Every finding on record at Bellevue Care Center

Based on medical record review, staff interview, physician interview, and policy review, the facility failed to ensure wound care was completed as required. This affected one (#69) of three residents reviewed for wound care. The facility census was 59. Findings Included: Review of Resident #69's medical record revealed an admitted [DATE]. Diagnoses included post operative orthopedic care of the right ankle, rib fracture, sacrum fracture, and cervical fracture due to a motor vehicle accident and congestive heart failure. Review of Resident #69's hospital note dated 09/18/24 revealed the resident was involved in a motor vehicle accident and suffered a fracture and dislocation of the right medial ankle joint. On release to the long-term care facility, the sutures remained intact along with wearing a hinged knee brace locked in extension and a foot/ankle splint. Review of Resident #69's admission Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was intact. The resident was assessed with one surgical wound. Review of Resident #69's care plan revealed a start date of 09/23/24 which indicated the resident had a surgical wound to her right leg due to surgery on a fracture and a laceration to the right ankle. Review of Resident #69's physician order dated 10/01/24 revealed staff were to cleanse the sutures with normal saline, pat dry, apply an abdominal pad, cover with Kerlix, and apply the Seattle splint (a brace used to treat orthopedic trauma/surgical repairs). The ordered ended on 10/09/24. Review of Resident #69's treatment administration record (TAR) for October 2024 revealed the resident did not have a dressing change completed to the right ankle wound between 10/10/24 and 10/24/24. Review of Resident #69's weekly observation review dated 10/16/24 revealed the resident assessment included an ORIF (open reduction and internal fixation) of the ankle which included a surgical wound. Review of Resident #69's physician order dated 10/25/24 revealed staff were to change the dressing daily to the right lower extremity, cleanse with normal saline, apply adaptic, an abdominal pad, and Kerlix once daily. The ordered had an end date of 10/31/24. Review of Resident #69's progress note dated 10/31/24 revealed the resident was being admitted to the hospital for surgery and debridement of the right ankle wound. Telephone interview with Orthopedic Surgeon (OS) #500 on 11/25/24 at 3:37 P.M. revealed Resident #69 suffered a severe ankle injury and had a lack of blood flow to the area. OS #500 stated the facility should have sought treatment for Resident #69's ankle wound because the resident had an open surgical wound and no active treatment orders from 10/10/24 through 10/24/24. OS #500 stated Resident #69 had many underlying factors and could not definitively say the lack of wound treatment orders between 10/10/24 and 10/24/24 caused the need for surgical intervention and debridement of the resident's right ankle. Interview with the Director of Nursing (DON) on 11/26/24 at 11:00 A.M. revealed Resident #69 had no wound treatment orders for the right ankle between 10/10/24 and 10/24/24. The DON stated she spoke with the wound care nurse and both were unaware of the reason Resident #69 failed to have wound care provided from 10/10/24 through 10/24/24. Review of the facility policy titled, Pressure Injury Prevention and Treatment Policy, revised 09/18/23, revealed injuries will be documented and orders obtained from providers for treatment. This deficiency represents non-compliance investigated under Complaint Number OH00160062 and Complaint Number OH00159749.

Based on observation and staff interview, the facility failed to ensure resident care equipment (fall mats) were maintained in a clean and sanitary condition. This affected four (#5, #26, #28 and #32) of four residents reviewed who use a fall matt for safety. The facility census was 59. Findings include: Observation on 10/03/24 between 11:00 A.M. and 11:34 A.M. with Maintenance Director(MD) #534 revealed the falls mats utilized by Residents #5, #26, #28 and #32 were old bed mattress that were held in place by velcro. Observations of these mattresses noted the velcro that held the mattress in place was brown in color and with numerous areas of stains, dirt and other debris on the velcro its self. The outer areas of the mattress had various levels of other dust, dirty and debris as well. An interview with MD #534 verified the condition of the fall mats at the time of observation.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to provide oral hygiene per physician orders and care plan. This affected one (#5) of one resident reviewed for activities of daily living. The facility census 59. Findings include Review of the medical record revealed Resident #5 had an admitted [DATE]. Diagnoses included diffuse traumatic brain injury, dysphagia, moderate intellectual disabilities, hypertension, cognitive communication deficit, and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for oral hygiene. Review of the care plan dated 03/04/24 revealed the resident had potential for oral/dental health problems. The resident was noted as resistant to brushing and flossing teeth at times. Interventions included to brush and floss teeth after each meal and at bedtime. Review of a physician order dated 01/19/24 revealed an order to brush teeth and floss after every meal and at bedtime. Review of a dental progress note dated 06/24/24 revealed the resident had a lot of plaque. Please make sure the resident's teeth were cleaned after every meal and flossed. Review of a dental note dated 09/19/24 revealed the resident's teeth had moderate plaque. Please brush and floss after each meal. Review of the nursing assistant task documentation from 09/02/24 through 10/02/24 revealed the resident's teeth were brushed per physician orders only once in the past 30 days. Review of the nurses notes dated 09/01/24 through 10/02/24 revealed the resident had not refused oral hygiene. Observation on 10/02/24 at 8:42 A.M. revealed Resident #5 had completed his breakfast meal in the dining room. Observation on 10/02/24 at 9:04 A.M. revealed State tested Nursing Assistant (STNA) #528 assisted the resident to his room and checked the resident for incontinence. Resident #5 had yellow discolored teeth. STNA #528 did not offer to brush Resident #5's or floss teeth after the breakfast meal. Interview on 10/02/24 at 9:08 A.M., STNA #528 revealed the resident required no further care and had not brushed or flossed Resident #5's teeth after breakfast. When asked about brushing the resident's teeth, STNA #528 revealed the resident's teeth were brushed before breakfast and not after. STNA #528 revealed the resident's teeth were brushed twice per day in the morning and at night. Observation on 10/02/24 at 12:45 P.M. revealed Resident #5 had completed his lunch meal in the dining room. STNA #532 and STNA #528 assisted Resident #5 to his room and transferred the resident with the mechanical lift from the wheelchair to the bed to check for incontinence. STNA #528 and STNA #532 then transferred Resident #5 back to his wheelchair and revealed his care was complete. Resident #5's teeth were not brushed or flossed. Interview on 10/02/24 at 12:55 P.M., STNA #532 revealed when asked about brushing and flossing Resident #5's teeth, the resident's teeth would not be brushed until after dinner. Interview on 10/02/24 at 1:08 P.M. with Licensed Practical Nurse (LPN) #542 verified Resident #5 had a physician order to brush and floss teeth after meals and at bedtime. Interview on 10/02/24 at 2:09 P.M. the Director of Nursing (DON) reviewed the oral care documentation for Resident #5 and revealed the resident's teeth were not brushed and flossed per physician orders and care plan. Review of the facility policy Morning Care/AM Care revised 11/08/23, and review of the policy Evening Care/PM Care, revised 06/15/20, revealed staff would assist with or provide oral hygiene.

Based on record review, staff and resident interview, and review of the facility policy, the facility failed to maintain fall safety interventions to prevent a resident from falling. This affected one (Resident #1) of three residents reviewed for falls. The facility census was 59. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included multiple sclerosis (MS), moderate protein calorie malnutrition, lymphedema, adult failure to thrive, and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/30/23, revealed Resident #1 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #1 was at high risk for falls. Review of the plan of care dated 06/26/23 revealed Resident #1 was at risk for falls due to history of fall, multiple sclerosis, and decreased mobility. Interventions included implementing preventative fall interventions/devices, call light in reach, non-skid footwear, wheelchair pedals to be on when transporting resident, and administering medication as ordered. Review of the fall investigation dated 08/12/23 revealed Resident #1 was sitting on side of bed. One state tested nursing aide (STNA) was assisting her with transferring to wheelchair, the floor was wet and slippery. The statement from STNA stated as she was getting Resident #1 up to her chair, she slid and lost balance and she assisted her down to the floor. The care plan stated two-person assists for transfers. A new intervention was making sure the floor was dry prior to getting Resident #1 up. Interview on 09/06/23 at 12:48 P.M. with Resident #1 revealed she had had a couple of falls a few weeks ago. Resident #60 stated she fell when she was being transferred from bed to wheelchair with one staff and her feet got tangled and she fell by bed. Resident #1 stated she has MS and at times her feet don't work like they should. Interview on 09/06/23 at 2:20 P.M. with the Director of Nursing (DON) and Administrator verified Resident #1 was a two-person assist for transfers and one STNA should not have transferred Resident #1 by herself. Interviews on 09/06/23 from 12:50 P.M. through 4:05 P.M. with Licensed Practical Nurse (LPN) #300, #301, STNA #302 and #303 revealed Resident #1 was a two-person assist for transfers. Review of the facility policy titled Fall Management, dated 12/09/19, revealed individualized interventions will be based on assessment and care plan accordingly. This deficiency represents non-compliance investigated under Complaint Number OH00146056.

Based on medical record review, family and staff interviews, and review of facility policy, the facility failed to provide oral care to residents who were dependent upon staff for oral care. This affected one resident (#29) of one residents reviewed for Activities of Daily Living (ADLs). The facility census was 47. Findings included: Review of the medical record for Resident #29 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment, dated 04/08/22, revealed Resident #29 was severely cognitively impaired, required extensive assistance with Activities of Daily Living (ADLs), and did not reject care. Review of the plan of care, revised 12/28/20, revealed Resident #29 had an ADL self care performance deficit related to impaired balance, limited mobility, musculoskeletal impairment, TBI, seizures. Resident #29 refused care at times and could be resistive, combative, and refused to allow staff to brush teeth and shave at times. Interventions included if care refused, attempt again later and oral care daily and as needed. Additional review revealed Resident #29 had potential for oral/dental problems due to resistance to brushing and flossing teeth. Interventions included brush teeth after every meal and at bedtime and oral care per routine and as needed. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of dentist progress notes dated 11/18/21 and 02/02/22 revealed Resident #29 had plaque build-up and needed to brush and floss teeth after each meal. Review of a dentist progress note dated 05/09/22 revealed Resident #29 had generalized plaque and needed to brush and floss after every meal and at bedtime. Review of State tested Nurse Aide (STNA) documentation from 04/01/22 through 05/16/22 revealed Resident #29 was to have his teeth brushed and flossed after each meal, document refusals. Additional review revealed oral care was not documented as provided or refused on 04/01/22, 04/02/22, 04/08/22, 04/17/22, 04/23/22, 04/27/22, 05/03/22, and 05/04/22. Further review revealed not applicable was documented on 04/05/22, 04/06/22, 04/12/22, 04/26/22, 04/28/22, 05/02/22, 05/07/22, 05/08/22, and 05/12/22. Review of nursing progress notes from 04/01/22 through 05/17/22 revealed no documentation Resident #29 refused ADL care, including oral care. Additional review of a note dated 05/09/22 revealed Resident #29 returned from a dental appointment and to encourage teeth brushing and flossing after each meal. Interview on 05/16/22 at 11:42 A.M. of Resident #29's family member revealed the facility did not regularly brush the Resident's teeth. The family member stated she had to take Resident #29 to the dentist every two to three months to have his teeth cleaned because the facility did not adequately keep up with oral care. Interview on 05/17/22 at 9:03 A.M. of Licenses Practical Nurse (LPN) #565 revealed Resident #29 required extensive assistance for all care, including oral hygiene. LPN #565 stated Resident #29 could be resistive to care but staff just needed to re-approach a few minutes later and he would accept care. Interview on 05/17/22 at 9:13 A.M. of State tested Nurse Aide (STNA) #508 revealed Resident #29 would resist oral care but would generally accept care if re-approached at a later time. Interview on 05/17/22 at 10:38 A.M. of STNA #512 revealed Resident #29 required extensive assistance with all areas of care, including oral care. While Resident #29 was not always cooperative with care, STNA #512 stated joking with the Resident was usually effective and Resident #29 would accept care. STNA #29 stated documentation of care provided to residents, including refusals of care, was documented in the resident's electronic medical records. Interview on 05/17/22 at 11:01 A.M. with the Director of Nursing (DON) revealed nursing staff would update resident physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified Resident #29's orders should have been updated to reflect the most recent dentist recommendation, dated 05/09/22, which included brushing and flossing after every meal and at bedtime. The DON stated nursing staff may have spoke with the dentist and received different orders, but she would have to look into whether that happened. The DON verified dental care was not documented as provided or refused by Resident #29 in the STNA documentation for the above identified dates or in nursing progress notes. The DON stated all care provided and refusals should be documented in the resident's electronic medical record (EMR) but she would have to check to see if staff had developed another way of documenting Resident #29's care or refusals of care. The DON also stated she would need to check if any additional orders had been provided by Resident #29's dentist. Follow up interview on 05/17/22 at 1:50 P.M. the DON verified no additional documentation was available related to Resident #29 being provided assistance with oral care or the resident refusing care. In addition, the DON verified there was no documentation of nursing staff contacting the dentist and/or received any other instructions different from the 05/09/22 dentist progress note. The DON stated the oral care physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility policy titled, Morning Care/AM Care, revised 06/15/20, revealed morning care, including oral care, would be offered each day to promote resident comfort, cleanliness, grooming and general wellbeing. Review of facility policy titled, Evening Care/PM Care, revised 06/15/20, revealed evening care, including oral care, would be offered to residents to promote personal hygiene, comfort, relaxation, and safety.

Based on medical record review, observation, resident and staff interview, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure pressure ulcer interventions were in place resulting in the development of an avoidable pressure ulcer. This resulted in actual harm when Resident #51 developed a deep tissue injury to the right heel. This affected one (#51) of three residents who were reviewed for pressure ulcers. The facility identified two current residents with pressure ulcers. The facility census was 56. Findings included: Review of Resident #51's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #51 was discharged to home on 04/04/18, but returned the next day due to inability to care for his/herself. Review of Resident #51's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was an extensive assist with all activities of daily living. The resident required a mechanical lift for transfers. The resident's brief interview for mental status was a 15 out of 15 indicating the resident was cognitively intact. Resident #51 was identified as being high risk for developing pressure ulcers. Review of Resident #51's current Comprehensive Care Plan revealed the resident was to be turned and repositioned every two hours, more often if needed and required a pressure reducing mattress on the bed. Prior to 04/09/18 there were no other pressure reducing interventions in place. Review of Resident #51's Braden Scale Form dated 04/05/18 revealed the resident was at low risk for development of pressure ulcers. Review of the Bi-Weekly Skin Observation Form dated 04/05/18 revealed Resident #51 did not have any skin breakdown to the right heel, but had a stage two pressure ulcer to the buttock. Review of the Bi-Weekly Skin Observation Form dated 04/09/18 revealed Resident #51 had a deep tissue injury to the right heel. The skin impairment was not noted on admission. The wound was documented as being necrotic, unstageable deep tissue injury. Review of Nurses Notes dated 04/09/18 revealed the wound to the right heel measured 1.6 centimeter (cm) by 3.0 cm by zero cm. The area was documented as being black in color and had no drainage. Interview with Resident #51 on 04/11/18 at 2:13 P.M. revealed she/he alerted staff to heel pain, but no examination was completed by staff. Resident #51 stated she/he could not remember when the staff was alerted but stated staff were not elevating her/his heels prior to the development of the pressure ulcer. Interview with the Director of Nursing (DON) on 04/11/18 at 2:15 P.M. confirmed Resident #51 went home on 04/04/18; however, returned the next day due to being unable to care for his/herself. The DON confirmed prior to 04/09/18 there were no pressure ulcer preventative measures in place specifically regarding prevention of pressure ulcers to the heel. Interview with Licensed Practical Nurse (LPN) #200 on 04/11/18 at 2:16 P.M. revealed Resident #51 was readmitted to the facility on [DATE] after being discharged for less than 24 hours at home. The resident's readmission assessment revealed no pressure areas to the heels; only a stage two to the right buttock. Observation of wound care was completed on 04/11/18 at 1:59 P.M. for Resident #51. Registered Nurse (RN) #105 and LPN #200 completed wound care. The right heel wound measured 3.0 cm by 3.0 cm by 0.1 cm with a small amount of serous sanguineous drainage noted on the bandage. Review of the facility policy titled Bi-Weekly Skin Checks dated 07/18/17 revealed the nurse will evaluate the resident at all pressure points and other skin areas, but not limited to, reddened areas, discoloration, excoriations, rashes, blisters and/or skin tears, etc. This will allow for each resident's skin to be observed at a minimum of four times each week. Review of information from the NPUAP revealed a deep tissue injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicated a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Further review of the NPUAP revealed staff should ensure that a resident's heels are free from the bed and consider using heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers.

Based on medical record review, facility investigation review, self reported incident (SRI) review, personnel file review, staff interview and policy review, the facility failed to ensure residents were free from misappropriation of medications. This affected two (#17, #42) residents out of six SRI's involving misappropriation reviewed from (MONTH) (YEAR) to present. Facility census of 56 residents. Findings include: 1. Resident #17 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the most current minimum data set (MDS) assessment dated [DATE] the resident is identified with minimal cognitive impairment (BIMS score of 9), able to make needs known, requires supervision and set-up assistance with activities of daily living (ADL's), and receives medication occasionally for the treatment of [REDACTED]. Further review of the record noted a physician order [REDACTED].M. and 12/30/17 at 6:45 A.M. No further administration was noted until the resident documented to receive two tablets on 03/16/18 at 2:00 A.M., 03/16/18 at 6:00 A.M., 03/25/18 at 11:00 P.M., 03/26/18 at 3:00 A.M. and 03/26/18 at 7:00 A.M. Review of a facility incident/accident or injury of unknown origin dated 03/25/18 noted a statement documenting the station two (2) nurse reported to Nurse #102 that the nurse she had followed Registered Nurse (RN) #101 gave as needed medications to resident in excess of what they usually take. The station 2 nurse wrote it down on a sticky note and this writer (Nurse #102) then called the director of nursing and notified her of the concerns. On 03/26/18 at 8:00 A.M. a statement from Resident #17 was obtained. The resident stated he has discomfort with his back through the night and he generally takes Tylenol for pain. The resident stated he does not like taking stronger pain medication and he did not ask for pain mediation and did not take any through the night. Resident #17 agreed to a drug screen and the physician was notified. Review of the drug panel dated 03/26/18 was noted to be negative for opiates. Review of an incident/accident or injury of unknown origin form noted RN #101 to submit a written statement on 03/26/18 noted the nurse to deny misappropriation of resident medications. According to RN#101's personal file noted a hire date of 02/06/18. On 02/06/18, RN #101 signed a general staff orientation and checklist indicating a policy acknowledgement regarding the facility policy on Resident abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of resident property. Review of the facility resident abuse policy revised 03/03/17 describes misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of residents belongings or money without the residents consent. All allegations of misappropriation of resident property must be reported immediately to the administrator, director of nursing and applicable state agency. The investigation must be completed within five working days from the alleged occurrence. The investigation protocol is to include interviews of the resident, the accused and all witnesses. Obtain written statements from the resident, if possible, the accused, and each witness. On 04/11/18 at 1:45 P.M. interview with the administrator during a review of the investigation revealed the facility obtained statements from the alleged RN #101, and Resident #17. No further statements were taken from potential witnesses. 2. Review of Resident #42's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #42's monthly physician orders [REDACTED]. Review of Resident #42's Medication Administration Record [REDACTED]. Review of Controlled Substance Record dated 03/09/18 revealed five [MEDICATION NAME] 2.0 mg/ml vials had been sent to the facility. Instructions included inject 0.5 ml (1.0 mg) intramuscularly before dressing change. Further review of narcotic count revealed on 03/20/18 the amount remaining should have been 1.5 ml. Review of facility's SRI dated 03/21/18 revealed Resident #42 had a vial of [MEDICATION NAME] 2.0 mg/ml and and order to receive 0.5 ml (1.0 mg). The vial was a single dose vial and the nurses were using it for multiple doses. The vial did not contain a measurement on the outside to ensure proper counting of the narcotic. The [MEDICATION NAME] was withdrawn from the remaining vial and was found to have 0.1 ml left. The nurses who signed the narcotic out were interviewed. The resident stated he had received his medication. The medication was discontinued on 03/21/18. Interview on 4/10/18 at 4:20 P.M. with Director of Nursing (DON) stated Resident #42 had single dose vials of [MEDICATION NAME] and the nurse's were using more than one dose from the vial. DON stated the nurses did not waste the rest of the medication in the vial and should have. DON stated there should have been 0.5 ml left in the rest of the vial but only 0.1 ml was obtained from the vial from the opened vial. DON stated interviews were completed with only the nurses who had contact with the [MEDICATION NAME]. DON stated the nurses were educated on drug diversion. DON stated the resident reported he received the medication. Review of facility investigation dated 03/21/18 revealed statements were obtained from RN #106, LPN #202, LPN #203 and LPN #204.

Based on medical record review, facility investigation review, self reported incident (SRI) review, personnel file review, staff interview and policy review, the facility failed to ensure policy was implemented to prevent misappropriation and to ensure incidents of misappropriation were thoroughly investigated. This affected two (#17, #42) residents out of six SRI's involving misappropriation reviewed from (MONTH) (YEAR) to present. Facility census of 56 residents. Findings include: 1. Resident #17 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the most current minimum data set (MDS) assessment dated [DATE] the resident is identified with minimal cognitive impairment (BIMS score of 9), able to make needs known, requires supervision and set-up assistance with activities of daily living (ADLs), and receives medication occasionally for the treatment of [REDACTED]. Further review of the record noted a physician order [REDACTED].M. and 12/30/17 at 6:45 A.M. No further administration was noted until the resident documented to receive two tablets on 03/16/18 at 2:00 A.M., 03/16/18 at 6:00 A.M., 03/25/18 at 11:00 P.M., 03/26/18 at 3:00 A.M. and 03/26/18 at 7:00 A.M. Review of a facility incident/accident or injury of unknown origin form dated 03/25/18 noted a statement documenting the station two (2) nurse reported to nurse #102 that the nurse she had followed Registered Nurse (RN) #101 gave as needed medications to resident in access of what they usually take. The station 2 nurse wrote it down on a sticky note and this writer (Nurse #102) then called the director of nursing and notified her of the concerns. On 03/26/18 at 8:00 A.M. a statement from Resident #17 was obtained. The resident stated he has discomfort with his back through the night and he generally takes Tylenol for pain. The resident stated he does not like taking stronger pain medication and he did not ask for pain mediation and did not take any through the night. Resident #17 agreed to a drug screen and the physician was notified. Review of the drug panel dated 03/26/18 was noted to be negative for opiates. Review of an incident/accident or injury of unknown origin form noted RN #101 to submit a written statement on 03/26/18 noted the nurse to deny misappropriation of resident medications. According to RN#101's personal file noted a hire date of 02/06/18. On 02/06/18 RN#101 signed a general staff orientation and checklist indicating a policy acknowledgement regarding the facility policy on Resident abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of resident property. Review of the facility resident abuse policy revised 03/03/17 describes misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of residents belongings or money without the residents consent. All allegations of misappropriation of resident property must be reported immediately to the administrator, director of nursing and applicable state agency. The investigation must be completed within five working days from the alleged occurrence. The investigation protocol is to include interviews of the resident, the accused and all witnesses. Obtain written statements from the resident, if possible, the accused, and each witness. On 04/11/18 at 1:45 P.M. interview with the administrator during a review of the investigation and facility policy revealed the facility obtained statements from the alleged RN #101, and Resident #17. No further statements were taken from potential witnesses. 2. Review of Resident #42's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #42's monthly physician orders [REDACTED]. Review of Resident #42's Medication Administration Record [REDACTED]. Review of Controlled Substance Record dated 03/09/18 revealed five [MEDICATION NAME] 2.0 mg/ml vials had been sent to the facility. Instructions included inject 0.5 ml (1.0 mg) intramuscularly before dressing change. Further review of narcotic count revealed on 03/20/18 the amount remaining should have been 1.5 ml. Review of facility's self reported incident dated 03/21/18 revealed Resident #42 had a vial of [MEDICATION NAME] 2.0 mg/ml and and order to receive 0.5 ml (1.0 mg). The vial was a single dose vial and the nurses were using it for multiple doses. The vial did not contain a measurement on the outside to ensure proper counting of the narcotic. The [MEDICATION NAME] was withdrawn from the remaining vial and was found to have 0.1 ml left. The nurses who signed the narcotic out were interviewed. The resident stated he had received his medication. The medication was discontinued on 03/21/18. Interview on 4/10/18 at 4:20 P.M. with Director of Nursing (DON) stated Resident #42 had single dose vials of [MEDICATION NAME] and the nurse's were using more than one dose from the vial. DON stated the nurses did not waste the rest of the medication in the vial and should have. DON stated there should have been 0.5 ml left in the rest of the vial but only 0.1 ml was obtained from the vial from the opened vial. DON stated interviews were completed with only the nurses who had contact with the [MEDICATION NAME]. DON stated the nurses were educated on drug diversion. DON stated the resident reported he received the medication. Review of facility investigation dated 03/21/18 revealed statements were obtained from RN #106, LPN #202, LPN #203 and LPN #204.

Based on medical record review, facility investigation review, self reported incident (SRI) review, personnel file review, staff interview and policy review, the facility failed to ensure incidents of misappropriation were thoroughly investigated. This affected two (#17, #42) residents out of six SRI's involving misappropriation reviewed from (MONTH) (YEAR) to present. Facility census of 56 residents. Findings include: 1. Resident #17 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the most current minimum data set (MDS) assessment dated [DATE] the resident is identified with minimal cognitive impairment (BIMS score of 9), able to make needs known, requires supervision and set-up assistance with activities of daily living (ADLs), and receives medication occasionally for the treatment of [REDACTED]. Further review of the record noted a physician order [REDACTED].M. and 12/30/17 at 6:45 A.M. No further administration was noted until the resident documented to receive two tablets on 03/16/18 at 2:00 A.M., 03/16/18 at 6:00 A.M., 03/25/18 at 11:00 P.M., 03/26/18 at 3:00 A.M. and 03/26/18 at 7:00 A.M. Review of a facility incident/accident or injury of unknown origin form dated 03/25/18 noted a statement documenting the station two (2) nurse reported to nurse #102 that the nurse she had followed Registered Nurse (RN) #101 gave as needed medications to resident in access of what they usually take. The station 2 nurse wrote it down on a sticky note and this writer (Nurse #102) then called the director of nursing and notified her of the concerns. On 03/26/18 at 8:00 A.M. a statement from Resident #17 was obtained. The resident stated he has discomfort with his back through the night and he generally takes Tylenol for pain. The resident stated he does not like taking stronger pain medication and he did not ask for pain mediation and did not take any through the night. Resident #17 agreed to a drug screen and the physician was notified. Review of the drug panel dated 03/26/18 was noted to be negative for opiates. Review of an incident/accident or injury of unknown origin form noted RN #101 to submit a written statement on 03/26/18 noted the nurse to deny misappropriation of resident medications. According to RN#101's personal file noted a hire date of 02/06/18. On 02/06/18 RN#101 signed a general staff orientation and checklist indicating a policy acknowledgement regarding the facility policy on Resident abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of resident property. Review of the facility resident abuse policy revised 03/03/17 describes misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of residents belongings or money without the residents consent. All allegations of misappropriation of resident property must be reported immediately to the administrator, director of nursing and applicable state agency. The investigation must be completed within five working days from the alleged occurrence. The investigation protocol is to include interviews of the resident, the accused and all witnesses. Obtain written statements from the resident, if possible, the accused, and each witness. On 04/11/18 at 1:45 P.M. interview with the administrator during a review of the investigation and facility policy revealed the facility obtained statements from the alleged RN #101, and Resident #17. No further statements were taken from potential witnesses. 2. Review of Resident #42's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #42's monthly physician orders [REDACTED]. Review of Resident #42's Medication Administration Record [REDACTED]. Review of Controlled Substance Record dated 03/09/18 revealed five [MEDICATION NAME] 2.0 mg/ml vials had been sent to the facility. Instructions included inject 0.5 ml (1.0 mg) intramuscularly before dressing change. Further review of narcotic count revealed on 03/20/18 the amount remaining should have been 1.5 ml. Review of facility's self reported incident dated 03/21/18 revealed Resident #42 had a vial of [MEDICATION NAME] 2.0 mg/ml and and order to receive 0.5 ml (1.0 mg). The vial was a single dose vial and the nurses were using it for multiple doses. The vial did not contain a measurement on the outside to ensure proper counting of the narcotic. The [MEDICATION NAME] was withdrawn from the remaining vial and was found to have 0.1 ml left. The nurses who signed the narcotic out were interviewed. The resident stated he had received his medication. The medication was discontinued on 03/21/18. Interview on 4/10/18 at 4:20 P.M. with Director of Nursing (DON) stated Resident #42 had single dose vials of [MEDICATION NAME] and the nurse's were using more than one dose from the vial. DON stated the nurses did not waste the rest of the medication in the vial and should have. DON stated there should have been 0.5 ml left in the rest of the vial but only 0.1 ml was obtained from the vial from the opened vial. DON stated interviews were completed with only the nurses who had contact with the [MEDICATION NAME]. DON stated the nurses were educated on drug diversion. DON stated the resident reported he received the medication. Review of facility investigation dated 03/21/18 revealed statements were obtained from RN #106, LPN #202, LPN #203 and LPN #204.

Based on medical record review, staff interview and policy review, the facility failed to ensure weights were obtained as ordered to monitor Resident #29's [MEDICAL CONDITION] affecting one (#29) of four residents reviewed weight loss and nutrition. The facility identified 56 residents with scheduled physician ordered monitored weights. Additionally, the facility failed to ensure skin protective sleeves were in place affecting one (#207) of six residents reviewed for skin protective sleeves. The facility census was 56. Findings include: 1. Review of Resident #29's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a high cognition level. The resident required extensive assistance with dressing. Review of Resident #29's medical records revealed a physician's order dated 01/16/18 for weekly weights to be completed. Review of Resident #29's weight record revealed weights were completed as ordered in (MONTH) (YEAR), taken on 02/07/18, 02/28/18, 03/01/18, 03/21/18, 3/28/18 and 04/02/18. However, weights were not assessed for the weeks of 02/16/18, 02/23/18, 03/08/18 and 03/15/18. Review of Resident #29's care plan revealed a [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #100 on 04/11/18 at 8:14 A.M. revealed the State tested Nursing Aides (STNA's) obtain resident's weights and then inform the nurse of the results. The nurses then document the weights into the computer system. The weights were not documented in any other place. Review of the facility policy titled Weights dated (MONTH) (YEAR) all weekly weights must be obtained on the same day each week. The day following weekly weight day the weights will be reviewed by the Director of Nursing (DON) or DON designee to ensure compliance to Saber standards and to determine if any re-weights are required. All weights for each resident are recorded in one central weight record. 2. Review of Resident #207's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #207's care plan revealed the resident to be at risk for impaired skin integrity and had skin tears bilateral upper and lower extremities. Review of Resident #207's physician order dated 03/30/18 revealed an order for [REDACTED]. Review of Resident #207's physician order dated 03/29/18 revealed an order for [REDACTED]. Observation on 04/10/18 at 11:12 A.M. and 4:10 P.M. of Resident #207 revealed the resident did not have protective sleeves in place to upper extremities as ordered. Interview on 04/10/18 at 4:15 P.M. with Licensed Practical Nurse (LPN) #201 verified Resident #207 did not have protective sleeves in place to bilateral arms as ordered. LPN #201 stated she did not know where they were or why they were not in place.

Based on observation, staff and resident interview, record review, review of the shower schedule, and review of facility policy, the facility failed to ensure showers were completed as scheduled for two residents (#33 and #44) and failed to provide adequate nail grooming for one resident (#33) Twenty three residents were reviewed for hygiene in the sample. The facility census was 60. Findings include 1. Medical record review revealed Resident #44 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment completed on 01/06/17 revealed Resident #44 required the physical assistance of one person for bathing. Review of the facility shower schedule revealed Resident #44 was scheduled for two showers per week on Sundays and Thursdays. Review of the activities of daily living tracking sheets and shower sheets from 11/01/16 through 02/09/16 revealed Resident #44 did not receive showers on 11/10/16, 11/20/16. 12/04/16, 01/12/17 and 01/26/17 with no noted refusals. Interview on 02/08/17 at 1:58 P.M. with Resident #44 revealed there had been several weeks where she only got one shower. Interview on 02/08/17 at 8:40 A.M. with the Director of Nursing (DON) revealed there was no documentation Resident #44 received showers on 11/10/16, 11/20/16, 12/04/16, 01/12/17 and 01/26/17. Review of the facility policy titled Bath and Shower Schedule, revised 09/2015, revealed each resident was scheduled a bath or shower at a minimum of two times per week according to personal preference. 2. Review of Resident #33's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #33's MDS assessment dated [DATE] revealed the resident to have severe cognitive impairment and required one person physical assist with bathing. Review of Resident #33's care plan revealed nail length, trim and clean on bath day. Observation of Resident #33 on 02/07/2017 at 11:26 A.M. and 2:30 P.M. revealed fingernails were long and not cut to an appropriate length. Observation of Resident #33 on 02/08/2017 at 9:06 A.M. and 02/09/17 at 8:30 A.M. revealed the resident's fingernails remain long and uncut. Interview on 02/08/2017 at 4:03 P.M., State tested Nursing Assistant (STNA) #3 stated Resident #33 would get a shower tonight after supper. Additionally, review of facility shower schedule revealed Resident #33 was to receive showers Wednesday and Sunday on second shift. Review of Resident #33's activities of daily living (ADL) tracking form dated January 2017 revealed only two showers were given during the month, on 01/08/17 and 01/16/17. Review of Resident #33's ADL tracking form dated December 2016 revealed one shower was given on 12/25/16. Review of Resident #33's ADL tracking form dated November 2016 revealed the resident received only two showers during the month on 11/14/16 and 11/27/16. Review of facility shower sheets dated 11/01/16 through 02/09/17 revealed Resident #33 did not receive a total of six showers. Review of facility policy titled Nail Care, dated January 2014, revealed nursing staff will administer nail care in order to provide cleanliness and prevent infection. Interview on 02/09/2017 at 8:38 A.M. with the DON verified Resident #33's fingernails were long and not cut to an appropriate length. The DON also verified Resident #33 did not receive six showers from November 2016 through February 2017.

Based on observation, review of facility policy, medical record review and staff interview, the facility failed to maintain residents dignity by failing to serve all residents seated at a table at the same time. This affected two (#1, #20 ) of 32 residents who received lunch in the dining room. The facility census was 60. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) comprehensive assessment revealed the resident required supervision with set up assistance only at meals, had no loss of liquids when swallowing, no holding of food in mouth, no coughing or choking, or no difficulty swallowing. Review of the resident's most recent care plan did not indicate Resident #1 had chewing, swallowing, or other difficulties eating. Review of Resident #20's clinical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #20's MDS assessment revealed the resident required supervisor with set up assistance only at meals, no loss of liquids when swallowing, no holding of food in mouth, no coughing or choking, and no difficulty swallowing. Review of the most recent care plan for Resident #20 revealed Resident #20 did not have chewing, swallowing or other difficulties eating. Observation of the dining room on 11/22/15, at 12:03 PM, revealed Resident #17, Resident #1, and Resident #20 were seated at a dining room table in the back area of the dining room. Resident #17 was served lunch at 12:03 PM. Nine residents (#78, #49, #81, #58, #44, #40, #46, #65) who were seated at multiple tables in the dining room were then served their noon meal. At 12:13 P.M., Resident #1 stood up and walked away from the table and also toward an exit door then toward the kitchen. Resident #1 was redirected by staff and encouraged to wait for his noon meal and taken back to his seat. At 12:17 PM, Resident #20 was served his noon meal and Resident #52 remained seated at the table. At 12:23 PM, Resident #1 was served his noon meal. Interview with Dietary Manager (DM) #7 on 11/22/15 at 12:25 P.M. verified the residents at the table were not served together as they were supposed to be. She further stated the residents who were at that table were not to be served their meal until a staff was available to monitor them. She verified Resident #1 and #20 had been seated at the table since delivery of lunch meal trays had been started at 12:00 P.M. and that Resident #1 did not receive his meal tray until 12:25 P.M. which was the last resident to be served. Interview with Registered Nurse (RN) # 4 on 11/22/15 at 12:30 P.M. verified Resident #17 was served a lunch meal with no staff at the table. She further verified Residents #1 and #20 were seated at the table when she brought Resident #52 to the table at 12:18 P.M. She verified Resident #52 received her food right away and Resident #20 then received his tray. She further verified Resident #1 did not receive his food at that time. Review of the facility policy titled Dining Room Environment, dated April 2011, indicated tables shall be served in a manner so all residents seated at a table receive meals at the same time. It further revealed residents were not to be served until at least one staff member was present in the dining room.

Based on facility record review and staff interview, the facility failed to track employee illness and infections for the presecense of potential communicable diseases. This had the potential to affect all 58 residents currently residing in the facility. Findings include: Review of the infection control logs for the facility revealed there was no documnetation of how the facility was tracking employees for potential communicable disease. Interview with the Director of Nursing (DON) #23 on 05/15/13 at 04:08 P. M. stated she was the infection control nurse. DON #23 stated there is no written documentation regarding employee tracking of infections for communicable disease. She explained if an employee is sick for three days or more, they require a physician excuse to return to work. If the employee is sick less than three days they do not ask what the sickness is, they do not require any documentation, and they do not evaluate any risk to residents. Interview with the Administrator and Regional Corporate Nurse # 24 on 05/16/13 at 01:15 P. M. verified the information regarding employee infection tracking was accurate and no program or tracking of employee infections is in place for employees. Review of the facility policy entitled "Facilities Attendance Policy" dated December 2011 revealed the if an employee is sick for three days or more, they require a physician excuse to return to work.

Based on surveyor observation and staff interview, the facility failed to secure medications under lock and lock potentially hazardous areas. This had the potential to affect three (#41, #28, #222) facility identified confused and independently mobile residents. The facility identified a total of 22 residents who are cognitively impaired. In addition, the facility failed to implement personal alarms utilized as a fall prevention devices for one resident. This affected one (#13) of three residents reviewed for falls. The facility identified 32 current residents who utilize personal alarms for fall prevention. The facility census was 58. Findings include: 1. Observation on 05/15/13 at 09:57 A. M. revealed a tube of Mometasone Furoate cream 0.1% was sitting on the top of Resident # 87's bedside table. Observations of tube indicated the cream was available by prescription only and contained a precautionary label of keep out of reach of children. This was verified by with Maintenance Supervisor # 18 at the time of discovery. 2. Observation on 05/15/13 at 10:11 A. M. revealed a door to the water heater room and electrical panel room was unlocked. Observations revealed potential resident access to an unsecured electrical panel and access to a faucet with hot water directly from the water heater. This was verified by with Maintenance Supervisor # 18 at the time of discovery. 3. Review of Resident #13's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE], indicated Resident #13's fall risk score was 11. A score greater than 10 indicates a high fall risk. The Pre-restraint Evaluation dated 08/31/12 was completed with recommendation of no restraints and indicated bed alarm and chair alarm were to be initiated for Resident #13. Review of the Nurses notes dated 10/31/12 at 3:00 P.M. indicated Resident #13 was found on the floor in his room. This unwitnessed fall resulted in a skin tear to the right upper back to Resident #13. Review of the Incident Report dated 10/31/12 indicates the therapy staff failed to turn on the alarms as ordered. Review of the Nurses notes dated 11/07/12 at 1:00 P.M. indicated Resident #13 was transported from the dining room to his room by his wife. Resident #13 was found on his knees in front of his bed. This unwitnessed fall resulted in a small abrasion to Resident #13's right knee. Review of the Incident Report dated 11/07/12 revealed the same findings. Review of the Nurses notes dated 12/22/12 at 5:00 A.M. indicated Resident #13 was found on the floor beside his bed. This unwitnessed fall resulted in a skin tear to Resident #13's right forearm. Review of the Incident Report dated 12/24/12 revealed the bed alarm and floor alarm were sounding and that Resident #13 attempted to get out of bed unassisted. Review of the Nurses notes dated 04/17/13 at 8:55 A.M. indicated Resident #13 had an unwitnessed fall in his bathroom. Review of the Incident Report dated 04/07/13 revealed the same findings. Review of the Care Plan dated 09/11/12 revealed a focus stating Resident #13 is at risk for falls. Goals of the Care Plan included no fall related injuries through next review dated 09/11/12. The Care Plan included interventions dated 09/11/12 with additional interventions added after falls to include multiple alarms and nonskid socks. The interventions, revisions and reviews failed to include any routine monitoring of Resident #13 or any increase assistance for Resident #13. Interview with Resident #13's family on 05/13/13 at 9:59 A.M. revealed she helps Resident #13 by turning off alarms for him. Additionally, she was observed at this time turning an alarm off. Interview with ADON #12 on 05/16/13 10:06 A.M. she reported the therapy staff did not turn on the ordered alarms prior to Resident #13's fall dated 10/31/12. Therapy staff were educated to initiate alarms as ordered at that time. She stated the alarms were not activated prior to fall dated 11/07/12 and on 04/07/13. Staff were disciplined as a result of the ordered alarms not being activated. Additional interview with ADON #12 on 05/16/13 at 11:43 A.M. verified interventions included multiple alarms and nonskid socks. She states that staff are responsible for activating alarms, doing rounds every two hours and assisting with his activities of daily living. This deficiency substantiates Complaint Number OH 100.

Based on surveyor observation and staff interview, the facility failed to ensure a resident's personal hygiene was maintained for a resident who was dependent on staff for incontinence care. This affected one (#24) of 30 residents observed in stage one. The facility identified 26 residents currently dependent on staff for incontinence care. The facility census was 58. Findings include: Observations of Resident # 24's room on 05/14/13 at 9:30 A.M. revealed a strong urine odor. The resident was observed sitting in a recliner with a hospital gown on. Observation of the resident's wheel chair revealed a incontinence pad soaked with urine. Further observations revealed on 05/14/13 at 11:00 A.M., 2:34 P.M. and on 05/15/13 at 9:40 A.M. revealed a strong urine odor still remained in the residents room. Interview with State tested Nurse Aide (STNA) #16 on 05/14/13 at 10:17 A.M. verified the wheel chair contained a soaked urine incontinence pad and she had not removed the pad. STNA#16 stated she and another STNA transferred the resident to her recliner from the wheel chair and had not provided any type of incontinence care prior to the transfer.

Based on medical record review and staff interview the facility failed to ensure nonpharmological interventions were attempted prior to the administration of an as needed anti-anxiety medication for one resident (#6). In addition, the facility failed to attempt a gradual dose reduction for a resident (#38) receiving a anti-anxiety medication. This affected two of ten resident reviewed for unnecessary medications. The facility identified 24 current residents receiving anti-anxiety medications in the facility. The facility census is 58. Findings include: 1. Review of Resident #6's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Monthly Physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the behavior tracking sheets for documenting interventions prior to administering the medication however, on these dates there is no documentation of non-pharmacological interventions being attempted to alleviate the resident's anxiety prior to the administration of the anti-anxiety medicine. Interviewed with the ADON #12 on 05/15/13 at 1:30 P.M. verified there is no documentation anywhere in the record for the above dates that non-pharmacological interventions were attempted that may have made the administration of the anti-anxiety medication unnecessary. 2. Review of Resident #38's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's monthly MAR indicated [REDACTED]. Review of the behavioral documentation for the months of April and May of 2013 revealed no episodes of anxiety documented from 04/18/13 through 05/16/13 to indicate a need for Lorazapam. Review of the last signed monthly physician order [REDACTED].#38 has been receiving Lorazapam 0.5 mg by mouth at bedtime since 12/06/11. The recommendation was to decrease of Lorazapam to 0.25 mg by mouth daily at bedtime be attempted. The Pharmacy Consultation Report remains on the chart pending review at the time of this investigation ending 05/16/13. Interview with Director of Nursing (DON) #23 on 05/16/13 at 1:15 P.M., verified there were had been no other pharmacy recommendations to decrease or discontinue the Lorazapam for Resident #38. Further, DON #23 verified that there is no facility policy for unnecessary medications or for gradual dose reductions of anti-anxiety medications.

Based on medical record review and staff interview the facility failed to develop a care plan with non-pharmacological interventions for a resident receiving as needed (PRN) anti-anxiety medication. This affected one (#6) of ten residents reviewed for unnecessary medications. The facility identified 12 current residents receiving PRN anti-anxiety medication. In addition, the facility failed to revise the care plan for one resident regarding fall interventions. This affected one (#13) of three residents reviewed for falls. The facility census is 58. Findings include: Review of Resident #6's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Monthly Physician orders [REDACTED]. Review of a care plan for an anti-anxiety medication on a PRN basis revealed the care plan addresses documenting behaviors, monitoring the resident for side effects from the medication and documenting the effectiveness of the medication. The care plan does not contain anything regarding attempting to use non-pharmacological interventions to relieve the residents anxiety prior to the use of the anti-anxiety medication. Interview with the Assistant director of Nursing (ADON) #12 on 05/15/13 at 1:30 P.M. verified the care plan addressing the use of the anti-anxiety medication for the residents anxiety was absent of any mention of attempting non-medication interventions prior to the use of the anti-anxiety medication. Review of Resident #13's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE], indicated Resident #13's fall risk score was 11. A score greater than 10 indicates a high fall risk. The Pre-restraint Evaluation dated 08/31/12 was completed with recommendation of no restraints and indicated bed alarm and chair alarm were to be initiated for Resident #13. Review of the Nurses notes dated 10/31/12 at 3:00 P.M. indicated Resident #13 was found on the floor in his room. This unwitnessed fall resulted in a skin tear to the right upper back to Resident #13. Review of the Incident Report dated 10/31/12 indicates the therapy staff failed to turn on the alarms as ordered. Review of the Nurses notes dated 11/07/12 at 1:00 P.M. indicated Resident #13 was transported from the dining room to his room by his wife. Resident #13 was found on his knees in front of his bed. This unwitnessed fall resulted in a small abrasion to Resident #13's right knee. Review of the Incident Report dated 11/07/12 revealed the same findings. Review of the Nurses notes dated 12/22/12 at 5:00 A.M. indicated Resident #13 was found on the floor beside his bed. This unwitnessed fall resulted in a skin tear to Resident #13's right forearm. Review of the Incident Report dated 12/24/12 revealed the bed alarm and floor alarm were sounding and that Resident #13 attempted to get out of bed unassisted. Review of the Nurses notes dated 04/17/13 at 8:55 A.M. indicated Resident #13 had an unwitnessed fall in his bathroom. Review of the Incident Report dated 04/07/13 revealed the same findings. Review of the Care Plan dated 09/11/12 revealed a focus stating Resident #13 is at risk for falls. Goals of the Care Plan included no fall related injuries through next review dated 09/11/12. The Care Plan included interventions dated 09/11/12 with additional interventions added after falls to include multiple alarms and nonskid socks. The interventions, revisions and reviews failed to include any routine monitoring of Resident #13 or any increase assistance for Resident #13. Interview with Resident #13's family on 05/13/13 at 9:59 A.M. revealed she helps Resident #13 by turning off alarms for him. Additionally, she was observed at this time turning an alarm off. Interview with ADON #12 on 05/16/13 10:06 A.M. she reported the therapy staff did not turn on the ordered alarms prior to Resident #13's fall dated 10/31/12. Therapy staff were educated to initiate alarms as ordered at that time. She stated the alarms were not activated prior to fall dated 11/07/12 and on 04/07/13. Staff were disciplined as a result of the ordered alarms not being activated. Additional interview with ADON #12 on 05/16/13 at 11:43 A.M. verified interventions included multiple alarms and nonskid socks. She states that staff are responsible for activating alarms, doing rounds every two hours and assisting with his activities of daily living. She verified that no additional monitoring or additional assistance was added to Resident #13's Plan of Care after. She further stated it is the facility policy to do two hour checks every two hours.

Based on surveyor observation and staff interview, the facility failed to provide a resident with a clean and sanitary room free from offensive urine odors. This affected one (#24) of 30 resident rooms observed in stage one of the survey. The facility census was 58. Findings include: Observations of Resident # 24's room on 05/14/13 at 9:30 A.M. revealed a strong urine odor. Observation of the resident's wheel chair revealed a incontinence pad soaked with urine. Further observations revealed on 05/14/13 at 11:00 A.M., 2:34 P.M. and on 05/15/13 at 9:40 A.M. revealed a strong urine odor still remained in the residents room. Interview with State tested Nurse Aide #16 on 05/14/13 at 10:17 A.M. verified the wheel chair contained a soaked urine incontinence pad. Interview with Maintenance Supervisor #18 on 05/15/13 at 9:40 A.M. verified the presence of a strong urine smell in Resident #24. This deficiency substantiates Complaint Number OH 100.

Based on surveyor observation and staff interview, the facility failed to maintain dignity and respect for two residents when staff failed to knock and/or ask permission to enter the residents room. This affected two (#6 and #24) of 30 residents observed for dignity. Facility census was 58. Findings include: Observation on 05/14/13 at 9:43 A. M. revealed State tested Nurse Aide (STNA) # 16 was observed not to knock or ask permission to enter Resident # 6 and Resident # 24's shared room but walked in without any type of permission or explanation. Interview with STNA # 16 on 05/14/13 at 10:17 A.M., verified she entered the resident's rooms without knocking and without permission. Observation on 05/14/13 at 10:09 A.M. revealed Dietary Aide # 15 knocked and walked into Resident # 6 and Resident # 24's shared room without permission and filled water cups without asking permission. Interview with Dietary Aide # 15 on 05/14/13 at 11:09 A.M. verified she entered and filled the water cups without permission. This deficiency substantiates Complaint Number OH 100.

Based on medical record review, staff interview and facility policy review the facility failed to provide a restorative ambulation program as recommended by physical therapy to maintain the resident's current level of performance and to prevent a decline. This affected one resident (#81) of three residents reviewed for rehabilitation. The facility identified 24 residents that receive a restorative ambulation program. The facility census is 58. Findings include: Review of Resident #81's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the physical therapy discharge summary dated 04/15/13 revealed a discharge plan that included a recommendation for a functional maintenance program (restorative) due to achieving maximum potential with non-weight bearing status. Review of the "Restorative Ambulation Program Daily Record" revealed Resident #81 was to walk in her room [ROOM NUMBER] to 7 days a week, three times a day for 15 minutes while maintaining non-weight bearing on her right leg. Review of the "Restorative Ambulation Program" for April 2013 reveals that Resident #81 received the restorative ambulation as directed once on 4/27/13 in the morning and once in the evening on 4/28/13, 4/29/13 and 4/30/13. Interview on 05/16/13 at 9:30 A.M. with Physical Therapy Assistant (PTA) #10 revealed that Resident #81 did receive physical therapy from 03/12/13 through 04/15/13 for therapeutic exercises and gait training. She verified that Resident #15 was discharged from physical therapy on 04/15/13 due to reaching her maximum potential with non-weight bearing on her right leg and was referred for a restorative ambulation program. PTA #10 revealed that this referral is communicated with the nursing staff during the facilities morning meeting. Interview on 05/16/13 at 9:35 A.M. with Minimum Data Set (MDS) Nurse #2 revealed that she is notified by therapy during the facility morning meeting when a resident is discharged from therapy and referred for a restorative program. She verified that Resident #81 was referred for a restorative ambulation program on 04/15/13 and did not receive the ambulation program as ordered. Review of the policy entitled, "Restorative Nursing Programs/Ambulation" last revised 10/12 reveals that the purpose of the Ambulation Program is to increase the resident ability to ambulate safely and to avoid or delay additional loss of independence. Also, the restorative aides will document daily the time spent completing the exercise and the initials of the staff member who assisted with the exercise.