Every finding on record at Country Pointe

Based on observation, interview, and review of facility policy, the facility failed to ensure garbage/refuse was contained within the dumpster. This had the potential to affect all 42 residents residing in the facility. Findings include: On 03/03/25 at 12:57 P.M., observation of the outside dumpster, which was in the parking lot approximately 50 feet away from the building, revealed the lid was broken and the trash in the dumpster was uncovered as a result. In addition, refuse including disposable gloves, disposable cups, straws, empty food packages and an incontinence brief were observed scattered about the dumpster. On 03/04/25 at 9:33 A.M., interview with the Administrator confirmed the dumpster lid was broken. She further stated the arm that held the dumpster lid in place was broken. Review of the facility policy titled Food-Related Garbage and Refuse Disposal, dated October 2017, revealed outside dumpsters would be kept closed and free of surrounding litter.

Based on record review, self-reported incident (SRI) review, and interview the facility failed to ensure Resident #33 received adequate supervision to manage his behaviors to prevent resident to resident abuse. This resulted in Actual Harm to Resident #33 when he sustained a posterior [CONDITION(S)] which required transportation to the hospital and five staples to the back of his head. This finding affected two residents (Residents #3 and #33) of four residents reviewed for abuse. The facility census was 42. Findings include: Review of Resident #3's medical record revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited memory problems. Review of Resident #3's Psychiatrist Follow Up Monthly Progress Note dated 11/13/22 indicated he was chronically delusional and wanted to have medications for an injury that happened years ago but overall manageable. Review of Resident #3's progress note dated 11/20/22 at 9:30 P.M. indicated he was involved in a physical altercation with a male peer (Resident #33). Per the resident, he and the male peer were standing in the smoke line talking about Whoppers. The male peer then became physically aggressive, striking him with a closed fist and he retaliated. A behavior plan was initiated per the facility policy and as needed medications were administered. No injuries were noted to Resident #3. Review of Resident #33's medical record revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's MDS 3.0 assessment dated [DATE] revealed he exhibited memory problems. Review of Resident #33's progress note dated 11/20/22 at 8:00 P.M. indicated he attempted to become physically aggressive with a male peer (Resident #3) striking him with a closed fist. The male peer retaliated and struck Resident #33 causing him to lose his balance and fall to the floor striking his head. A laceration was noted to the back of his head, and first aid was attempted by the nursing staff. Emergency Medical Services (EMS) was notified, the physician was called, the Director of Nursing (DON) was called, and an attempt was made to contact the guardian. Review of Resident #33's progress note dated 11/20/22 at 8:20 P.M. indicated he was transported by EMS to the hospital for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #33's progress note dated 11/20/22 at 10:37 P.M. indicated a computerized tomography ( CT scan, a series of cross-sectional X-ray images of the body) was done which was negative. Resident #33 received five staples to a laceration of the posterior head and was transported back to the facility. Review of Resident #33's Psychiatrist Follow-Up Monthly Progress Note form dated 11/26/22 revealed he continued to have aggressive episodes. He was hospitalized with a laceration of his head. He was in his room most of the time. Interview on 11/28/22 at 9:50 A.M. with the DON indicated Resident #33 heard voices. The DON stated the facility had 100% (percent) behavioral residents. She indicated Resident #33's voices tell him to hurt people and they do the best they can with behavioral modification and medication management. They also try to avoid having Resident #33 stand in lines, separate during smoke breaks and during meals. She stated Resident #33 was seen by a psychiatrist to adjust his medications, but he was not sent out to the hospital for a psychiatric evaluation following the incident on 11/20/22 because he was not appropriate to be admitted . She stated he was sent to the hospital for the laceration on the back of his head. Interview on 11/28/22 at 10:08 A.M. with Resident #33 indicated he heard voices, and they told him to punch someone. He remembered the altercation with Resident #3 but could not give details as to what happened. Interview on 11/28/22 at 10:13 A.M. with Resident #3 indicated Resident #33 came up to him and sucker punched him in the back of the head. He denied concerns of abuse and stated he felt safe in the facility. Telephone interview on 11/28/22 at 11:30 A.M. with Physician #804 indicated Resident #33 would hear a commanding voice and then act upon the voice; it was part of his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Telephone interview on 11/28/22 at 12:17 P.M. with Licensed Practical Nurse (LPN) #806 indicated she worked on 11/20/22 on the second shift when the incident occurred between Residents #3 and #33. She indicated the residents were standing in line waiting to go outside to smoke when Resident #33 was observed hitting Resident #3. At that point, Resident #3 retaliated and hit Resident #33 back. She indicated both were separated and assessed for injuries. Interview on 11/28/22 at 1:50 P.M. with the Administrator indicated the SRI investigation for physical abuse between Resident #3 and Resident #33 was unsubstantiated on 11/20/22 because both residents were cognitively impaired and could not participate in willful abuse. Review of a physical abuse SRI investigation dated 11/20/22 revealed Resident #3 was standing in the smoke line talking about Whoppers when Resident #33 became physically aggressive with Resident #3, striking him with a closed fist. Resident #3 then became physically aggressive with Resident #33, striking him and causing him to lose his balance and fall to the floor striking his head. They were immediately separated and assessed for injuries. Resident #3 was noted to have no injuries, and Resident #33 had a [CONDITION(S)] with significant bleeding. Resident #33 was transported to the local emergency department for evaluation and treatment. A CT scan was negative, and he received five staples in his [CONDITION(S)]. Review of the Abuse Investigation and Reporting policy, revised 07/17, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. This deficiency substantiates Complaint Number OH 774.

Based on record review and interview the facility failed to ensure Resident #33 received adequate supervision to manage known aggressive behaviors towards other residents. This finding affected one (Resident #33) and had the potential to affect all 42 residents residing on the secured behavioral health unit. The facility census was 42. Findings include: Review of Resident #33's medical record revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited memory problems. Review of Resident #33's progress note dated 10/16/22 at 4:01 P.M. indicated he entered a common area and walked up behind a male peer and became physically aggressive. Both were separated immediately before further altercation could occur. Resident #33 indicated he was hearing voices and had a known history of becoming physically aggressive when he was feeling this way. Review of Resident #33's progress note dated 10/16/22 at 5:30 P.M. indicated a State tested Nursing Assistant (STNA) reported that he approached a male peer and attempted to become physically aggressive with him. The male pushed Resident #33 back with open hands to avoid an altercation. He was asked to return to his room to self soothe and no injuries were noted. Review of Resident #33's progress note dated 10/18/22 at 1:24 P.M. indicated the nurse was informed by the STNA that Resident #33 struck another resident with a closed fist in the jaw while they were outside at the smoke break. He was sent to his room to self-soothe. Review of Resident #33's progress note dated 10/18/22 at 4:20 P.M. indicated the resident's roommate approached the nursing station and reported that Resident #33 attempted to become physically aggressive with him for unprovoked reasons in their room. One to one observation was attempted but ineffective and oral [MEDICATION(S)] (anti-anxiety medication) was offered and accepted. The roommate was moved to another room to avoid further interactions. Review of Resident #33's progress note dated 10/28/22 at 2:36 P.M. indicated he became physical with another resident and had three lacerations around the left eye due to the physical altercation. The superior eye laceration measured 0.2 cm (centimeters) by 0.7 cm; a laceration near the corner of the outer eye measured 0.2 cm by 1.0 cm and the left cheek laceration measured 0.2 cm by 0.5 cm. He had a bruise under the left eye. Redirection and one to one were ineffective and an as needed medication was administered per order. Review of Resident #33's progress note dated 10/28/22 at 3:00 P.M. indicated he started kicking another male resident who was lying on the floor. He was redirected away and to sit back on the bench in line of sight of nursing. He again got up and became physical with another male resident (resulting in two scratch marks to his right outer eye area which measured 0.2 cm by 2 cm by 5 cm). He sat down again and when another male resident came to the nursing room door, he became physical with him (resulting in a scratch to the right cheek which measured 0.3 cm by 0.5 cm). Redirection and one to one were ineffective. Review of Resident #33's progress note dated 11/01/22 at 4:33 P.M. indicated he approached another male in the common area and became physically aggressive, attempting to strike the peer. He was redirected to his room to decrease environmental stimuli and an as needed medication was administered per order. Review of Resident #33's progress note dated 11/03/22 at 5:03 P.M. indicated the STNA reported that he approached another male peer in the dining room and attempted to become physically aggressive. They were separated before injuries could occur. He was sent to his room to self-soothe and placed on a behavior plan per the facility policy. Review of Resident #33's progress note dated 11/08/22 at 7:45 P.M. indicated he was in the lobby and became physically aggressive with a male peer. He was redirected and was assisted back to his bedroom to self soothe. Review of Resident #33's progress note dated 11/10/22 at 10:58 A.M. indicated he was physical with another peer while standing in the drink line. He stated he was hearing voices. He lost smoking privileges and only water and house snacks for the next 24 hours. Review of Resident #33's progress note dated 11/12/22 at 8:10 P.M. indicated he was on the 300-hall returning from a smoke break when he became physically aggressive with a male peer. The residents were separated before injury could occur and he was sent to his room to self soothe. Review of Resident #33's progress note dated 11/17/22 at 7:56 P.M. indicated he was in the smoke line when he turned to a male peer and became physically aggressive. He stated he was hearing voices and a behavior plan was initiated per the facility policy. Review of Resident #33's progress note dated 11/20/22 at 8:00 P.M. indicated he became physically aggressive with another male resident, striking him with a closed fist. The resident retaliated and struck Resident #33 causing him to lose his balance and he fell to the floor, striking his head. A laceration was noted to the back of his head and first aid was attempted by the nursing staff. The emergency squad was notified, the physician was called, the Director of Nursing (DON) was called, and an attempt was made to contact the guardian. Refer to F600. Review of Resident #33's progress note dated 11/24/22 at 5:35 P.M. indicated he was physically aggressive with a peer in the dining room. Both residents were separated, and no injuries were noted. Redirection and one to one were ineffective. Review of Resident #33's Psychiatrist Follow-Up Monthly Progress Note dated 11/26/22 revealed he continued to have aggressive episodes. He was hospitalized with a laceration of his head. He was in his room most of the time. Interview on 11/28/22 at 9:50 A.M. with the DON indicated Resident #33 heard voices. The DON stated the facility had 100% (percent) behavioral residents. She indicated Resident #33's voices tell him to hurt people and they do the best they can with behavioral modification and medication management. They also try to avoid having Resident #33 stand in lines, separate during smoke breaks and during meals. She stated Resident #33 was seen by a psychiatrist to adjust his medications, but he was not sent out to the hospital for a psychiatric evaluation following the incident on 11/20/22 because he was not appropriate to be admitted . She stated he was sent to the hospital for the laceration on the back of his head. Telephone interview on 11/28/22 at 11:30 A.M. with Physician #804 stated Resident #33 would hear a commanding voice and then act upon the voice; it was part of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/28/22 at 2:11 P.M. with Psychiatrist #805 indicated he had assessed Resident #33 recently and ordered bloodwork. This deficiency substantiates Complaint Number OH 774.

Based on record review and staff interview the facility failed to ensure advance directives matched in the electronic health record and paper medical record. This affected one resident (#9) of 18 residents reviewed for advance directives. Findings include: Review of Resident #9's medical record revealed an admitted [DATE] with admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic health record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the EHR also revealed the resident information code status indicated DNRCC-A. Review of the hard chart/paper medical record included a resident face sheet which indicated a code status of Full Code. Further review of the paper medical record found no evidence of advance directives or a DNR form which indicated a DNRCC-A code status was in place. Interview with the Director of Nursing (DON) on 10/12/22 at 8:45 A.M. verified the electronic health record and hard chart/paper medical record for the resident did not match. The DON revealed the hard chart should have indicated Resident #9 was a DNRCC-A and also contain the physician and resident representative signed DNRCC-A form.

Based on record review and interview the facility failed to ensure pharmacy recommendations were complete and provided rationale for the continued use or psychoactive medications (with or without gradual dose reductions) for Resident #19. This affected one resident (#19) of five residents reviewed for unnecessary medication use. Finding include: Record review revealed Resident #19 was admitted to this facility on 08/14/20 with admitting diagnoses including type II diabetes, [CONDITION(S)] of right lower limb, open wound of right great toe, repeated falls, heart failure, post traumatic seizures, depressive disorder and [CONDITION(S)] disorder. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/30/22 revealed the resident had severe cognitive impairment, required extensive assistance from one staff for dressing and supervision from one staff for bed mobility, transfers, toilet use and personal hygiene. The MDS assessment revealed the resident received anti-psychotic, anti-anxiety and anti-depressant medications during the assessment reference period. Review of the pharmacy review and monitoring for Resident #19 revealed on 02/16/22 and 08/07/22 the pharmacy sent a gradual dose reduction letter to Resident #19's physician. The letter on 02/16/22 noted the resident received the following psychoactive medications: - [MEDICATION(S)] 50 milligrams (mg) daily - [MEDICATION(S)] 100 mg two tablets at bed time - [MEDICATION(S)] 1 mg three times a day - [MEDICATION(S)] 100 mg at bedtime - [MEDICATION(S)] 5 mg give one and one half tablet (7.5 mg) two times a day - [MEDICATION(S)] 5 mg every 6 hours as needed for agitation - [MEDICATION(S)] 5 mg/ml give every 6 hours intramuscularly as needed for agitation - Vibryd 40 mg daily - [MEDICATION(S)] 60 mg daily The recommendation revealed to please update the facility psychoactive medication documentation by completing the information requested. However, nothing was filled out to show if a gradual dose reduction was clinically indicated or contraindicated. There was no rational listed as to why dose reductions would be indicated or contraindicated. The physician only signed his name to the form. The pharmacy recommendation, dated 08/07/22 was almost a duplicate copy of the 02/16/22 notice with the exception of two additional medications added ([MEDICATION(S)] 3 mg at bedtime and [MEDICATION(S)] 2 mg at bedtime; not to exceed 3 mg). There was no evidence the physician addressed the recommendation to provide evidence as to whether a a gradual dose reduction was indicated or contraindicated. There was no rationale included indicating why the dose reductions were indicated or contraindicated. Again, the physician just signed his name to the form. Interview with the Director of Nursing on 10/13/22 at 8:15 A.M. verified the above findings and verified his documentation as well as the psychiatrist documentation did not address whether gradual dose reductions were indicated or contraindicated at the time of the pharmacist review in 02/2022 and 08/2022.

Based on observations, interviews and record review, the facility failed to ensure the smoking area held ashtrays for disposal of ashes and failed to maintain a clean environment free of cigarette butts. This affected twenty-four (Resident #28, #19, #31, #39, #33, #8, #42, #15, #1, #24, #27, #29, #30, #18, #38, #36, #40, #22, #20, #32, #14, #9, #3 and #34) of thirty-two residents who smoke. Findings include: An observation on 09/30/19 at 3:08 P.M. of the smoking area revealed there were twenty-four residents (Resident #28, #19, #31, #39, #33, #8, #42, #15, #1, #24, #27, #29, #30, #18, #38, #36, #40, #22, #20, #32, #14, #9, #3 and #34) smoking in the outdoor designated area. There were two metal pails with lids in the area, one was in the center of the outdoor canopied space with twelve surrounding small benches placed in a square. Each bench was approximately four feet from the metal pail. The other pail was near the entrance door on the right side of the door as you would exit. There were no ashtrays present in this designated smoking area. The pails were used to dispose of used cigarette butts. There were nineteen residents on the benches and five residents sitting on the concrete ground of the area leaning against the fence. The fence was a chain link, and there was grass surrounding the enclosed area for smoking. All twenty-four residents dropped their cigarette ashes to the concrete ground near them. Two residents (Resident #42 and Resident #20)flicked their ashes through the chain link fence to the outside grassy area. There were used cigarette butts just outside of the fenced area around the smoking space on all sides of the enclosure and there were approximately 60 to 100 used butts under the benches and on the concrete floor. The two metal pails were each half full of cigarette butts. This was verified by State tested Nursing Assistant (STNA) #118 who revealed they would usually clean up the area after each break. There were eight cigarette breaks each day. During this cigarette break, neither STNA who had supervised smoking reminded residents to use the pails and not the ground or floor area for ashes. An interview on 09/30/19 at 3:29 P.M. with STNA #118 revealed during each cigarette break, each resident was given one cigarette only and they were supervised by two STNAs. All residents required some level of supervision for smoking. An interview and observation on 10/02/19 at 10:06 [NAME]M. of the smoking area with Maintenance Supervisor #155 revealed and confirmed there were no ashtrays in the smoking area. He agreed there were ash marks on the concrete and fifteen cigarette butts still on the ground. An interview on 10/02/19 at 10:11 [NAME]M. with Licensed Practical Nurse (LPN) #101 revealed the STNAs were supposed to pick up cigarette butts at the end of each shift. She had no information regarding ash trays. A record review of the smoking policy, revised (MONTH) (YEAR), revealed the facility should establish and maintain safe smoking practices. The policy stated, ashtrays are emptied into designated receptacles.

Based on record review and interviews, the facility failed to implement policies for injuries of an unknown origin for Resident #1. This affected one resident (Resident #1) out of three reviewed for injury of unknown origin including [MEDICAL CONDITION] over the left maxilla and left periorbital. The facility census was 42 Findings include: A record review of the file of Resident #1 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. His care plan dated 08/03/18 revealed this resident exhibited behavioral symptoms that are not easily altered, he was at risk for falls, he was at risk for cognitive impairments, had a history of [REDACTED]. This resident was prone to anger and aggression. His progress notes dated 03/07/19 revealed no indication of a fall or potential for abuse and/or injury. On 03/09/19 there were notes to indicate [MEDICAL CONDITION] over the left maxilla and left periorbital area which had increased in size over the day. No investigation followed these findings of either date per policies. An interview on 03/21/19 at 9:06 A.M. with Licensed Practical Nurse (LPN) #102 revealed she had seen Resident #1 on Thursday and Friday (03/07/19 and 03/08/19) and he did not have any injuries at that time . LPN #103 had then phoned her the next day (Saturday the 9th) and said Resident #1 had some slight swelling around his left eye. LPN #102 got a hold of the Director of Nursing (DON)and the Medical Director. [MEDICATION NAME] was ordered for him however it was ineffective. Around 8 or 9 P.M. that evening the swelling became worse. They got a hold of the doctor (Medical Director) again and sent him out to the hospital emergency room to be checked. Wooster Community Hospital then sent him to the Akron City hospital trauma unit after discovering fractures of the face. They completed x-rays on his face and discovered multiple fractures around the orbital left eye. The doctors could not identify if these fractures were acute or old injuries. When LPN #102 returned to work on Sunday it came to her attention that Resident #1 had been seen on the floor on Thursday (03/07/19). She could not locate any notes regarding him being found or being assessed. There had not been any investigation started on 03/07/19 after the potential fall or on 03/09/19 after the discovery of the [MEDICAL CONDITION] to the left eye. An interview on 03/21/19 at 10:32 A.M. with State tested Nurse Aide (STNA) #105 revealed when she came into the facility on Saturday (03/09), the eye of Resident #1 was red and very swollen. She revealed she would report any indications of abuse as necessary. She did not report a potential abuse to anyone. A review of the policy dated (MONTH) (YEAR) on Investigating Injuries revealed all injuries would be assessed and clinical findings documented in the clinical record. If an incident was suspected, a facility approved incident form would be completed. An injury of unknown source was defined as an injury unobserved and the source of the injury could not be explained. A review of the falls protocol policy dated (MONTH) (YEAR) revealed residents would be identified as a falls risk. When a fall occurs the nurse shall assess, document and report the following: vital signs, recent injury, musculoskeletal function, change in condition and level of consciousness, neurological status, pain, frequency and number of falls, precipitating factors, all current medications and all active diagnoses. It was verified with the Administrator and DON on 03/21/19 at 4:12 P.M. that there were no investigations or reports filed prior to 03/10/19 after receiving the report from the hospital regarding the fractures of Resident #1. This deficiency substantiates Complaint Number OH 161.

Based on record review and interviews, the facility failed to report injuries of an unknown origin and the possibility of abuse for Resident #1. This affected one resident (Resident #1) out of three reviewed for injury of unknown origin including [MEDICAL CONDITION] over the left maxilla and left periorbital. The facility census was 42. Findings include: A record review of the file of Resident #1 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. His care plan dated 08/03/18 revealed this resident exhibited behavioral symptoms that are not easily altered, he was at risk for falls, he was at risk for cognitive impairments, had a history of [REDACTED]. This resident was prone to anger and aggression. His progress notes dated 03/07/19 revealed no indication of a fall or potential for abuse and/or injury. On 03/09/19 there were notes to indicate [MEDICAL CONDITION] over the left maxilla and left periorbital area which had increased in size over the day. No investigation followed these findings of either date per policies. An interview on 03/21/19 at 9:06 A.M. with Licensed Practical Nurse (LPN) #102 revealed she had seen Resident #1 on Thursday and Friday (03/07/19 and 03/08/19) and he did not have any injuries at that time . LPN #103 had then phoned her the next day (Saturday the 9th) and said Resident #1 had some slight swelling around his left eye. LPN #102 got a hold of the Director of Nursing (DON)and the Medical Director. [MEDICATION NAME] was ordered for him however it was ineffective. Around 8 or 9 P.M. that evening the swelling became worse. They got a hold of the doctor (Medical Director) again and sent him out to the hospital emergency room to be checked. Wooster Community Hospital then sent him to the Akron City hospital trauma unit after discovering fractures of the face. They completed x-rays on his face and discovered multiple fractures around the orbital left eye. The doctors could not identify if these fractures were acute or old injuries. When LPN #102 returned to work on Sunday it came to her attention that Resident #1 had been seen on the floor on Thursday (03/07/19). She could not locate any notes regarding him being found or being assessed. There had not been any investigation started on 03/07/19 after the possible fall or on 03/09/19 after the discovery of the [MEDICAL CONDITION] to the left eye. An interview on 03/21/19 at 9:55 A.M. with LPN #104 revealed she had worked on Saturday, 03/09/19 and during shift change (around 3:00 P.M.) they discovered the Periorbital [MEDICAL CONDITION] with no bruising about Resident #1's left eye. It was charted, they emailed the Medical Director (physician) and phoned the DON. It was treated with [MEDICATION NAME] for an allergic reaction but this was ineffective. After Resident #1 returned from the hospital very early Monday morning, an investigation was initiated due to the fractures discovered at the hospitals. It was treated as a fall with injury since he had been found Thursday (03/07/19) on the floor outside of his room. The x-rays from Akron City determined the fractures could not be determined to be old or recent. An interview on 03/21/19 with LPN #104 at 3:10 P.M. revealed she was told on 03/10/19 by STNA #107 that she believed she knew what had happened to Resident #1 regarding his facial problems and swelling. She revealed he had a fall on 03/07/19. LPN #108 had come to STNA #107 asking for help to get Resident #1 off the floor. She was not asked for a statement. An interview on 03/21/19 at 10:05 A.M. with the DON revealed it would take an extremely hard blow to the orbital area of the eye to cause a fracture. There was no evidence to support any physical force of that kind of injury. An interview on 03/21/19 at 10:32 A.M. with State tested Nurse Aide (STNA) #105 revealed she when she came into the facility on Saturday (03/09), the eye of Resident #1 was red and very swollen. She revealed she would report any indications of abuse as necessary. She did not report this situation as a potential abuse to anyone. An interview on 03/21/19 at 10:50 A.M. with the Administrator revealed the DON called her on Sunday the 10th when they had identified what was going on with the face of Resident #1. There was no sign of injuries at any time. There was nothing to suggest anything malicious had happened. He returned to the facility on Monday very early morning with the x-ray results. At that time they started the investigation. She was upset that the nurses did not document the fall on the previous Thursday even though they did say they assessed him. He did have an unwitnessed fall on Thursday (03/07/19). No one was able to tell if his fractures were chronic or acute. The care provided after the unwitnessed fall was undocumented and the nurses were disciplined. An interview on 03/21/19 at 12:26 P.M. with LPN #106 revealed on Sunday the 10th of March, 2019 she had observed swelling on the left eye of Resident #1. No one knew what had happened and they phoned the doctor. He had ordered [MEDICATION NAME] to rule out any allergies [REDACTED]. She left after her shift had ended. She was not asked for a statement. An interview on 03/21/19 with LPN #104 at 3:10 P.M. revealed she was told on 03/10/19 by STNA #107 that she believed she knew what had happened to Resident #1 regarding his facial problems and swelling. She revealed he had a fall on 03/07/19. LPN #108 had come to STNA #107 asking for help to get Resident #1 off the floor. She was not asked for a statement. An interview on 03/21/19 with LPN #109 at 3:16 P.M. revealed she had been working at the facility on 03/07/19. She had seen Resident #1 come in from smoking with Resident #4 pushing him in his wheelchair. She was at the nurse's station looking down the 300 hallway and heard a commotion. Resident #4 was holding the wheelchair and Resident #1 was on the floor. She helped to assist him back to his chair after checking for any obvious injuries of which there were none. She did not report the fall. An interview on 03/21/19 with STNA #107 at 3:16 P.M. revealed she was working on 03/07/19. STNA #107 was questioned by LPN #108 as to how Resident #1 got back down to his room from the lobby. LPN #108 stated he had fallen out of his wheelchair and face planted on the floor. STNA #107 did not see any fall but was told by LPN #108 that they needed make sure someone was with Resident #1 constantly. They believed Resident #4 pushed him back to his room. She was not asked for any statement. She had seen Resident #1 later that day and he looked fine. She next saw him on Saturday the 9th and his face was swollen (around 3:20 P.M.). Later that evening it appeared to had gotten worse. An interview on 03/21/19 at 3:49 P.M. with Registered Nurse (RN) #108 revealed she had never seen Resident #1 on the floor on 03/07/19. She was the last person to respond to his alarm going off and at that time he was trying to stand up. Nobody had told her they found him on the floor. She helped to put him back in his wheelchair. He did not have any bruises. She revealed she had made notes prior to that day about him attempting to get out of his wheelchair but not on 03/07/19. She stated she did not believe he fell and did not believe anyone had hit him. She was not aware of anything until his face had swollen. A review of the policy dated (MONTH) (YEAR) on Investigating Injuries revealed all injuries would be assessed and clinical findings documented in the clinical record. If an incident was suspected, a facility approved incident form would be completed. An injury of unknown source was defined as an injury unobserved and the source of the injury could not be explained. A review of the falls protocol policy dated (MONTH) (YEAR) revealed residents would be identified as a falls risk. When a fall occurs the nurse shall assess, document and report the following: vital signs, recent injury, musculoskeletal function, change in condition and level of consciousness, neurological status, pain, frequency and number of falls, precipitating factors, all current medications and all active diagnoses. A review of the nurse's progress notes dated 03/09/19 for Resident #1 revealed there was [MEDICAL CONDITION] over the left maxilla and left periorbital area. There was no ecchymosis or [DIAGNOSES REDACTED] noted to the area. Resident #1 denied any pain. Ice was applied and the physician updated. Later that day the [MEDICAL CONDITION] had increased over the course of the shift. The red area was noted at 1.5 cm x 2 cm. Resident #1 still denied any pain. [MEDICATION NAME] was ordered and was ineffective. The staff continued to monitor. On 03/10/19 at 9:14 A.M. emergency services were contacted to transport Resident #1 to Wooster Community Hospital. The DON and guardian were notified. On 03/10/19 at 1:20 P.M. Wooster Community Hospital revealed Resident #1 had multiple fractures around his left eye and he was being transferred to Akron City Hospital. The guardian/mother was updated. On 03/10/19 at 3:05 P.M. LPN #104 became aware of a possible resident fall (Resident #1). STNA #107 had reported to her that Resident #1 was found on the floor outside of his room on 03/07/19 and LPN #108 had asked her to help get him up off the floor and help him at that time. At 11:25 P.M. (03/20/19) the facility received a call from Akron City Hospital who stated Resident #1 was being discharged . She reported he had multiple fractures to his left maxillary sinus, orbital wall and zygomatic arch. Resident #1 was to follow up with the ophthalmologist and plastic surgeon. Resident #1 was to return to the facility on [MEDICATION NAME]. The discharge [DIAGNOSES REDACTED]. On 03/11/19 at 7:48 A.M. resident's guardian/mother was up-dated. A review of the Akron City hospital report dated 03/10/19 revealed Resident #1 had been taken there for trauma. Different tests were conducted with findings which showed multiple fractures through the left maxillary sinus and left lateral orbital wall and left zygomatic arch with orbital floor. There was fluid in the left maxillary sinus with extensive soft tissue [MEDICAL CONDITION] changes the left side of the orbit and neck in this edentulous patient. There was deformity of the left ethmoid air cells with inward bowing of the medial left maxillary sinus with some opacified air cells. This may be from acute trauma or represent a chronic appearance. A review of the Wooster Community hospital report dated 03/10/19 for Resident #1 revealed this resident had multiple orbital floor fractures, zygomatic fractures and quite a bit of air. He was transferred to Akron City trauma as a possibility of entrapment. It was verified with the Administrator and DON on 03/21/19 at 4:12 P.M. that there were no investigations or reports filed prior to 03/10/19 after receiving the report from the hospital regarding the fractures of Resident #1. This deficiency substantiates Complaint Number OH 161.

Based on record review and interviews, the facility failed to report injuries of an unknown origin and the possibility of abuse for Resident #1. This affected one resident (Resident #1) out of three reviewed for injury of unknown origin including [MEDICAL CONDITION] over the left maxilla and left periorbital. The facility census was 42. Findings include: A record review of the file of Resident #1 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. His care plan dated 08/03/18 revealed this resident exhibited behavioral symptoms that are not easily altered, he was at risk for falls, he was at risk for cognitive impairments, had a history of [REDACTED]. This resident was prone to anger and aggression. His progress notes dated 03/07/19 revealed no indication of a fall or potential for abuse and/or injury. On 03/09/19 there were notes to indicate [MEDICAL CONDITION] over the left maxilla and left periorbital area which had increased in size over the day. No investigation followed these findings of either date per policies. An interview on 03/21/19 at 9:06 A.M. with Licensed Practical Nurse (LPN) #102 revealed she had seen Resident #1 on Thursday and Friday (03/07/19 and 03/08/19) and he did not have any injuries at that time . LPN #103 had then phoned her the next day (Saturday the 9th) and said Resident #1 had some slight swelling around his left eye. LPN #102 got a hold of the Director of Nursing (DON)and the Medical Director. [MEDICATION NAME] was ordered for him however it was ineffective. Around 8 or 9 P.M. that evening the swelling became worse. They got a hold of the doctor (Medical Director) again and sent him out to the hospital emergency room to be checked. Wooster Community Hospital then sent him to the Akron City hospital trauma unit after discovering fractures of the face. They completed x-rays on his face and discovered multiple fractures around the orbital left eye. The doctors could not identify if these fractures were acute or old injuries. When LPN #102 returned to work on Sunday it came to her attention that Resident #1 had been seen on the floor on Thursday (03/07/19). She could not locate any notes regarding him being found or being assessed. There had not been any investigation started on 03/07/19 after the possible fall or on 03/09/19 after the discovery of the [MEDICAL CONDITION] to the left eye. An interview on 03/21/19 at 9:55 A.M. with LPN #104 revealed she had worked on Saturday, 03/09/19 and during shift change (around 3:00 P.M.) they discovered the Periorbital [MEDICAL CONDITION] with no bruising about Resident #1's left eye. It was charted, they emailed the Medical Director (physician) and phoned the DON. It was treated with [MEDICATION NAME] for an allergic reaction but this was ineffective. After Resident #1 returned from the hospital very early Monday morning, an investigation was initiated due to the fractures discovered at the hospitals. It was treated as a fall with injury since he had been found Thursday (03/07/19) on the floor outside of his room. The x-rays from Akron City determined the fractures could not be determined to be old or recent. An interview on 03/21/19 with LPN #104 at 3:10 P.M. revealed she was told on 03/10/19 by STNA #107 that she believed she knew what had happened to Resident #1 regarding his facial problems and swelling. She revealed he had a fall on 03/07/19. LPN #108 had come to STNA #107 asking for help to get Resident #1 off the floor. She was not asked for a statement. An interview on 03/21/19 at 10:05 A.M. with the DON revealed it would take an extremely hard blow to the orbital area of the eye to cause a fracture. There was no evidence to support any physical force of that kind of injury. An interview on 03/21/19 at 10:32 A.M. with State tested Nurse Aide (STNA) #105 revealed she when she came into the facility on Saturday (03/09), the eye of Resident #1 was red and very swollen. She revealed she would report any indications of abuse as necessary. She did not report this situation as a potential abuse to anyone. An interview on 03/21/19 at 10:50 A.M. with the Administrator revealed the DON called her on Sunday the 10th when they had identified what was going on with the face of Resident #1. There was no sign of injuries at any time. There was nothing to suggest anything malicious had happened. He returned to the facility on Monday very early morning with the x-ray results. At that time they started the investigation. She was upset that the nurses did not document the fall on the previous Thursday even though they did say they assessed him. He did have an unwitnessed fall on Thursday (03/07/19). No one was able to tell if his fractures were chronic or acute. The care provided after the unwitnessed fall was undocumented and the nurses were disciplined. An interview on 03/21/19 at 12:26 P.M. with LPN #106 revealed on Sunday the 10th of March, 2019 she had observed swelling on the left eye of Resident #1. No one knew what had happened and they phoned the doctor. He had ordered [MEDICATION NAME] to rule out any allergies [REDACTED]. She left after her shift had ended. She was not asked for a statement. An interview on 03/21/19 with LPN #104 at 3:10 P.M. revealed she was told on 03/10/19 by STNA #107 that she believed she knew what had happened to Resident #1 regarding his facial problems and swelling. She revealed he had a fall on 03/07/19. LPN #108 had come to STNA #107 asking for help to get Resident #1 off the floor. She was not asked for a statement. An interview on 03/21/19 with LPN #109 at 3:16 P.M. revealed she had been working at the facility on 03/07/19. She had seen Resident #1 come in from smoking with Resident #4 pushing him in his wheelchair. She was at the nurse's station looking down the 300 hallway and heard a commotion. Resident #4 was holding the wheelchair and Resident #1 was on the floor. She helped to assist him back to his chair after checking for any obvious injuries of which there were none. She did not report the fall. An interview on 03/21/19 with STNA #107 at 3:16 P.M. revealed she was working on 03/07/19. STNA #107 was questioned by LPN #108 as to how Resident #1 got back down to his room from the lobby. LPN #108 stated he had fallen out of his wheelchair and face planted on the floor. STNA #107 did not see any fall but was told by LPN #108 that they needed make sure someone was with Resident #1 constantly. They believed Resident #4 pushed him back to his room. She was not asked for any statement. She had seen Resident #1 later that day and he looked fine. She next saw him on Saturday the 9th and his face was swollen (around 3:20 P.M.). Later that evening it appeared to had gotten worse. An interview on 03/21/19 at 3:49 P.M. with Registered Nurse (RN) #108 revealed she had never seen Resident #1 on the floor on 03/07/19. She was the last person to respond to his alarm going off and at that time he was trying to stand up. Nobody had told her they found him on the floor. She helped to put him back in his wheelchair. He did not have any bruises. She revealed she had made notes prior to that day about him attempting to get out of his wheelchair but not on 03/07/19. She stated she did not believe he fell and did not believe anyone had hit him. She was not aware of anything until his face had swollen. A review of the policy dated (MONTH) (YEAR) on Investigating Injuries revealed all injuries would be assessed and clinical findings documented in the clinical record. If an incident was suspected, a facility approved incident form would be completed. An injury of unknown source was defined as an injury unobserved and the source of the injury could not be explained. A review of the falls protocol policy dated (MONTH) (YEAR) revealed residents would be identified as a falls risk. When a fall occurs the nurse shall assess, document and report the following: vital signs, recent injury, musculoskeletal function, change in condition and level of consciousness, neurological status, pain, frequency and number of falls, precipitating factors, all current medications and all active diagnoses. A review of the nurse's progress notes dated 03/09/19 for Resident #1 revealed there was [MEDICAL CONDITION] over the left maxilla and left periorbital area. There was no ecchymosis or [DIAGNOSES REDACTED] noted to the area. Resident #1 denied any pain. Ice was applied and the physician updated. Later that day the [MEDICAL CONDITION] had increased over the course of the shift. The red area was noted at 1.5 cm x 2 cm. Resident #1 still denied any pain. [MEDICATION NAME] was ordered and was ineffective. The staff continued to monitor. On 03/10/19 at 9:14 A.M. emergency services were contacted to transport Resident #1 to Wooster Community Hospital. The DON and guardian were notified. On 03/10/19 at 1:20 P.M. Wooster Community Hospital revealed Resident #1 had multiple fractures around his left eye and he was being transferred to Akron City Hospital. The guardian/mother was updated. On 03/10/19 at 3:05 P.M. LPN #104 became aware of a possible resident fall (Resident #1). STNA #107 had reported to her that Resident #1 was found on the floor outside of his room on 03/07/19 and LPN #108 had asked her to help get him up off the floor and help him at that time. At 11:25 P.M. (03/20/19) the facility received a call from Akron City Hospital who stated Resident #1 was being discharged . She reported he had multiple fractures to his left maxillary sinus, orbital wall and zygomatic arch. Resident #1 was to follow up with the ophthalmologist and plastic surgeon. Resident #1 was to return to the facility on [MEDICATION NAME]. The discharge [DIAGNOSES REDACTED]. On 03/11/19 at 7:48 A.M. resident's guardian/mother was up-dated. A review of the Akron City hospital report dated 03/10/19 revealed Resident #1 had been taken there for trauma. Different tests were conducted with findings which showed multiple fractures through the left maxillary sinus and left lateral orbital wall and left zygomatic arch with orbital floor. There was fluid in the left maxillary sinus with extensive soft tissue [MEDICAL CONDITION] changes the left side of the orbit and neck in this edentulous patient. There was deformity of the left ethmoid air cells with inward bowing of the medial left maxillary sinus with some opacified air cells. This may be from acute trauma or represent a chronic appearance. A review of the Wooster Community hospital report dated 03/10/19 for Resident #1 revealed this resident had multiple orbital floor fractures, zygomatic fractures and quite a bit of air. He was transferred to Akron City trauma as a possibility of entrapment. It was verified with the Administrator and DON on 03/21/19 at 4:12 P.M. that there were no investigations or reports filed prior to 03/10/19 after receiving the report from the hospital regarding the fractures of Resident #1. This deficiency substantiates Complaint Number OH 161.

Based on observation, record review and interview, the facility failed to ensure Minimum Data Set assessments were accurate related to infections for Residents #25, #31, #35, and #15. This affected four of 16 residents reviewed for assessments. The facility census was 42. Findings include: 1. Observations conducted on 09/17/18 at 9:10 A.M. revealed Resident #25 was awake in bed in the resident's room. The resident was alert, dressed and groomed and in no acute distress. Resident #25 was not interviewable. There was no evidence of isolation precautions in use for Resident #25. Review of a facility provided Minimum Data Set 3.0 (MDS) Matrix dated 09/17/18 revealed Resident # 25 had an infection and indicated the infection was a [MEDICAL CONDITION]. Record review revealed Resident #25 was admitted to the facility 07/12/13 with admission [DIAGNOSES REDACTED]. Continued record review of the most recent annual MDS assessment dated [DATE] revealed the resident had a multidrug resistant organism infection. Review of the current resident record revealed no evidence of any nurses notes, physician progress notes [REDACTED]. An interview was conducted with the facility MDS nurse, Registered Nurse (RN) #100 on 09/19/18 at 12:50 P.M. RN #100 stated Matrix information was pulled from MDS assessments conducted on each facility resident. RN #100 confirmed Resident #25 did not have an active [DIAGNOSES REDACTED]. 2. Initial observations conducted for Resident #31 on 09/17/18 at 8:50 A.M. revealed the resident self ambulated in the hallways of the care unit with a somewhat unsteady gait, was clean and well groomed but not interviewable. The resident was in no respiratory distress. Review of a facility provided MDS Matrix dated 09/17/18 revealed Resident #31 had an infection and indicated the infection was pneumonia. Record review revealed Resident #31 was admitted to the facility 10/12/12 with readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual MDS assessment for Resident #31 dated 08/04/18 revealed documentation the resident had an active [DIAGNOSES REDACTED].#31 at the time of the MDS assessment. An interview was conducted with the facility MDS nurse, RN #100, on 09/19/18 at 12:50 P.M. During the interview RN #100 confirmed Resident #31 did not have an active [DIAGNOSES REDACTED]. 3. Observations conducted on 09/17/18 at 9:15 A.M. revealed Resident #35 was asleep in bed in the resident's room. The resident was in no acute distress. There was no evidence of isolation precautions in use for Resident #35. Review of a facility provided MDS Matrix dated 09/17/18 revealed Resident #35 had an infection and indicated the infection was a [MEDICAL CONDITION] (MDRO). Record review revealed Resident #35 was admitted to the facility 07/30/12 with readmitted d of 06/16/13. Admission [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #35 had an infection and indicated MDRO. Continued record review of nurses notes , physician progress notes [REDACTED].#35 at the time of the MDS assessment. An interview was conducted with RN #100 on 09/19/18 at 12:50 P.M. During the interview RN #100 confirmed Resident #35 did not have an active [DIAGNOSES REDACTED]. 4. A record review for Resident #15 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations from 09/17/18 to 09/20/18 between 9:12 A.M. until 5:21 P.M. of Resident #15 revealed he had no signs or symptoms of having pneumonia. A record review of the MDS assessment dated [DATE] revealed Resident #15 had an active [DIAGNOSES REDACTED]. An interview on 09/19/18 at 12:50 P.M. with RN #100 revealed Resident #15 did not have an active [DIAGNOSES REDACTED].#100 verified the MDS assessment information completed on 07/05/18 was not accurate and would have to be corrected.

Based on observation and interview, the facility failed to ensure the walk-in freezer and dishwasher were consistently maintained. This had the potential to affect all 39 residents who ate food prepared in the kitchen of the facility. Findings include: Observation in the main kitchen building was conducted with Food Service Manager (FSM) #15 on 07/20/15 at 8:55 A.M. The walk-in freezer had a heavy accumulation of ice and frost buildup on the condenser unit cables. Underneath this condenser unit was food shelving which had several trays to catch the drippage; these trays had ice mounds measuring three to four inches high. On the top shelf was a large box of cool whip containers which had ice buildup on its surface. FSM #15 indicated she used the trays to catch the condenser drippage and added, It's a never-ending battle. The metal wall connecter box on the inside of the freezer door had a three-inch accumulation of ice/frost coming out from the fixture, and there were ice drips frozen on the interior freezer ceiling. Observations of the dishwasher in the Subacute building on 07/20/15 at 9:30 A.M. and on 07/22/15 at 7:47 A.M. revealed a 12-inch circular puddle of water on the floor in front of the machine and a catch-basin bin containing two inches of water underneath the dishwashing machine. Interview with Food Service Worker (FSW) #3 on 07/22/15 at 7:48 A.M. indicated the dishwasher had been leaking for several months. Interview with FSM #15 on 07/22/15 at 7:55 A.M. confirmed the dishwasher had been leaking, and they fixed a bearing or something and verified it's still leaking. Review of the government inspection report dated 02/02/15 identified the leaking dishwasher and noted Dishwasher shall be repaired and restored to proper working order. The freezer was inspected at that time and the report noted a small amount of ice was on a tray. Person in charge stated it has been repaired and is monitored. The above continuing issues were confirmed with FSM #15 on 07/22/15 at 7:55 A.M.

Based on observations and interview, the facility failed to provide handrails that were secure to the walls. This affected 38 residents who ambulated with assistance. Finding include: On 7/22/15 at 10:00 A.M. an observation of the hand rail on the 200 hall revealed the hand rail located between rooms 206 and 207, about 36 feet long and on the left side wall as a resident would walk away from the nursing station, was hanging from the wall because the screws to secure the handrail were pulled completely out of the wall and were lying on the floor. Five of the eight metal devices used with three screws to secure the rail to the wall were loose. This finding was verified with Director of Maintenance #1 on 07/22/15 at 10:55 A.M.

Based on record review and interview, the facility failed to ensure documented attendance of all required members at the quarterly Quality Assessment and Assurance Committee meetings. This had the potential to affect all 39 residents in the facility. Findings include: Interview with the Administrator regarding Quality Assessment and Assurance committee (QAA) was conducted on 07/23/15 at 10:31 A.M. She indicated the Medical Director was an active member of the committee and provided documented evidence these meetings had been held on 04/20/15, 01/19/15, 10/20/14 and 07/21/14. Review of the quarterly QAA attendance records for those dates revealed the Medical Director did not attend any of the four scheduled QAA meetings. The Administrator stated the Medical Director reviewed all QAA content prior to and following the formal quarterly meetings. Environmental concerns, including maintenance issues and pests, were cited on a complaint investigation dated 08/05/14, and kitchen equipment (freezer and dishwasher) were concerns identified on a governmental inspection dated 02/02/15. The corrective actions for those visits included timely repairs and monitoring to establish continued compliance. Both areas were cited on this annual survey. On 07/23/15 at 11:14 A.M. the Administrator confirmed the Medical Director was not able to attend the meetings on the dates scheduled and there was no designated physician representative at those meetings.

Based on observations and interviews, the facility failed to provide an environment free of pests and insects. This affected all 39 residents who resided in the facility. Findings include: An observation on 07/22/15 at 8:54 A.M. of the bathroom in room 205 revealed a wet cloth, cloth towels, paper towels and a urine-soiled diaper on the floor. The soiled diaper had six to eight gnats and several flies flying around and landing on the diaper. The flies were also observed in the resident's room and landing on the bed linens. This finding was verified with Licenced Practical Nurse (LPN) #4 on 07/22/15 at 8:56 A.M. In an interview with Resident #14 on 07/22/15 at 2:20 P.M., she revealed flies and gnats had been a problem in the facility and she saw them daily. An interview with Resident #30 on 07/23/15 at 8:37 A.M. revealed the resident stated the flies and gnats in the facility had been a constant problem and she had encountered these insects daily. She stated she saw them in the gathering areas, dining areas and her room. An interview on 7/23/15 at 8:48 A.M. with Resident #38 stated that flies had been a constant problem in the facility. He stated they landed on him and he had to swat them away.

Based on observations and interviews, the facility did not provide chairs or a bench for residents' use in their rooms, gathering areas and smoking areas and privacy curtains that would surround the beds and cover the windows. This affected 23 residents (Residents #7, #33, #35, #38, #41, #3, #13, #32, #30, #29 and 13 smokers) of 39 residents who were in the facility. Findings include: On 07/20/15 at 2:17 P.M., observations at the nursing station located on the second floor revealed Residents #7, #33, #35, #38 and #41 sat on the floor by the nursing station. There were no chairs or benches in the area for resident use. This was verified with Licensed Practical Nurse (LPN) #5 on 07/20/15 at 2:18 P.M. Observation on 07/20/15 at 2:25 P.M. of the fenced-in area that was used by the residents for smoking revealed the area did not have any chairs, benches or devices for the residents to sit on while smoking. The observation included 16 residents who were smoking. Three residents remained in their wheelchairs and 13 residents sat on the gravel ground, concrete slab or the 3 inch metal support bars that were on the ground for canopy support. If a resident wanted to sit down they would have to sit on the gravel that covered the ground in the smoking area. Observations on 07/22/15 at 1:50 P.M. of 18 semi-private rooms revealed the rooms did not contain chairs that could be used by the residents for sitting. Rooms 205a, 205b, 208b, 209a, 209b, 213b, 214b, 215b, 305a, 305b and 306a did not contain a chair in the room for personal use. These findings were verified with Director of Maintenance #1 on 07/22/15 at 1:55 P.M. He also verified there were no chairs or benchs in the outside smoking area. Observations on 07/22/15 at 2:25 P.M. revealed seven residents stood around the nursing station and Residents #3, #13 and #32, sat on the floor with their legs extended, next to the entrance door. No benches or chairs were observed in the area that could have been used for a resident to sit in. This observation was verified with LPN #4 on 07/22/15 at 2:27 P.M. An interview on 07/23/15 at 8:30 A.M. with Resident #30 revealed the resident stated that the residents often would sit on the floors in the gathering and common areas because there were no chairs available to sit down on and relax. She stated it would be nice to have a place to sit. She stated the residents who smoked had no chairs to sit in out in the smoking area, and the residents had to sit on the ground while smoking. On 07/23/15 at 8:37 A.M. Resident #29 was observed sitting on the floor across from the nursing station in the gathering area. The area did not contain any seats or chairs for resident use. An observation at 8:44 A.M. revealed Resident #38 sat on the floor with his back to the nursing station. No chairs or seating areas were available for use by the residents. These two observations were verified with Registered Nurse (RN) #6 on 07/23/15 at 8:45 A.M. In an interview with Resident #38 on 07/23/15 at 8:48 A.M. while he was sitting on the floor in front of the nursing station, the resident stated he would like to have a place to sit but the facility did not provide any chairs or benches for them. He said he went outside to smoke every day and the facility did not provide chairs or a bench for the residents to sit on while smoking.

Based on observation and interviews, the facility failed to maintain the lights in the resident rooms in operating condition. This affected four of 14 lights sampled for proper operation and function. Findings include: Observations of the light units attached to the walls above the beds was conducted on 07/23/15 at 1:10 P.M. The light units were four feet long and could be activated by a pull chain that was 4 inches long. The light units in rooms 208b, 214a, 215b and 216b did not have a pull chain attached to the light unit and the lights were not able to be turned on because of the missing pull chains. The findings of the inoperable lights was verified with Director of Maintenance #1 on 07/23/15 at 1:15 P.M.

Based on observations and interview, the facility failed to provide privacy curtains or window coverings to the residents in semi - private rooms. This affected 25 of 37 resident bedroom areas. Findings include: Tour of 19 rooms on 07/22/15 at 11:00 A.M. revealed rooms 205a, 206a and b, 207a and b, 208a and b, 209a and b, 216a and b, 304a and b, 305a and b, 306a and b, 307a and b, all semi-private rooms shared by two residents, did not have ceiling suspended privacy curtains to provide total visual privacy in combination with adjacent walls and curtains. These findings were verified with Director of Maintenance #1 on 07/22/15 at 1:50 P.M. Observations of the windows in resident rooms revealed in nine rooms, Rooms 205, 207, 208, 209, 212, 213, 216, 310 and 314, the window did not contain any blind or covering that would provide the residents privacy from the outside environment. These findings were verified with Director of Maintenance #1 on 07/22/15 at 1:50 P.M.

Based on staff interview and medical record review, the facility failed to accurately assess two residents (Residents #8 and #10) of 11 residents reviewed for comprehensive assessments. Findings Include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurses' notes dated 05/06/15 revealed Resident #8 had fallen while in the bathroom. The resident was unable to tell the staff what had happened. Review of the nurses' notes dated 07/01/15 revealed Resident #8 had fallen while re-entering the facility from the smoking area. The nurses' notes indicated the resident had two small raised areas on his right arm which later turned into a large lump that was green in color. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact but delusional, and had no falls since the previous assessment dated [DATE]. An interview with the Director of Nursing (DON) on 07/21/15 at 5:50 P.M. confirmed the MDS 3.0 assessment dated [DATE] should have indicated Resident #8 had two falls since the previous assessment. 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the occupational therapy evaluation completed on 10/31/14 revealed Resident #10 had contractures to both of his feet and both of his hands. Review of the Monthly Summary assessments dated 03/26/15 and 04/29/15 indicated Resident #10 had contractures to both of his hands and to both of his feet. Review of Resident #10's MDS 3.0 assessment dated [DATE] revealed the resident had restricted range of motion (contractures) only to his legs/feet. An interview with Rehabilitation Director #2 on 07/22/15 at 10:53 A.M. confirmed Resident #10 had contractures to his hands and feet. An interview with the DON on 07/22/15 at 3:40 P.M. verified the MDS 3.0 assessment dated [DATE] which indicated Resident #10 only had contractures to his legs/feet was inaccurate. The DON confirmed the resident also had contractures to his hands.

Based on observation, record review and interview, the facility failed to the required posted daily nurse staffing contained complete data. This affected all 39 residents in the facility. Findings include: Observations on 07/20/15 at 10:00 A.M., 07/21/15 at 9:37 A.M. and on 07/22/15 at 9:13 A.M. revealed posted nurse staffing data on a window across from the nurses station. It contained accurate nursing hour data, but failed to include the daily census of the building. Review of the past seven months of postings confirmed no resident census data had been included on the daily postings from 01/01/15 to 07/22/15. The above findings were confirmed with the Director of Nursing on 07/22/15 at 9:17 A.M.

Based on observation and interview, the facility failed to ensure survey results were readily available and accessible to residents. This affected all 39 residents in the facility. Findings include: Observation on 07/21/15 at 8:00 A.M. revealed a sign posted behind the receptionist desk on ground level indicating that survey results were located behind the nurses station. On 07/21/15 at 8:02 A.M., the Administrator looked for the survey results in three rooms, and several drawers and cabinets, then went upstairs to see if they were at the nurses station. At 8:10 A.M. she asked Licensed Practical Nurse (LPN) #4 if he had the survey results. LPN #4 stated, I'll look. and brought out an incorrect binder and said, Is this it? At 8:21 A.M. the Administrator confirmed she was unable to locate the survey results binder. On 07/21/15 at 10:10 A.M. the Administrator located the binder and confirmed it was not easily accessible to residents.

Based on interview, observation and record review the facility failed to ensure one resident's safe mobility (Resident #16) resulting in a fall with a fracture. This affected one of five residents reviewed for accidents/hazards. The facility census was 30. Findings include: Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16 required extensive assistance for activities of daily living skills including bathing, dressing, transfers and feeding. Review of Resident #16's physician's transfer orders dated 03/09/12 revealed the resident required the use of a recliner chair due to unsafe wheelchair mobility. The transfer orders revealed the resident was to be in a geri-recliner chair daily as tolerated. Although Resident #16 owned a motorized wheelchair, Resident #16 did not have a physician's order to use/operate the motorized wheelchair. Due to contractures and chronic pain, the residents could not sit upright, limiting the resident's ability to see where he was going in the motorized wheelchair. Review of Resident #16's Interdisciplinary Resident/Patient Discharge Note dated 03/09/12 revealed the resident had an activity restriction to be up in a reclining chair daily as tolerated and for the use of a mechanical lift for transfers. Review of an undated hand written note by the director of nursing (DON) taped to Resident #16's chart revealed the resident was to be in a geri-recliner chair due to being dangerous with his electric wheelchair. Review of Resident #16's admission initial plan of care dated 03/09/12 revealed potential problems with decreased activities of daily ling skills, loss of ability of sight and walking and the potential for falls related to contractures and hemiparesis. Interventions included out of bed everyday in (no device indicated), compensate for loss by using health aids and implement fall protocol. The geri- recliner chair and motorized wheelchair were not listed on the plan of care. Review of nurse's notes dated 03/10/12, timed 01:44 and authored by Registered Nurse (RN) #35, revealed the resident had used an electric wheelchair for locomotion, "but not at present due to danger to self and others when the wheelchair was used at high speed, which is the resident's normal behavior." Review of Resident #16's nurse's notes's dated 03/10/12, timed 4:50 P.M. and authored by Licensed Practical Nurse (LPN) #34, revealed the resident was propelling the motorized wheelchair on the sidewalk near the designated smoking area. The wheel on the wheelchair went off the sidewalk and the wheelchair tipped over. Resident #16 landed partially on the ground and the sidewalk. He complained of pain in the left hip and knee area. Resident #16 was transferred to the hospital for evaluation and diagnosed with [REDACTED]. On 03/12/12, Resident #16 was returned to the facility with a full leg brace on the left leg. Interview with LPN #34 on 03/18/12 at 8:40 P.M. revealed Resident #16 was a new admission and she had only met the resident twice. LPN #34 stated Resident #16 had gone to out to smoke and drove off the right side of the sidewalk and tipped over. LPN #34 stated Resident #34 was laying partially on the sidewalk and in the grass. LPN #34 stated she assessed the resident and called 911 to have the resident transported to the hospital. LPN #34 described the sidewalk as sloping downward toward the parking area without protective edges or guardrails to prevent a wheelchair from going off the cemented sidewalk and into the grass. Interview with Resident #16 on 03/19/12 at 1:40 P.M. revealed when at his previous facility the wheelchair was taken away due to his inability to drive it safely. Resident #16 stated because of his contractures, he had problems operating the joystick on the wheelchair and when he would let go of the joystick the wheelchair would keep on going. Resident # 16 stated on the day of the accident he was in the wheelchair, not in a full upright position and attempted to operate the wheelchair to go outside for his "smoke break." Resident #16 stated he wanted to be in the sun and started down the sidewalk and the "wheelchair got away from him" and he went off the right side of the sidewalk and tipped over. Resident #16 stated he fell on his left side. Resident #16 stated he had severe pain in his left hip and was taken to the hospital and diagnosed with [REDACTED]. Interview with the DON on 03/18/12 at 6:40 P.M. confirmed there was no physician's order for Resident #16 to use his motorized wheelchair. The DON confirmed Resident #16 tipped his wheelchair over on 03/10/12 and sustained a fractured left femur. This deficiency substantiates Complaint Number OH 872.