 minute checks when in bed. The other residents on the unit were interviewed and indicated they had not been bothered by any other resident. Resident #17 was checked on every 30 minutes to determine how her well being was. The facility investigation did not include written statements from the staff who witnessed the incident. Interview with Resident #17 on 05/30/18 at 10:34 A.M. revealed there had been a resident at the facility who did terrible things and made a lot of girls cry. She was happy he was gone. Interview with the Administrator and the Assistant Director of Nursing (ADON) on 05/30/18 at 4:45 P.M. revealed the facility substantiated SRI # 5 for sexual abuse for Resident #17. Resident #17 was severely cognitively impaired and was not able to give informed consent for Resident #190 to touch her in a sexual manner. Resident #190 was not under psychiatric care as the facility did not have a psychiatrist available until after the resident was discharged . The administrator confirmed no staff statements were available for review. Review of the facility's Resident Abuse and Neglect policy, dated (MONTH) (YEAR), revealed administration would investigate all allegations of abuse, neglect, misappropriation, and injuries of unknown origin. Sources of information included review of documentation, review of the medical record, staff witness statements, and interviews with residents and any family or visitors present at the time of the allegation.

Based on closed record review and interview the facility failed to prevent a fall with fracture for Resident #7. The facility also failed to ensure new interventions were initiated timely and all fall interventions were in place and properly functioning to prevent falls. Actual harm occurred when Resident #7, who had a history of [REDACTED]. This affected one resident (Resident #7) of three residents reviewed for falls. Findings include: Review of Resident #7's closed medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with Hospice Medicaid. A fall risk assessment dated [DATE] revealed the resident had a history of [REDACTED]. Record review revealed a plan of care, initiated 03/30/16 that reflected the resident was at risk for falls and/or impaired safety due to unsteady gait, impaired balance, decreased coordination and decreased safety awareness. The care plan also reflected the resident was impulsive. Interventions included on 04/11/16 to use devices as ordered on admission, on 06/14/16 a sensor pad bed alarm and on 07/12/16 a chair alarm. A plan of care, initiated 04/11/16 revealed the resident had a self care deficit- activities of daily living (ADL) and required extensive assistance from staff with ADL's to perform tasks. The care plan revealed the resident presented with decreased safety awareness, decreased cognition and required extensive staff assistance. Interventions included for staff to provide extensive assist with ambulation, transfer and toileting. Record review revealed updated interventions following a fall on 05/20/16 included the use of non-skid socks at all times. The investigation dated 05/26/16 revealed the resident was placed on every 15 minute checks. The progress notes for Resident #7 dated 07/12/16 at 5:15 P.M. revealed the State tested nursing assistant (STNA) alerted the nurse the resident was on the floor in the dining room. The investigation dated 07/15/16 regarding the fall on 07/12/16 revealed antibiotic therapy was initiated due to the change in condition and a sensor alarm was ordered for the chair. The progress notes dated 10/23/16 at 4:30 P.M. revealed the STNA alerted the nurse Resident #7 was on the floor in the dining room. The nurse observed the resident lying flat on the floor with a pillow under her head. The facility information revealed the sensor pad alarm did not sound at the time of the fall. A new alarm was placed on the wheelchair. The investigation dated 10/28/16 regarding the fall revealed all falls were reviewed by therapy. The plan of care, documentation, history and medications were reviewed at that time. The progress notes dated 11/07/16 at 10:30 P.M. revealed the nurse entered Resident #7's room after hearing the faint noise of a bed alarm. The resident was noted to be lying on the floor in front of the bathroom door with her head against the empty bed's footboard. The resident was noted to be barefoot and the wheeled walker was in the bathroom. The resident stated she was trying to go to the bathroom, she confirmed hitting her head and denied any pain. The facility information revealed the volume of the alarm was too low at the time of the fall and turned it on high after the incident. Staff were educated regarding the volume of the bed alarm. A restorative nurse toileting program was to be reviewed. The progress notes dated 12/01/16 at 1:15 A.M. revealed the STNA heard an alarm from Resident #7's room. The STNA found the resident in the bathroom, sitting on the floor with her back against the commode. The resident was instructed to use the call light. The resident was noted to have on regular socks at the time of the fall. Staff put gripper socks on the resident. The investigation regarding the fall revealed a perimeter defining mattress was added for safety. The progress notes dated 12/07/16 at 6:47 P.M. revealed Resident #7 was in the dining area when the STNA heard a noise. The STNA found the resident laying on the floor beside the table. The resident stated she slid down. The alarm was still intact attached to the resident's collar. The staff were instructed to attach the alarm to the resident's back so she could not reach it. A skin tear was noted to the outer right elbow. Geriatric sleeves to both arms and a Dycem to the wheelchair were initiated. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/03/16 revealed the resident exhibited cognitive impairment with a Brief Interview for Mental Status (BIMS) score of three. The assessment also revealed the resident required extensive assistance from staff for ADL's. A late entry progress notes dated 12/12/16 at 5:00 P.M. revealed Resident #7 was in the dining room when a nurse responded to the sensor pad alarm sounding. The nurse and the assistant director of nursing (ADON) #10 observed the resident on the floor. The resident was noted to be next to the Broda chair in a sitting position with legs straight out facing the television in the dining room. The resident was noted to be incontinent. The investigation dated 12/20/16 regarding the fall on 12/12/16 revealed the resident had been taken to the toilet at 4:15 P.M., transferred to the Broda chair and taken to the dining room. Staff were advised the resident was to be the last resident to enter the dining room and the first resident to exit the dining room. The progress note dated 01/14/17 at 12:15 P.M. revealed the nurse was alerted that Resident #7 was in her room on the floor. The nurse observed the resident on the floor laying on her left side with her legs bent and head positioned towards the door. The resident's alarm was not intact and not sounding at the time of the fall. The resident was assisted to the toilet and noted to be incontinent of loose bowel. The resident was unable to state what happened. The STNA stated the resident had two other episodes of loose bowel previously in the shift. Staff were educated to ensure the alarm was intact when doing every 15 minute checks. The investigation dated 01/15/17 revealed the restorative nurse was to evaluate the resident for programs to increase the resident's endurance. A late entry progress note dated 01/29/17 at 4:10 A.M. revealed an STNA alerted the nurse Resident #7 was on the floor. The STNA was alerted to the resident's room by an alarm sounding. The resident was laying on her back, slightly on her left side with her head under the bed and feet out toward the other bed in the room. The gripper socks were noted to be on the resident. The resident was unable to state what happened, but was alert and oriented as per her usual. Neurological checks were initiated as per protocol. ROM to the upper body and right leg were within normal limits. ROM to the left leg was assessed. The resident was able to move the left leg and complained of pain while moving. The resident was offered a pain medication, but refused. There was no protrusion of the left hip and the left leg was straight. The resident was transferred to the bed with two staff assists. A skin sweep was completed. A grape size bump was noted on the resident's head behind the left ear and a pin sized red abrasion was noted behind the left hip near the buttock. The resident's brief was wet and was changed. The resident complained of pain in the left hip while she was being turned only. The resident was offered pain medication and refused. A maintenance requisition was completed for non-skid strips to the floor where the resident entered and exited the bed. The physician was paged. The X-ray company was called for an X-ray of the left hip at 4:15 A.M. The progress notes revealed the neurological checks were completed every 15 minutes, four times, after the fall as per protocol. The neurological checks and vital signs were completed on 01/29/17 at 4:10 A.M., 4:25 A.M., 4:40 A.M., 4:55 A.M. and 5:25 A.M. as per protocol. The progress notes revealed the neurological checks that were due at 5:55 A.M. were not completed because the technician, who was performing the X-ray of the left hip, was in the resident's room and the emergency medical technicians (EMT) entered the resident's room after the X-ray was completed. At 6:25 A.M. the resident was sent to the hospital for an evaluation and treatment per nursing judgement. The preliminary X-ray report indicated the resident had a left hip fracture. The POA was aware and stated would meet the resident at the hospital. Record review revealed the resident did not return to the facility after being sent to the hospital. An interview with the ADON #10 on 03/15/17 at 12:40 P.M. regarding Resident #7 verified the times of the neurological checks after the fall on 01/29/17. He stated the licensed practical nurse (LPN) had explained the neurological checks that were due at 5:55 A.M. were not able to be completed due to the X-ray that was taken and the EMTs who arrived to transport the resident. The interview with the ADON also revealed the interdisciplinary (IDT) meetings were conducted with both of the resident's sons present and the resident's daughters on the telephone. The ADON stated he saw the resident's son almost every morning that he worked. An interview with the DON on 03/16/17 at 11:10 A.M. verified the resident's sensor pad alarm did not sound at the time of the fall on 10/23/16. There was no documentation that therapy reviewed the falls as was mentioned in the investigation. There were no new interventions initiated. The DON verified the alarm was on low when the fall of 11/07/16 occurred. The resident did not have gripper socks on prior to the fall of 12/01/16 which were ordered after the fall on 05/20/16. The fall on 12/07/16 was in the dining room, as were multiple falls, and there were no new interventions initiated to prevent falls when in the dining room. The fall on 01/14/17 from the resident's bed revealed the alarm was intact, but not sounding. The DON verified the resident sustained [REDACTED]. This deficiency substantiates Complaint Number OH 912.

Based on observation, interview and record review the facility failed to ensure appropriate wheelchair positioning for Resident #54 to prevent a fall resulting in facial and head injuries. Further the facility failed to ensure assessments and interventions were in place to prevent falls for Resident #53. This affected two of four residents reviewed for accidents. The facility census was 41. Findings include: 1. Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall risk assessment dated [DATE] indicated the resident was at risk for falls. The Minimum Data Set (MDS) 3.0 dated 12/14/11 indicated the resident had severe cognitive impairment and verbal behavior towards others. Nurses progress notes dated 12/24/11 at 10:21 A.M. indicated the resident was found on the floor by State tested Nurse Aide (STNA) #10. The resident had swelling to the left forehead and a laceration to the right index finger. Licensed Practical Nurse (LPN) #5 cleansed the index finger with normal saline and applied a Band-Aid. Nursing progress noted dated 12/25/11 at 10:30 AM indicated the resident had a purplish green bruise to the left side of the face and head starting above the mid left eyebrow extending to the back of left ear. A self-reported incident dated 12/25/11 indicated the resident was assisted into her wheelchair by two STNAs (STNA #10 and #11) on 12/24/11. The STNAs did not properly position the resident or apply the foot rests to the resident's wheelchair. The resident fell face forward from the wheelchair onto the floor sustaining the facial hematoma. Interview with the assistant director of nursing (ADON) on 09/13/12 at 9:45 A.M. revealed the STNAs did not tilt the wheelchair back for proper positioning and did not apply the wheelchair foot rests. The resident fell forward from the wheelchair onto the floor sustaining the injury. 2. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE] revealed the resident had an unsteady gait and required extensive assistance to transfer and ambulate. The record did not contain a fall risk assessment or an admission plan of care addressing the risk for falls with interventions to prevent falls. Review of the admission minimum data set assessment ((MDS) dated [DATE] revealed the resident was cognitively intact. The assessment revealed that the resident had a fall in the previous two to six months. Review of the nursing notes dated 08/23/12 at 7:46 A.M. revealed that the resident had an "extremely unsteady gait, shuffling feet and grasping at items as she passed." The note indicated she required extensive assist of two staff, but with staff encouragement, showed great improvement when returning to bed, although her gait remained unsteady. A nursing note dated 08/30/12 at 3:39 A.M. revealed at 2:45 A.M., the resident was heard to call for help. She was found on the floor by the bathroom doorway on her buttocks. She had gripper socks on her feet but stated that she had not used her walker. The resident did not have an injury according to the note. The note stated the importance of use of the call light for assistance was explained to the resident. The resident was observed on 09/11/12 at 1:30 P.M. ambulating in the hall with a walker with the assistance of one staff member. The resident was pleasant but slightly confused. Interview with the director of nursing (DON) on 09/11/12 at 3:50 P.M. revealed that newly admitted residents were considered a fall risk and that all residents were instructed on the use of the call light. She verified that a fall risk assessment had not been completed for Resident #53, and that falls and safety had not been initially care planned to provide staff with interventions to prevent falls. She verified that the documentation indicated the resident was confused and required assistance to the bathroom.

Based on observation, interview and record review, the facility failed to ensure comprehensive care and services to address the diabetic needs of Resident #36. This affected one of 10 sampled residents, with a facility census of 35. Findings include: Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the notes from the hospital indicated that on 06/28/11, the resident's diabetes was "out of control" and blood sugar was over 300, in part due to steroid use. The note from the hospital on [DATE] revealed that the resident was having low blood sugar episodes with a level of 30 that morning. The resident had a admitting orders written on 06/30/11, including an oral anti-diabetic medication to stabilize blood sugars and insulin to be given per a sliding scaled based on the resident's blood sugar four times a day at 7:00 AM, 12:00 noon, 5:00 PM and 8:00 PM. The sliding scale indicated that the physician was to be called if the resident's blood sugar was below 70, above 350 or if it were to be more than 250 twice in 24 hours. The admitting orders also indicated that the physician was to be faxed the results of the blood sugars each day with medications given. Review of the residents diabetic flow sheet and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The blood sugar on 07/05/11 at 7:00 AM was 62, but there was no documentation of notification of the physician. The resident signs or symptoms of [DIAGNOSES REDACTED] or treatment for [REDACTED]. On 07/05/11 at 12:00 P.M., the resident's blood sugar was 204 and the record indicated he received 2 units of coverage of insulin instead of the ordered 4 units of insulin. Review of the diabetic flow record indicated no blood sugar checks for 07/06/11 at 12:00 noon or 4:00 PM. The Medication Administration Record, written by the sliding scale area and no further sliding scale dosages were recorded after 7:00 AM on 07/06/11. Although a separate section on the MAR indicated [REDACTED]. The resident's blood sugar was 313 on 07/06/11 at 8:00 PM and 317 on 07/07/11 at 12:00 noon. No indication was in the record that the resident received the required 10 units of insulin for the 313 and 317 levels. Further review of the record revealed a physician order [REDACTED]. On 07/06/11 at 2:45 PM, a physician order [REDACTED]. There was no indication that this medication was given on 07/06/11 in the MAR. An order was written on 07/07/11 at 4:45 P.M. to increase the resident's oral anti-diabetic medication to 10 mg once a day. There was no indication that this medication was given on the MAR. The resident had blood sugars over 400 on 07/07/11 at 4:00 PM and 8:00 PM with coverage given after phone calls to the physician. On 07/08/11 at 2:15 AM, nurses notes indicated that the resident was found unresponsive and clammy, with a flushed face. His blood sugar at that time was 40 and staff attempted to give the resident juice, which he was unable to swallow. The note indicated that glucose gel was given to the [MEDICATION NAME] area at 2:30 A.M. when his blood sugar was 39, and then a [MEDICATION NAME] injection was given per protocol at 2:45 A.M. for a blood sugar of 58. His blood sugar was 296 at 3:00 AM. A note dated 07/08/11 at 4:00 AM revealed the resident was up drinking ginger ale and eating crackers, stating that he felt much better. A note at 6:20 AM revealed the resident having spastic type [MEDICAL CONDITION] movements. The physician was notified and the resident was sent to the hospital. His blood sugar was recorded at 6:30 AM as 121. Review of the hypoglycemic assessment, notification guidelines and standard provider orders revealed that the physician should be notified immediately with a blood sugar less than 70, or greater than 250 after insulin. or if a diabetic has a sudden change in level of consciousness. The guidelines indicate that if the blood sugar is less than 70, the staff should give juice or glucose gel and reassess the blood sugar in 15 minutes. If the blood sugar was still under 70, the initial process should be repeated. The next step indicated that if signs and symptoms are not relieved, the nurse should give [MEDICATION NAME] 1 milligram intramuscularly stat. The protocol then indicated that the treatment should be followed with complex carbohydrate intake and monitor until blood glucose is stabilized. Review of the resident's care plans revealed a care plan for potential for injury related to falls and one for potential for impairment in skin integrity. Both care plans were dated 07/01/11. The assistant director of nursing verified on 07/13/11 at 9:00 AM that no care plan had been in place or found in the record to address and provide guidance for the management of the resident's diabetic needs. Interview with the director of nursing on 07/13/11 at 8:30 AM verified that the physician was not notified, that the protocol was not followed and that complex carbohydrates were not given on 07/08/11 after two doses of medication to raise the blood sugar quickly. The director of nursing also verified at that time that the ordered oral antidiabetic medication had not been given as ordered on [DATE] or 07/07/1. She verified that although the orders had been written in the afternoon, the nurse should have either given the medication or clarified with the physician to wait to give the medication until the next morning at the time that once a day medications were routinely administered. She further verified that the record was not complete in relation to several blood sugar levels and interventions taken by the staff in response to those levels.