Every finding on record at Falling Water Healthcare Center

Based on observation, interview, record review, and review of facility policy the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect 87 residents out of 91 residents who received food from the kitchen. Four residents (Resident #4, #37, #53, and #91) were identified as not receiving anything by mouth and received no food from the kitchen. The facility census was 91.Findings include: Observation on 07/28/25 from 8:22 A.M. through 8:36 A.M. with Registered Dietitian (RD) #950 revealed that in the dry storage area, there was a bottle of vanilla with a cracked lid. In the cooking area, the large floor mixer had dried batter on the back splash and the top of the mixing mechanism, and microwave had dried food splatter inside. The reach-in refrigerator had dried food splatter on the outside and there was vanilla pudding at labeled or dated. The cook's reach in refrigerator the following items were not labeled and dated: sliced American cheese, bologna, and a chef salad. In the reach-in freezer, there were pork chops not wrapped properly with no label or date on the unopened bag. In the dish area, the floor was greasy, and the three-compartment sink had food residue inside the empty compartments. [NAME] #800 stated that no one used the dish area yet.Observation of dishmachine on 07/29/25 at 10:12 A.M. revealed that the clean area of the dish machine had clumps of oatmeal on the drain board that when clean dishes finished the washing and sanitizing process, the racks pushed the oatmeal on the drainboard.Observation on 07/29/25 at 10:13 A.M. revealed that Dietary Manager (DM) #808 removed a clean rack of dishes after the warewashing process and placed it on the dirty drainboard of the three-compartment pot sink.Observation on 07/29/25 at 10:16 A.M. revealed Dietary Aide (DA) #806 was wearing gloves while putting dirty dishes on dish racks to get cleaned via dishmachine. DA #806 went to the clean side of the dishmachine and touched clean dishes to put away without changing gloves and preforming hand hygiene. DM #808 explained to DA #806 that she must change gloves and perform hand hygiene prior to touching clean dishes. Review of the facility policy dated 05/2014 with a current revision date of 02/2023 titled, Warewashing, revealed that all dishware, serviceware, and utensils will be cleaned and sanitized after use using proper technique. Review of the facility policy dated 09/2017 titled, Receiving, revealed that safe handling practices will be followed.Review of the facility policy dated 05/2014 with a current revision date of 02/2023 titled, Food Storage: Cold Food, revealed that foods should be labeled and dated.

Based on record reviews and interviews the facility did not ensure care conference meetings were offered or held for residents #6, #22, #41 and #80. This affected four residents (#6, #22, #41 and #80) of four residents reviewed for participation in care planning. The census was 91. 1.Review of the medical record for Resident #6 revealed an admission date of 10/27/24. Diagnoses included atrial fibrillation, hypertension and anemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of the MDS report from March 2025 to July 2025 revealed Resident #6 had quarterly assessments completed on 03/15/25 and 06/13/25. Review of the miscellaneous tab in the electronic medical record (EMR) revealed the last documented care plan meeting was Resident #6's 72-hour meeting at admission. An interview on 07/28/25 at 2:29 P.M. with Resident #6 revealed he was only invited to one meeting, besides the 72-hour meeting, however he missed it. 2.Review of the medical record for Resident #22 revealed an admission date of 09/08/23. Diagnoses included hemiplegia and hemiparesis, diabetes and anxiety. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact. Review of the MDS report from March 2025 to July 2025 revealed Resident #22 had quarterly assessments completed on 04/01/25 and 07/11/25. Review of the miscellaneous tab in the EMR revealed the last documented care plan meeting was on 12/09/24 for Resident #22. Interview on 07/28/25 at 1:58 P.M. with Resident #22 and his mother revealed she used to receive invitations but had not gotten one in a while. Resident #22 stated he had not been invited to attend any care plan meetings. 3.Review of the medical record for Resident #41 revealed an admission date of 09/06/23. Diagnoses included end stage renal disease, respiratory failure and dysphagia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #41 was cognitively impaired. Review of the MDS report from March 2025 to July 2025 revealed Resident #41 had quarterly assessments completed on 03/06/25 and 06/06/25. Review of the miscellaneous tab in the EMR revealed the last documented care plan meeting was 12/09/24. Phone interview on 07/28/25 at 1:10 P.M. with family of Resident #41 revealed the facility did not communicate with her even when she was visiting in the facility and she was not being invited to plan of care meetings. 4.Review of the medical record for Resident #80 revealed an admission date of 08/30/24. Diagnoses included quadriplegia, chronic pain syndrome and emphysema. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed he was cognitively intact. Review of the MDS report from March 2025 to July 2025 revealed Resident #80 had quarterly assessments completed on 03/07/25 and 06/06/25. Review of the miscellaneous tab in the EMR revealed the last documented care plan meeting was 02/10/25. An interview on 07/28/25 at 9:30 A.M. with Resident #80 revealed he was not involved in plan of care meetings in the year he had been there. An interview on 07/29/25 at 1:40 P.M. with licensed Social Worker (LSW) #560 revealed she identified an issue with the facility not offering care plan meetings possibly due to changes in LSW position and coverage from other buildings. She stated they had a few meetings for discharge planning. The team had not yet implemented a schedule or system for plan of care meetings. An interview on 07/30/25 at 10:07 A.M. with Licensed Practical Nurse (LPN) #538 revealed they have had some plan of care meetings for discharge planning however they have not had plan of care meetings for all residents as required. An interview on 07/30/25 at 3:00 P.M. with Regional MDS Registered Nurse (RN) revealed meetings should be held at 72-hour after admission, quarterly, annually and with a significant change. Review of the facility policy titled Plan of Care Overview, not dated, revealed the purpose of the policy was to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning. The policy read residents/representatives would be informed of their plan of care in the most understandable manner possible and would be offered opportunities to voice their view. They would be allowed to request meetings, be included in planning process and establish goals. The facility would hold meetings at a time when resident was functioning at his/her best and schedule meeting to accommodate a resident's representative that may include conference calls, video conference sessions of live sessions. This deficiency represents non-compliance investigated under Complaint Number 1300240.

Based on resident record review, observations, resident interview, staff interview, and facility policy review, the facility failed to ensure dependent residents had access to call lights. This affected one resident (#9) of 24 residents reviewed for call lights. The facility census was 91.Findings include:Review of the medical record for Resident #9 revealed an admission date of 10/05/21 with diagnoses that included Parkinson's disease without dyskinesia, cerebral atherosclerosis, and dementia.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 3 that indicated short- and long-term memory impairment. Review of the MDS assessment revealed Resident #9 was dependent on staff for activities of daily living (ADLs).Review of the care plan dated 06/30/25 revealed Resident #9 had an ADL self-care performance deficit that required assistance with all ADLs including, but not limited to, all upper and lower body care and feeding with interventions that included placing call light within reach.Review of the progress note dated 07/24/25 at 8:49 P.M. revealed Resident #9 was currently receiving hospice services, had significant mobility limitations and was dependent on staff for all care including, but not limited to, bed mobility, hydration and feeding.Interview on 07/28/25 at 11:07 A.M. with Licensed Practical Nurse (LPN) #549 revealed Resident #9 was unable to have full conversations. LPN #549 revealed Resident #9 was able to give small responses that mainly consisted of yes and no answers. LPN #549 revealed Resident #9 required a call light to be within reach for staff assistance.Observation on 07/28/25 at 11:08 A.M. revealed Resident #9 in bed with no call light within reach. Resident #9 revealed a need for something to drink and could not reach the call light if wanted to. Resident #9's bed was observed pushed against another bed that allowed no space between the two. Resident #9's call light was not visible.Interview and observation on 07/28/25 at 11:11 A.M. with Registered Nurse (RN) #501 revealed Resident #9 gave yes and no responses when providing care. RN #501 revealed Resident #9 required a 2-person assist for all care needs including bed mobility, feeding and hydration. RN #501 revealed Resident #9 shared a room with their spouse and Resident #9's spouse would typically tell staff of needs. RN #501 revealed if Resident #9's spouse was out of the room while the call light was out of reach, Resident #9 would not be able to alert staff of needs. RN #501 revealed the call light was currently out of reach and Resident #9 would not be able to reach it. RN #501 observed Resident #9's call light was out of reach and on the floor between the two beds. RN #501 was observed moving both beds to retrieve call light from the floor underneath the beds and tangled up. RN #501 placed the call light on the right-side pillow next to Resident #9's head. Resident #9 was still unable to reach the call light. RN #501 confirmed and verified Resident #9's call light was out of reach.Interview on 07/30/25 at 1:24 P.M. with LPN #534 revealed Resident #9 was currently receiving hospice services and was completely dependent on staff for all care needs. LPN #534 revealed Resident #9 required to have the call light within reach for staff to meet all care needs.Observation on 07/30/25 at 1:30 P.M. revealed Resident #9 in bed with the call light not in reach. The call light was observed wrapped around the right-side bed rail. Resident #9 was unable to reach the call light.Interview and observation on 07/30/25 at 1:33 P.M. with Certified Nurse Assistant (CNA) #495 and #575 revealed Resident #9 was completely dependent on staff for everything including eating and drinking. CNAs #495 and #575 revealed Resident #9 was able to use the call light and it should always be within reach. Resident #9 was observed in bed with the call light between two beds pushed together. CNA #495 was observed reaching between both beds, retrieving call light and placed it in Resident #9 hand. Resident #9 demonstrated ability to utilize call light. CNA #495 and #575 confirmed and verified Resident #9 call light was out of reach.Review of the facility document titled Resident Rights undated, revealed the facility had a policy in place that the facility would ensure a method to communicate needs to staff via call light or bell access within reach.

Based on interview and record review, the facility failed to ensure Resident #68 had access to his social security allowance as required. This affected one resident (#68) of five residents reviewed for funds. The facility census was 91.Findings include:Review of the medical record for Resident #68 revealed and admission date of 03/01/24 with diagnoses including depression, quadriplegia, and need for personal care.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #68 was cognitively intact. Review of Resident #68's personal fund authorization was witnessed by two people that were not associated with the facility on 12/20/24.Review of the first quarterly statement for 2025 revealed that the facility received Resident #68's social security (SS) check was deposited into his personal funds account. Further review of the first quarterly statement of 2025 revealed that SS asked for his SS check to be returned, which was returned 02/18/25.Further review of the first quarterly statement of 2025 revealed that Resident #68's SS check was deposited, and he received his $50.00 allowance in March 2025. Review of the receipt dated 03/25/25 revealed that Resident #68 signed that he withdrew $50.00.Review of the second quarterly statement revealed that Resident #68's SS check for April was deposited on 04/03/25 and Resident #68's $50.00 allowance was allotted to him. Further review of the second quarterly statement revealed that Resident #68's SS check for February was deposited on 04/14/25 however Resident #68 was not given his $50.00 allowance retroactive from February. Resident #68 did not withdraw any monies in April 2025.Review of the second quarterly statement revealed that Resident #68's SS check for May was deposited on 05/02/25 and Resident #68's $50.00 allowance was allotted to him. Review of the receipt dated 05/08/25 revealed that Resident #68 signed that he withdrew $50.00.Review of the second quarterly statement revealed that Resident #68's SS check for June was deposited on 06/03/25 and Resident #68's $50.00 allowance was allotted to him. Review of the receipt dated 06/10/25 revealed that Resident #68 signed that he withdrew $10.00.Review of the receipt dated 06/18/25 revealed that Resident #68 signed that he withdrew $40.00.Interview on 08/04/25 at 2:28 P.M. with Regional Business Office Manager (RBOM) #900 revealed that Resident #68's SS check in February was recalled by SS, so the check was not deposited. Resident #68 ‘s February check was deposited in April, so the system would not have recognized that Resident #68 should have been given his allowance of $50.00 retroactive from February. RBOM #900 verified the facility did not ensure Resident #68 received his $50 allowance from his February SS check as required. This deficiency represents non-compliance investigated under Complaint Number 1300243.

Based on record review and interview, the facility failed to ensure residents had accurate advance directive orders and information in place throughout the medical record for Resident #86. This affected one resident (#86) out of 24 residents reviewed for advanced directives. The facility census was 91.Findings include:Review of the medical record for Resident #86 revealed an admission date of [DATE] with diagnoses including chronic kidney disease, vascular dementia, and heart failure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 was severely cognitively impaired and dependent for activities of daily living. Review of the physician's orders for Resident #86 revealed cardiopulmonary resuscitation (CPR) will be performed. Review of the hard medical chart for Resident #86 revealed a Do Not Resuscitate Comfort Care- Arrest (DNRCCA) code status (meaning invasive or extreme life-supporting measures were allowed under any circumstance except for cardiac or respiratory arrest. In the event of cardiac or respiratory arrest only comfort measures would be initiated) dated [DATE]. Interview on [DATE] at 1:52 P.M. with Licensed Practical Nurse (LPN) #442 stated that she would check the electronic chart for code status. The electronic chart stated that the code status was CPR, while the hard chart had a signed DNRCC-A dated [DATE]. LPN #442 verified the mismatched code status for Resident #86. Review of the undated facility's policy titled, Advance Directives, revealed it is the policy to support and facilitate a resident's right to discontinue medical treatment and formulate an advance directive.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to administer medications as ordered. There were two errors observed out of 28 opportunities for a medication error rate of 7.14 percent (%). This affected one resident (#10) out of seven residents observed for medication administration. The facility census was 91. Findings include: Review of the medical record for Resident #10 revealed an admission date of 02/27/24 with diagnoses including type two diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and chronic kidney disease with dependence on dialysis.Review of the physician orders dated 03/25/25 revealed Resident #10 had an order for 44 units of Lantus Insulin (long acting insulin) to be administered subcutaneously (SQ) by Insulin Pen injector in the morning as well as 14 units of Fiasp Insulin (short acting insulin) to be administered SQ by Insulin Pen injector before meals. Observation on 07/28/25 at 9:20 A.M. revealed Licensed Practical Nurse (LPN #559) preparing Resident #10's insulin medications. LPN #559 attached the needle to the Lantus insulin pen and dialed 44 units on the pen. LPN #559 then attached the needle to the Fiasp insulin pen and dialed 14 units on the pen. LPN #559 then administered each dose to Resident #10's left side of abdomen without priming either of the insulin pens to ensure no air bubbles were present and the pen was functioning appropriately.Interview on 07/28/25 at 9:25 A.M. with LPN #559 verified that she did not prime either insulin pens and stated she was not aware that they had to be primed prior to dialing the dosages.Review of both Lantus Solo Star Subcutaneous Pen Injector and Fiasp Flex Insulin Pen Injector's manufacturer instructions revealed before each injection small amounts of air could collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing turn the dose selector to two units. Hold the insulin pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push button all the way in. The dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times.Review of the facility policy titled, Medication Administration, no date, did not address insulin administration via pen.

Based on observation, interview, and record review, the facility failed to provide residents with foods to accommodate their allergies and preferences during meals. This affected three residents (#13, #40, and #46) of three reviewed for food/nutrition. The facility census was 91.Findings include: 1. Review of Resident #13's medical record revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, major depressive disorder, and panic disorder. Review of Resident #13's physician orders for July 2025 revealed an order for a regular diet, thin liquid consistency. Resident #13 was ordered as allergic to eggs and egg products. Review of Resident #13's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and was independent for eating. Observation and interview on 07/30/25 at 12:04 P.M. revealed that Resident #13's tray was completed and put into the food cart to be delivered for lunch. Resident #13's tray ticket stated that she was to receive a #10 scoop of ground fruit cocktail as a preference. Dietary Manager (DM) #808 moved Resident #13's tray from food cart and verified that her diet ticket stated that Resident #13 was to get ground fruit cocktail but was served regular fruit cocktail. DM #808 removed the regular fruit cocktail and made ground fruit cocktail. This was verified by DM #808 at time of observation. 2. Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, major depressive disorder, and moderate protein malnutrition. Review of Resident #40's physician orders for July 2025 revealed an order for a regular dysphagia advance diet, thin liquid consistency. Resident #40 was to receive double entree all meals. Review of Resident #40's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate impaired cognition and was independent for eating. Observation and interview on 07/30/25 at 11:53 A.M. revealed that Resident #40's tray was completed and put into the food cart to be delivered. Resident #40's tray ticket stated that he had an order for double portions. Dietary Aide (DA) #801 removed Resident #40's tray from the food cart and verified that his tray ticket stated that Resident #40 was to receive double portions and was served a regular size portion of chicken piccata. This was verified by Regional Dietary Manager (RDM) #809 at time of observation. 3. Review of Resident #46's medical record revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, depression, and chronic kidney disease. Review of Resident #46's physician orders for July 2025 revealed an order for a carbohydrate control renal diet, thin liquid consistency. Resident #46 was allergic to lactose. Review of Resident #46's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and was independent for eating.Review of the recipe for chicken piccata revealed that an ingredient was two percent milk. Observation and interview on 07/30/25 at 11:47 A.M. revealed that Resident #46's tray was completed and put into the food cart to be delivered. Resident #46 tray ticket stated that she had a dairy allergen and was to receive a three ounce baked chicken breast instead of the chicken piccata being served as the main entree'. RDM #809 removed Resident #46's tray from the food cart and verified that her diet ticket stated that Resident #46 had a dietary allergen, was to receive a baked chicken breast but was served chicken piccata. This was verified by RDM #809 at time of observation. This deficiency represents non-compliance investigated under Complaint Number 1300241, Complaint Number 1300243, and Complaint Number 1300248.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, record review and interview, the facility failed to provide adequate care and services to prevent a second degree burn on the Resident #68's right hand. Actual Harm occurred on 12/03/24 when Resident #68 sustained a second degree burn to her right dorsal hand after spilling hot noodle soup onto her right hand. The soup had been heated in a microwave by nursing staff at an unknown hot temperature and then handed to the resident who was standing in the area. This affected one resident (#68) of three residents reviewed for accidents/hazards. Findings include: Review of Resident #68's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, essential hypertension and bipolar disorder. Review of Resident #68's physician orders revealed an order dated 06/28/24 for a regular diet, regular texture with regular consistency. Review of Resident #68's Hot Liquid Evaluation form dated 09/26/24 revealed the resident did not have indicators for severe cognitive impairment, poor safety awareness, tremors, contractures, weakness or posture concerns. The assessment revealed there were no other indicators not listed above. Review of Resident #68's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. The resident resided on the secured memory care unit on the second floor. Review of a facility Occurrence Form #1223725 dated 12/03/24 at 4:11 P.M. revealed the nurse was sitting at the nursing station charting and the resident was handed a cooked noodle cup by the Certified Nursing Assistant (CNA). The resident sat the noodle cup on her roller walker and took a step backwards and lost her balance falling onto the floor. The incident was witnessed by staff. Review of Resident #68's Acute Visit Nurse Practitioner (NP) note dated 12/03/24 authored by NP #815 revealed the resident had a past medical history (PMH) of hypertension, diabetes, bipolar fell on to the floor in the secured unit. This was a witnessed fall. She hit her head to the floor with no bleeding, no hematoma and neurological checks were initiated. Her mental status was per the baseline and range of motion was per the baseline. The resident stood up with assistance and started walking with the walker. She also had spilled hot soup on her right hand and complained of burning. No blisters and an ice pack was applied. Review of Resident #68's Skin Grid Non-Pressure form dated 12/03/24 at 4:12 P.M. revealed the resident had right hand (back) redness which was classified as a burn. The wound measured one cm (centimeter) length by 2.0 cm width with no depth. The wound was red, moist grainy, with optimal granulation color and pain. Review of Resident #68's progress note dated 12/03/24 at 8:31 P.M. authored by Licensed Practical Nurse (LPN) #810 revealed while the nurse was sitting at the nursing station charting, the resident was handed a cooked noodle cup by the CNA. The resident sat the noodle cup on the roller walker and took a step backwards. She lost her balance and fell on to the floor. The resident was observed hitting her head but denied pain due to the recent fall. The skin was intact, and no injury was noted. The resident complained of pain to the right hand and stated the noodle cup got on her hand. The NP was made aware and assessed the resident. An ice pack to the right hand was ordered and neurological checks were ordered. The power of attorney (POA) was made aware, and urine was sent to the lab this morning. Review of Resident #68's progress note dated 12/04/24 at 1:00 A.M. authored by NP #815 revealed the encounter was a follow up post fall and burns to the right hand. The resident was seen in the hallway sitting in the walker seat. The resident denied a new headache, mental status at baseline and neurological checks continued. The resident complained of right elbow pain post fall and elbow redness was found on the bony area. No dislocation was identified and burns to the right hand. Bacitracin external ointment twice daily was ordered. Review of Resident #68's physician orders revealed an order dated 12/04/24 at 5:00 P.M. authored by NP #815 for bacitracin external ointment 500 units/gram apply to right hand/wrist two times a day. Review of Resident #68's physician orders revealed an order dated 12/04/24 to apply an ice pack to the right hand due to complaints of pain as tolerated by the resident; an order dated 12/04/24 for bacitracin external ointment 500 units/gram apply to right hand/wrist topically two times a day for seven days for a burn; and an order dated 12/12/24 to cleanse the right dorsal hand second degree burn with wound cleanser, apply Silvadene cream 1% (silver Sulfadiazine) to base of the wound, leave open to air and complete twice daily and as needed. Review of Resident #68's medication administration records (MARS) and treatment administration records (TARS) from 12/03/24 to 12/17/24 revealed treatments were completed as ordered. Review of Resident #68's Skin and Wound Note dated 12/13/24 at 3:30 P.M. revealed the visit was for a new skin and wound consult. Resident #68 presented with a burn to the dorsal right hand. The wound was new and was 1.5 cm length by one cm width with 0.1 cm depth with dryness to the peri wound and scant amount of serous exudate. The wound was classified as a right dorsal hand second degree burn. The order was to cleanse the right hand with Silvadene cream 1% to the base of the wound and leave open to air twice daily. Interview on 12/17/24 at 6:57 A.M. with CNA #808 revealed Resident #68 did not like the facility food and the resident's daughter would bring in ramen noodle cups for the resident. She revealed on 12/03/24 at approximately 8:25 P.M. she heated up a ramen noodle cup for Resident #68 at (approximately) one minute and 30 seconds in the microwave. The CNA stated the resident said it was not hot enough and she heated it for another 60 seconds in the microwave and then handed it to the resident. She revealed Resident #68 put the soup down on her walker and some of the soup splashed onto her hand. CNA #808 revealed the resident became startled and took a step back falling to the floor and hitting her elbow and head. CNA #808 revealed she was aware the facility policy indicated not to heat foods for residents, but she stated she had always heated Resident #68's noodle soup. She confirmed the resident had cognitive impairment and resided on the secured memory care unit. Interview on 12/17/24 at 7:26 A.M. with LPN #810 revealed he was sitting at the nursing station on 12/03/24 when CNA #808 handed Resident #68 her soup. LPN #810 confirmed the resident's family does bring in food for the resident. He revealed at the time of the incident, the resident stepped back and fell backwards to the floor striking her elbow and head on the floor. He revealed he did not see injuries to her hand but was more concerned about the injuries to her elbow and head. He confirmed staff were not supposed to be heating soup up for the residents and he stated he called the resident's daughter and NP following the incident with the resident. An attempted interview on 12/17/24 at 10:47 A.M. with Resident #68 revealed she was not able to answer interview questions. Observation of Resident #68's right hand at the time of the interview revealed she had a healing burn on the right hand between the thumb and first finger which appeared shiny pink and it had a scabbed area in the middle of the shiny pink area which appeared to be a healing blister. Interview on 12/17/24 at 12:22 P.M. with NP #815 revealed on 12/03/24 Resident #68 had soup on the seat of her walker) and burned her hand on it which caused her to fall backwards to the floor and hit her head. NP #815 revealed she had assessed the resident while she was still on the floor because she was in the building. She revealed Resident #68 did not have injuries to her shoulder and had a bruise to the right elbow and a burn to the right hand. She revealed at the time of the observation the resident's hand was just reddened, and she ordered an ice pack to be applied to the area. NP #815 revealed she assessed the resident on 12/04/24 and noted the resident's top layer of skin on the resident's right hand was peeling. She denied the resident had blisters at this time. Interview on 12/17/24 at 12:50 P.M. with the Interim Director of Nursing (DON) revealed Resident #68 developed a blister on 12/06/24 between the thumb and pointer finger (top uppermost part) as a result of the burn on 12/03/24. Review of the undated Storage of Resident Food policy indicated dietary services would provide any re-heating of foods but in the event dietary staff were not available, a trained staff member may re-heat foods brought in from outside sources. Foods must be re-heated in 15 second increments until the temperature reaches 165 degrees Fahrenheit. Allow the food to cool prior to serving for resident preference and palatability. The deficiency was corrected on 12/04/24 when the facility implemented the following corrective actions: On 12/03/24 at 4:08 P.M., LPN Unit Manager (UM) #825 completed a skin assessment on Resident #68 and noted redness to the right hand measuring one cm length by two cm width with no depth. The resident's skin was intact at this time. On 12/03/24 at 4:20 P.M. LPN UM #825 completed interviews with unit staff. The staff reported Resident #68 lost her balance due to being distracted and talking to other residents. On 12/03/24 at 4:30 P.M., the Interim DON was notified of the incident by LPN UM #825. On 12/03/24 at 4:31 P.M. the Interim DON reviewed Resident #68's diet order. The order was for a regular/regular/regular diet with no devices. On 12/03/24 at 4:45 P.M., the Interim DON reviewed Resident #68's MDS and Care Plans and no diet modifications were noted. On 12/03/24 at 4:45 P.M. the Interim DON completed an audit by assessing all residents in house for potential for risk of injury due to hot food items/liquids. No abnormal findings were identified. On 12/03/24 at 6:05 P.M. LPN UM #825 educated all facility staff on Hot Liquids and initiated an in-service. On 12/03/24 at 6:38 P.M., NP #815 ordered an ice pack to Resident #68's right hand twice daily as tolerated, and the ice pack was added to the resident order list. Review of the Outside Food policy by the Administrator and DON on 12/4/2024 revealed no changes were made. On 12/04/24 at 4:15 P.M. NP #815 assessed Resident #68. No swelling to the head was observed. Redness to the right hand was observed with intact skin. Neurological checks were within normal limits (WNL) and range of motion (ROM) was WNL. A verbal order for an ice pack was received and initiated. On 12/04/24 at 9:50 A.M., an interdisciplinary team meeting was held regarding the incident which included the Administrator, Interim DON, LPN UM #832, LPN UM #825, LPN MDS #861, Therapy #602, Licensed Social Worker (LSW) #603. On 12/04/24 at 2:30 P.M., NP #815 followed up with Resident #68 and treatment orders were obtained and implemented. On 12/04/24 at 3:00 P.M., NP #815 ordered bacitracin ointment to the right hand twice daily. On 12/04/24 at 4:00 P.M. the Interim DON initiated ongoing monitoring audits three times a week for four weeks related to monitoring residents for risk for injury related to hot liquids/foods. The audits were being monitored for compliance by the DON in conjunction with the Administrator daily during the clinical meeting and weekly during the nursing risk meeting. On 12/04/24 at 5:00 P.M. LPN UM #825 completed Storage of Resident Food Hot policy in-service with focus on hot liquids/foods to all facility staff. On 12/05/24 at 11:46 A.M., Speech Therapy evaluation was completed by Speech Therapist #604 and an order received for ST services three times a week for four weeks for cognitive skills development On 12/06/24 at 10:33 A.M., a skin evaluation was completed on Resident #68's right hand burn. The resident was added to wound care rounds with Wound NP #985 (routine). The burn to the right hand measured one cm length by two cm width with no depth and was red in color with no exudate and no pain. The physician orders were to continue the treatment of Bacitracin topically twice daily. The resident's right hand had an intact blister which was noted to the center of the burn. On 12/12/24 at 4:00 P.M. a wound assessment was completed with the facility wound nurse LPN UM #825 and Wound NP #985. The burn to the right hand measured at 1.5 cm length by one cm width with 0.1 cm depth. Dryness was noted to the periwound with scant serous exudate. The treatment orders was changed to Silverdene cream 1% twice daily and as needed. On 12/12/24 at 8:04 P.M. the treatment order for Resident #68 was changed to Silvadene twice daily and as needed by Wound NP #985. This deficiency represents non-compliance investigated under Complaint Number OH00160640.

Based on closed record review and interview, the facility failed to implement comprehensive, individualized and effective behavioral health interventions for Resident #107, who was diagnosed with dementia and had a history of inappropriate sexual behaviors, to prevent additional inappropriate sexual behaviors from occurring. This affected one resident (#107) of nineteen residents who resided on the SMCU. Findings include: Review of Resident #107's closed medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including vascular dementia, anxiety disorder and depression. Resident #107 was listed as the resident representative. Review of Resident #107's behavior care plans revealed interventions including administer medications as ordered dated 08/19/24; speak in a calm manor dated 08/19/24; encourage to express feelings dated 08/19/24; intervene as necessary dated 08/19/24; monitor behavior episodes and attempt to determine underlying causes dated 08/19/24, observe and anticipate resident needs dated 08/19/24; behavioral health consults as needed dated 08/19/24; and monitor for inappropriate sexual behaviors dated 10/07/24. Review of the plan of care revealed no updated or new interventions were included following an incident on 09/29/24 until 10/07/24 when the intervention to monitor for inappropriate sexual behaviors was added. Review of Resident #107's Admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #107's Behavior Note dated 09/29/24 at 9:45 P.M. revealed the resident was observed by staff being sexually inappropriate with a male resident. The note indicated staff separated the residents. Review of a facility submitted Self-Reported Incident (SRI) Investigation, Tracking Number 252563, completed 10/02/24 for an allegation of sexual abuse revealed on 09/29/24 Resident #107 and Resident #57 were on the couch in the common area of the SMCU engaging in a sexual interaction. Review of Resident #107's Psychiatry note dated 10/08/24 revealed the resident had an encounter with another resident where they both appeared to be fondling one another. The resident's hands were allegedly near or in another male resident's pants and the other resident's hands were allegedly near or on this resident's breast per reports of staff. The resident denied the incident reported by staff and stated there was no physical interactions between her and any other residents. The resident did not appear to be sad, anxious or in any distress. The provider did not identify any safety concerns for Resident #107 or any other resident at this time. However, the note included frequent monitoring was encouraged when the resident was interacting with other residents. The resident denied any recollection of the incident and had very poor insight. Review of a facility submitted SRI, Tracking Number 253264, dated 10/23/24, for an allegation of sexual abuse revealed per conversation with CNA, she observed Resident #107 and Resident #60 in bed together. At the time of questioning the CNA reported that when she opened up the door to the room that both residents moved very quickly and she could not state if they had been touching one another, only that they had not been facing one another in bed. The CNA reported she was unsure if the male resident had both his pants and briefs lowered or just his pants. The CNA reported Resident #107 was fully unclothed and that her clothes were lying next to the bed on the floor. The CNA reported she had seen Resident #107 15 minutes prior and noted her to be positioned in the living room area. Review of the undated SRI Witness statement revealed on 10/23/24 at approximately 7:45 P.M., Resident #107 was in the living room wearing a sweatshirt and pants. The CNA went to provide care to another resident and upon return noticed Resident #107 was not in the living room. A search of the SMCU found Resident #107 in Resident #60's room. Upon entering Resident #60's room, the resident was in bed with Resident #107. Resident #60 had on a shirt, but his brief and pants were down to his knees. Resident #107 was completely naked. They were laying against each other with Resident #107's back facing Resident #60's stomach. Review of Resident #107's Behavior Note dated 10/23/24 at 8:45 P.M. revealed the resident was observed by a CNA in another resident's room in an inappropriate situation. Both residents (Residents #60 and #107) were immediately separated and the note revealed one to one maintained for the remainder of the shift. The family and doctor were notified. Review of Resident #107's Telehealth Notification progress note dated 10/24/24 revealed the resident was in bed with a male resident and both were undressed but had only been in bed for a short while. The Administration was notified. The note included, both resident's have dementia, not clear that either can consent but it did not appear that anything happened against either's will. The resident's brother was notified. Information obtained via email on 12/19/24 at 11:14 A.M. from Registered Nurse (RN) Regional #801 revealed on 10/07/24 in conjunction with the investigation, behavior monitoring orders were implemented for Resident #107's sexually inappropriate behaviors such as touching others inappropriately or touching herself in public locations with five non-pharmacological interventions listed to implement if necessary. A second email dated 12/19/24 at 12:04 P.M. from RN Regional #801 revealed Resident #107 was assessed by psych services after the first incident in September 2024, was cleared and her medications were reviewed. The resident had behavior monitoring implemented to reduce the risk, but the facility did not provide one to one monitoring indefinitely nor was this intervention included on the resident's plan of care. Regional #801 confirmed Resident #107 exhibited inappropriate sexual behaviors on 09/29/24 and displayed inappropriate sexual behaviors a second time on 10/23/24. Review of the Secured (Locked) Unit policy revised 2017 revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of those residents. Review of the undated Behavioral Management General policy revealed it was the policy of the facility to identify and safely manage residents who are exhibiting behaviors related to psychiatric diagnoses or who may present a danger to themselves or others. This deficiency represents non-compliance investigated under Complaint Number OH00159742.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 108 residents residing in the facility. Findings include: Review of the PBJ Staffing Data Report form submitted from 10/01/23 to 12/31/23 revealed on the following dates submitted for the first quarter of the fiscal year 2024, the facility was low on RN hours in the building on 10/01 (Sunday); 10/14 (Saturday); 10/15 (Sunday); 10/28 (Saturday); 10/29 (Sunday); 11/11 (Saturday); 11/12 (Sunday); 11/25 (Saturday), and 11/26 (Sunday). Interview on 09/25/24 at 7:54 A.M. with the Administrator revealed she began working at the facility in April 2024 and at that time was told there was a concern with getting registered nurses hired. The administrator stated they hired RNs since then and they should be okay now. Review of schedules and assignment sheets from 10/01/23 to 12/31/23 with Payroll Specialist (PS) #279 on 09/25/24 at 8:47 A.M. confirmed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the first fiscal quarter of 2024: 10/01 (Sunday); 10/14 (Saturday); 10/15 (Sunday); 10/28 (Saturday); 10/29 (Sunday) 11/11 (Saturday); 11/12 (Sunday); 11/25 (Saturday), and 11/26 (Sunday). Review of schedules and assignment sheets from 01/01/24 through 03/31/24 with PS #279 on 09/25/24 at 8:47 A.M. revealed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the second fiscal quarter of 2024: 01/06 (Saturday); 02/17 (Saturday); 02/18 (Sunday); 03/16 (Saturday); 03/17 (Sunday), and 03/31 (Sunday). Review of schedules and assignment sheets from 04/01/24 through 06/30/24 with PS #279 on 09/25/24 at 8:57 A.M. revealed a RN was not present in the building for at least eight consecutive hours a day, seven days a week as required on the following dates during the third fiscal quarter of 2024: 04/13 (Saturday); 04/14 (Sunday), and on 06/30 (Sunday) when the scheduled RN left four hours early related to an emergency. The deficient practice was corrected on 07/01/24 when the facility implemented the following corrective actions. On 05/01/24 The scheduler, Director of Nursing (DON) and Administrator were in-serviced on the need to have a RN in the building 24 hours seven days a week by the Regional Director of Operations. On 05/01/24, the corporation started daily meetings to ensure RN coverage. The attendees included the Administrator, DON, Regional Director of Operations (RDO), Facility Scheduler, and Divisional Director of Workforce Management. The daily meetings looked forward regarding staffing and reached out and offered overtime to staff in sister facilities to ensure appropriate coverage. On 05/01/24, the corporation started weekly Zoom meetings to audit RN coverage. The attendees included the Administrator, DON, Regional Director of Operations (RDO), Facility Scheduler, and Divisional Director of Workforce Management. This weekly meeting monitored RN coverage and looked at the past week to ensure proper RN coverage. On 05/01/24 the facility implemented an on-call RN, who would work eight consecutive hours if a RN called off on a weekend. On 05/01/24, the facility implemented a corporate scholarship program within the facility for RNs from foreign countries that did not have Ohio RN licensure. This included curricular and practicum training at the facility. The Bachelor degreed RNs from their country of origin would sit for the United States National Council Licensure Exam (US NCLEX) exam and upon passing would be hired by the facility. The facility hired four RNs (RN #258, RN # 268, RN #252, and RN #900), who received housing, meals and transportation. The RNs were contracted for three years of employment and worked as State tested Nurse Aides (STNAs) after becoming certified until passing the NCLEX. Review of the personnel files for RN #258, RN # 268, RN #252, and RN #900 revealed each had required licenses and appropriate screening and hiring procedures were followed. On 05/20/24, RN #252 was hired. On 07/22/24, an Assisted Director of Nursing (RN) was hired. On 08/20/24, RN #301 was hired. On 09/19/24, RN #900 was hired. Review of schedules and assignment sheets from 07/01/24 through 09/22/24 with PS #279 on 09/25/24 at 9:07 A.M. revealed a RN was present in the building for at least eight consecutive hours a day, seven days a week as required. This deficiency represents non-compliance investigated under Complaint Number OH00157574.

Based on record review, interview and policy review, the facility failed to ensure notification of a resident's change in condition and subsequent hospitalization . This affected one resident (#31) of one resident investigated for notification. The census was 108. Findings include: Review of Resident #31's record revealed an admitted [DATE]. Diagnoses included multiple sclerosis, diabetes mellitus II and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 required staff assistance with all activities of daily living. Further review of the medical record including progress notes revealed no documentation Resident #31's family was notified of a change in status with subsequent hospitalization . Review of the Telehealth notification dated 08/24/24 at 7:19 P.M. revealed Resident #31 on video, repeating, I feel good, I feel good, and I feel oriented, I feel oriented, and I feel good, I feel good, I'm getting ready to watch a movie, I'm getting ready to watch a movie. Then back to, I feel good. She appeared lethargic. Further review revealed nursing stating she was usually alert and oriented times four. Sending her to emergency room (ER) for further treatments and evaluation. Feel she may need a urinalysis and/or CT of head. Review of a nurse note dated 08/24/24 timed at 7:57 P.M. revealed Resident #31 was repeating words over and over. She was alert to self and place only. She did not seem like her usual self. Telehealth was notified and ordered her to be sent out. Interview with the Licensed Practical Nurse/Unit Manager #316 on 09/25/24 at 10:57 P.M. confirmed the lack of notification to the family concerning Resident #31's change in status and subsequent hospitalization . Review of the facility's undated policy Notification of Change in Condition revealed the attending practitioner would be promptly notified of significant changes in condition and the medical record must reflect the notification, response and interventions implemented to address the resident's condition. The policy also revealed when a change in condition was noted, the nursing staff would contact the resident representative. Notifications that for emergency situations required prompt notification as soon as time permitted. Examples included but were not limited to: transfer to hospital, severe change in physical or mental health and unexpected death. This deficiency represents non-compliance investigated under Complaint Number OH00157587.

Based on interview and record review, the facility failed to ensure dependent residents received routine showers. This affected two residents (Resident #13 and #31) of three residents (Residents #13, #31, and #70) reviewed for activities of daily living (ADLs). The facility census was 108. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including history of traumatic brain injury, depression, anxiety disorder, and seizures. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/06/24, revealed Resident #13 had intact cognition and was dependent for ADLs. Further review of the medical record revealed no documentation of Resident #13 refusing showers. Interview on 09/24/24 at 9:30 A.M. with Resident #13 revealed he did not receive showers as scheduled. Resident #13 stated that he had to repeatedly ask for showers. Interview on 09/25/24 at 9:07 A.M. with Licensed Practical Nurse (LPN) #316 revealed LPN #316 could only find one completed shower sheet for Resident #13. LPN #316 confirmed this was the only documentation indicating Resident #13 received a shower in the past three months. Review of Resident #13's shower sheets revealed that only one shower was documented for the past three months. 2. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including multiple sclerosis, major depressive disorder, and anxiety disorders. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 09/06/24, revealed Resident #13 had intact cognition and was dependent for all ADLs except eating. Interview on 09/24/24 at 9:28 A.M. with Resident #31 revealed she did not get showered like she was supposed to. Interview on 09/25/24 at 9:07 A.M. with Licensed Practical Nurse (LPN) #316 revealed LPN #316 could only find one completed shower sheet for Resident #31. LPN #316 confirmed this was the only documentation indicating Resident #31 received a shower in the past three months. Review of the facility's policy Routine Care, dated 05/01/24 revealed routine care by a nursing assistant included but was not limited to bathing, dressing, and toileting.

Based on observation, record review, interview, and policy review the facility failed to ensure infection control measures were followed during medication administration. This affected one of four residents observed during medication administration, Resident (#59). The census was 108. Findings include: Record review for Resident #59 revealed an admitted [DATE]. Diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, epilepsy and alcohol abuse with intoxication. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #59 required assistance from staff for activities of daily living. Review of Resident #59's physician orders revealed on order dated 12/08/23 for levetiracetam oral tablet 750 milligrams (mg). Give two tablets by mouth every morning and at bedtime for epilepsy. Observation on 09/24/24 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #315 preparing to administer medication for Resident #59. LPN #315 popped two levetiracetam tablets directly into her hand from a blister pack then put them in the medication cup that was on the medication cart. Interview with LPN #315 immediately after popping the two tablets of levetiracetam directly into her bare hand revealed she did it because they were large tablets. Review of the facility policy Medication Administration, dated 04/16/24 revealed the procedures for administering medications included not touching the medications with bare hands when opening a liquid or dose pack.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, resident and staff interview, review of medial imaging results, review of staff statements, and review of facility corrective action, the facility failed to provide adequate and sufficient assistance during personal care to prevent a fall with major injury for Resident #30. Actual harm occurred on 05/28/24 when Resident #30, who required staff assistance (care planned to require two-person assistance and/or substantial to maximal assistance with activities of daily living (ADLs)) sustained a fall out of bed resulting in a fractured left hip. At the time of the incident, one (1) staff member was providing care to the resident. This affected one (#30) of three residents reviewed for falls. The census was 99. Findings Include: Review of Resident #30's medical record revealed an admitted [DATE] with diagnoses including anemia, orthostatic hypotension, retention of urine, muscle weakness, chronic kidney disease, congestive heart failure, anxiety, and major depression. Review of a fall risk care plan dated 04/17/24 revealed Resident #30 was placed at risk for falls related to incontinence, weakness, anemia, end stage renal disease, diabetes mellitus, wounds, and immobility. Appropriate interventions were implemented to include use of non-skid footwear, maintain the resident's room free of accidents and hazards, ensure bed locks are engaged, place the call light in reach, and move the resident's room closer to the nurses' station. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was assessed with intact cognition with no range of motion impairments to the upper or lower extremities. Review of Resident #30's plan of care revised 05/16/24 revealed the resident had an ADL self-care deficit and the resident required assistance with ADLs related to incontinence, diabetes mellitus, weakness, and immobility. Interventions included the resident was totally dependent on staff for toilet hygiene, showers/bathing, and chair to bed transfers requiring two (2) or more helpers to do all of the work. An intervention included the resident required substantial/maximal assistance where helpers do more than half the effort to complete upper body dressing, personal hygiene, and rolling left and right. An intervention was also implemented which indicated the resident's assistance level with ADLs may vary based on the time of day, pain, mood, or fatigue and staff should document and adjust as indicated. Review of a late entry nursing progress note dated 05/28/24 at 7:45 P.M. revealed staff were alerted to Resident #30's room by a State tested Nursing Assistant (STNA) and Resident #30 yelling out for help. As the writer of the progress note entered the room, Resident #30 was observed rolling out of bed from behind a privacy curtain. The resident was mechanical (Hoyer) lifted from the floor using four (4) staff members to get the resident into bed. Resident #30 was noted with abrasions to his head, a skin tear to the top of the right hand, an abrasion to the front of the right shin, and bruising to the left arm. The resident was to be assisted by two staff for hygiene care, repositioning in bed, etc. The physician was notified, and x-ray imaging was ordered for the resident's hips and pelvis as the resident complained of pain while moving back to bed. The resident was able to move all 4 extremities. Review of a post-fall evaluation document dated 05/28/24 at 7:45 P.M. revealed Resident #30 sustained a fall in his room from bed which was in normal position. The resident was wearing non-skid socks and was not using any assistive devices. It was noted the last time the resident was toileted was on 05/28/24 at 7:45 P.M. and STNA #114 was the only witness to the fall. Vital signs were within normal limits, and the resident was complaining of pain in both hips and the left antecubital. The pain was described as achy and tender. Resident #30 was assessed with three (3) small abrasions on the top of his scalp, a skin tear on the back of the right hand, and an abrasion to the front of the right lower leg. Notification was made to the physician and resident's responsible party at 8:00 P.M. When the resident was asked what he was doing prior to the fall the resident responded that he was being changed and rolled off the side of the bed. The suspected root cause of the fall was the resident was holding onto a grab bar and started rolling off the edge of the bed. STNA #114 was not able to get to the other side of the bed fast enough to stop the resident from falling. It was also noted the resident was on an air mattress as a suspected root cause. Following the incident, staff identified the resident required two staff members to provide care at all times. Review of a written statement dated 05/28/24 given by STNA #114 revealed at approximately 7:45 P.M. he was doing a bed change on Resident #30. STNA #114 documented he rolled the resident over to face the door and the resident was grabbing the side rail holding himself over. As STNA #114 was putting the corners of the sheet on the bed, Resident #30 started to roll off the bed. STNA #114 reached to grab for the resident and yelled for help. STNA #114 documented Resident #30 slipped from his grip and rolled off the bed just as staff members entered the room. Review of a typed statement dated 05/29/24 at 2:25 P.M. given by Licensed Practical Nurse (LPN) #132 revealed she just had finished shift report and was at the nurses' station charting when she heard a yell for help and a thud. LPN #132 observed Resident #30 laying on the floor between the two beds in his bedroom and his nurse aide was on the opposite side of the bed moving toward the resident. LPN #132 stated the resident was alert and oriented and indicated he rolled out of bed when the nurse aide was providing care and was not sure how it happened as it happened so quickly. LPN #132 documented the resident was assessed and was able to move his hands and arms with no issues. The resident indicated he had discomfort in both hips and he was able to move his right left more than his left leg. There was no obvious external rotation or significant length differences when comparing the resident's legs. Review of a nursing progress note dated 05/29/24 at 5:22 P.M. revealed Resident #30 complained of severe left arm pain in the morning and an order for x-ray imaging of the left arm from shoulder to fingertips was ordered. The resident was medicated with narcotic pain medications; however, the medication was not effective. Results of the resident's x-rays revealed a possible fracture of the left hip and the resident was sent out to the hospital. Review of a subsequent nursing progress note on 05/29/24 at 11:40 P.M. revealed Resident #30 was being admitted to the hospital due to a left hip fracture from a fall. Review of x-ray imagine results dated 05/29/24 revealed Resident #30 was found with irregularity of the left intratrochanteric region and may represent a nondisplaced fracture. The femoral heads showed no concerns, and the surrounding soft tissue was normal. X-rays of the left hand to shoulder revealed no acute fractures and the surrounding tissue was normal. Interview with the Administrator on 06/04/24 at 3:30 P.M. verified Resident #30 rolled out of bed approximately at 7:45 P.M. on 05/28/24. At the time of the incident, Resident #30 was holding the upper assist rail and his legs started going off the bariatric low air loss mattress with bolsters mattress. The Administrator revealed prior to the incident, the resident could hold the rail once assisted to roll onto his side, but stated the resident did not have the upper arm strength to roll himself over. The Administrator stated STNA #114 was providing incontinence care for the resident at the time of the incident. The Administrator indicated the facility notified the family, an x-ray was ordered, and the x-ray showed a possible fracture of the resident's left hip. Observation of Resident #30 on 06/06/24 at 7:57 A.M. revealed the resident was laying in bed with no obvious concerns noted. An interview was attempted with the resident; however, no information was able to be provided regarding the fall on 05/28/24 from the resident. Interview on 06/06/24 at 3:53 P.M. with STNA #114 via telephone revealed (on 05/28/24) he had to do a full bed change on Resident #30. While providing care, STNA #114 indicated he turned the resident to wipe his back side, and the resident was fine. STNA #114 stated Resident #30 was holding on to the upper side rail while he went to fit the corner of the sheet on the corner of the bed. STNA #114 stated, out of the corner of his eye, he could see Resident #30 started to slip. STNA #114 stated he got a little hold of Resident #30, but the resident slipped from his grasp. STNA #114 stated he called for help and Resident #30 fell off the bed as 2 staff members were coming in. As a results of the incident, the facility implemented the following corrective actions to correct the deficient practice on 06/03/24: On 05/29/24, Resident #30 was sent out to the hospital for evaluation and treatment of a suspected left hip fracture. The resident was readmitted to the facility on [DATE]. On 05/31/24, an audit was completed on all residents with air mattress to ensure there were not issues with the mattresses and application of the mattresses was appropriate. There were no concerns noted. On 05/31/24, all resident care plans were reviewed and updated to ensure proper interventions were in place for assistance with care with no concerns noted. On 05/31/24, all staff members were educated that all residents utilizing an air mattress required a 2-persons assistance with care and to check the resident's Kardex for updates to the resident's tasks. On 06/03/24, audits were initiated to ensure 2-person assistance with utilized for residents with low air loss mattress. The audits were of three residents weekly for three weeks to ensure compliance. Review of the audits completed for the weeks of 06/03/24 and 06/10/24 revealed no concerns were identified. This deficiency represents noncompliance investigated under Complaint Number OH00154514.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to maintain a medication error rate of less than five percent (%). The medication error was 12.00% due to three observed medication errors for 25 medication administration opportunities. This affected two (Residents #9 and #42) of four residents observed for medication administration. The facility census was 94 residents. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including dysphagia, hemiplegia, aphasia, anxiety disorder and reflux disease. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #9 dated [DATE] revealed the resident had impaired cognition and required staff assistance with bed mobility, transfers, and personal hygiene. Review of the [DATE] physician's orders for Resident #9 revealed the resident had an order for Aspirin 81 milligram (mg) enteric coated, delayed release tablet by mouth daily. Observation on [DATE] at 8:32 A.M. revealed Licensed Practical Nurse (LPN) #204 prepared Resident #9's morning medications which included a chewable Aspirin 81 mg tablet. The aspirin tablet was administered whole, and the resident swallowed the tablet with water. Interview on [DATE] at 8:44 A.M. with LPN #204 confirmed she administered a chewable aspirin tablet to Resident #9, but the resident's order was for an enteric coated, delayed release tablet. 2. Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including bipolar disorder, depression, chronic obstructive pulmonary disease, and coronary artery disease. Review of the comprehensive MDS assessment for Resident #42 dated [DATE] revealed the resident had impaired cognition and required staff assistance with bed mobility, transfers, and personal hygiene. Review of the [DATE] physician's orders for Resident #42 revealed an order for Mucinex 600 mg by mouth every 12 hours and an order to give an iron tablet extend release by mouth every morning and evening for iron deficiency. The order did not indicate how many mg of iron was needed. Observation on [DATE] at 9:00 A.M. revealed LPN #250 administered Resident #42's morning medications including a Mucinex 600 mg with an expiration date of ,d+[DATE] and an iron 50 mg extended-release tablet to the resident. Interview on [DATE] at 9:07 A.M. with LPN #250 confirmed she did not check Resident #42's Mucinex for an expiration date and the dose she administered to the resident was expired. LPN #250 further confirmed Resident #42's iron order did not include a dose, and she administered iron 50 mg extended release because it was the only extended iron tablet available. Interview on [DATE] at 9:09 A.M. with LPN #210, Clinical Manager, confirmed the order for Resident #42's iron had no dose listed. Review of the facility policy titled Medication Administration revealed the policy was to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the resident. This deficiency represents noncompliance investigated under Complaint Number OH00151491.

Based on medical record review, staff interview, review of the emergency medical service report (EMS), and review of the facility policy, the facility failed to ensure the resident medical record included accurate documentation. This affected one (Resident #95) of three residents whose records were reviewed for medical record documentation. The facility census was 94 residents. Finding include: Review of the medical record for Resident #95 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cerebral infarction, a stroke, chronic kidney disease. Review of the Minimum Data Set (MDS) assessment for Resident #95 dated 02/18/24 revealed the resident had moderately impaired cognition and was dependent on staff assistance with transfers and used a wheelchair. Review of the progress note for Resident #95 dated 03/14/24 timed at 2:21 P.M. revealed the resident left for an eye appointment. Review of the progress note for Resident #95 dated 03/15/24 timed at 04:04 A.M. revealed the nurse called the emergency room for an update on the resident. Review of the EMS report for Resident #95 dated 3/14/23 timed at 5:04 P.M. revealed the resident was in the back of the facility van and started sliding out of her wheelchair. The resident complained of chest pain and stated she felt weak and sick. Further review of the report revealed the resident was taken off the van, put on a stretcher, and transported via ambulance to the emergency room . Interview on 04/04/24 at 3:15 P.M. with Transporter #233 confirmed upon return trip back from an appointment Resident #95 started to slide out of her chair. The transporter stopped the van, called 911, and positioned himself against the resident's knees to prevent the resident from sliding out of her chair. The resident was transported by EMS to the emergency room . Review of the progress notes for Resident #95 dated 03/14/24 through 03/15/24 revealed the notes did not include documentation regarding the incident described by Transporter #233 in which the resident started to slide out of her chair and was transported to the hospital via EMS. Interview on 04/15/24 at 3:03 P.M. with the Director of Nursing (DON) confirmed Resident #95's medical record did include documentation regarding the incident described by Transporter #233 in which the resident started to slide out of her chair and was transported to the hospital via EMS. Review of the policy titled Clinical Documentation Standards undated revealed nurses should follow the basic standard of practice for documentation which included providing a timely and accurate account of resident information in the medical record.

Based on observation, interview and record review the facility failed to ensure personal protective equipment (PPE) was worn while providing care to a resident on contact precautions. This affected 10 of 10 residents who received care provided by State tested Nurse Aide (STNA) #209, Residents #5, #24, #37, #48, #54, #57, #63, #69, #76 and #77. Findings include: Review of Resident #5's medical records revealed an admitted [DATE]. Diagnoses included muscle weakness, falls and cellulitis (bacterial infection involving the inner layers of the skin). Review of Resident #5's Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition, required extensive assistance with bed mobility, toileting and personal hygiene. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 09/20/23 revealed Resident #5 had a Clostridium Difficile (C-diff) infection (bacterial infection that causes diarrhea and inflammation of the colon) and was on isolation precautions. Interventions included implement isolation precautions. Review of current physician orders dated 09/26/23 revealed an order to place Resident #5 in isolation precautions. Review of progress note dated 09/27/23 revealed Resident #5's stool sample tested positive for C-diff. Observation on 10/03/23 at 11:40 A.M. revealed a sign posted outside of Resident #5's room indicating contact precautions and an isolation bin that included gowns, gloves and masks. Further observation revealed STNA #209 exiting Resident #5's room without PPE and immediately entered another resident's room. Continued observation revealed STNA #245 exiting Resident #5's room at 11:42 A.M. and doffing a gown and gloves. Interview with STNA #245, at time of observation, revealed Resident #5 was on contact precautions for C-diff. STNA #245 stated she was required to don PPE including a gown and gloves prior to entering Resident #5's room. STNA #245 stated she had assisted STNA #209 with providing Resident #5 with a bed bath and incontinence care. Interview on 10/03/23 at 12:07 P.M. with STNA #209 revealed he was aware Resident #5 was on contact precautions for C-diff. STNA #209 confirmed he had not worn PPE while in Resident #5's room providing care and was unable to provide an explanation as to why he had not worn PPE while providing Resident #5's care. Interview on 10/04/23 at 1:55 P.M. with the Director of Nursing (DON) revealed she had been made aware of STNA #209 not wearing appropriate PPE while providing care for Resident #5 who was on contact precautions. The DON stated she had immediately educated STNA #209 regarding proper PPE usage and stated STNA #209 was unable to provide an explanation regarding why PPE was not utilized as required. Review of STNA #209's assignment for 10/03/23 revealed STNA was assigned to care for Residents #5, #24, #37, #48, #54, #57, #63, #69, #76 and #77. Review of facility informational handout (undated) revealed healthcare providers were to wear gown and gloves while providing care to residents with C-diff infections. This deficiency represents non-compliance investigated under Complaint Number OH00146583.

Based on interview, record review and review of the facility policy, the facility failed to ensure one resident's representative was fully informed of the resident's total health status and the care to be furnished. Resident #149's responsible part was not notified of the resident's wound care status including physician orders, wound to the coccyx including the progression of the wound, and a new pressure ulcer to the left heel. This affected one resident, Resident #149 of three residents reviewed. The facility census was 92. Findings include: Review of the medical record for Resident #149 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #149 was readmitted [DATE] and discharged [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge summary for Resident #149 dated 08/08/22 at 2:32 P.M. completed by Licensed Practical Nurse (LPN) #319 revealed Resident #149 had no wounds documented upon discharge on 08/08/22. Resident #149 was discharged to home. Review of the Admission assessment dated [DATE] at 7:29 P.M. completed by Registered Nurse (RN) #303 revealed Resident #149 was admitted for weakness, Resident #149 had confusion, late onset Alzheimer's dementia, and Resident #149 had a pressure area to the sacrum. Dressing was applied to the wound. Resident #149 was a two person assist for bed mobility and unable to understand and verbalize response. Further record review revealed no description or measurement of the wound to the sacrum was completed and no other wounds were documented. Review of the skin grid dated 08/14/22 revealed Resident #149 had an unstageable pressure ulcer to the sacrum. Treatment continued with a foam dressing. There was no description or measurement of the wound to the sacrum, and no further wounds were recorded. Review of the plan of care for Resident #149 dated 08/15/22 revealed Resident #149 had impaired skin integrity and was at risk for altered skin integrity related to incontinence and impaired mobility. Interventions included to administer treatment as ordered, complete weekly skin checks, evaluate existing wound daily for changes, and monitor meal intake. Review of the physician orders for August 2022 for Resident #149 revealed an order was received on 08/15/22 revealing wound to the sacrum, apply bordered foam dressing to the sacrum every three days and as needed. Review of the Health Professional Progress note dated 08/16/22 at 3:13 P.M. completed by Certified Nurse Practitioner (CNP) #306 revealed Resident #149 presented with right knee pain, overall, no acute distress, right knee tender, plan [MEDICATION(S)] as needed. (No documentation of Resident #149 wound was noted in the assessment). Review of the Social Service progress note dated 08/17/22 completed by Licensed Social Worker (LSW) #305 revealed care management meeting was held with interdisciplinary team (IDT) on 8/17/22. Resident #149 was not ambulating and dependent for all activities of daily living. LSW to contact granddaughter to discuss discharge plans. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #149's cognition was severely impaired. Resident #149 required extensive assistance with bed mobility, transfers, dressing, grooming, eating, personal hygiene and required total dependence for toilet use. Resident #149 had one unhealed pressure ulcer on admission that was unstageable. Review of the wound evaluation dated 08/24/22 at 10:21 A.M. completed by CNP #320 for Resident #149 revealed the wound to the sacrum measured 5.31 centimeters (cm) in length by 2.71 cm in width by 0.20 cm in depth with 4.51 cm black tissue and 0.70 cm yellow tissue. The wound was present on readmission and was worsening. The wound was stage four previously to an unstageable today. Etiology was a pressure ulcer unstageable. Wound to left heel was present on admission. Pressure ulcer suspected deep tissue injury. The wound measured 4.21 cm in length by 1.77 cm in width with 1.68 cm black tissue and .13 cm yellow tissue. Review of the Health Professional Progress note dated 08/24/22 at 2:38 P.M. completed by CNP #306 revealed care and Resident #149's status was discussed with Resident #149's granddaughter, agreed to hospital transfer. (No documentation of wound was noted). Review of the progress note dated 08/24/22 at 6:11 P.M. completed by LPN #313 revealed Resident #149 transferred to the hospital on 08/24/22 at 6:10 P.M. Further review of Resident #149's medical records revealed no documentation of Resident #149 's wound to the left heel or description of the wound to the sacrum until 08/24/22 by CNP #320, date of discharge to the hospital. Interview on 09/21/22 at 5:25 P.M. with LSW #305 revealed she had never spoken to Resident #149's family members during care plan meetings regarding Resident #149 wounds. LSW #305 revealed she was unaware Resident #149 had wounds after readmission on 08/13/22. Interview on 09/21/22 at 5:00 P.M. with the Director of Nursing (DON) confirmed there was no documentation in the medical record of Resident #149's Representative, Emergency Contact #1 being notified Resident #149 had any wounds, the progression of the wounds, or treatments ordered for the wounds. Review of facility policy titled Skin Care and Wound Management Overview, dated 05/30/19, revealed the interdisciplinary team worked with the resident/patient and or family/responsible party to identify and implement interventions to prevent and to treat potential skin integrity issues. This deficiency substantiates Complaint Number OH 583.

Based on closed record review and review of the facility policy, the facility failed to complete a wound assessment upon admission to include the wound description and measurements for a wound to the coccyx, obtain physician orders for the wound care upon admission when the wound to the coccyx was identified, complete wound care for the wound as ordered to the coccyx when obtained two days after the wound was identified and assess and treat the wound to the left heel prior to date of discharge. This affected one resident, Resident #149, of three residents reviewed for wounds. The facility census was 92. Findings include: Review of the medical record for Resident #149 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #149 was readmitted [DATE] and discharged [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge summary for Resident #149 dated 08/08/22 at 2:32 P.M. completed by Licensed Practical Nurse (LPN) #319 revealed Resident #149 had no wounds documented upon discharge on 08/08/22. Resident #149 was discharged to home. Review of the Admission assessment dated [DATE] at 7:29 P.M. completed by Registered Nurse (RN) #303 revealed Resident #149 was admitted for weakness, Resident #149 had confusion, late onset Alzheimer's dementia, and Resident #149 had a pressure area to the sacrum. Dressing was applied to the wound. Resident #149 was a two person assist for bed mobility and unable to understand and verbalize response. Further record review revealed no description or measurement of the wound to the sacrum was completed. Review of the skin grid dated 08/14/22 revealed Resident #149 had an unstageable pressure ulcer to the sacrum. Treatment continued with a foam dressing. There was no description or measurement of the wound to the sacrum. Review of the Braden Observation Tool completed 08/14/22 by LPN #321 revealed Resident #149 was at moderate risk for pressure ulcers. Review of the plan of care for Resident #149 dated 08/15/22 revealed Resident #149 had impaired skin integrity and was at risk for altered skin integrity related to incontinence and impaired mobility. Interventions included to administer treatment as ordered, complete weekly skin checks, evaluate existing wound daily for changes, and monitor meal intake. Review of the physician orders for August 2022 for Resident #149 revealed an order was received on 08/15/22 revealing wound to the sacrum, apply bordered foam dressing to the sacrum every three days and as needed. (No previous order was documented for the wound to the sacrum prior to 08/15/22). In addition an order was received for weekly skin assessments. Review of the Treatment Administration Record (TAR) from 08/13/22 through 08/24/22 for Resident #149 revealed a weekly skin assessment was completed on 08/16/22. The skin assessment scheduled for 08/23/22 had no signature as completed on 08/23/22. The treatment ordered 08/15/22 for the wound to the sacrum (apply bordered foam dressing to the sacrum every three days and as needed) was not initiated until 08/20/22. (admitted with wound 08/13/22). Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #149's cognition was severely impaired. Resident #149 required extensive assistance with bed mobility, transfers, dressing, grooming, eating, personal hygiene and had total dependence for toilet use. Resident #149 had unhealed pressure ulcer on admission that was unstageable. Review of the progress note dated 08/16/22 completed by Licensed Practical Nurse (LPN) #318 revealed Resident #149 had poor intake. Review of the Health Professional Progress note dated 08/16/22 at 3:13 P.M. completed by Certified Nurse Practitioner (CNP) #306 revealed Resident #149 presented with right knee pain, overall, no acute distress, right knee tender, the plan included use of [MEDICATION(S)] as needed. (No documentation of Resident #149 wound was noted in the assessment). Review of the Social Service progress note dated 08/17/22 completed by Licensed Social Worker (LSW) #305 revealed a care management meeting was held with the interdisciplinary team (IDT) on 08/17/22. Resident #149 was participating in therapy. Resident #149 was not ambulating and dependent for all activities of daily living. Review of the Nutritional assessment dated [DATE] at 11:35 A.M. revealed Resident #149's appetite was poor per nursing staff. Resident #149 was dependent on staff for feeding. There was no intake noted, reported to be less than 25 percent for meals. Intake was inadequate, Resident #149 liked sweets and sweet foods and supplements to trays/between meals would be added. The assessment indicated wound to sacrum. Review of the wound evaluation dated 08/24/22 at 10:21 A.M. completed by CNP #320 for Resident #149 revealed the wound to the sacrum measured 5.31 centimeters (cm) in length by 2.71 cm in width by .20 cm in depth with 4.51 cm black tissue and .70 cm yellow tissue. The wound was present on readmission and worsening. The wound was stage four previously to an unstageable today. Etiology was a pressure ulcer unstageable. Wound to left heel was present on admission. Pressure ulcer suspected deep tissue injury. The wound measured 4.21 cm in length by 1.77 cm in width with 1.68 cm black tissue and .13 cm yellow tissue. Review of the progress note dated 08/24/22 at 6:11 P.M. completed by LPN #313 revealed Resident #149 transferred to the hospital on 08/24/22 at 6:10 P.M. Review of Resident #149's medical records revealed no documentation of Resident #149's wounds to the left heel or description of the wound to the sacrum until 08/24/22 by CNP #320, date of discharge to the hospital. Interview on 09/21/22 at 5:00 P.M. with the Director of Nursing (DON) confirmed there was no description including wound measurements of the pressure ulcer to Resident #149's sacral wound on admission or weekly until date of discharge 08/24/22. The DON also confirmed there was no order obtained on 08/13/22, date of admission for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed there was no documentation of wound care being completed on the TAR or in Resident #149's medical records for the sacral wound until 08/20/22. There was no assessment or treatment obtained for the wound to the left heel until 08/24/22, date of discharge. Review of facility policy titled Skin Care and Wound Management Overview, dated 05/30/19, revealed the facility staff strived to prevent resident/patient skin impairment and to promote the healing of existing wounds. The interdisciplinary team worked with the resident/patient and or family/responsible party to identify and implement interventions to prevent and to treat potential skin integrity issues. The interdisciplinary team evaluated and documented identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition and description of impairment to determine appropriate treatment. Skin care and wound management included application of treatment protocols based on clinical best practice standards for promoting wound healing. The treatment included obtaining a physician order and document the treatment on the TAR. This deficiency substantiates Complaint Number OH 583.

Based on interview, soft file review, record review and policy review, the facility failed to ensure timely notification of changes in condition. This affected one resident (Resident #16) of three residents reviewed for falls. The facility census was 85 residents. Findings include: Review of Resident #16's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 had two family members listed as power of attorney (POA). Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, did not reject care, was totally dependent on two staff for transfers and was totally dependent on one staff for bed mobility. Resident #16 had upper and lower extremity impairment on both sides and utilized a wheelchair. No falls were recorded on the MDS assessment. Review of Resident #16's physicians' orders revealed an order dated 03/28/22 for mechanical lift and two staff assist with transfers. Continued review of Resident #16's medical record revealed no recent fall or injury assessments. Review of Resident #16's progress notes from January 2022 through April 2022 revealed a note dated 03/11/22 indicating Resident #16 was turned and repositioned and his leaking Foley (urinary catheter) was cleaned up. No nurses' notes were immediately available regarding an incident on 03/15/22. The next available progress note was a late entry note dated for 03/23/22 and written by Certified Nurse Practitioner (CNP) #458 on 03/25/22 that indicated Resident #16 was seen due to an alleged fall several days ago (actual time frame was eight days later) with head injury from the mechanical lift. No visual injuries to head noted. Resident #16 noted a minimal headache that was controlled with Tylenol (pain-relieving medication). Neurological checks were within normal limits. Review of a progress note dated 03/23/22 and written by the Director of Nursing (DON) revealed Resident #16 and his sister approached her to verbalize concerns of an alleged incident with his shower a week ago Tuesday (03/15/22). Nurse practitioner assessed and no injuries noted. Investigation initiated. Review of a progress note dated 03/24/22 and written by the DON revealed upon completion of investigation it had been determined Resident #16 did not fall from the mechanical lift on 03/15/22. Review of Resident #16's care plans revealed a plan of care for falls dated 05/06/21 for potential for falls related to impaired mobility related to [CONDITION(S)], bowel incontinence, cardiac history and [CONDITION(S)]. Listed interventions included initiate neuro (neurological) checks if fall was unwitnessed or if the head was involved. A care plan for [CONDITION(S)] and activities of daily living (ADLs) dated 05/06/21 revealed Resident #16 was dependent on nursing staff for all ADLs. Resident #16 was supervised in his motorized chair once he was transferred from the mechanical lift into the chair. Listed interventions included Resident #16 required the use of the mechanical lift with two-person support. Review of a soft file for Resident #16 alleged an incident on 03/15/22 that was reported on 03/23/22. The progress notes from the DON dated 03/23/22 and 03/24/22 and the assessment from CNP #458 were included in the file. A skin assessment dated [DATE] revealed no skin impairment or changes. Staff education was provided with the file regarding use of the mechanical lift. Staff statements were included in the file including a statement from Licensed Practical Nurse (LPN) #437 dated 03/23/22 that denied knowledge of any incidents with Resident #16 and denied anyone reporting such to her. An undated statement by State tested Nursing Assistant (STNA) #484 revealed she was getting Resident #16 up with another coworker (not identified). STNA #484 started to pull Resident #16 back into the chair and the mechanical lift started to tip and part of the mechanical lift hit Resident #16 in the head. STNA #484 told the nurse (not identified) what happened and she looked him over. Resident #16 stated he was fine but his head hurt a little where the mechanical lift had hit his head but there were no other injuries and the pain subsided after an hour. The incident happened on 03/15/22. Interview on 04/15/22 at 9:21 A.M. with Resident #16 revealed recently in the past two months the mechanical lift tipped over during a transfer and hit him in the head. Resident #16 denied any injuries from the incident and verified while two staff were present at the time of the incident, no one had assessed him after the incident occurred. No injuries were observed to Resident #16's face or head during the interview. Interview on 04/15/22 at 12:48 P.M. with the Regional Director of Operations (RDO) who was serving as the facility's administrator during the survey revealed there had been an incident with Resident #16 and the mechanical lift in March 2022. STNA #484 had been transferring Resident #16 into a chair using the mechanical lift and another STNA (not identified during the interview) had been present. For an undetermined reason, the mechanical lift began to tip and the top bar of the lift hit Resident #16 in the head. The RDO denied Resident #16 falling as a result of the incident. The RDO confirmed the incident was not reported to nursing staff so physician notifications and proper assessment of Resident #16 did not occur until after Resident #16 and his sister brought the concern up to the DON over a week later. Interview on 04/15/22 starting at 12:49 P.M. with STNA #484 verified she had been present for the incident regarding Resident #16 and the mechanical lift on 03/15/22. STNA #484 stated STNA #460 had also been present at the time of the transfer. STNA #484 stated the mechanical lift had been appropriately opened and angled towards Resident #16's motorized chair and Resident #16 was in the sling pad. As soon as STNA #484 began to pull the mechanical lift back the lift started to tip and the top part of the mechanical lift that had the hook attachments hit Resident #16 in the head. STNA #484 stated she told Licensed Practical Nurse (LPN) #437 about the incident. A follow-up interview on 04/15/22 at 3:29 P.M. with the RDO verified STNA #484 did not report the incident with Resident #16 to the nurse although her written statement and her verbal interview had indicated that she did so. The RDO verified this caused the facility to not assess or notify the physician or family of changes with Resident #16 in a timely manner. A phone interview on 04/15/22 at 3:41 P.M. with LPN #437 verified her written statement. LPN #437 reiterated no concerns or incidents regarding Resident #16 or the mechanical lift had been reported to her and thus no post-incident assessments or notifications had been completed. LPN #437 stated she found out about the incident on 03/15/22 during the facility's investigation of the incident the following week. LPN #437 indicated STNAs were supposed to report any changes in condition and incidents to the nurse for further follow-up. Phone interview was attempted with STNA #460 on 04/15/22 at 3:48 P.M. but was unsuccessful. During an interview on 04/15/22 at 4:00 P.M. with the RDO, the DON and Regional Clinical Nurse (RCN) #461 shared STNA #484 had received disciplinary action as a result of the failure to report the incident regarding Resident #16 in a timely manner. Phone interview on 04/15/22 at 4:06 P.M. with CNP #458 verified he had assessed Resident #16 on 03/23/22 and found no head injuries or negative findings during the assessment. CNP #458 confirmed there had been a delay between the incident and his assessment and denied being notified of the incident at the actual time it occurred. Review of a policy, Notification for Changes in Condition, revised 11/30/18 revealed the nurse aide would identify basic changes and promptly notify the nurse. Nurses will be skilled at identifying changes in condition for a resident and report changes to the unit manager. The unit manager will provide additional assessments to address any concerns and report unresolved issues to the DON. The DON/designee will intervene as a clinical expert and provide skilled nursing knowledge for direction/notification. Physician notification would be documented in the medical record. The attending practitioner must be immediately notified of significant changes in condition and the medical record must reflect the notification, response and interventions implemented to address the residents' condition.

Based on medical record review, interviews with staff, Police Officer (PO) #1 and Restaurant Employee (RE) #2, review of the facility incident investigation documentation, the self-reported incident (SRI) related to the incident, elopement policy and police " Call for Service " report, the facility failed to provide adequate supervision for Resident #1, who was identified at risk for elopement, when the resident was found approximately three quarters mile from the facility across a major five lane city highway at a local restaurant. In addition the facility failed to ensure Resident #78 had an assistive device in place as ordered to alert staff when the resident exited the building. This resulted in Immediate Jeopardy for two (Resident #1 and #78) of 13 residents who were identified by the facility to be at risk for elopement. The facility census was 126. On 11/06/14 at 4:15 P.M., the Executive Director (ED), Director of Nursing (DON) and Regional Registered Nurse (RN) #3 were notified that Immediate Jeopardy began on 10/25/14 at 7:16 P.M. when Resident #1 was found at a local restaurant wearing a t-shirt, shorts and tennis shoes without staff knowledge that he had left the building unsupervised. Restaurant employee #2, during an interview on 11/06/14 stated the resident was alone when he arrived to the restaurant, confused, unable to tell her his name and unable to state where he had come from. Local police were called and on 10/25/14 at 8:06 P.M. the resident was transported from the restaurant to a local hospital for care. The Immediate Jeopardy continued on 11/04/14 when Resident #78 who was determined to be at elopement risk did not have the assistive device in place that was ordered to alert staff when the resident attempted to exit the building. The Immediate Jeopardy was removed on 11/07/14 when the facility implemented the following corrective measures: ? On 10/25/14 following the incident, Environmental Services Director (ESD) #19 indicated he verbally discussed the facility ' s current Elopement Procedure policy, dated 05/20/14 with 12 nursing staff, including the DON, six State-tested Nurse Aides (STNAs), four LPNs and one RN who were on-site in the facility at that time. ? On 10/27/14 the DON indicated the interdisciplinary team, including the ED, Assistant Director of Nursing (RN #39), the wound nurse (RN #38), Social Service Employee #9, Dietitian #40, Activities Director #41, RN #42 (the restorative nurse) and the Physical Therapy Assistant Rehabilitation Manager (PTA #43) met and discussed residents at risk for elopement. The DON indicated no new residents were identified to be at risk for elopement at that time. ? On 10/30/14 the Administrator began providing all staff training related to elopements, checking Wanderguard devices, and signing the treatment administration records. On 10/30/14, sixty-nine of 124 employees attended the training. On 11/06/14 the Administrator completed training for 50 additional employees. As of 11/07/14 the facility provided evidence that 119 of 124 employees had received training with a plan in place to ensure the five additional employees were trained prior to working. ? On 11/04/14 Receptionist #44 provided a list of twelve current residents at risk for elopement, this included Residents #8, #35, #39, #41, #56, #65, #74, #75, #78, #90, #110 and #122. Record review revealed each of these residents had a current elopement risk assessment. On 11/04/14 beginning at 1:46 P.M., observation of all 12 residents revealed Resident #78 did not have a Wanderguard device in place as ordered. ESD #19 confirmed the resident did not have a Wanderguard device in place. LPN #12 also verified the Wanderguard device was not in place and indicated she would obtain a one for the resident. ? On 11/05/14, ESD #19 provided training to Central Supply Coordinator (CSC) #27, an unlicensed employee, which reflected one of his daily job responsibilities was to check the proper functioning of the Wanderguard system and also the application of Wanderguard devices to residents at risk for elopement. The education included record keeping of such activity. ? On 11/06/14 beginning at 2:50 P.M. observation of all 12 residents revealed each resident had a Wanderguard device in place as ordered. ? On 11/04/14, 11/05/14, 11/06/14 and 11/07/14 interview with the DON, LPN #13, LPN #28, LPN #5, LPN #8, RN #17, STNA #18, STNA #45, STNA #46, STNA #30, STNA #33, ESD #19 and CSC #27 revealed all staff interviewed were knowledgeable of the facility elopement policy and use of Wanderguard system in the facility. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was implementing an on-going system for monitoring the corrective measures and all employees had not been trained. Findings include: 1. Review of Resident #1 ' s closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the facility ' s unsecured second floor unit for rehabilitation. A Wandering Risk Assessment, dated 10/06/14, completed by RN #6 revealed the resident was disoriented (times two spheres), forgetful and had a short attention span, did not understand his surroundings, was ambulatory with one staff assist and was prescribed anti-psychotic medications. The assessment form provided only the above noted data but did not evaluate the resident ' s wandering/elopement risk or identify specific interventions to be implemented. An admission nursing summary progress note, dated 10/06/14 at 7:25 P.M., completed by RN #6 revealed the resident arrived to the unit via wheelchair, was alert to self only, confused and disoriented. The resident stated he was at a hotel and was waiting for his grandson. The resident was assisted to bed and a bed alarm was applied to alert staff of unassisted transfers. A behavior progress note, dated 10/07/14 at 5:01 A.M., completed by RN #7 revealed Resident #1 frequently transferred himself, turned off his alarm once and took the alarm wires out of the alarm box five times. On 10/07/14 at 1:30 P.M., a physician telephone order was written by LPN #8 for a Wanderguard device to be applied at all times. The order indicated to check placement and function every shift. On 10/07/14 at 3:54 P.M., a nursing progress note completed by LPN #8 revealed the resident was up ad lib (as desired) and continued to have confusion with delusional behaviors. On 10/07/14 at 9:30 P.M., a plan of care note, completed by the Care Transition Manager (CTM) #10 revealed the resident was in the hallway looking everywhere (cupboards, up and down hallways) for his mother and unable to answer questions appropriately. The note indicated the resident ' s sister was contacted and discussed the immediate plan to place a Wanderguard device and monitor closely as well as evaluate baseline laboratory values. The resident ' s sister agreed with the plan stating, " do whatever you feel will keep him safe because if he gets anxious he would be at risk and try to leave " . CTM #10 indicated she discussed possible alternative placement for the resident if the resident ' s safety needs could not be met at the facility compared to one that had a locked unit. The resident ' s sister indicated she understood and was in agreement; expressing safety of the resident was " first priority " . On 10/08/14 a plan of care was initiated related to the resident ' s risk for elopement due to confusion and that the resident " hides from staff " . The goal developed was for the Resident #1 to remain safely within the facility unless accompanied by a staff or family member. Interventions included to apply a Wanderguard device; check function every shift and change battery monthly, assess for hunger, thirst, ambulation or toileting needs when found attempting to exit, assess for need for secure unit, provide diversionary activities, notify physician and family of behavior changes and complete elopement risk assessment quarterly and as needed. Continued review of nursing progress notes, dated 10/09/14 through 10/21/14 revealed multiple behavioral entries and entries related to the resident ' s impaired cognition, confusion and wandering behaviors. On 10/25/14 at 1:51 A.M., RN #16 documented the resident was forgetful and confused, needed frequent one to one but was easily redirected. The note indicated Resident #1 had alarms to his bed and wheelchair which he removed at times and a Wanderguard device was in place. The next nursing progress note, dated 10/26/14 at 1:27 A.M. and documented by LPN #5 revealed the nurse went into the resident ' s room at approximately 8:30 P.M. to administer the resident ' s medications. Resident #1 was not in his room. The note indicated the room was searched and then the LPN " called DR wander " , notifying all staff the resident was unable to be located. The note indicated the RN #17 contacted (no time noted) the DON and police. The note indicated the police found the resident (no time noted) and transported him to the hospital (no time noted). The note also indicated the resident ' s sister was contacted and notified (no time noted). Review of a self-reported incident (SRI) submitted to the State agency regarding the incident revealed the incident was reported to the State agency on 10/26/14 at 2:52 P.M. as an initial report of injury of unknown source. A description of the incident revealed on 10/25/14 at approximately 8:30 P.M., Resident #1 was discovered missing from the facility. Police were notified and police advised facility the resident was found at a local restaurant and transferred to the emergency room . The report indicated the resident did not have leave of absence (LOA) approval. A summary of the incident revealed the resident left at approximately 6:45 P.M. to go to dinner with friends at a local restaurant and did not notify staff he was leaving. The report also indicated the resident called 911 from the restaurant stating he was confused. Review of the facility investigation revealed statements were obtained from staff which included the following staff members: LPN #5, the nurse assigned to care for the resident on 10/25/14 from 7:00 P.M. to 7:00 A.M.; RN #17, the nursing supervisor on duty on 10/25/14 from 7:00 P.M. to 7:00 A.M., STNA #26 and STNA #18 who were assigned to provide care to Resident #1 on 10/25/14. The statement, dated 10/25/14 from STNA #26, whose assignment indicated she was assigned to care for Resident #1 on this date beginning at 12:00 P.M. revealed at 8:45 P.M. a page went overhead and " we " looked everywhere on the first floor in rooms, under beds, in bathrooms and in the lobby. Then " we " were told he was located. There was no documentation related to when the STNA had interacted or last seen Resident #1 on 10/25/14 included with the statement or as part of the investigation. The statement, dated 10/25/14 (no time noted) from STNA #18 revealed she had given Resident #1 his dinner tray and proceeded to continue to pass trays. Handwritten above the words " his dinner " , was an entry written in different handwriting " 5:30-5:45 " . The statement indicated she saw the resident again, walking with his tray while she was still passing hall trays and he refused to go and sit back down. The statement indicated the resident told STNA #18 that he was going to see " Jeff " . STNA #18 stated she asked who Jeff was and the resident did not reply. Resident #1 continued to carry his tray with him onto the west hall (the resident resided on the south hall) and STNA #18 continued passing trays and answering lights. The statement from LPN #5 revealed the LPN came to the 2 South hall to get report at 7:00 P.M. and did not see Resident #1 at all. LPN #5 ' s statement indicated she was told by LPN #8 in report that the resident went to bed. LPN #5 indicated she entered the resident ' s room to administer his medication at 8:30 P.M. and he was not in his room. The statement obtained from RN #17 reflected her involvement in the incident from the time LPN #5 alerted her that the resident was missing including at 8:40 P.M. when the " Dr. Wander " alert was called via the facility overhead paging system. There was no evidence RN #17 had any physical contact with Resident #1 on 10/25/14. RN #17 ' s statement indicated the local police told her they had picked Resident #1 up at a local restaurant (no time noted) and took him to the hospital (no time noted). The resident had reported to police he had been involved in an auto accident (which he had not been) per the statement. RN #17 ' s statement included information that the resident was very confused and did not have a Wanderguard device or wallet on him. RN #17 ' s statement indicated she was told the resident was last seen at " dinner time " and the police department stated the resident called them at 7:15 P.M. A statement from STNA #20 revealed she saw the resident around 4:00 P.M. sitting on the south unit by the television in his wheelchair. Statements from two staff, STNA #21 and STNA #22 revealed they had observed the resident at 4:30 P.M. and 4:45 P.M. but did not include where they saw him or what he was doing. None of the staff statements obtained reflected what the resident was wearing and/or the status of the Wanderguard device he was to wear. Additionally, no statement was obtained from LPN #8, the LPN assigned to care for the resident on 10/25/14 from 7:00 A.M. to 7:00 P.M. (day shift). The facility investigation also failed to include statements or information from the local police or from the restaurant staff where the resident was found. The facility investigation included a statement, dated 10/25/14 from Environmental Service Director (ESD) #19 who stated he was called on 10/25/14 at 9:00 P.M. to come to the facility to check all the exit doors and alarm equipped doors including Wanderguard alarms and magnetic lock alarms to ensure they were all properly working. ESD #19 ' s statement indicated all doors were properly functioning when checked by him after 9:00 P.M. on 10/25/14 after he arrived to the facility. A document entitled Emergency Prep Drill: Conduct an Elopement Drill, completed by ESD #19 revealed the DON was completing further investigation and gathering nursing staff statements on the elopement. ESD #19 documented the incident on 10/25/14 with a start time of 8:30 P.M. and end time of 9:45 P.M. and reflected external weather conditions included temperature of upper 40 degrees Fahrenheit and rain. Review of a police " Call for Service " report, obtained by the surveyor from the local police department revealed a call came in on 10/25/14 at 7:16 P.M. from a local restaurant. The report indicated first responders from the local fire department were dispatched on 10/25/14 at 7:20 P.M., arrived to the restaurant at 7:26 P.M., left the restaurant with the resident at 8:06 P.M. and arrived to the hospital at 8:14 P.M. The report also reflected police were dispatched to the restaurant on 10/25/14 at 7:50 P.M. and arrived at 7:56 P.M. The narrative note accompanying the dispatch times revealed there was a male at the restaurant indicating he was unable to drive home, stating he was involved in an accident earlier in the day in a neighboring city. The note indicated the male indicated he was in too much pain to drive home. The male advised medics he put his car in a ditch somewhere earlier of the same road as the restaurant. The officer witnessed male walking on same road earlier. No reports of vehicles in ditches on road. The male was confused. The officer checked the road and no vehicles were in ditches. At 9:25 P.M. the dispatch report stated the nursing facility called and noted " this male went missing from their facility earlier this evening " . The facility was advised to contact the hospital per the dispatch report. On 11/06/14 at 10:20 A.M., interview with the DON verified the investigation provided by the facility regarding Resident #1 ' s elopement included a timeline she determined and also included staff statements. The DON verified the investigation did not include a conclusion of how or why the incident occurred or the circumstances surrounding the incident. The DON also indicated she entered the 5:30-5:45 time on STNA #18 ' s written statement based on the information she had obtained from the STNA. The DON indicated following the incident on 10/25/14, the five total licensed and unlicensed nursing staff on duty at that time were re-educated by her regarding the facility ' s elopement policy. An all staff in-service was not initiated until 10/30/14 (five days after the incident occurred with Resident #1). On 11/06/14 at 10:08 A.M. telephone interview with LPN #8 revealed she was assigned to care for Resident #1 on 10/25/14 during the day shift and she was on duty until 7:00 P.M. The LPN indicated the resident was pleasantly confused, which was per his normal. The LPN indicated she thought she saw the resident in the television room on 10/25/14 at approximately 6:00 P.M. The LPN indicated it had been a busy day and there were only three or four STNAs on duty on this date. The LPN stated during the interview, she was unsure if the resident had a Wanderguard device in place on this date and if he did, she could not recall where it was. LPN #8 stated LPN #5 told her the resident had taken his Wanderguard device off his leg and it was on his wheelchair. LPN #8 stated she did not know why it would be on the wheelchair as the resident was mobile, but again could not state what she saw but because the facility was short staffed, she did not have time to check to see where the Wanderguard device was prior to her leaving for the day. On 11/06/14 at 10:43 A.M., interview with STNA #18 revealed she had provided care to Resident #1 throughout his stay in the facility and was aware of his care needs and behaviors. The STNA stated on 10/25/14 he seemed more anxious and described the resident as " antsy " . She stated it was a busy evening and there were only four STNA ' s working on the unit, she indicated she was assigned to care for a lot of residents and felt the facility was short staffed. The STNA stated she had taken the resident his dinner in the lounge area on the south unit and indicated the resident was sitting in a wheelchair at that time. When asked if the resident had a Wanderguard device on his body, she indicated she didn ' t remember seeing one on his body but thought it was on his wheelchair. The STNA denied hearing any Wanderguard alarms sound during or after dinner. The STNA was unable to state exactly what time she last saw the resident on 10/25/14 as she indicated she was busy with the dinner meal and other residents. She was aware the resident seemed more " antsy " on this date and was wandering during and after the dinner meal. STNA #18 indicated later in the evening, maybe around 7:30 P.M. (unable to recall exact time), LPN #5 realized Resident #1 was missing and both she and LPN #5 searched the unit with no success in finding him. STNA #18 stated she did not see Resident #1 again before she left at the end of her shift which was around 11:00 P.M. On 11/06/14 at 1:40 P.M. interview with Restaurant Employee (RE) #2 revealed she was the manager on duty on 10/25/14 at a little after 7:00 P.M. when a male, who was very confused entered, wearing a t-shirt, shorts and tennis shoes. RE #2 indicated the male was by himself and made no indication he was there to eat or to meet anyone. RE #2 indicated the male, was unable to provide his name but was insistent that she call the police and tell them he had been in a car accident. RE #2 indicated there were no obvious signs of trauma or injury to the male that would support he had been in a car accident. RE #2 stated the male wanted her to call the police from another town and not the town they were currently in. RE #2 indicated she quickly determined the male was confused and not making sense. He did not have any type of identification on him and RE #2 indicated she did not observe him wearing any type of identification band or band that might look like an alarm. RE #2 stated she dialed the non-emergency police number from the restaurant phone for the male, handed him the phone and he proceeded to tell the caller he needed the police to come as he had been in a car accident. RE #2 stated responders from the local fire department arrived shortly after the call was placed and were onsite with the male for almost 45 minutes trying to determine who he was and where he came from. The male was unable to provide any significant information to assist the responders to determine this and the male was ultimately transported willingly to the hospital. RE #2 stated no one had contacted her or requested any information about this male or this incident prior to this date and what was asked by the surveyors. On 11/06/14 at 2:20 P.M. interview with Police Officer (PO) #1 revealed he was working on 10/25/14 when a call came in for assist of a male at a local restaurant who indicated he had " put his car in a ditch " earlier somewhere on the same road as the restaurant. The officer indicated the initial call, which came in at 7:16 P.M. dispatched first responders from the fire department, who arrived to the restaurant at 7:26 P.M. per review of the dispatch call for service report with PO #1. PO #1 revealed when he arrived to the restaurant at approximately 7:55 P.M. he recognized the male as a person he had seen walking on the street earlier in the day. When asked what time he had seen this male, he indicated he had seen the male walking on the sidewalk, close to the restaurant between 3:30 P.M. and 3:50 P.M. He said he recognized him because of the clothes (a t-shirt and shorts) he was wearing. PO #1 indicated the male was cooperative but unable to provide any contact information or next of kin information and therefore was ultimately taken to the hospital. The police officer stated there was no evidence the male had recently been involved in a motor vehicle accident and there was no indication he had a car or access to a car at that time. PO #1 also stated there was no indication the male was a resident of a nursing facility and he did not have any type of identification bands or alarming devices on his person. The police officer also verified the facility called police on 10/25/14 at 9:25 P.M. and alerted police this same male went missing from their facility earlier in the evening. The facility was advised to call the local hospital. On 11/06/14 at 3:24 P.M., telephone interview with LPN #5 revealed on 10/25/14 she arrived for work at 7:00 P.M. and did not see Resident #1. The LPN indicated she got report from LPN #8 who reported Resident #1 had just gone to bed. During the interview, LPN #5 stated she had cared for Resident #1 prior to this incident. When asked about the use of a Wanderguard device, LPN #5 indicated she thought the resident had a device he wore on his ankle. LPN #5 stated on 10/25/14 she went to administer medications to the resident somewhere around 8:00 P.M. (couldn ' t recall exact time) when she couldn ' t find him. LPN #5 verified the contents of the nursing progress note, dated 10/26/14 at 1:27 A.M. as noted above and indicated she did not see Resident #1 at all on 10/25/14. The LPN indicated she did not hear any Wanderguard alarms on this date. When asked again about the status of the Wanderguard device for the resident on 10/25/14, LPN #5 indicated the resident ' s family reported the device was on the resident ' s wheelchair and not being worn on his body. LPN #5 did report she was concerned that there wasn ' t enough staff in the building to adequately provide care and also indicated she didn ' t feel Resident #1 was an appropriate resident for the facility related to his behaviors and need for more constant supervision. On 11/06/14 at 4:00 P.M. interview with the DON, Executive Director (ED) and RN #3 verified Resident #1, who was admitted on [DATE] was at risk for elopement and was to have a Wanderguard device, which was initiated on 10/07/14. There was no evidence in the resident ' s medical record the resident removed his Wanderguard device, or if the device was placed on his wheelchair or on his body. The DON verified the facility failed to complete a comprehensive and thorough investigation including the circumstances surrounding when, why or how the resident was able to leave the facility unattended without staff knowledge. There was no evidence the facility investigated to determine what door the resident might have left from or what the resident was wearing when he left the facility. There was no evidence the facility obtained information from the restaurant staff, police department or fire department, as witnesses to the event with firsthand knowledge as part of their investigation. There was no evidence the investigation looked at whether the resident had a Wanderguard device in place at the time he left the facility and the conflicting information provided to the surveyors from staff as noted above regarding the placement of the Wanderguard device was also discussed during the interview (i.e. whether the Wanderguard device was on the resident ' s wheelchair or on his person). The DON also verified LPN #5 was the staff person who first identified Resident #1 was missing at approximately 8:30 P.M.; however the local police were not called until 9:25 P.M. (almost an hour later). Based on police dispatch information, the resident was at the restaurant, which was 0.74 miles down the road at 7:16 P.M. (an hour before staff noted he was missing). On 11/06/14 at 4:30 P.M. interview with RN #17 revealed she was the nursing supervisor on duty on 10/25/14 during the 7:00 P.M. to 7:00 A.M. and also had a resident assignment on the first floor. RN #17 stated she was notified by LPN #5, Resident #1 who resided on the second floor was missing. RN #17 stated she had never met Resident #1 and did not know what he looked like. RN #17 stated she assisted in looking for the resident and made calls to both the DON and ED on the evening of 10/25/14. RN #17 verified when police were contacted to notify the facility had a missing resident the police identified he was in a local hospital. When asked about the status of the Wanderguard device, RN #17 stated she believed the staff on the second floor (unable to recall specifically who) had told her the device was on the resident ' s wheelchair and therefore did not alarm when the resident walked out the door. Review of the facility Elopement Procedure, dated 05/20/14 revealed residents assessed for wandering risk would have a Wanderguard device applied to the ankle. If the resident was wheelchair bound, the device could be placed on the wheelchair. For a resident identified missing, the following information was included as part of the facility procedure. The search leader pages " Dr. W. Ander, call *_______ " *Identify the resident ' s name and unit that the resident is missing from. If the resident was not located within 15 minutes, the local police were to be called. 2. A review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#78 was independently mobile but cognitively impaired. Review of the Elopement Risk assessment dated [DATE] completed by RN #47 revealed Resident #78 was forgetful and had a short attention span. The resident was independently mobile with the use of a front wheeled walker. She had a [DIAGNOSES REDACTED]. There was no elopement risk score but the interdisciplinary team had determined Resident #78 was an elopement risk and should have a Wanderguard device in place. Review of the physician's orders [REDACTED].#78's left ankle. On 11/04/14 at 1:46 P.M. an observation was made of the Wanderguard device placement. Resident #78 was sitting in the front lobby of the building on the first floor. A Wanderguard device was not found on either Resident #78's body or on her front wheeled walker. This was confirmed by ESD #19 and CSC #27. The ESD #19 and CSC #27, in the presence of the surveyor searched Resident #78's room but did not locate the Wanderguard device. Interview with LPN #12 on 11/04/14 at 1:55 P.M. verified there was an order for [REDACTED]. LPN #12 reported she would obtain a Wanderguard device and place it on the resident's left ankle. This deficiency substantiates Self-Reported Incident Control Number OH 868.