Every finding on record at Chillicothe Post Acute

Based on observation and interview, the facility failed to ensure that the floors in resident bathrooms were in good repair. This affected 19 (Residents #10, #11, #20, #23, #31, #32, #35, #37, #52, #57, #61, #65, #66, #68, #76, #79, #87, #89, and #93) residents. The facility census was 80.Findings include:Observation of the facility on 03/05/2026 at 10:22 A.M. revealed that the resident bathroom floors for Residents #10, #11, #20, #23, #31, #32, #35, #37, #52, #57, #61, #65, #66, #68, #76, #79, #87, #89, and #93 were torn, cracked, warped and/or peeling away from the walls.Interview with Resident #52 on 03/052026 at 10:32 A.M. revealed that the bathroom floor is in need of replacement and the staff is aware.Interview with Maintenance Assistant #345 on 03/05/2026 at 10:35 A.M. revealed that some bathroom floors in resident rooms are in disrepair therefore the facility has obtained quotes as they need replaced.

Based on observation, and interview, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability. This had the potential to affect 78 residents who received meals in the facility. The facility identified Residents #87 and #93 as not receiving food from the kitchen. The facility census was 80.Findings include:An interview conducted on 03/02/26 at 9:43 A.M. with Resident #31 revealed that meals are hardly ever hot.An interview conducted on 03/02/2026 at 9:51 A.M. with Resident #61 revealed that the food is not good and comes out cold.An interview conducted on 03/03/26 at 7:58 A.M. with Resident #73 revealed the food is alright, but they often get things that they do not like or cannot eat such as corn and bread. Resident #73 stated that dietary is aware of their preferences and has been reminded. Observation of meal trays being passed on 03/05/2026 at 8:20 A.M. revealed Resident #69 with complaints that the French Toast could not be cut or chewed. Substitute requested.Test tray sampling on 03/05/2026 at 8:43 A.M. revealed milk temperature of 50.2 degrees and juice temperature of 48 degrees with all temps verified by Dietary Manager (DM) #448. Further investigation revealed the French toast was unable to be cut with a fork and butter knife.Interview with DM #448 on 03/05/26 at 8:45 A.M. revealed that the French Toast was hard and unable to be cut with utensils.

Based on observation, interview and policy review, the facility failed to properly store food. This had the potential to affect 78 residents who received meals in the facility. The facility identified Residents #87 and #93 as not receiving food from the kitchen. The facility census was 80.Findings include:Observation of the kitchen during the initial tour on 03/02/2026 at 8:30 A.M. revealed opened packages of hotdogs, pepperonis, and a container half full of sliced cheese with no dates. The freezer further revealed an opened bag of chicken strips with no date.Interview with Dietary Manager (DM) #448 on 03/02/2026 at 8:35 A.M. during the initial kitchen tour confirmed the observations of no dates on opened packages of hot dogs, pepperonis, sliced cheese and chicken strips.Review of the Food Receiving and Storage Policy N.D. on 03/03/2026 revealed that all foods stored in the refrigerator or freezer are to be covered, labeled and dated ( use-by date). Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.

Based on record reviews, staff interview, review of facility infection surveillance logs, and review of facility policy, the facility failed to ensure residents with in-house acquired Clostridium Difficile (C-Diff) infections were reviewed for patterns and trends to decrease the spread of infection. This affected seven residents (#36, #42, #52, #71, #103, #104, and #228) identified by the facility as having acquiring C-Diff infections in the facility since 11/01/2025. The facility census was 80.Findings include:Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. Record review for Resident #36 revealed the resident was admitted to the facility on [DATE].Record review for Resident #42 revealed the resident was admitted to the facility on [DATE],Record review for Resident #52 revealed the resident was admitted to the facility on [DATE].Record review for Resident #71 revealed the resident was admitted to the facility on [DATE].Record review for Resident #103 revealed the resident was admitted to the facility on [DATE].Record review for Resident #104 revealed the resident was admitted to the facility on [DATE].Review of the facility line listings of infections revealed Resident #42 was documented to have an in-house acquired infection with C-Diff on 11/19, Resident #103 was documented to have an in-house acquired infection with C-Diff on 11/20/25, Resident #52 was diagnoses to have an in-house acquired infection with C-Diff on 11/21/25, Resident #104 was documented to have an in-house acquired infection with C-Diff on 11/26/25, Resident #36 was documented to have an in-house acquired infection with C-Diff on 12/05/25, Resident #42 was documented to have an in-house acquired infection with C-Diff on 02/03/26, Resident #71 was documented to have an in-house acquired infection with C-Diff on 02/06/26, and Resident #22 was documented to have an in-house acquired infection with C-Diff on 02/15/26. Review of the facility Healthcare Acquired Infection Rate - Tracking and Trending, and Variance Analysis - Monthly Analysis of Trends forms for the month of 11/2025, 12/2025, and 01/2026 revealed the facility rate of gastrointestinal infections was zero. No review of commonalities or clusters, causative factors, or plans for further monitoring/interventions for C-Diff infections were noted.Interview with Licensed Practical Nurse (LPN)/Infection Control Nurse #363 on 03/05/26 at 2:15 P.M. confirmed there were no gastrointestinal infections documented on the Healthcare Acquired Infection Rate - Tracking and Trending and Variance Analysis - Monthly Analysis of Trends forms for the months of 11/2025, 12/2025, and 01/2026. LPN /Infection Control Nurse #363 confirmed there was no review of commonalities or clusters, causative factors, or plans for further monitoring/interventions for C-Diff infections for those months. Review of the facility policy titled Surveillance for Infection, dated 2001, revealed the infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections.This deficiency represents non-compliance identified during the investigation of Complaint 2735113.

Based on interview and record review, the facility failed to ensure psychotropic medications were ordered for appropriate diagnoses. This affected one resident (#7) out of five reviewed for unnecessary medications. The facility census was 80 at the time of survey. Findings include:Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included radiculopathy, peripheral vascular disease, chronic obstructive pulmonary disease, atherosclerosis of coronary artery bypass graft, and bipolar disorder with current episode hypomanic. Review of most recent psychiatric services documentation dated 02/04/2026 revealed Resident #7 had mental health diagnoses of bipolar disorder, anxiety, and insomnia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander.Review of medication orders for Resident #7 revealed orders as follows:Citalopram Hydrobromide tablet 10MG: Give 1 tablet by mouth one time a day for depression.Duloxetine HCL Capsule Delayed Release Particles 60 MG: Give 1 capsule by mouth one time a day for depression.Interview on 03/04/2026 with Director of Nursing revealed that Resident #7 did not have a diagnosis of depression but was being ordered Divalproex and Citalopram for the mood disorder bipolar disorder.

Based on record reviews, interviews, and policy review, the facility failed to develop a care plan to address elopement risk. This affected one resident (Resident #61) of one resident reviewed for care plan accuracy. The facility identified five residents at risk for elopement. The facility census was 80.Findings include:Review of the medical record for Resident #61 revealed an admission date of 03/20/25 with diagnoses including hemiplegia and hemiparesis affecting his right, non-dominant side, aphasia following cerebral infarction, depression, and high blood pressure. Further record review revealed on admission, his Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating he had moderate cognitive impairment.Review of the annual Minimum Data Set 3.0 (MDS) assessment completed on 02/09/26 revealed Resident #61 was independently mobile with the use of a manual wheelchair. He required maximal assistance with toileting, showering, dressing, and positioning. Resident #61 had displayed no verbal or physical disruptive behaviors, no rejection of care, and no wandering or exit-seeking behaviors. Resident #61 had a Wanderguard in place.Review of nursing progress notes revealed on 05/17/25 at around 6:00 P.M., Resident #61 was found in the facility parking lot by an employee leaving at the end of their shift. Resident #61 informed the nurse assisting him that he was trying to go home. The nurse was able to assist Resident #61 back into the facility where a Wanderguard was applied to his wheelchair. Resident #61 made multiple successful trips outside of the building and was resistant to return inside. Later in the evening, staff noted Resident #61 continued to leave the facility with other staff members as they left the building and required multiple individuals to encourage him to return to the building. No further elopement attempts or instances of unsafe wandering were documented.Review of physician orders revealed an order on 05/17/25 for a Wanderguard to be applied to Resident #61's wheelchair due to poor safety awareness. Review of Resident #61's care plan revealed no goals or interventions indicating Resident #61 had poor safety awareness requiring the use of a Wanderguard or a history of unsafe wandering or elopement attempts.Interview on 03/05/26 at 8:36 A.M. with Director of Nursing (DON) #301 stated the Elopement and Wandering Risk Observation Assessments are completed for each resident upon admission, quarterly, and as needed if behaviors develop. DON #301 stated a resident is considered to have eloped if they leave the property without staff knowledge; if the resident is cognitively impaired, they are considered to have eloped if the resident leaves the building. DON #301 confirmed that the Elopement and Wandering Risk Observation Assessments completed after the elopement were inaccurate and confirmed Resident #61 required a Wanderguard alarm. DON #301 confirmed Resident #61's care plan should have been updated following the elopement and application of the Wanderguard alarm.Review of the policy titled Emergency Procedure - Missing Resident, revised 08/2018, stated a resident's care plan should be updated following an elopement.

Based on medical record review and resident and staff interviews, the facility failed to monitor resident's blood sugars. This had the potential to affect one (Resident #99) of 15 residents the facility identified as diagnosed Type 2 Diabetes Mellitus (T2DM). The facility census was 80 residents. Findings include: Review of the medical records for Resident #99 revealed admission date of 02/23/26 with diagnoses of urinary tract infect ion, Parkinsonism and T2DM with hyperglycemia, T2DM with other specified complications, and T2DM with diabetic neuropathy, unspecified. Review of the Discharge summary dated [DATE] revealed an order for TRUEplus Lancets 33G. Review of the 02/24/26 facility nurse practioner's progress note dated 02/24/26 and 02/26/26 revealed to continue blood glucose monitoring per facility protocol. Review of the 02/27/26 progress note by the facility medical director revealed there is currently no need for change to the current care. Nursing has orders and they are assisting in the stability of the patient at this time. Review of 03/03/26 progress nurse by the facility nurse practitioner referenced to continue blood glucose monitoring per facility protocol. Review of Resident #99 orders revealed no current order for blood glucose monitoring. Resident #99 medication for T2DM includes Glimepiride Oral Tablet 4 MG (Glimepiride) one time daily, Glucagon Emergency Inject 1 vial intramuscularly (IM) as needed for Low Blood Sugar 1 vial IM as needed if blood sugar less than 70 or if resident is unresponsive and notify physician, Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 45 unit subcutaneously one time a day for DM, MetFORMIN HCl ER Tablet Extended Release 24 Hour 500 MG Give 2 tablet by mouth two times a day for DM, and Ozempic (2 MG/DOSE) Subcutaneous Solution Pen injector 8 MG/3ML (Semaglutide) Inject 2 mg subcutaneously one time a day every Thursday for DM.Interview on 03/04/25 at 1:09 P.M. with Resident #99 stated his blood sugar was not checked as of 03/04/26 but was checked on 03/03/26 by Associate #304. Interview on 03/04/26 at 2:00 P.M. with Associate #301 confirmed facility does not have a blood glucose monitoring protocol. Associate #301 stated orders were obtained for Resident #99 for Accuchecks without coverage with meals for diabetes mellitus (DM), HGB A1C every six months-August & February.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure wound care orders for the treatment of pressure ulcers were implemented timely and appropriately. This affected one resident (#93) out of the three residents reviewed for pressure ulcers. The facility census was 80.Findings include:Record review for Resident #93 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included stage three pressure ulcer (full-thickness skin loss, in which fat tissue is visible in the ulcer and granulation tissue and rolled wound edges is often present) of the sacral region, cellulitis, and aphasia following cerebral infarction.Review of the care plan, dated 02/26/26, revealed the resident had impaired skin integrity present on admission as evidenced by a stage four pressure ulcer (a pressure ulcer in which there is full-thickness tissue loss with exposed or directly palpable fascia, mucle, tendon, ligament, cartilage, or bone in the ulcer) to the sacrum. Interventions included to administer treatments as ordered, apply barrier cream as indicated, and keep skin clean and dry to the extent possible. Review of the hospital WOC (Wound, Ostomy, Incontinence)/ET (Enterostomal Therapy) Nursing Consult/Evaluation Note, dated 02/20/26, revealed the residents stage four sacrococcyx wound was to have Vashe (a hypochlorous acid-based solution designed to safely cleanse, irrigate, and promote healing of acute and chronic wounds) moistened gauze packing twice daily, or once per shift, per nursing staff. Cover with an ABD Pad or Sorbex pad, and secure with Medipore adhesive. Discharge instructions included resident may continue care as prescribed above at discharge. Review of the facility Comprehensive Skin Assessment, dated 02/24/26, revealed Resident #93 was assessed to have a pressure ulcer to the sacrum present. Review of the active physician order, dated 03/01/26, revealed an order to cleanse open area to coccyx with normal saline, pack with Vashe covered gauze, and cover with a foam patch daily and as needed. Review of all additional active and discontinued physician orders for Resident #93 on 03/03/26 revealed no treatment orders for the pressure ulcer on Resident #93's coccyx were documented to be implemented from 02/24/26 through 02/28/26. Review of the Treatment Administration Record (TAR) for Resident #93 on 03/03/36 revealed no treatments were documented to have been completed to the pressure ulcer on Resident #93's coccyx from 02/24/26 through 02/28/26. Review of the physician order, created by Licensed Practical Nurse (LPN) #363 on 03/04/26 at 7:54 A.M., revealed an order to cleanse sacrococcyx with Vashe, pack wound with Vashe moistened gauze, and cover with ABD pad or Sorbex pad and secure with Medipore tape daily and as needed. The order was documented to have been ordered on 02/25/26. Review of the TAR for Resident #93 on 03/04/26 revealed the order created by LPN #363 on 03/04/26 at 7:54 A.M. had been added to the TAR. LPN #363 had documented the completion of wound care treatment to the pressure ulcer on Resident #93's coccyx as being completed on 02/25/26. No documentation of wound care being completed on 02/26/26, 02/27/26, or 02/28/26 was present. Interview on 03/03/26 at 1:45 P.M. with Licensed Practical Nurse (LPN) #310 confirmed there had not been a physician order put in place for the wound care treatment for Resident #93's pressure ulcer until 03/01/26. LPN #310 confirmed she had contacted LPN #363 and had obtained an order for the treatment, so she knew what to do and had completed the treatment on 02/27/26 and 02/28/26 as well. Interview on 03/03/26 at 1:55 P.M. with LPN #363 confirmed she was on call when LPN #310 called her and obtained treatment orders for Resident #93's pressure ulcer. LPN #363 confirmed she had given LPN #310 orders for the wound care treatment as the physician trusted the nurses to come up with treatment orders and then signed off on them. LPN #310 confirmed there was no documentation of treatment orders being implemented or completed for Resident #93's pressure ulcer from 02/24/26 when she was admitted through 02/28/26. Telephone interview on 03/04/26 at 10:15 A.M. with Physician #599 confirmed resident wounds were to be assessed by facility nursing staff then discussed with the physician or nurse practitioner so wound care treatment orders could be provided. Physician #599 confirmed wound care treatment orders were not to be ordered and implemented by facility nurses without discussion with the physician or nurse practitioner. Observation on 03/04/26 at 10:40 A.M. of the wound care treatment being completed for the pressure ulcer to Resident #93's coccyx by Registered Nurse (RN) #321 and LPN #426 revealed the residents wound was free from signs or symptoms of infection. Wound care was completed as ordered with no concerns. RN #321 confirmed wound care treatment orders were to be reviewed prior to the completion of wound care. Review of the facility procedure titled Wound Care, dated 2001, revealed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. The following information should be documented in the residents medical record: the type of wound care given, the date and time would care was given, and the name and title of the individual performing wound care. This deficiency represents non-compliance identified during the investigation of Complaint 2733569.

Based on record reviews, interviews, and policy reviews, the facility failed to ensure one resident (Resident #61) was free of elopements. This affected one resident (#61) of four residents reviewed for elopements. The facility census was 80.Findings include: Review of the medical record for Resident #61 revealed an admission date of 03/20/25 with diagnoses including hemiplegia and hemiparesis affecting his right, non-dominant side, aphasia following cerebral infarction, depression, and high blood pressure. Further record review revealed on admission, his Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating he had moderate cognitive impairment.Review of the annual Minimum Data Set 3.0 (MDS) assessment completed on 02/09/26 revealed Resident #61 was independently mobile with the use of a manual wheelchair. He required maximal assistance with toileting, showering, dressing, and positioning. Resident #61 had displayed no verbal or physical disruptive behaviors, no rejection of care, and no wandering or exit-seeking behaviors. Resident #61 had a Wanderguard in place.Review of nursing progress notes revealed on 05/17/25 at around 6:00 P.M., Resident #61 was found in the facility parking lot by an employee leaving at the end of their shift. Resident #61 informed the nurse assisting him that he was trying to go home. The nurse was able to assist Resident #61 back into the facility where a Wanderguard was applied to his wheelchair. Resident #61 made multiple successful trips outside of the building and was resistant to return inside. Later in the evening, staff noted Resident #61 continued to leave the facility with other staff members as they left the building and required multiple individuals to encourage him to return to the building. No further elopement attempts or instances of unsafe wandering were documented in Resident #61's medical record.Review of physician orders revealed an order on 05/17/25 for a Wanderguard to be applied to Resident #61's wheelchair due to poor safety awareness. Review of the Elopement and Wandering Risk Observation Assessments completed on admission on [DATE], and quarterly thereafter on 06/13/25, 09/08/25, 12/04/25, and 03/02/26 revealed Resident #61 was able to self-propel his wheelchair; was alert and oriented to person, place and time; had never expressed a desire to leave the facility; and had never exhibited unsafe wandering or elopement attempts. The conclusion for each assessment was that use of a wander alarm was not indicated.Review of Resident #61's care plan revealed no goals or interventions indicating Resident #61 had poor safety awareness requiring the use of a Wanderguard or a history of unsafe wandering or elopement attempts.Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for March 2026 revealed the unit nurse confirmed the Wanderguard was in place on Resident #61's wheelchair as ordered.Observations made on 03/03/26 at 3:47 P.M., 03/04/26 at 8:08 A.M., 8:49 A.M., and 1:32 P.M., and 03/05/26 at 8:33 A.M. revealed Resident #61's Wanderguard was not applied to his wheelchair or his person. Interview on 03/04/26 at 1:32 P.M. with RN #329 confirmed Resident #61 has an order for a Wanderguard to be placed on his wheelchair. RN #329 confirmed the Wanderguard was not on his wheelchair or his person. RN #329 retrieved a new Wanderguard bracelet and attempted to apply it to Resident #61's wheelchair but he refused.Interview on 03/05/26 at 8:36 A.M. with Director of Nursing (DON) #301 stated the Elopement and Wandering Risk Observation Assessments are completed for each resident upon admission, quarterly, and as needed if behaviors develop. DON #301 stated a resident is considered to have eloped if they leave the property without staff knowledge; if the resident is cognitively impaired, they are considered to have eloped if the resident leaves the building. DON #301 confirmed that the Elopement and Wandering Risk Observation Assessments completed after the elopement were inaccurate and confirmed Resident #61 required a Wanderguard alarm. DON #301 confirmed Resident #61's care plan should have been updated following the elopement and application of the Wanderguard alarm.Review of the policy titled Emergency Procedure - Missing Resident, revised 08/2018, stated a resident's care plan should be updated following an elopement. The policy stated after the missing resident is found, the facility should complete an incident report and report the incident to the State Licensing and Certification agency according to state regulations.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure tube feedings were administered at the rate ordered by the physician. This affected two residents (#87 and #93) out of the three residents reviewed for tube feeding. The facility census was 80.Findings include:1. Record review for Resident #87 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included paroxysmal atrial fibrillation, type two diabetes mellitus, and dysphagia. Review of the admission Minimum Data Set (MDS) assessment, dated 02/25/26, revealed the resident was assessed to have mildly impaired cognition. Review of the care plan, dated 02/19/26, revealed the resident was at risk for malnutrition due to gastrostomy tube, requires enteral nutrition. Interventions included to administer enteral nutrition as ordered. Review of the active physician order, dated 02/25/26, revealed the resident was to receive Diabetisource AC by PEG (Percutaneous Endoscopic Gastrostomy) tube at a rate of 85 milliliters (ml) per hour with a 75 ml flush of water every four hours continuously. Observation on 03/02/26 at 9:33 A.M. revealed Resident #87 was lying in bed. Diabetisource AC was being administered by a pump through his PEG tube at a rate of 75 ml per hour with a 150 flush of water every four hours. Observation on 03/02/26 at 1:45 P.M. revealed Resident #87 continued to have DIabetisource AC being administered by a pump through his PEG tube at a rate of 75 ml per hour with a 150 ml flush of water every four hours. Interview with Licensed Practical Nurse (LPN) #304 at the time of the observation confirmed Resident #93's Diabetisource AC was running at a rate of 75 ml per hour with a 150 ml flush of water every four hours when it should have been running at a rate of 85 ml per hour with a 75 ml flush of water every four hours. LPN #304 then set the feeding pump to administer the correct amount of Diabetisource AC and water flushes. 2. Record review for Resident #92 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included a stage three pressure ulcer of the sacral region, aphasia following cerebral infarction, and gastrostomy status. Review of the care plan, dated 02/26/26, revealed the resident had a GT (Gastrostomy Tube) and was at risk for enteral nutrition complications. Interventions included to provide enteral tube care as ordered and check for tube placement as ordered. Review of the active physician order, dated 02/27/26, revealed the resident was to receive Osmolite 0.5 calorie by PEG tube at a rate of 80 ml per hour continuously with a 100 ml flush of free water every four hours. Observation on 03/02/26 at 8:25 A.M. revealed Resident #93 was lying in bed. Osmolite 0.5 calorie was being administered by a pump through her PEG tube at a rate of 60 ml per hour with a 100 ml flush of water every four hours. Observation on 03/02/26 at 1:58 P.M. revealed Resident #93 continued to have Osmolite 0.5 calorie being administered by a pump through his PEG tube at a rate of 60 ml per hour with a 100 ml flush of water every four hours. Interview with LPN #304 at the time of the observation confirmed Resident #93's Osmolite 0.5 calorie was running at a rate of 60 ml per hour with a 100 ml flush of water every four hours when it should have been running at a rate of 80 ml per hour with a 100 ml flush of water every four hours. LPN #304 then set the feeding pump to administer the correct amount of Osmolite 0.5 calorie and water flushes. Review of the facility procedure titled Enteral Nutrition, dated 2001, revealed adequate nutritional support through enteral nutrition is provided to residents as ordered.

Based on interview, observation, record review, and facility policy review, the facility failed to ensure orders were in place for oxygen administration. This affected one resident (#6) out of three reviewed for oxygen administration. The facility census was 80 at the time of survey. Findings Include:Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disorder, type II diabetes mellitus with diabetic neuropathy, and hepatic encephalopathy.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was mildly cognitively impaired with a BIMS of 08 out of 15, had no behaviors, did not reject care, and did not wander.Observation of Resident #6 on 03/02/2026 at 10:18 A.M. revealed an oxygen concentrator to be running next to Resident #6's bed. Resident #6's oxygen tubing was being changed.Review of Resident #6's physician orders revealed no order for oxygen therapy existed for Resident #6.Interview with Registered Nurse (RN) #310 on 03/04/2026 at 7:34 A.M. revealed that Resident #6 had been on oxygen therapy since admission. RN #310 confirmed that no orders existed for oxygen therapy for Resident #6.Review of facility policy titled Oxygen Administration dated October 2010, revealed that step 1 of oxygen administration states Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.

Based on closed record reviews, review of hospital discharge orders, staff interview, and facility policy review, the facility failed to ensure medications were not administered longer than prescribed by the physician. This affected one resident (#103) out of the nine residents reviewed for Clostridium difficile (C-Diff) infections. The facility census was 80.Findings include: Closed record review for Resident #103 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included cellulitis of the right lower limb, anemia, and atrial fibrillation. The resident was discharged from the facility on 01/22/26. Review of the hospital discharge orders, dated 10/30/25, revealed the resident was ordered to receive 100 milligrams (mg) of Doxycycline (an antibiotic medication) twice a day for 9 days.Review of the facility physician order, dated 10/30/25, revealed the resident was ordered to receive 100 mg of Doxycycline twice a day. The order did not contain a stop date.Review of the Medication Administration Record (MAR) for Resident #103 revealed the resident was documented to have been administered Doxycycline from 10/30/25 through 11/30/25 when she was transferred to the hospital (22 days longer than ordered by the hospital).Review of the facility Alert Note, dated 11/09/25, revealed the resident was documented to have loose stool/diarrhea in 24 hours. Stool softener held.Review of the facility Alert Note, dated 11/10/25, revealed the resident was documented to have loose stool/diarrhea in 24 hours. Stool softener held. Fluids encouraged.Review of the facility Alert Note, dated 11/12/25, revealed the resident was documented to have loose stool/diarrhea in 24 hours. Stool softener held per resident request.Review of the facility Alert Note, dated 11/16/25, revealed the resident was documented to have loose stool/diarrhea in 24 hours. Fluids encouraged.Review of the facility Alert Note, dated 11/18/25, revealed the resident was documented to have loose stool/diarrhea in 24 hours. Fluids encouraged.Review of the facility Alert Note, dated 11/20/25, revealed the resident was documented to have loose stool/diarrhea in 24 hours. Encouraged fluids.Review of the laboratory test results, dated 11/20/25, revealed the resident tested positive for C-Diff infection.Review of the Nurse Practitioner progress note, dated 11/20/25, revealed Resident #103 had tested positive for C-Diff colitis. Resident is receiving doxycycline since discharge from the hospital. Since she is still receiving antibiotic, will initiate extended treatment. In addition to diarrhea, resident is also having significant nausea. As needed zofran is ordered and contact precautions being initiated.Interview 03/05/26 at 2:16 P.M. with Licensed Practical Nurse (LPN)/Infection Control Nurse #363 Resident #103's hospital discharge orders directed the resident to only receive Doxycycline for nine days after discharge but the resident continued to receive the medication through 11/30/25. LPN/Infection Control Nurse #363 confirmed there were several documented instances of loose stools/diarrhea beginning on 11/09/25 through 11/20/25 when the resident was diagnosed with C-Diff infection. Review of the facility policy titled Administering Medications, dated 2001, revealed medications shall be administered in a safe and timely manner, and as prescribed.This deficiency represents non-compliance identified during the investigation of Complaint 2735113.

Based on record reviews, interviews, and policy reviews, the facility failed to ensure that medications were not left unattended at a resident's bedside. This affected one resident (Resident #31) of 19 residents observed during initial observations. The facility census was 80. Findings include: Review of the medical record for Resident #31 revealed an admission date of 10/07/25. She had diagnoses including congestive heart failure, type II diabetes, and hypertension.Review of the Minimum Data Set 3.0 (MDS) assessment completed on 10/14/25 revealed Resident #31 was cognitively intact.Observation on 03/02/26 at 10:27 A.M. revealed a small cup with multiple medications on Resident #31's bedside table.Interview on 03/02/26 at 10:27 A.M. with Resident #31 confirmed her medications were left on her bedside. Resident #31 confirmed her nurse will usually leave her pills for her in the morning if she is too tired to take her medications.Review of physician's orders revealed Resident #61 was administered the following medications in the 9:00 A.M. medication administration timeframe: Allopurinol 100mg tablet, one tablet daily with 300mg tablet, total 400mg for gout; Allopurinol 300mg tablet, one tablet daily with 100mg tablet, total 400mg for gout; CoQ-10 200mg capsule, one table daily for supplement; Metoprolol Succinate ER 50mg, one tablet daily for hypertension; Senna-Docusate Sodium 8.6-50mg, one tablet daily for constipation; Sertraline HCl 100mg, one tablet daily for depression; Eliquis 5mg, one tablet daily for atrial fibrillation; and Magnesium Oxide 400mg, two tablets twice daily for magnesium deficiency.Review of the policy, Administering Oral Medications, revised 10/2010, stated the nurse or medication aide providing medications should remain with the resident until all medications have been taken.

Based on medical record review and resident and staff interviews, the facility failed to honor resident meal preferences. This had the potential to affect one (Resident #99) of 78 residents at the facility that receives meals from the kitchen. The facility identified Residents #87 and #93 as not receiving food from the kitchen. The facility census was 80 residents.Observation on 03/03/26 at 12:15 P.M. revealed Resident #99 received lunch meal which included beef tips and mashed potatoes with gravy. Review of Resident #99's meal ticket lists dislikes that included broccoli-cauliflower, asparagus, pork and gravy. Interview on 03/02/26 at 12:15 P.M. revealed Resident #99 waved down surveyor and stated, why give facility list of likes and dislikes if facility is not going to honor preferences. Interview on 03/02/26 Staff #327 confirmed resident beef tips and mashed potatoes were covered in gravy and meal ticket list gravy as a dislike.

Based on record reviews, interviews, and policy review, the facility failed to ensure an accurate medical record. This affected one resident (Resident #61) of 24 residents reviewed for accuracy of medical records. The facility census was 80.Findings include: Review of the medical record for Resident #61 revealed an admission date of 03/20/25 with diagnoses including hemiplegia and hemiparesis affecting his right, non-dominant side, aphasia following cerebral infarction, depression, and high blood pressure. Further record review revealed on admission, his Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating he had moderate cognitive impairment.Review of the annual Minimum Data Set 3.0 (MDS) assessment completed on 02/09/26 revealed Resident #61 was independently mobile with the use of a manual wheelchair. He required maximal assistance with toileting, showering, dressing, and positioning. Resident #61 had displayed no verbal or physical disruptive behaviors, no rejection of care, and no wandering or exit-seeking behaviors. Resident #61 had a Wanderguard in place.Review of nursing progress notes revealed on 05/17/25 at around 6:00 P.M., Resident #61 was found in the facility parking lot by an employee leaving at the end of their shift. Resident #61 informed the nurse assisting him that he was trying to go home. The nurse was able to assist Resident #61 back into the facility where a Wanderguard was applied to his wheelchair. Resident #61 made multiple successful trips outside of the building and was resistant to return inside. Later in the evening, staff noted Resident #61 continued to leave the facility with other staff members as they left the building and required multiple individuals to encourage him to return to the building. No further elopement attempts or instances of unsafe wandering were documented in Resident #61's medical record.Review of physician orders revealed an order on 05/17/25 for a Wanderguard to be applied to Resident #61's wheelchair due to poor safety awareness. Review of the Elopement and Wandering Risk Observation Assessments completed on admission on [DATE], and quarterly thereafter on 06/13/25, 09/08/25, 12/04/25, and 03/02/26 revealed Resident #61 was able to self-propel his wheelchair; was alert and oriented to person, place and time; had never expressed a desire to leave the facility; and had never exhibited unsafe wandering or elopement attempts. The conclusion for each assessment was that use of a wander alarm was not indicated.Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for March 2026 revealed the unit nurse confirmed the Wanderguard was in place on Resident #61's wheelchair as ordered.Observations made on 03/03/26 at 3:47 P.M., 03/04/26 at 8:08 A.M., 8:49 A.M., and 1:32 P.M., and 03/05/26 at 8:33 A.M. revealed Resident #61's Wanderguard was not applied to his wheelchair or his person. Interview on 03/04/26 at 1:32 P.M. with Registered Nurse (RN) #329 confirmed Resident #61 has an order for a Wanderguard to be placed on his wheelchair. RN #329 confirmed the Wanderguard was not on his wheelchair or his person. RN #329 retrieved a new Wanderguard bracelet and attempted to apply it to Resident #61's wheelchair but he refused.Interview on 03/05/26 at 8:36 A.M. with Director of Nursing (DON) #301 stated the Elopement and Wandering Risk Observation Assessments are completed for each resident upon admission, quarterly, and as needed if behaviors develop. DON #301 stated a resident is considered to have eloped if they leave the property without staff knowledge; if the resident is cognitively impaired, they are considered to have eloped if the resident leaves the building. DON #301 confirmed that the Elopement and Wandering Risk Observation Assessments completed after the elopement were inaccurate and confirmed Resident #61 required a Wanderguard alarm.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was immediately notified of a resident's change of condition. This affected one (#120) of three residents reviewed for change of condition. The facility census was 70.Findings include: Medical record review for Resident #120 revealed an admission date of 07/17/25 and was discharged on 07/19/25. Diagnoses included coronary artery disease, hydronephrosis, renal insufficiency, anxiety, depression, atrial fibrillation, and cardiomyopathy. Review of the five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 was moderately cognitively impaired, and was partial to moderate assistance for toileting, bed mobility, and for transfers. Review of the progress note dated 07/19/25 at 12:19 A.M. revealed Resident #120 was yelling and the staff entered the room and found her on the floor next to the bed. The resident said she rolled out of the bed. The resident was assessed and had an open hematoma to the right lower leg. There was a knot to the right back of the head and small red area to the right eyebrow. Range of motion was within normal limits, and the resident complained of a headache, which Tylenol was administered, and the pain was relieved. The resident was assisted to get off the floor and was put in a Broda chair and taken out to the nursing station so she could be monitored. She was talking to the staff at the time. The family was called by telephone, the unit manager was notified by a text message, and the physician was notified via fax message. Neurological checks were started, and they were negative. During an interview on 08/28/25 at 11:00 A.M., Physician #200 stated he was not contacted regarding the unwitnessed fall of Resident #120 on 07/18/25. He stated the usual protocol was for the nurse to call to report an injury, including a bump in the back of the head. Physician #200 stated he was unaware of a fax sent from the facility on 07/18/25. During an interview on 08/28/25 at 11:33 A.M., Licensed Practical Nurse, (LPN), #65 revealed on 07/18/25 at approximately 11:15 P.M., Resident 120 was discovered on the floor near her bed. The resident's vital signs were within normal limits, and the resident had a small golf ball sized raised area on the back of her head. The resident had hematoma on her right leg and reddened right eyebrow. The resident was alert, reported no pain and stated she rolled out of bed. LPN #65 stated he faxed the information of the resident's fall, condition change and the initiation of neurological checks to the Physician #200 at approximately 11:30 P.M. He did not receive any return communication from Physician #200. LPN 65 stated he should have called Physician #200 after there had been no return communication. Review of the policy titled Changes in Resident's Condition or Status dated 02/01/21 revealed the facility will promptly notify the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition. The deficient practice was corrected on 07/19/25 when the facility implemented the following corrective actions: On 07/19/25, the Director of Nursing (DON)/Designee conducted a comprehensive review of all current residents with similar risk profiles to ensure appropriate fall risk assessments were current and fall prevention protocols were in place. The assessment included review of notification procedures for all recent incidents to identify any patterns of communication protocol deviations. No additional concerns were identified during this comprehensive facility-wide evaluation, confirming that this incident represented an isolated occurrence of notification protocol deviation rather than a systemic care issue. Review of the documents revealed this was completed. On 07/19/25, the DON/Designee provided comprehensive re-education to all nursing staff regarding critical communication protocols. Physician Notification Requirements for Fall Incidents: It is essential all nursing staff understand the distinction between routine and urgent physician notification requirements following resident falls. When a fall results in ANY injury, including bruising, swelling, wounds, or head trauma, immediate telephone notification to the attending physician or on-call provider is required. Fax notification alone does not meet the standard for incidents involving injuries, as direct verbal communication allows for immediate clinical guidance and potential order modifications. This requirement ensures timely medical evaluation and intervention when indicated. Emergency Contact Notification Procedures: Staff must attempt to contact ALL listed emergency contacts when notifying families of significant incidents. When the primary contact cannot be reached directly, staff must make reasonable attempts to contact secondary contacts within the same timeframe. This includes calling alternative phone numbers, attempting contact with adult children or other designated contacts. Review of the documents revealed this was completed. Enhanced auditing processes were implemented effective 07/19/25, with the DON conducting focused audits on a minimum of five fall incidents and notification procedures weekly for four weeks, then as needed thereafter. These audits specifically evaluate notification methods, timing, and documentation completeness for all incidents involving potential injuries or condition changes, with any identified issues forwarded to the Quality Assurance committee for immediate follow-up. Review of these documents revealed this was completed. This deficiency represents non-compliance investigated under Complaint Number 2572441 and Control Number 2572194.

Based on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure bathroom flooring and resident room doors were maintained in a clean and safe condition. Additionally, the facility failed to ensure linens were changed upon being soiled in a timely manner. This affected eight (#20, #23, #35, #75, #235, #236, and #238) of eight residents reviewed for environment. The facility census was 87. Findings include: 1. Observation on 07/15/24 at 9:40 A.M. revealed the linoleum in the bathroom of Resident #235 and Resident #236 was taped down across the doorway with duct tape, which was dirty and tattered. There was a gap between the edge of the linoleum and the walls which went around the bathroom. Dirt and debris were observed in the gap between the linoleum and walls. 2. Observation on 07/15/24 at 9:50 A.M. revealed the linoleum in the bathroom of Resident #238 and Resident #75 was taped down across the doorway with duct tape which was dirty, tattered, and had a mold-like substance on it. There was a gap between the edge of the linoleum and the walls which went around the bathroom. Dirt and debris were observed in the gap between the linoleum and walls. The linoleum was loose from the floor and had formed wave like patterns across most of the bathroom floor. Interview on 07/16/24 at 4:10 P.M. with Resident #238 confirmed the bathroom floor was in poor repair, causing it to be difficult and unsafe to wheel across in a wheelchair. Observation and concurrent interview on 07/16/24 at 4:15 P.M. with Maintenance Director (MD) #55 confirmed Resident #75, Resident #235, Resident #236, and Resident #238 resided in rooms with bathroom flooring which was in poor repair, dirty, duct taped down across the doorways and in need of being replaced. 44070 3. Observation on 07/15/24 at 12:09 P.M. revealed the flooring in Resident #20 and Resident #35's bathroom was peeling, torn, and curling up at the doorway. The flooring under the sink also appeared wavy. Interview of Residents #20 and #35 at the time of the observation revealed the flooring had been in disrepair for several months. 4. Observation on 07/16/24 at 9:24 A.M. revealed Resident #23's bathroom flooring was peeling and had been secured with duct tape, which was also beginning to peel and curl up. Additionally, the room and bathroom doors had gouges in the wood along the edges. Concurrent interview with Resident #23 revealed the bathroom flooring had been in disrepair for some time and the resident was fearful of getting splinters from the gouges in the room and bathroom doors. Interview on 07/16/24 at 3:40 P.M. with MD #55 revealed he was aware of the flooring concerns in resident bathrooms. MD #55 stated the facility had obtained several quotes in November 2023 to replace the flooring, but they were waiting for approval from the corporate office. MD #55 verified the findings in Residents #20, #35 and #23's bathrooms. Additionally, MD #55 verified the large gouges to the room and bathroom doors in Resident #23's room and stated he should sand the doors to prevent injury. 5. Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included heart disease, anemia, muscle weakness, dysphasia and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Observation on 07/15/24 at 12:09 P.M. revealed an approximately six by six inch area on Resident #20's fitted bed sheet with dried blood spots. The area was uncovered, making it visible upon entering the room. Concurrent interview with Resident #20 revealed the blood on his sheets was from a skin tear to his elbow. Resident #20 had a bandage on his left elbow. Resident #20 stated he would like his sheets changed due to the dried blood, but staff had not done it yet. Observation on 07/16/24 at 3:27 P.M. revealed Resident #20's bed linens had blood spots in the same area as observed the previous day. Concurrent interview with Resident #20 confirmed his linens had not been changed. Interview on 07/16/24 at 3:40 P.M. with MD #55, and concurrent observation, confirmed Resident #20's bed linen had spots of dried blood. MD #55 stated he would request the sheets be changed. Review of facility policy titled, ADL Care, dated 11/30/23 revealed Resident linen should be changed on shower days and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00154488.

Based on observation, staff interview and review of facility policy, the facility failed to ensure food was prepared in a manner to prevent food-borne illness. This had the potential to affect all residents residing in the facility, with the exception of two residents (#48 and #237) identified by the facility as having no food by mouth (NPO). The facility census was 87. Findings include: Observation on 07/15/24 at 9:00 A.M. revealed two large, uncooked pork loins in plastic packaging, lying in the sink. The two raw pork loins were submerged in water with the drain plug in place, keeping the water from draining. No water was running into the sink. Dietary Manager (DM) #500 obtained the temperature of the water the pork loins were submerged in with a facility thermometer. The water temperature was 62 degrees Fahrenheit (F). Interview with DM #500 on 07/15/24 at 9:02 A.M. confirmed the two raw pork loins were submerged in standing water, which had a temperature of 62 degrees F. DM #500 confirmed raw meats were only to be thawed under cold running water. Review of the facility policy titled Time and Temperature Control and Recording, undated, revealed during thawing, the surface of foods can warm up enough to allow dangerous bacteria to grow. Since it can take more than four hours to thaw most foods, it is imperative to do so in a safe manner to discourage the growth of bacteria. For cold water thawing, thaw frozen food, in its leak-proof packaging, completely submerged under clean, cold, running water. This method is not appropriate for large roasts/cuts of meat that will not thaw within the four hour timeframe of exposure to temperatures above 41 degrees F.

Based on observations, resident interview and staff interview, the facility failed to ensure resident dignity was maintained during dining experiences. This affected two (#36 and #242) of two residents observed for dining. The facility census was 87. Findings include: 1. Observation on 07/15/24 at 11:59 A.M. revealed State tested Nursing Assistant (STNA) #54 entered the room of Resident #41, carrying the resident's lunch meal tray. STNA #54 set up the resident's tray and began to feed the resident while standing at the side of the resident's bed. Resident #242, Resident #41's roommate, was sitting in his wheelchair in the room and had not received a lunch meal tray. Interview on 07/15/24 at 12:08 P.M. with Resident #242 confirmed the lunch meal Resident #41 was being fed smelled good. Resident #242 additionally confirmed he was hungry and was still waiting for his lunch meal to be delivered to the room Interview on 07/15/24 at 12:10 P.M. with STNA #54 confirmed residents who required assistance consuming meals received their meal trays first so staff could assist them. While Resident #242 was in the same room as Resident #41, STNA #54 stated Resident #242 would receive his lunch meal tray once it was brought to the hallway by kitchen staff. Additional observation on 07/17/24 at 11:20 A.M. revealed STNA #60 entered the room of Resident #41, carrying the resident's lunch meal tray. STNA #60 set up the resident's tray and squatted down beside the resident's bed and began feeding the resident. Resident #242 was sitting in his wheelchair in the room and had not received a lunch meal tray. Interview on 07/17/24 at 11:26 A.M. with Resident #242 revealed the lunch meal tray Resident #41 was being fed smelled good, as he was hungry. Resident #242 confirmed Resident #41 always received his lunch meal tray first, while he received his meal approximately 30 minutes later. Resident #242 stated he preferred to receive his meal tray at the same time as Resident #41. Observation on 07/17/24 at 11:43 A.M. revealed the lunch meal for Resident #242 was served to the resident in his room, approximately 23 minutes after Resident #41 had been served his meal. 33023 2. Observation on 07/15/24 at 12:00 P.M. revealed Resident #31 was being fed by facility staff. Resident #36 was also observed in the room, without a meal tray. Concurrent interview with Resident #36 revealed she was hungry and always received her meal tray after her roommate, Resident #31, had already been fed. Resident #36 stated she always had to watch while Resident #31 was fed. Interview on 07/17/24 at 11:00 A.M. with Dietary Manager (DM) #500 verified meal trays for residents who required assistance were sent out to the floor first and fed by staff before the rest of the residents received meal trays. Additional observation on 07/17/24 at 11:46 A.M. revealed Resident #31 was being fed the lunch meal by facility staff. Resident #36 was also observed in the room, without a lunch meal. Interview on 07/17/24 at 11:56 A.M. with Resident #36 revealed her roommate, Resident #31, always received her meal tray first. Resident #36 stated she had to watch her roommate eat while she had to wait.

Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were invited to care conferences. This affected one (#23) of one residents reviewed for care conferences. The facility census was 87. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included diabetes, schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, cerebral ischemic attack, restlessness and agitation and impulsive behavior. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of the care conferences dated 12/16/23, 03/08/24 and 05/20/24 revealed no evidence Resident #23 was invited to or attended the care conferences. Interview on 07/16/24 at 9:24 A.M. with Resident #23 revealed she was unaware of any care conferences and had not been invited to any. Resident #23 stated she would have attended had she been invited. Interview on 07/17/24 at 9:40 A.M. with the Director of Nursing (DON) and Social Services (SS) #52 confirmed the facility had no evidence of who attended Resident #23's care conferences, including any documentation of Resident #23 being invited, attending, or declining to participate. Review of the facility policy titled IDT Care Conference Documentation, dated 11/20/23, revealed interdisciplinary care conferences would be held and residents would be invited to attend. The conferences would be scheduled quarterly and invitations would be sent to residents to attend. Each discipline would report on current status and revise goals. Resident questions would be answered and documentation would be kept in the electronic medical record.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the police report, review of the local hospital records, policy review, review of the facility investigation, and review of the Self-Reported Incident (SRI), the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This resulted in Immediate Jeopardy when Resident #01, who had history of exit seeking behaviors and dementia, left the facility unknown to staff and was found one tenth of a mile from the facility by a civilian and was transported to a nearby hospital and subsequently found to have a non-displaced [MEDICAL CONDITION] condyle of the right humerus. The facility staff heard door alarms sounding; however, staff cleared all the door alarms and did not follow-up to ensure all residents of the facility were accounted for to ensure the safety of all residents and in accordance with their facility policy. This affected one resident (#01) of five reviewed who were assessed with [REDACTED]. On 01/08/21 at 3:12 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 12/03/20 between 9:45 P.M. and 10:10 P.M., when Resident #01 who had a documented history of exit seeking behaviors had eloped from the facility unknown to staff and was transported to the hospital and subsequently found to have a non-displaced [MEDICAL CONDITION] condyle of the right humerus. Facility staff heard the door alarms sounding; however, staff cleared all the door alarms and no follow-up was completed to ensure all residents were safe and accounted for in accordance with facility policy. The Immediate Jeopardy was removed, and the deficient practice corrected on 12/08/20, when the facility implemented the following corrective actions: · On 12/03/20 at 10:48 P.M., Registered Nurse (RN) #89 completed a head count of all residents and everyone was accounted for except for Resident #01. · On 12/03/20 at 11:50 P.M., the DON and the Administrator arrived at the facility and immediately interviewed all staff who were on duty. The staff included: Licensed Practical Nurse (LPN) #91, LPN #90, RN #89, State tested Nursing Assistants (STNA) #61, #60, #63, and #62. The summary of the interviews indicated the door alarms sounded at three different locations; the front door, the rear door, and the door at the end of the hallway located near Resident #01's room. · On 12/04/20 at 12:30 A.M., Maintenance Director #50 inspected all doors and alarms and found all were in proper working condition. Maintenance Director #50 contacted the Secure Care company requesting on-site inspection of doors and the wander guard system. · The facility investigation revealed two STNA's (#60 and #61) stated they responded to the alarm sounding at the end of the hallway near Resident #01's room at approximately 10:15 P.M. to 10:20 P.M. and found the door to be closed. Both STNA's exited the door and viewed the immediate outdoor area and did not notice anyone in the area. Both STNA's re-entered the building through the same door which required a code for entry. The STNA's reported not seeing anyone outdoors to the nurse. · On 12/04/20 at approximately 1:10 A.M., Resident #01 was transported back to the facility and was immediately placed on one-to-one supervision which continued until his planned discharge from the facility on 12/06/20. · On 12/04/20, the DON provided on-site education to all staff working at the time of the incident on Missing Resident action steps with focus on needing to complete head count. · On 12/04/20 at approximately 3:15 A.M., a missing resident drill was completed by the DON and the Administrator for all staff working at the time of the incident. · On 12/04/20, a Quality Assurance (QA) Meeting was held to review the incident, action steps taken, and the audit plan. Those attending the meeting were Medical Director #33, the Administrator, the DON, RN #70, RN #71, and LPN #40. · On 12/04/20, the DON continued education for all staff on Missing Residents and Abuse and Neglect. RN #70 provided education on the head count policy. All staff had been educated as of 12/08/20. Education on abuse and neglect was also provided by facility department supervisors, which included Director of Rehabilitation #19, Housekeeping Supervisor #17, Dietary Manager #16, the DON, Activity Supervisor #26, and the Administrator. · On 12/04/20, the Administrator, the DON, and designee's RN #70, RN #71, and LPN #26 initiated missing resident drills on every shift since the incident. The last every shift drill was completed on 12/08/20. · On 12/04/20, the local county sheriff's office was contacted to discuss getting a Global Positioning System (GPS) tracker for Resident #01 upon discharge per RN #37. Discharge was planned for 12/06/20, prior to the incident taking place. Anticipated discharge date remains for 12/06/20. The Sheriff's Department indicated they will follow-up with family regarding the GPS tracker. · On 12/04/20, Resident #01's plan of care was reviewed and updated to reflect one-to-one supervision. · On 12/04/20, Nurse Practitioner #600 reviewed Resident #01's condition, medication, and hospital records. A follow-up orthopedic appointment was scheduled for 12/12/20 and Resident #01's family was made aware. · On 12/04/20, Medical Records were reviewed of like residents deemed at risk for exit seeking, wander guard functioning verified, exit seeking binder reviewed and current, which includes: Resident #10, Resident #02, Resident #01, Resident #03, and Resident #05. · Future admissions who display exit seeking behaviors will have Wander guard applied, assessment completed, care plans updated and exit seeking binder updated to reflect new admissions at risk. · On 12/07/20, weekly audits began for Exit Seeking Quality Assessment and Performance improvement tool and were completed weekly for 4 weeks. These audits were completed by the DON or RN #70 on 12/07/20, 12/14/20, 12/23/20, and 01/07/21. · On 12/08/20, the Secure Care Technician arrived and completed inspection and found aside from a few minor adjustments, the doors and alarming system was functioning properly. · On 01/08/21 from 9:15 A.M. to 4:00 P.M., observations revealed no exit doors were alarming and residents were not observed exit seeking. · On 01/08/21, review of the exit seeking binder revealed Resident #16 was newly admitted and identified as having exit seeking behavior. The facility followed their action plan for Resident #16. · Interviews on 01/08/21 from 9:15 A.M. to 4:00 P.M., LPN #40 revealed she had been educated on elopement the first week of December 2020 and she responded she would immediately respond to any door alarm, if she did not see anyone trying to go out, they should open the door and look in the vicinity, if no one was seen, they would check the residents on their assigned hall for a head count. · Interviews on 01/14/21 from 12:40 P.M. to 1:06 P.M. with LPN #35, STNA #39, STNA #41, STNA #42, and STNA #43 revealed they had been educated on elopement the first week of December 2020 and responded they would immediately respond to any door alarm, if they did not see anyone trying to go out they would open the door and look in the vicinity, if no one was seen, they would check the residents on their assigned hall for a head count and notify the nurse in charge. Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #01 was discharged home with his spouse on 12/06/20. Review of the transitional care note from the hospital dated 11/18/20 revealed Resident #01 had altered mental status and sundowning. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had severe cognitive deficits and exhibited wandering behavior. Review of the nurse's notes dated 11/19/20 revealed Resident #01 appeared confused with reorientation given frequently as to why he was in the facility. He was at risk for falls and had poor safety awareness. The note dated 11/24/20 revealed Resident #01 was noted to be out of his room wandering the hallway and was redirected to his room multiple times. Resident #01 had attempted to open the hallway wing door and the alarm sounded and he was assisted back to his room. Approximately an hour later, Resident #01 was noted by therapy staff outside the facility. Resident #01 was brought back inside by staff, and it was noted he had climbed out his window to get outside. Resident #01 revealed he was looking for his wife and one-on-one supervision was started, and a secure bracelet was placed on his right ankle. Review of the plan of care dated 11/24/20 revealed Resident #01 had exit seeking behavior and was at risk for elopement due to he climbed out of a window and got out of the wing door related to impaired cognition, newly admitted , and short and long term memory loss. The goal was Resident #01 would not leave the facility unattended. Interventions included an alert bracelet, calmly redirect to an appropriate area, allow to vent feelings and frustrations, check alert bracelet placement every shift and function, educate family and visitors to alert staff when leaving, engage in activities to keep occupied. On 12/04/20 an updated intervention for one-on-one supervision for safety was added. Review of a physician telephone order dated 11/24/20 revealed Resident #01 was started on [MEDICATION NAME] (a medication for dementia). Review of the Restraint assessment dated [DATE] revealed Resident #01 was exit seeking and required a secure bracelet to alert staff when he was attempting to go outside unsupervised. His gait was unsteady, he would not normally ambulate long distances as he tired easily and would become weak. Resident #01 had cognitive impairment, with short and long-term memory deficits, he had wandered outside his room and this was the first time he displayed exit seeking behaviors. A secure bracelet was applied to his right ankle. Staff would maintain and monitor this device and check for functioning daily. Resident #01 was confused daily and required use of the bracelet to alert staff he was attempting to go outside. This alarm would allow the resident to ambulate throughout the facility ad lib within a safe environment. Review of the physician progress notes [REDACTED].#01 was a poor historian due to cognitive/psychiatric impairment and had behavior issues of climbing out of the window to leave stating he had to get up north to pay bills and had poor understanding where he was and why he was at the facility. Review of the certified nurse practitioner note dated 12/03/20 at 3:25 P.M., revealed Resident #01 presented with Covid-19 in early October with continued brain fog with associated confusion, impulsivity, and [MEDICAL CONDITION]. He was alert to self only. Review of the nurse's notes dated 12/03/20 at 10:41 P.M. written by the DON revealed she had received a call from the facility that the police had arrived and came to the door to report a missing resident. The neighbors had reported finding Resident #01 sitting on the ground, the police were notified and had reported he was transported to the local hospital for examination. The local hospital also called the facility and stated they had Resident #01 there and he had a skin tear on his right arm and had complained of his right arm hurting. The local hospital completed X-rays and found a [MEDICAL CONDITION] condyle humerus nondisplaced and they had splinted the right arm with a soft splint. Review of the emergency department report dated 12/03/20 at 10:47 P.M. revealed Resident #01 had altered mental status and was brought to the emergency room by emergency medical staff because he was found wandering around, had an alarm on his right leg, he was wearing shoes, no coat, was confused and cold, and warm blankets were placed on the resident. Review of the hospital paperwork dated 12/03/20 at 11:03 P.M. revealed Resident #01 was found wandering around the street and brought to the emergency department by emergency medical staff and his emergency contact was called and she told them he was from a nearby long-term care facility. Resident #01 was confused and had a skin tear to his right elbow and warm blankets were placed on him for comfort. The facility was notified and confirmed he was a resident there. Review of the hospital discharge disposition paperwork revealed Resident #01 was transferred to the facility with a closed fracture of lateral condyle humerus, fall, dementia, and exposure to cold. He had a history of [REDACTED]. Resident #01 stated he was wandering around for approximately two hours trying to find his way home and apparently, he left the facility without being found by staff members. He had an abrasion to his right elbow and upon range of motion stated his right wrist hurt also. An X-ray of the right elbow revealed a nondisplaced [MEDICAL CONDITION] epicondyle. X-ray to right wrist revealed a smoothly marginated deformity of the fifth metacarpal and proximal phalanx likely related to remote trauma. A follow-up radiographic series was recommended in seven to 10 days. After a sugar tong splint and sling were placed on the right arm, the resident was discharged back to the facility. Review of the nurse's note dated 12/04/20 at 1:30 A.M. revealed Resident #01 had returned to the facility from the hospital. He was alert to self only and confused. He had a soft splint applied to his right arm with an ace wrap for support. Review of facilities discharge assessment dated [DATE] revealed Resident #01 discharged home under his wife's care. Resident #01 was confused daily and had poor safety awareness. He was exit seeking during his stay at the facility. Review of the police report dated 12/03/20 revealed a call was received in at 10:10 P.M. The caller stated an elderly male with a cane was sitting on the ground and would like a well check. The caller was unsure if he fell or if he was having medical issues. The local police were dispatched at 10:13 P.M. and arrived on the scene at 10:17 P.M. The resident was transported to the local hospital at 10:34 P.M. Review of the SRI dated 12/04/20 revealed on 12/03/20 a resident (Resident #01) was located outside of the facility by a civilian approximately one tenth of a mile from the facility. The police were notified, and Resident #01 was taken to the hospital for evaluation and returned to the facility on [DATE] at 1:10 A.M. and placed on one-on-one supervision. Review of the witness statement dated 12/03/20 for STNA #65 revealed she was a float STNA the evening of 12/03/20 and the last time she saw Resident #01 was around 8:30 P.M. when he came to the doorway asking about his shoes. STNA #65 stated he was not having any behaviors and not attempting to exit. STNA #65 stated Resident #01 usually does not venture far from his room. She stated she was not aware of the rehabilitation door alarm going off anytime during her shift. Review of the witness statement dated 12/04/20 for STNA #62 revealed she had worked the night of 12/03/20 and heard the doorbell go off at the front door and when she answered it there was two police officers who stated they may have found one of our residents and they were not sure of his name. The police showed a picture and STNA #62 confirmed it was Resident #01. They stated he had fallen, and they called the emergency squad and they took him to the hospital. STNA #62 stated she arrived at work at 10:00 P.M. on 12/03/20 and there were no door alarms since her arrival, and she had not seen Resident #01 on 12/03/20. Review of the witness statement dated 12/04/20 for STNA #63 revealed she arrived to work at 9:50 P.M. on 12/03/20. She denied any alarms going off on her shift and had not seen Resident #01. Review of the witness statement dated 12/04/20 for LPN #90 verified she had worked the evening of 12/03/20 and had not seen Resident #01 all evening. She stated the front door, the rehabilitation door, and the back door were all alarming at the same time. LPN #90 directed STNA #61 to check the rehabilitation door, she checked the front door, and LPN #91 went with her to check the back door. STNA #61 reported she did not see anyone, so she turned the alarm off. We did not complete a census count because we had thought it was the doors being ajar from the weather. She was not aware of any wandering or exit seeking behaviors from Resident #01 the evening of 12/03/20. Review of the witness statement dated 12/04/20 and timed 1:22 A.M. for RN #89 revealed she had arrived at 7:00 P.M. on 12/03/20 and had not seen Resident #01 as she had not gone down his hall. She stated she talked to the police when they arrived at the facility stating they received a call from someone in the neighborhood and they came out to investigate. The police stated Resident #01 had fallen and they assumed he may be a resident here. The police stated they did not seen any injuries, but they called the emergency squad and he was transported to the local hospital. RN #89 further documented after the police left, she immediately called the DON to inform her of what happened. RN #89 stated she had not heard any alarms sounding. Review of the witness statement dated 12/04/20 and timed 1:56 A.M. for LPN #91 revealed there were three alarms going off at the same time between 9:30 P.M. and 10:00 P.M. which were the front door, the back door, and the rehabilitation door. LPN #91 stated her and LPN #90 checked the back door, STNA #61 checked the rehabilitation door and LPN #90 checked the front door and no one saw anyone, and all doors were cleared. Review of the witness statement dated 12/04/20 for STNA #60 revealed she reported to work on 12/03/20 at 6:00 P.M. and had seen Resident #01 in bed at approximately 6:05 P.M. STNA #60 stated all the doors were going off at some point in time that evening. STNA #60 stated they were alarming on their own. She stated her and STNA #61 had heard the alarm go off and the door was shut so they just reset the alarm. STNA #60 stated she looked outside both ways and did not see anyone. STNA #60 stated it was about 10:15 P.M. when the alarm sounded. STNA #60 stated she was not aware of any exit seeking behaviors that day or evening from Resident #01. Review of the witness statement dated 12/04/20 for STNA #61 revealed she reported to work at 6:00 P.M. on 12/03/20 and she did not see Resident #01 at anytime. She stated every alarm in the building went off at some point and when she went to respond it took three times to reset. She stated alarms on the doors were going off on their own. STNA #61 stated the alarm went off on the rehabilitation unit and her and STNA #60 responded and the door was shut, and she stated they looked outside both ways and did not see anyone and the door reset itself. She stated it was around 10:15 P.M. to 10:20 P.M. when the alarm sounded. STNA #61 stated she was not aware of any exit seeking behaviors that day or evening from Resident #01. Review of the witness statement dated 12/04/20 and timed 8:40 A.M. for STNA #64 revealed she last saw Resident #01 at 9:45 P.M. on 12/03/20. She said Resident #01 came to his door once during evening shift and asked if we had seen his shoes and he was told no, it was bedtime anyway and he went back over to his bed and laid down. STNA #64 stated Resident #01 had no behaviors and was not wandering. She stated the rehabilitation door had not alarmed any on her shift. Interview on 01/08/21 at 9:30 A.M., the Administrator, the DON, and LPN #40 verified Resident #01 had went out the window on 11/24/20 and was immediately seen by staff and he had eloped without staff knowledge on 12/03/20. Telephone interviews were attempted on 01/08/21 from 5:15 P.M. to 5:30 P.M. and on 01/12/21 from 6:00 P.M. to 6:10 P.M. with LPN #91, RN #89, LPN #90, STNA #63, STNA #61 and STNA #64 with no answer and no return contact. Review of the facility policy titled Wandering Policy dated 2015 revealed residents are identified as at risk to wander when one or more of the following risk factors are present: verbalizes a desire to exit, demonstrates behavioral symptoms indicating desire to exit, physically attempts to exit, and wanders into potentially unsafe areas. The personal security bracelet serves as an alert to the resident of safe boundary limits and as an alert to staff if resident is close to an alarmed door. Bracelet placement and functioning of sensor is validated every day. Exit doors and stairwell doors are alarmed. Door alarms are checked for functionality per manufactures guidelines. Staff response drills are conducted monthly. Review of the facility policy titled Conducting a Head Count Policy dated March 2011 revealed head counts are conducted to help identify the location of our residents at a given point in time. It is more than the actual counting of heads. It is a validation process that requires visual confirmation and documentation regarding the location of each resident in the facility. Head counts are conducted when door alarms sounded, and staff are unable to identify who triggered the alarm. This deficiency substantiates allegations in Complaint Control Number OH 270.

Based on observation, medical record review, staff and resident interviews, review of the nursing home and local fire department's reports, and review of the facility's smoking policy, the facility failed to provide adequate supervision of residents identified as unsafe smokers to prevent them from having and utilizing smoking materials in their rooms. This resulted in Immediate Jeopardy when Resident #1, who had a history of [REDACTED]. The flame ignited the resident's oxygen tubing, blankets, and mattress on fire in Resident #1's room. Additionally, the facility failed to ensure Resident #2 and Resident #4 did not have smoking materials on their person or smoke unsupervised per facility policy after the fire incident occurred. This placed all 96 residents (#1 - #96) residing in the facility at risk for the likelihood of serious injury, impairment, or death due to potential burns and/or smoke inhalation as facility staff failed to follow their Emergency/Disaster Plan after the fire occurred. On 01/23/17 at 3:22 P.M., the Administrator, Director of Nursing (DON), Director of Operations, and the Quality Assurance Consultant were notified Immediate Jeopardy began on 01/20/17 at 1:00 A.M. when Resident #1, who was assessed as being an unsafe smoker and at risk for harm or injury due to poor decision making, utilized a lighter in bed while continuous oxygen was being administered following a breathing treatment via mask and nasal cannula. The flame ignited his oxygen tubing, bedding and mattress causing a fire and smoke to fill the resident's room and corridor of the unit and subsequent evacuation and relocation of other residents on the unit to another area of the facility. The facility failed to have any monitoring system in place to ensure residents did not have access to smoking materials. The Immediate Jeopardy was removed on 01/24/17 when the facility implemented the following corrective actions: · On 01/20/17 at 2:10 A.M., the initial investigation post fire was started by Licensed Practical Nurse (LPN) #6. All residents were interviewed to see if they had smoking accessories on them and there were no other cigarettes or lighters found. · On 01/20/17 at 2:30 A.M., all residents on Jericho hallway (#1, #3, #5, #6, #10, #14, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33 and #34) were assessed for smoke inhalation or injury by Registered Nurse (RN) #89 and the DON. · On 01/20/17 at 9:30 A.M., Hospice nurse (RN #138) assessed and evaluated the needs of Resident #1. · On 1/20/17 at 10:00 A.M., Human Resources Director (HRD) #86 and Maintenance Director (MD) #39 began education with all staff in regards to R. A.C.E. (Rescue, Alarm, Contain, and Extinguish) and the smoking policy. Staff were directed that no residents were to be left smoking unsupervised. Residents were to smoke at designated times, in the designated smoking area and the staff were to secure all smoking equipment and materials. · On 01/20/17 at 10:00 A.M., all smoking assessments and care plans were evaluated and updated for all smoking residents residing in the facility by unit managers (RN #54 and RN #48) and by the DON for Residents #1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17. · On 01/20/17 at 10:00 A.M., Resident #1 and Resident #3 were assessed by physician assistant (PA) #139 who made notations of the residents' conditions. There were no apparent injuries. · On 01/20/17 at 1:00 P.M., oxygen orders were evaluated and care plans were updated on all residents on oxygen by unit managers (RN #54 and RN #48) and by the DON. · On 01/20/17 at 1:00 P.M., Social Services (SS) #20 and the Administrator met with the smoking residents and in-serviced them on the smoking policy. · On 01/23/17 at 10:00 A.M., Resident #2 was observed with a cigarette and lighter on this day. Resident #2 was re-educated by SS #20 along with all other smokers. Resident #2's care plan and smoking assessment was reviewed and updated. · On 01/23/17 at 10:30 A.M., the Administrator educated all department heads on the smoking policy and R.A.C.E. The education included two staff members were to monitor residents while smoking. · On 01/23/17, HRD #86, Payroll Clerk (PC) #73, Physical Therapy Assistant (PTA) #9, Unit Manager (UM) #54, Food Service Director (FSD) #37, Business Office Manager (BOM) #82, Admissions Director (AD) #132, the Administrator, LPN #88, Acting Housekeeping Supervisor (HS) #87, began in-servicing all facility staff on the facility's Emergency/Disaster Plan including R.A.C.E and Fire Safety. All staff were in-serviced by 01/24/17. · On 01/23/17 at 1:00 P.M., SS #20 re-educated all smokers on the smoking policy and residents that were in agreement and willing to follow the policy. All smoking residents signed they understood the facility policy. · On 01/23/17 at 1:30 P.M., Activities Director (AD) #110 and the Administrator held a resident council meeting with residents and reviewed the facility smoking policy. · On 01/23/17 at 6:00 P.M., a Quality Assurance meeting was held by the Administrator including the medical director. The smoking residents will be monitored by a department manager and one floor staff for all smoking breaks, four times a day for the next two weeks, then two times per week for two weeks and then monthly thereafter. Staff will be using the Quality Assurance Performance Improvement (QAPI) tool making sure all accessories are collected and residents do not keep smoking accessories on their person. · On 01/23/17 at 6:30 P.M., a binder was created by the Administrator for visitors and families to sign in and out smoking materials when they take residents off the property. Only a nurse is able to handle this process. Nurses will utilize the daily interdisciplinary report to communicate status of smoking materials signed out. Signs were posted in the facility to remind families, visitors and friends not to give residents smoking materials or lighters during visits. They may log the smoking materials and lighters at the nurse's station. · On 01/23/17, the facility began utilizing a monitoring tool to assess for compliance with smoking accessories. Any residents who smoke that do not participate in the smoke break would have a member of the interdisciplinary team go to their room to inquire if they have any smoking accessories on them that the facility would safely secure. The monitoring tool will be utilized for 14 days and then two times per week for two weeks and then monthly thereafter per the DON. Signs were posted in the facility to remind family, visitors and friends not to give residents smoking materials. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Review of a smoking evaluation dated 10/06/16 revealed Resident #1 was admitted to the facility with facial burns due to wearing oxygen and smoking at the same time. Review of the smoking evaluation dated 10/11/16 revealed the resident had short term memory deficits and was an unsafe smoker. The resident was noted at risk of harm or injury due to poor decision making and would smoke at the facility in designated areas. The assessment revealed the resident did not require the use of a smoking apron. Review of the care plan dated 10/07/16 revealed the resident had a history of [REDACTED]. Interventions included to not leave resident unattended while smoking and secure smoking materials at nurse's station or other designated areas for storage. Review of Resident #1's care plan note dated 11/17/16 revealed the resident continued to be an at risk smoker due to poor decision making, weakness and shortness of breath. Resident smokes at designated smoking times with supervision. Review of Resident #1's progress note dated 12/13/16 revealed the resident continued to be an unsafe smoker and would smoke at the facility in designated areas. The resident was very forgetful and had a history of [REDACTED]. The resident needed to wear an apron due to having a hard time holding his upper body up. Staff were to monitor close with a lit cigarette. Review of Resident #1's progress note dated 12/15/16 revealed the resident had been outside to smoke and staff had informed him he should not be outside to smoke due to the wind chill and temperature. The resident stated to staff that he was sitting in the truck of another resident to smoke. There was no documented evidence of staff monitoring the resident during this time of smoking. Review of January 2017 physician's orders [REDACTED]. Review of Resident #1's quarterly assessment progress note dated 01/17/17 revealed the resident was an at risk smoker due to poor decision making, weakness and shortness of breath. Resident smokes in designated smoking times with supervision. Review of the Nursing Home Fire Report dated 01/20/17 revealed at 1:00 A.M., LPN #6 was at the desk and noticed a flash from Room #16 and called to Registered Nurse (RN) #89, who was already on the hall, to check. RN #89 entered the room to find Resident #1 on the side of the bed with oxygen tubing on fire and a lighter in the resident's hand. RN #89 removed the tubing and mask, threw them on the floor and stomped out the flames. STNA #1 brought a fire extinguisher, but the fire was out. There were burns on the mattress and blanket and soot on the floor where the tubing was stomped out. Both residents in Room #16 were removed. The unit was evacuated. The fire department arrived and vented the smoke from the building. Review of the local fire department report dated 01/20/17 revealed they arrived at the facility at 1:11 A.M. They were dispatched to the facility for a room fire and heavy smoke. The remarks included Engine (E) three was on scene and heavy smoke was throughout the hallway of one wing (C-D). The fire was out when E one rolled in and there was no heat of any significance. The fire was set by room occupant using a Bic cigarette lighter burning his oxygen tubing and bedding. There were no injuries to the occupant or the attending nurse. However, both persons had blackened hands and soot on their fingers. The fire was initially seen by the head nurse who reported seeing sparks in the hallway from the open door to the room. Another nurse batted the fire out and shut the oxygen off. The facility began evacuation of the rooms in the wing due to the black heavy smoke from plastic burning. Smoke was removed by electric fans closing all doors on the wing except the fire room (with window open) and opening the far hallway door. Successfully removed all the smoke within five minutes and allowed the room to be re-occupied. No smoke detector sounded and none were present in the room. One inactivated sprinkler head was over each bed. The main concern regarding the incident was no alarms sounded and lack of sheltering in place for the residents. While staff did well to remove the residents in a timely manner, they were clearly winded by the exercise and actually exposed the residents to more smoke than if they had been sheltered in place. It was suggested to the head nurse that she talk with management about (procedure/practice) and perhaps a better way would be to initially shut all doors opening each as the residents are removed. Review of the documented facility interview with RN #89 on 01/20/17 revealed LPN #6 was sitting at the nurses station and noticed flashes of light coming from Room #16 and told RN #89 to go see what was going on in that room. RN #89 entered the room and found Resident #1 with a blue lighter lit and the oxygen tubing on fire. The lighter was removed from his hand and thrown out into the hallway. The oxygen tubing was removed from his hands and RN #89 yelled out there was a fire and to bring the extinguishers and call the fire department. The other staff began running into the room to provide assistance. RN #89 began stomping and patting out all areas of the fire in the room. State tested Nurse's Aide (STNA) #101 turned off the oxygen concentrator, the fire was out and all staff began moving residents out of the hallway because of the smoke. The fire department came and assessed the scene and used fans to remove smoke from the hallway. Review of Resident #1's progress note dated 01/20/17 revealed the resident was assessed for injuries and respiratory problems after a fire broke out in the room. There were no injuries noted and lung sounds were diminished per the resident's baseline. The resident denied any distress, discomfort or respiratory difficulty. Resident #1 continued to ask staff if he could go outside to smoke and staff educated him he cannot go outside by himself, staff had to be present and it had to be done at the designated smoking times. Review of Resident #1's progress note dated 01/20/17 revealed social services met with Resident #1 and discussed the incident from 01/20/17. The resident stated he remembered trying to put flames out that were on the floor. He could not recall how he ended up having a lighter or trying to light it. The facility smoking policy was discussed and he stated he was aware that cigarettes and lighters are to be turned into the staff. Observation of the facility on 01/20/17 at 2:50 P.M. revealed Room #16 had no residents or furniture in the room and there was a small blackened area to the tile on the floor where the first bed would have been located. The room had a burnt smell and there were fans blowing in the room. MD #39 was in the room repairing the tile on the floor. MD #39 stated luckily damage was minimal from fire. An interview was conducted on 01/20/17 at 3:37 P.M. with the Administrator and the DON. The DON stated she received a call at 1:20 A.M. from RN #89 who stated LPN #6 noticed a light flicker coming from Resident #1's room and LPN #6 directed RN #89 to the resident's room and LPN #6 then called 911. RN #89 reported to the DON Resident #1 had a lighter and his oxygen tubing was on fire but he was not smoking. RN #89 threw his oxygen tubing on the floor and a blanket that was hanging off the bed and RN #89 had stomped the fire out and got Resident #1 and Resident #3 out of the room. When other staff arrived with fire extinguishers, the fire was already put out. The DON stated staff were evacuating residents when the fire department arrived. The DON verified Resident #1 was a smoker and had a lighter in his possession and he should not have had the lighter. An interview and observation was conducted with Resident #1 on 01/20/17 at 4:30 P.M. Resident #1 was in his new room in bed with oxygen on at five liters per nasal cannula. During a discussion regarding the earlier incident on 01/20/17 he stated he was trying to light a cigarette. He stated he remembered seeing a fire on the right side of the bottom of his bed and the floor. He stated he did not remember where he had gotten the lighter but did have a lighter about a week ago in his pocket. He stated he goes outside to smoke and was supposed to give his lighter back to staff but he did not always do that. During an interview on 01/22/17 at 12:20 P.M., RN #121 revealed she had never seen Resident #1 with a lighter however, she had heard of him having lighters before and they were taken away from him. She stated she received this information in report as recently as two weeks ago from a night shift nurse but was not able to recall the exact time, date or who reported it. An interview was conducted on 01/22/17 at 12:35 P.M. with Resident #3, who was Resident #1's roommate at time of the fire. He stated Resident #1 had a lighter with oxygen and there was a fire in the room and a lot of smoke in the room and in the hallway. He stated staff took them out of the room to the nurse's station and the fire department came. Interview on 01/22/17 at 12:40 P.M. with STNA #49 revealed he had seen Resident #1 with a lighter outside and did not take it away because he seemed safe enough. He was unable to recall the last time he observed the resident with a lighter on him. A telephone interview on 01/23/17 at 10:46 A.M. with RN #77 revealed Resident #1 used to be an independent smoker and went outside to smoke. RN #77 stated an independent smoker was when a resident could sign himself out and get cigarettes and a lighter from the nurse and then they could go off the premises to smoke and then residents would have to return smoking materials to the nurse upon their return. Interview on 01/23/17 at 10:50 A.M. with the Administrator revealed the facility had two residents (Resident #2 and Resident #4) this date with smoking violations identified. The Administrator stated Resident #2 was observed with cigarettes and a lighter on his possession and Resident #4 was observed smoking out in front of the facility this morning unsupervised. Interview on 01/23/17 at 11:45 A.M. with LPN #60 revealed independent smokers would keep their own cigarettes and would sign themselves out of the facility and the nurse would give them a lighter. LPN #60 stated residents were to return the items upon returning to the facility and sign back in. She verified there was no log or monitoring of smoking materials that were given to, or returned, by residents. Interview on 01/23/17 at 11:51 A.M. with LPN #96 revealed independent smokers would sign themselves out of the facility and were given cigarettes and a lighter and verified there was no documentation that lighters or cigarettes were given to or returned by the residents, only that residents signed in and out of the facility. Interview on 01/23/17 at 12:00 P.M. with LPN #93 verified the facility did not have any monitoring system in place to ensure cigarettes and lighters were returned after residents signed back into the facility. Interview on 01/23/17 at 12:08 P.M. with the DON revealed in June 2016, the Administrator and social services met with all smokers and they were to come to the nurse's station to get accessories and go to the smoke area and then return accessories back in. The DON verified there was no monitoring system in place that ensured smoking materials were returned by the residents. The DON stated prior to June 2016, they had residents who signed themselves out of the facility and were observed out on the lawn, leaning against trees, and going across the street smoking which was why they met with smokers in June 2016. The DON stated she expected staff to retrieve any lighters or cigarettes found on residents and to notify social services, the DON and Administrator. The DON verified no staff has reported taking smoking materials from any residents in the past six months. Interview on 01/23/17 at 2:00 P.M. with STNA #49 revealed before 01/20/17, he did observe residents with lighters and he would just confiscate them. During a telephone interview on 01/23/17 at 4:25 P.M. with LPN #6 she verified she was Resident #1's nurse the night of 01/20/17. She stated she was at the computer when she saw flashes of light from Resident #1's room and she told RN #89 to check it out as she was close to the room. She stated RN #89 yelled out fire and she called 911. She then stated she ran to get a fire extinguisher and RN #89 had already stomped out the fire when she arrived to Resident #1's room. She verified Resident #1 had been observed several times with a lighter before and the last time was about two weeks ago. LPN #6 verified she would just take them away from him. 2. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's smoking assessment dated [DATE] revealed the resident was an unsafe smoker requiring staff, family or friend for physical support or supervision to smoke. The resident had been smoking in the community and wished to continue to smoke at the facility. The resident was not making reasonable decisions about his oxygen usage and smoking. He was unsafe to smoke independently. Staff would continue to monitor smoking safety and he would smoke in the designated smoking area, supervised at all times. Review of the care plan dated 01/20/17 revealed a history of smoking in community and inappropriate smoking related to oxygen use and is an at risk smoker. Interventions included to check with resident frequently to ensure he has no smoking materials on him outside of the designated smoke times, do not leave unattended while smoking, instruct to ask staff to provide and light smoking material and to secure smoking materials at nurses station or other designated area for storage. Observation on 01/23/17 at 10:00 A.M. of the facility's smoke break revealed there were six residents in attendance including Resident #2 and two staff members (LPN #96 and Housekeeping Supervisor #107). Observation revealed Resident #2 took a pack of cigarettes and a lighter from inside his jacket pockets and lit a cigarette. This occurred before staff began passing out any smoking materials to residents. Interview on 01/23/17 at 10:15 A.M. with LPN #96 verified Resident #2 had on his possession a pack of cigarettes and a lighter and stated he was an independent smoker prior to now and still needed education. Review of a progress note dated 01/23/17 revealed the resident was observed with smoking materials on his person at supervised smoke time. He lit his cigarette per self with cigarette and lighter he had on him. An interview was completed on 01/23/17 at 11:21 A.M. with Resident #2, who was in his room in bed, and stated he was very upset and did not want to talk to anyone and that he was done with this facility. He then stated he has always had his cigarettes and lighter and he was not stupid enough to smoke with his oxygen on. He refused to answer any questions. 3. Review of Resident #4's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 01/17/17 revealed the resident had a history of [REDACTED]. Interventions included not to leave unattended while smoking and secure smoking materials at nurses' station or other designated area for storage. Review of Resident 4's smoking evaluation dated 01/20/17 revealed he was a smoker in the community and wished to continue to smoke while a resident at the facility. He has been observed smoking in undesignated areas on the premises. Safe smoking technique and procedures reinforced. Resident will require staff supervision for smoking during scheduled smoke times. Review of a progress note dated 01/23/17 revealed social services was alerted by the administrator that he was found outside smoking unsupervised. An interview conducted on 01/23/17 at 3:00 P.M. with Resident #4 revealed he was a smoker and been at the facility for a few months. Resident #4 stated he was called a privileged smoker meaning he could go outside anytime he wanted to smoke and now he has to smoke four times a day with supervision. He stated before he would go to the nurse's station and get his cigarettes and lighter and then go outside. He denied ever having smoking materials kept in his possession. He verified he was smoking outside on 01/23/17 unsupervised and he would not do that again. He stated he did not have his own cigarettes and lighter and he had obtained a cigarette outside from a man and stated he was not an employee. During an interview conducted on 01/25/17 at 9:00 A.M. with the DON she verified there were only four smoke times for the facility at 10:00 A.M, 1:00 P.M, 4:00 P.M. and 7:00 P.M. The DON stated all smokers would be supervised at these specified times. Review of the facility's smoking guidelines dated 11/01/13 revealed the purpose was to determine if a resident was an independent smoker or an at risk smoker before the resident exercised the privilege to smoke while residing within the center and to establish smoking guidelines for all residents that desired to smoke at the center. Residents that smoke will be evaluated by using the smoking evaluation tool. Upon completion of this evaluation, the interdisciplinary team will make a decision whether a resident was an independent smoker or an at risk smoker. If a resident was determined to be an independent smoker, the resident may smoke without assistance at the center's designated times. If a resident was determined to be an at risk smoker, the resident was required to wear a protective smoking vest or apron if needed and supervised while smoking. Retention, storage and distribution of smoking accessories were to be kept under the control of center staff when not in use. This included cigarettes, pipes, lighters, matches, lighter fluid, electronic cigarettes, etc. Staff members were to distribute smoking accessories to residents at the center's designated smoke times. Residents may only smoke in designated center locations outside the center and at designated times. Smoking was not permitted while oxygen was in use. Instruct residents, family members and visitors not to share lighted cigarettes, lighters or other smoking accessories with other residents. Any noncompliance with the smoking guidelines was addressed with the resident and family members as the noncompliant activities occur. This deficiency substantiates Complaint #OH 081

Based on staff interview and record review the facility failed to ensure that a resident received the required two person assistance during transfer using a mechanical lift. This resulted in harm when one State tested Nurse Aide (STNA) transferred a resident alone using a mechanical lift resulting in the resident falling and sustaining a left hip fracture. This affected one former resident (Resident #1) of three residents sampled for transfer. The facility census was 93. Findings include: Record review of Resident #1 on 04/20/15 at 9:45 A.M. revealed this resident was admitted to Heartland of Chillicothe on 02/05/2008 with the following medical Diagnoses: [REDACTED]. Resident #1 was discharged to hospital on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert and oriented to person, place, and time with cognitive impairment. The functional assessment completed on the same date of 04/01/15 revealed that Resident #1 was totally dependent with all care with a two-person assist for transfers, locomotion, and activities of daily living. Review of care plan revealed that Resident #1 required two person assist, utilizing a stand up lift for all transfers due to history of falls, and impaired mobility. Review of Nurse's Notes revealed that on 04/04/15 at approximately 1:00 P.M., Resident #1 was being transferred by a STNA to her bed following use of the restroom. The STNA transferred the resident using a standing mechanical lift. The note revealed that Resident #1 slid out of the lift onto the floor. Resident #1 was assessed per the nurse on duty with no apparent injuries or redness at that time. The physician and family members were notified following the fall. On 04/05/15, Resident #1 was assessed as a post fall precaution and no injuries or problems noted at 7:27 A.M. No complaints of pain were voiced by Resident #1. Review of progress notes revealed that Resident #1 was not transferred from her bed for the next two days following her fall on 04/04/15 until she was transferred to hospital on [DATE]. On 04/06/15, Resident #1 was assessed with [REDACTED]. The physician and family members notified with a new order for an X-Ray of the left hip and knee to be obtained at 12:17 P.M. The resident was effectively medicated for pain at that time. The nurses notes revealed during assessments throughout the 3 P.M. to 11 P.M. shift Resident #1 denied pain and had no further change in condition noted. At approximately 11:25 P.M., the X-Ray results were obtained with the reading of a proximal left femur fracture. The physician was notified and ordered Resident #1 sent to the hospital for evaluation and treatment. Review of History and Physical for Resident #1 on 04/07/15 from the hospital revealed that Resident #1 presented with a left acute impacted and angulated femoral fracture, and a chest X-Ray revealed right basilar atelectasis. Interview with the Director of Nursing on 04/20/15 at 11:00 A.M. revealed that the use of each mechanical lift requires two staff members with each transfer. The Director of Nursing stated that on 04/04/15 Resident #1 was transferred to her bed by one staff member when the resident slid from the mechanical lift onto the floor. The Director of Nursing further stated that both nursing assistants were aware of transfer methods at that time. The Director of Nursing stated that an investigation took place immediately following report of the incident and that both nursing assistants were disciplined for not following facility policy. The Director of Nursing verified that two staff members were not present during the transfer of Resident #1 at the time of the fall. Interview with STNA #1 on 04/21/15 at 10:00 A.M. revealed that she responded to Resident #1's room after another aide came and got her. Resident #1 was on the floor beside the mechanical lift after she fell from the lift. STNA #1 that there were eight nursing assistants were working that day. STNA #1 stated that STNA #6 was transferring Resident #1 by a mechanical lift, and that she was performing this task by herself. She further stated that she was busy providing care with another resident in that hallway at the time of the incident. Interview with STNA #6 on 04/21/15 at 10:25 A.M. revealed that she answered the call light for Resident #1 who was using the bathroom when she arrived in the room. STNA #6 stated that she was unfamiliar with the use of the standing mechanical lift, and attempted to get help from STNA #1 but could not find her. She further stated that Resident #1 was yelling to get her back to bed, so she attempted to use the mechanical lift by herself. Stated that she did not even think to ask the nurse on duty for assistance. STNA #6 stated that she assisted Resident #1 into the lift and transported her to her bed which was too high, when she went around the bed to lower it, the resident let go of the hand bars and slid out of the lift onto the floor. She stated that she then called for help, at which time the nurse on duty and STNA #1 responded to help place the resident from the floor to her bed. STNA #6 stated that Resident #1 did not complain of any type of pain for the rest of the day or the following day. Interview with the Administrator on 04/21/15 at 9:00 A.M. revealed that the facility had in-serviced all staff members regarding the use of both mechanical lifts, and re-educated staff on the requirement that two facility staff members must be present when using any type of lift on a resident that requires it's use. The Administrator stated each resident in the facility was reassessed for the use of the mechanical lifts and all care plans were updated in regards to the proper use of each lift. Review of the facility policy dated 03/2015 for the use of lift devices on 04/20/15 at 1:00 P.M. revealed that it is facility policy to have a minimum of two staff members to provide care while using both types of mechanical lift devices. This deficiency substantiates Complaint Number OH 779.