Every finding on record at Grafton Oaks Nursing Center

Based on interview, record review, and facility policy review, the facility failed to develop a baseline care plan for Resident #91. This affected one (Resident #91) of 14 sampled residents reviewed for baseline care plans.Findings include:Medical record review revealed Resident #91 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, and respiratory disorders. Review of Resident #91's medical record revealed no evidence of a baseline care plan. During an interview on 01/28/26 at 1:06 P.M., Licensed Practical Nurse (LPN) #6 stated a baseline care plan should be completed upon admission. LPBN #6 stated she was unable to locate a baseline care plan for Resident #91 and confirmed the resident did not have a baseline care plan. During an interview on 01/28/26 at 1:12 P.M., Registered Nurse (RN) #3 confirmed Resident #91 did not have a baseline care plan, despite being admitted on [DATE]. During an interview on 01/28/26 at 1:34 P.M., the Minimum Data Set (MDS) Nurse #600 stated the admitting nurse was responsible for completing a resident's baseline care plan during the resident's admission. MDS Nurse #600 stated the baseline care plan was needed to guide staff and ensure proper care. Per the MDS Nurse, Resident #91's baseline care plan was overdue.During an interview on 01/28/26 at 4:37 P.M., the Assistant Director of Nursing (ADON) #650 stated she was the admitting nurse for Resident #91 and confirmed she did not implement the required baseline care plan for Resident #91, adding that it was an omission. During an interview on 01/29/26 at 4:31 P.M., the Director of Nursing (DON) stated the facility had 48 hours to complete a baseline care plan after a resident's admission. The DON stated the admitting nurse was responsible for the completion of a resident's baseline care plan. The DON stated she was not able to tell why Resident #91's baseline care plan was not completed. The Administrator stated the baseline care plan was the plan developed prior to completion of the comprehensive care plan to ensure staff knew the care and services each resident required. The Administrator stated that although Resident #91 had been in the facility for eight days, the facility failed to complete the resident's baseline care plan timely and that was an error.A facility policy titled Baseline Care Plan revised 01/10/25 revealed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The baseline care plan will be developed within 48 hours of a resident's admission.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan addressed non-invasive mechanical ventilator use for two (Resident #69 and Resident #93) of three sampled residents reviewed for respiratory care. Findings include:1. Medical record review revealed Resident #69 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea. The Order Summary Report with active orders as of 01/30/26, revealed an order dated 10/21/25, for auto bilevel positive airway pressure (BiPAP) (a non-invasive mechanical ventilator) every night at bedtime and as needed throughout the day during sleep. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #69 had moderately impaired cognitive skills for daily decision-making. The MDS indicated the resident used a non-invasive mechanical ventilator during the last 14 days of the assessment period. Resident #69's comprehensive Care Plan Report with an admission date of 07/18/25 revealed the care plan did not address the resident's use of a BiPAP machine. During observations on 01/27/26 at 9:55 A.M. and 01/29/26 at 3:55 P.M., Resident #69 had a BiPAP machine in their room. During an interview on 01/30/26 at 10:33 A.M., MDS Nurse #500 stated she was responsible for a resident's nursing care plans. MDS Nurse #500 reviewed Resident #69's comprehensive care plan report and confirmed the resident did not have a care plan for the use of the BiPAP machine. The MDS Nurse stated Resident #69 should have a care plan and it was important so that staff knew the resident had a BiPAP. During an interview on 01/30/26 at 1:34 P.M., the Director of Nursing stated she expected the BiPAP to be addressed on a resident's comprehensive care plan. During an interview on 01/30/26 at 2:39 P.M., the Administrator stated each department completed their own section of the comprehensive care plan, then the MDS Nurse would ensure the care plan was completed. The Administrator stated she expected the BiPAP machine to be addressed on the comprehensive care plan for Resident #69. 2. Medical record review revealed Resident #93 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure and obstructive sleep apnea. The Order Summary Report revealed an order dated 08/21/25, for Resident #93 was to wear the Bilevel Positive Airway Pressure (BiPAP) (a noninvasive mechanical ventilator) at night at bedtime for sleep apnea. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident used a non-invasive mechanical ventilator during the last 14 days of the assessment period. Review of Resident #93's comprehensive Care Plan Report with an admission date of 08/20/25 revealed the care plan did not address the resident's use of a BiPAP machine. During an interview on 01/30/26 at 1:26 P.M., the MDS Nurse #500 acknowledged Resident #93's care plan did not have any interventions related to the resident's use of the BiPaP machine. A facility policy titled Comprehensive Care Plans, revised 01/10/25, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. This deficiency represents non-compliance investigated under Complaint Number 2627520.

Based on observation, staff interview, record review, and facility policy review, the facility failed to specify the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department for Resident #40. This affected one (Resident #40) of two sampled residents reviewed for fluid restriction. Findings include:Medical record review revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included supraventricular tachycardia, systolic congestive heart failure, cardiomyopathy, and hypertension. The Care Plan Report included special instructions for a 2,000 milliliter (ml) fluid restriction. The Care Plan Report did not include a breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department. Resident #40's Order Summary Report with active orders as of 01/29/26, revealed an order dated 12/26/24 for a 2,000 ml fluid restriction diet. The Order Summary Report did not include a breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department. Resident #40's medication administration record (MAR) for 11/2025, 12/2025, and 01/2026, revealed no evidence to indicate staff monitored the fluids offered and/or consumed by the resident. During an observation on 01/29/26 at 8:15 A.M., Resident #40's breakfast tray contained 120 ml of orange juice, 240 ml of milk, and a 28-ounce plastic water pitcher that contained fluids. During a concurrent observation and interview on 01/29/26 at 8:35 A.M., Licensed Practical Nurse (LPN) #11 noted Resident #40 had a plastic water pitcher on their overbed table that contained approximately 240 ml of water. LPN #11 stated that Resident #40 consumed 120 ml of water with their morning medication administration on 01/29/26. LPN #11 stated she was not aware the resident had a physician's order for a fluid restriction. LPN #11 confirmed the resident's MAR for 01/2026 did not record the amount of fluids nursing staff could provide, and there was no place to document the amount of fluids consumed. During an interview on 01/29/26 at 8:52 A.M., LPN Case Manager #13 stated when a resident received an order for fluid restriction, the physician wrote the order and sometimes included the amount nursing and dietary could provide, but when the order did not include those instructions, the Registered Dietitian (RD) would calculate that. During an interview on 01/29/26 at 10:31 A.M., Dietetic Technician (DT) #505 stated if a resident had a physician's order for fluid restriction, she was responsible to calculate the amount of fluids nursing and dietary departments could provide to the resident and place the calculation in the computer for each department to be aware of. DT #505 stated this would also populate on the resident's MAR so that the nurse could record the amount of fluid received per shift. DT #505 reviewed Resident #40's medical record and stated that she saw the physician's order for fluid restriction in the computer and saw that she recorded the resident was on a fluid restriction in 11/2025 but confirmed she did not break down the order for the fluids provided for each department so this did not show up on the MAR for nursing to record the amount of fluids received each shift. DT #505 stated she did not have an explanation for this. During an interview on 01/30/26 at 2:57 P.M., Registered Dietitian (RD) #610 stated the DT was responsible to divide fluids between the nursing and dietary department for residents with a physician's order for fluid restriction. RD #610 stated that if a resident had an order for fluid restriction, the DT would divide the fluids between nursing and dietary, talk to the resident to find out preferences on how the fluid would be divided, answer any questions of the resident, and relay to nursing and dietary how the fluids would be divided. During an interview on 01/29/26 at 9:21 A.M., the Director of Nursing (DON) confirmed the MAR for Resident #40 did not have a task in place for the nurse to record the amount of fluids consumed, and the physician's order did not break down the amount of fluids provided per department. A facility policy titled Fluid Restriction revised 01/10/2025 revealed it is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's order. Compliance Guidelines included the nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department, and will be recorded on the medication record or other format as per facility protocol.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a bi-level positive airway pressure (BiPAP) mask was stored properly when not in use for one (Resident #69) of two sampled residents reviewed for respiratory care. Findings include:Medical record review revealed Resident #69 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea.A quarterly Minimum Data Set (MDS assessment dated [DATE], revealed Resident #69 had moderately impaired cognitive skills for daily decision-making. The MDS indicated the resident used a non-invasive mechanical ventilator during the last 14 days of the assessment period. Resident #69's Order Summary Report with active orders as of 01/30/26, revealed an order dated 10/21/25, for auto bilevel positive airway pressure (BiPAP) (a non-invasive mechanical ventilator) every night at bedtime and as needed throughout the day during sleep.During an observation on 01/27/26 at 9:55 A.M., Resident #69's BiPAP mask was attached to the machine, located on the resident's bedside table, and it was uncovered. During an observation on 01/29/26 at 3:55 P.M., Resident #69's BiPAP mask was on the floor at the head of the bed.During a concurrent observation and interview on 01/29/26 at 3:59 P.M., Licensed Practical Nurse (LPN) #7 stated the BiPAP mask should be stored in a plastic bag where there was not a lot of clutter when not in use. LPN #7 observed Resident #69's BiPAP mask on the floor at the head of the resident's bed and verified the BiPAP mask was not where it should be stored.During an interview on 01/30/26 at 1:34 P.M., the Director of Nursing (DON) stated if the BiPAP mask was not on the resident then it should be stored in the bag. The DON stated that once removed, the mask should be wiped down before putting it in the bag to store until next use. The DON stated she expected the BiPAP mask to be stored in a bag when not in use.During an interview on 01/30/26 at 2:39 P.M., the Administrator stated she expected the BiPAP masks to be cleaned and stored in a bag or covered for sanitation purposes.An undated facility policy titled CPAP [continuous positive airway pressure]/BiPAP Therapy, revealed under qquipment storage, it stated to store clean, dry equipment in a labeled, breathable container. Keep away from sinks, toilets, and contaminated surfaces.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure their medication error rate was not greater than five percent (%). There were four errors out of 25 opportunities, which resulted in a medication error rate of 16%. This affected three (Residents #2, #15, and #44) of five residents observed for medication administration.Findings include:1. Medical record review revealed Resident #15 admitted to the facility on [DATE]. Diagnoses included chronic embolism and thrombosis of bilateral lower extremity and stage II chronic kidney disease.Resident #15's Order Summary Report, with active orders as of 01/28/26, revealed an order dated 03/29/24 for aspirin 81 milligrams (mg) oral chewable tablet, give 81 mg by mouth one time a day for deep vein thrombosis prevention; an order dated 09/06/24, that specified, May crush medications or open capsules as needed unless contraindicated; and an order dated 09/15/25, for potassium chloride extended release 10 milliequivalent (mEq) oral tablet, give one tablet by mouth one time a day for chronic kidney disease.During medication administration observation on 01/28/26 at 9:05 A.M., Registered Nurse (RN) #3 administered Resident #15's medications, to include enteric coated aspirin 81 mg and potassium chloride 10 mEq. RN #3 crushed Resident #15's medications prior to administering the medications in chocolate pudding to the resident. During an interview on 01/28/26 at 9:35 AM, RN #3 looked at the potassium card for Resident #15 and stated, It does not say do not crush. RN #3 stated she did not know if enteric coated was the same as chewable.The undated package insert for potassium chloride 10 mEq published by the United States Food and Drug Administration, specified, To take each dose without crushing, chewing or sucking the tablets.The undated package insert for enteric coated aspirin, specified, Do not chew, crush, or cut this medication. 2. Medical record review revealed Resident #44 admitted to the facility on [DATE]. Diagnoses included cerebral infarction and acute ischemic heart disease.Resident #44's Order Summary Report, with active orders as of 01/28/26, revealed an order dated 03/22/24 for aspirin 81 milligrams (mg) oral chewable tablet, give one tablet by mouth one time a day for heart disease, and an order dated 09/06/24, that specified May crush medications or open capsules as needed unless contraindicated.During medication administration observation on 01/28/26 at 9:18 A.M., Registered Nurse (RN) #3 administered Resident #44's medications, to include enteric coated aspirin 81 mg tablet. RN #3 crushed Resident #44's medications prior to administering the medications in chocolate pudding to the resident.During an interview on 01/28/26 at 9:24 A.M., RN #3 verified she crushed all of Resident #44's medications and administered the crushed medications with pudding. RN #3 stated the physician orders indicated may crush or open unless contraindicated. RN #3 acknowledged medications such as potassium could not be crushed but did not know what other medications should not be crushed. The undated package insert for enteric coated aspirin, specified, Do not chew, crush, or cut this medication. 3. Medical record review revealed Resident #2 admitted to the facility on [DATE] and had a diagnosis of constipation.Resident #2's Order Summary Report, with active orders as of 01/29/26, revealed an order dated 01/25/23 for senna 8.6 milligrams (mg) oral tablet, give one table by mouth two times a day for constipation.During medication administration observation on 01/28/26 at 4:11 P.M., Licensed Practical Nurse (LPN) #7 administered Resident #2's medications, to include Senna Plus one tablet to Resident #2. During a concurrent observation and interview on 01/28/26 at 4:41 P.M., LPN #7 obtained the bottle of Senna Plus and confirmed that was the bottle she used to administer the medication to Resident #2. LPN #7 reviewed and confirmed the physician order was for one tablet twice a day of senna oral tablet 8.6 mg. LPN #7 stated the active ingredients in the Senna Plus bottle were docusate sodium and sennosides. LPN #7 stated the medication was not the same as senna 8.6 mg. LPN #7 stated the wrong medication or dose could cause problems and verified she did not follow the physician's orders.During an interview on 01/29/26 at 2:15 P.M., the Director of Nursing (DON) stated there was a difference between senna and Senna Plus. The DON stated her expectation was for the facility medication error rate to be less than 5%.During an interview on 01/30/26 at 2:39 P.M., the Administrator stated the process for medication administration was to follow the physician orders. The Administrator stated she expected the medication error rate to be less than 5%.A facility policy titled Medication Administration revised 01/10/25 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on interview, record review, and facility policy review, the facility failed to ensure Resident #69's physician orders were transcribed to the medication administration record/treatment administration record. This affected one (#69) of 24 residents reviewed for medical record accuracy. Findings include:Medical record review revealed Resident #69 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had a Staff Assessment for Mental Status (SAMS), that indicated the resident had moderately impaired cognitive skills for daily decision-making. The MDS indicated the resident used a non-invasive mechanical ventilator during the last 14 days of the assessment period. Resident #69's Order Summary Report with active orders as of 01/30/26, revealed an order dated 09/18/25 to clean the resident's BiPAP mask daily with warm soapy water and allow to air dry every day shift. Resident #69's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the timeframe 01/01/26 to 01/31/26, revealed no evidence of a transcription of the physician's order to clean the resident's BiPAP mask daily with warm soapy water and allow it to air dry every day shift. During an interview on 01/29/26 at 3:59 P.M., Licensed Practical Nurse (LPN) #7 stated the nurses were responsible for cleaning a resident's BiPAP mask.During a telephone interview on 01/30/26 at 4:31 A.M., LPN #8 stated the cleaning of a resident's BiPAP mask was signed off by the nurse who cleaned the BiPAP mask on the resident's TAR then placed in a bag.During an interview on 01/30/26 at 1:34 P.M., the Director of Nursing stated the physician order should be transcribed on to the resident's MAR or TAR. During an interview on 01/30/26 at 2:39 P.M., the Administrator stated if the nurses obtained physician orders either from the hospital or the physician, they should transcribe the physician order in the system to the resident's MAR. The Administrator stated that when staff received the physician order for the BiPAP and its cleaning, they should have transcribed the order to the resident's MAR or TAR. The Administrator stated the nurses were responsible for the transcription of orders.A facility policy titled Documentation in Medical Record revised 01/10/25 revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessment, observation, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the brakes on a resident's wheelchair was maintained in a safe and functional manner for one (Resident #67) of three sampled residents reviewed for patient care equipment. Findings include:Medical record review revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction affecting right dominant side, abnormalities of the gait and mobility, and polyarthritis. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had intact cognition and utilized a wheelchair. During a concurrent observation and interview on 01/27/26 at 11:26 A.M., Resident #67's left brake handle of their wheelchair dangled from the seating bar. The left wheelchair brake handle was non-functioning as the resident was unable to apply pressure to prevent the wheel from moving. Resident #67 stated their left wheelchair brake had been broken for a few months. Resident #67 stated they grabbed the wheel with their bare hand to stop the wheelchair from moving forward. Resident #67 stated the former Maintenance Director was aware of the broken brake and they were told the facility would order replacement parts. During an interview on 01/30/26 at 8:26 A.M., Certified Nursing Assistant (CNA) #9 confirmed she was informed of Resident #67's broken wheelchair brake handle. CNA #9 stated the brake had been broken since 11/2025 and the former Maintenance Director was aware. CNA #9 stated a work order had been submitted for repairs and she believed the facility was awaiting parts to repair. Review of the facility records revealed no evidence of a work order related to Resident #67's wheelchair brake handle. During an interview on 01/30/26 at 12:41 P.M., Maintenance Director #620 stated he was unaware of Resident #67's broken brake handle until when the Director of Nursing notified him on 01/30/26. According to Maintenance Director #620, Resident #67's broken wheelchair handle was reported to the former Maintenance Director and he did not know why it had not been resolved. The Maintenance Director stated he fixed the resident's wheelchair, it was resolved, and he was sorry the resident had to wait as that never should have happened. During an interview on 01/30/26 at 3:47 P.M., the Administrator stated it was her expectation for all staff to inform maintenance or management of a resident issue. An undated facility policy titled Maintenance request/ Environment revealed the Maintenance and Housekeeping department will try to complete work orders as quickly as possible depending on the day, staffing, parts, and materials available and severity of the request. Hazardous and safety concerns will be considered urgent and when all possible addressed the same day.

Based on medical record review, review of a Self-Reported Incident (SRI), review of facility investigation documents, staff interview, resident interview, police detective interview, and facility policy review, the facility failed to ensure residents were free from sexual abuse. This resulted in Actual Harm on 08/29/25 for Resident #12, a severely cognitively impaired resident, was sexually abused when Resident #10 entered Resident #12's room, lifted the resident's top, and began touching and sucking on her breasts. Staff witnessed the sexual abuse per Resident #10 towards Resident #12 but did not intervene to stop the abuse. This affected one (Resident #12) of six residents reviewed for abuse. The facility census was 75 residents.Findings include: Review of the medical record for Resident #10 revealed an admission date of 04/18/25 with diagnoses including myocardial infarction, peripheral vascular disease, hypertension, type two diabetes, and anxiety disorder. Resident #10 was discharged from the facility on 08/29/25 to a local law enforcement agency. Review of the care plan for Resident #10 dated 04/20/25 revealed the resident was compliant with care, could make his needs known and displayed no negative behaviors. Resident #10 was receiving rehabilitation services with a goal to return to the community. Review of a check of the national sex offender public website on 06/25/25 revealed Resident #10 was not listed as a sex offender. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 07/24/25 revealed the resident was cognitively intact, used a walker for mobility, and required limited assistance with activities of daily living (ADLs). Review of the facility incident report regarding Resident #10 dated 08/29/25 at 4:38 P.M. revealed Resident #10 was in female Resident #12's room touching her breasts. Resident #10 stated he was trying to make friends with Resident #12. He was removed from Resident #12's room and immediately moved to a different unit on another floor with one-on-one supervision. Review of the medical record for Resident #12 revealed an admission date of 05/03/23 with diagnoses including schizophrenia, bipolar disorder, diabetes, anxiety disorder, and dementia. Review of the MDS assessment for Resident #12 dated 08/13/25 revealed the resident was severely cognitively impaired and required staff assistance with ADLs. Review of the care plan for Resident #12 dated 08/13/25 revealed the resident had an ADL self-care performance deficit related to confusion and dementia. Resident #12 required prompts, cues and direction for all tasks and was compliant with care. Review of the facility incident report regarding Resident #12 dated 08/29/25 at 4:38 P.M. revealed Resident #12 was lying in bed, and a staff member witnessed a male, Resident #10, touching Resident #12's breasts. Resident #12 stated that she had not seen a male in her room, and she had been asleep all morning when staff asked why Resident #10 was in her room. Review of the facility SRI dated 08/29/25 administration was notified of an allegation of sexual abuse per Resident #10 towards Resident #12. Housekeepers (HKs) #110 and #115 stated on 08/29/25 they walked into Resident #12's room and observed Resident #10 touching Resident #12's breasts with his hands and also had his mouth on the resident's breasts. Both witnesses stated Resident #12 was lying still in her bed and was not moving, fighting or attempting to move out of the presence of Resident #10. HKs #110 and #115 stated they were not sure if they were witnessing a consensual event or a nonconsensual event so they decided one of them would stay in the room for safety and the other would go and seek immediate assistance. While HK #115 was in the room, Resident #10 stopped the touching and proceeded to adjust Resident #12's clothing and walk away from her bed. Physician #120 examined Resident #12 on 08/29/25 following the incident and found no injuries. Registered Nuse (RN) #105 assessed Resident #12 and noted the resident showed no verbal or non-verbal signs of pain or discomfort. When staff interviewed Resident #12 she did not recall the incident and stated that she had been sleeping in bed all day. The facility notified the local police department of the incident on 08/29/25. Police interviewed Resident #12 who was pleasant and cooperative and lacked any distress during the interview, but she could not provide any meaningful information. Police interviewed Resident #10 who was also cooperative and told police he was trying to start a friendship with Resident #12 when and he thought the sexual contact with her was consensual. Resident #10 was monitored by the staff after the incident until he was removed and taken into custody by the police. Review of an interview statement dated 08/29/25 with Resident #12 conducted by Social Service Designee (SSD) #200 revealed the resident did not remember a man coming into her and she had been sleeping all day. Review of an interview statement dated 08/29/25 with Resident #10 conducted by SSD#200 revealed Resident #10 acknowledged he had touched Resident #12, because he was trying to make friends with her. Review of HK #110's witness statement dated 08/29/25 revealed she was coming down the hall to clean a room when she noticed Resident #10 in Resident #12's room and observed Resident #10 rubbing Resident #12 all over her body. HK #110 went to find an aide or nurse while her co-worker HK #115 stayed by Resident #12's room. Housekeeper #115 witnessed Resident #10 pull Resident #12's shirt up and then Resident #10 began sucking Resident #12's breast. Then Resident #10 pulled Resident #12's shirt down and covered her back up. RN #105 then arrived in the room and questioned Resident #10. Review of HK #115's witness statement dated 08/29/25 revealed Resident #10 was in Resident #12's room rubbing her upper body and proceeded to lift Resident #12's shirt up. He went from the right side of her body and started sucking her breasts on both sides and when he was done he pulled her shirt down, closed her cardigan and folded her hands on the top of it, like nothing ever happened. When Resident #10 was asked what he was doing he said he was asking Resident #12 if she was going to the cookout, but Resident #12 did not respond. Review of RN #105's witness statement dated 08/29/25 revealed she was called to Resident #10's room and found Resident #10 standing next to Resident #12 who was lying in her bed. RN #105 asked Resident #10 what he was doing in Resident #12's room and told him he wasn't supposed to be in her room. Resident #10 told the nurse he was going to ask Resident #12 if she wanted to go to the cookout. Resident #10 then walked out of the room. HK #110 and #115 reported to RN #105 that they saw Resident #10 pulling Resident #12's clothes up and putting his hand on her and sucking on her breasts. Review of the local law enforcement person in custody report dated 09/02/25 revealed Resident #10 was being held in custody at the county jail on a charge of gross sexual imposition related to the incident with Resident #12 in her room on 08/29/25. During an interview on 09/10/25 at 9:53 A.M., Resident #12 responded to simple questions but could not remember what she had for breakfast. During an interview on 09/10/25 at 1:19 P. M., Resident #12 was alert to name only, she could not recall the month, who the president of the United States was or what she had for lunch. Resident #12 did not recall any man being in her room alongside of her bed, lifting her shirt, and touching her breast and or her body. She denied ever talking to a police officer. During an interview on 09/10/25, at 9:57 A.M., Activity Director (AD) #100 stated Resident #12 was confused and needed to be reminded where her room was located. During an interview on 09/10/25 at 11:27 A.M., RN #105 stated she was working the day of the incident. She was passing medications in the opposite hall when two housekeepers called for her. She stopped passing medications and went to Resident #12's room with HK #110 and observed HK #115 was standing outside the door. RN #105 observed Resident #10 standing by the side of Resident #12's bed. Resident #12 was lying in her bed awake, with no expression on her face and not talking. RN #105 asked Resident #10 what he was doing in Resident #12's room and instructed him to leave. Resident #10 used his walker and left. After Resident #10 left the room, RN #105 asked Resident #12 if she was ok and the resident said she was fine. RN #105 did a full body assessment on Resident #12 and there were no areas of concern. During an interview on 09/10/25, at 1:00 P. M., the Administrator stated HK #110 and #115 were no longer employed with the facility because they did not follow the Health Insurance Portability and Accountability Act (HIPAA) privacy rules and discussed the incident between Resident #10 and Resident #12 with other staff and residents. Attempts to reach HK #110 and #115 on 09/10/25 and 09/11/25 via telephone for interview were unsuccessful. During an interview on 09/10/25, at 3:15 P. M., Detective #118 stated he arrived at the facility on 08/29/25 and interviewed Resident #12 and he realized within minutes the resident had severe dementia as she could not recall a male resident had been in her room and touched her. Detective #118 stated he then interviewed Resident #10 who confirmed he did touch Resident #12 with his mouth on her breast, chest and stomach area. Resident #10 reported he was unaware Resident #12 suffered from dementia. Detective #118 confirmed he then read Resident #10 his rights and handcuffed and arrested the resident for gross sexual imposition. Resident #10 left the facility with Detective #118. Review of facility policy titled Resident Rights to Freedom from Abuse. Neglect, and Exploitation undated revealed the facility residents had the right to be free from abuse. The facility would ensure residents were free from sexual aggressive behavior such as inappropriate sexual touching and grabbing. Anytime the facility had reason to suspect a resident might not have the capacity to consent to sexual activity, the facility would take steps to ensure the resident was protected from abuse. This deficiency represents non-compliance investigated under Complaint Number 2610266.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to maintain the confidentiality of resident private health information. This affected one (Resident #82) of three residents reviewed for confidentiality. The facility census was 78 residents. Findings include:Review of the medical record for Resident #82 revealed an admission date of 07/01/25 with diagnoses including acute myeloblastic leukemia, type two diabetes mellitus, atherosclerotic heart disease, and hypertension and a discharge date of 07/14/25. Review of the Minimum Data Set (MDS) assessment for Resident dated 07/07/25 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the discontinued physician orders for Resident #82 revealed an order for Lasix 40 milligrams (mg) one tablet daily for hypertension.Review of the facility investigation dated 07/17/25 revealed Resident #82's medication card for Lasix 40 mg was given to another resident (Resident #81) at discharge. Review of the investigation revealed Resident #81's family notified the facility they received Resident #82's medication in error. Interview on 08/18/25 at 10:13 A.M. with the Administrator and the Director of Nursing (DON) verified staff accidently sent Resident #82's medication card for Lasix home with Resident #81 at discharge. The Administrator stated Resident #81's family contacted the facility to inform staff of the error, but did not return the medication as requested.Review of the facility policy titled Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security undated revealed it was the policy of the facility to protect the confidentiality of resident protected health information.This deficiency represents noncompliance investigated under iQIES Complaint Number 2582200.

Based on record review and staff interview, the facility failed to ensure a resident was provided a Notice of Medicare Non Coverage (NOMNC) or Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNF ABN) to inform the resident of terminated services and potential liability for non-covered services. This affected one (Resident #198) of three residents reviewed for beneficiary notices. The facility census was 57. Findings include: Review of Resident #198's medical record revealed the resident admitted to the facility on [DATE], with diagnoses including vascular dementia, hyperlipidemia, iron deficiency anemia, chronic kidney disease, other specified anxiety disorders, convulsions, weakness, difficulty in walking, muscle weakness, and hypertension. Review of Resident #198's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with eating, bed mobility, transfers, and dressing. Resident #198 required total dependence with toileting and personal hygiene. Review of Resident #198's payer source documentation revealed Resident #198 was on Medicare Part A from 09/30/22 to 10/07/22. Resident #198's payer source was changed to Medicaid on 10/07/22. Review of Resident #198's NOMNC and SNF ABN revealed Resident #198 or Resident #198's representative was not provided a NOMNC or SNF ABN to inform the resident service termination and potential liability for non-covered services on 10/06/22. Interview with the Administrator on 02/14/23 at 12:00 P.M. verified Resident #198's NOMNC and SNF ABN were not provided on 10/06/22 and Resident #198's last covered day of Medicare Part A services was on 10/07/22.

Based on observation, resident interview, and staff interview, the facility failed to assist a female resident with facial hair removal. This affected one (Resident #28) of two residents reviewed for Activities of Daily Living(ADLs) assistance. The facility's census was 57. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), heart disease and depression. Review of the Minimum Data Set (MDS) assessment revealed Resident #28 was cognitively intact. Resident #28 required assistance of one staff member with bathing and maintaining hygiene. Review of Resident #28's progress notes from 01/01/23 to 02/13/23 revealed no documentation Resident #28 was asked if she wanted her facial hair removed, nor was there documentation showing Resident #28 refused facial hair removal. Review of Resident #28's Plan of Care last updated 11/15/22 revealed Resident #28 required one-person assistance for personal hygiene care and bathing. Skin inspections were to be performed with shower days. Review of Resident #28's shower sheets from 1/19/23 to 2/13/23 revealed no indication of Resident #28 being asked to have her facial hair plucked or shaved. Observation on 2/13/23 at 1:01 P.M. revealed Resident #28 had approximately five 1.5 inch (in) white hairs on her chin, in which were easily noticeable. Resident #28 verified she gets a shower two times per week. Observation and interview on 02/14/23 at 2:38 P.M. revealed Resident #28 still had white hairs on her chin present. Resident #28 reported she would prefer staff pluck her facial hair. Registered Nurse (RN) #91 was present during the observation and verified Resident #28 had facial hair present. Observation on 2/15/23 at 10:24 A.M. revealed Resident #28 still had white hairs on her chin present. Interview on 02/15/23 at 12:15 P.M. with the Director of Nursing (DON) verified Resident #28 received two showers per week and during showers, aides were to perform skin inspections.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls. This affected one (Resident #308) of three residents reviewed for fall follow up. The facility's census was 57. Findings include: Medical record review of Resident #308 revealed an admitted [DATE], with diagnoses including chronic obstructive pulmonary disease, bladder disorder, restless leg syndrome, anxiety, hypothyroidism, obesity, chronic embolism in lower extremity, type two diabetes with diabetic neuropathy, neuralgia and neuritis, anemia, cardiomegaly, depression, pain, history of Coronavirus 2019 (COVID-19), schizoaffective disorder, and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #308 was cognitively intact. Resident #308 had delusions and rejected care regularly. Resident #308 required supervision for bed mobility, transfers, toileting, and eating. Resident #308 had a fall in the last two to six months, prior to admission. No therapy services had been provided since admission. Review of the plan of care dated 02/01/23 revealed Resident #308 was at risk for falls related to deconditioning, gait, balance problems, and psychoactive drug use. Interventions included anticipate and meet resident's needs in a timely manner, be sure call light is within reach and encourage/cue/remind to use it for assistance as needed, encourage and invite resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, encourage room change to be closer to nurses station, ensure a safe environment with: even floors, free from spills and/or clutter, adequate, glare-free light, bed in low locked position, personal items within reach, ensure non-skid footwear when ambulating, follow facility fall protocol, monitor oxygen saturation and mental status, notify physician of acute changes, physical therapy evaluate and treat as ordered, send to emergency room as ordered, and urine analysis due to mental status change. Review of Resident #308's active physician orders for the month of February 2023 revealed an order dated 02/15/23 for Norco (pain medication) oral tablet 5-235 milligrams (mg), one tablet by mouth every six hours as needed (PRN) for pain. Further review revealed an order dated 02/16/23 for Haldol (antipsychotic medication) oral tablet, give one eight mg tablet three times a day for schizoaffective disorder. A urinalysis with culture sensitivity was ordered 02/14/23. On 02/13/23 an order was added to monitor Resident #308 for the following: tearfulness, agitation, sleeplessness, and refusal of oxygen and medication every shift. Review of the elopement risk assessment dated [DATE] revealed Resident #308 was not cognitively impaired, ambulated independently, and had no history of elopements. Resident #308 was considered at minimal risk for elopement. Review of the social service progress notes dated 01/31/23 at 3:19 P.M. revealed Resident #308 admitted to the facility from another facility. Resident #308 had a healthcare power of attorney (POA). The resident had episodes of refusing medication and refusing blood sugars to be drawn. Staff continue to encourage and educate the resident on the importance of medication and blood sugar monitoring. There were no plans for the resident to discharge due to health care needs. Review of the facility incident and accident log dated 02/01/23 to 02/14/23 revealed on 02/14/23, Resident #308 was involved in an incident outdoors and sustained injuries. Review of the late progress note dated 02/14/23 at 12:30 A.M. and recreated on 02/15/23 at 7:37 A.M. revealed Resident #308 was in her room resting in bed at midnight. Resident #308 left her room and went down the stairs. The Licensed Practical Nurse (LPN) and the aide went down the stairs looking for Resident #308. The resident was found attempting to leave the building. By the time the LPN got to the resident, she had fallen right in front of the back door. Resident #308 was assessed before bringing her back upstairs to her room. Resident #308 had a few abrasions/scratches that were charted. Resident #308 stated she was waiting on her ride to Tennessee. Resident #308 was more confused than usual. Resident #308 had no complaints of pain at the time. Resident #308 was assessed in her room, cleaned up and put back in bed. The Director of Nursing (DON) was called, along with the physician, and her POA. One-on-one (1:1) care was provided after the incident for the shift and the resident would be monitored. Review of the facility's pre-printed, three-paged Fall Incident Investigation (paper version) dated 02/14/23 at 12:30 A.M. completed by LPN #17, revealed Resident #308 was injured and first aid was provided. Vitals signs were obtained with a blood pressure reading of 146 systolic over 85 diastolic (146/85), temperature was 96.5 Fahrenheit (F), heart rate (p) of 108, and respirations (r) of 20. Additionally, off to the side of the document was a second set of vitals (without time documented) which recorded a blood pressure reading of 142/81, temperature of 96.7 F, p 98 and r 18. Further review revealed the physician was contacted, power of attorney (POA) was notified, and the location of the fall incident was noted to be in a hall on the first floor. Resident #308 was confused, disoriented, and had a change in mental status. LPN #17 documented the resident toileted herself and the last time the resident received care was 12:00 A.M. Further review of the fall investigation revealed a question if the environment was new or changed and the answer was no specially regarding sufficient lighting and accessible handrail. The fall investigation documented items marked as no problem included clothing, bed, noise, chair, and bathroom. Review of the Conclusion Section revealed the resident was in bed resting at midnight. The aide heard the resident go out the stairwell door and the alarm sounded. Staff went after the resident. The resident was found and assessed and brought back to her room. Resident #308 was cleaned up, bandaged, and put back to bed. The last section of the document identified immediate interventions of: Resident #308 was assessed before bringing her back to her room. Resident #308 denied pain at the time. The resident was brought back to her room and any abrasions and scratches were cleaned. After the resident was assessed, the DON, doctor, and POA were notified. The resident had 1:1 care the remainder of shift. The investigation did not contain documentation for wounds measurements, location of wounds, there was no documentation regarding a head-to-toe assessment, what solution was used to clean injured areas and what dressings were applied, blood sugar levels or range of motions evaluation. Additionally, the investigation did not contain documentation for a root cause analysis to determine the possible reason for the fall. Review of the late entry progress note effective 02/14/23 at 8:55 A.M. revealed Resident #308 refused to move rooms and refused a Wanderguard (a device worn in which activates a door alarm to alert staff if the individual wearing the device opened and/or exited a door). Review of the progress note dated 02/14/23 at 9:21 A.M. revealed Resident #308 had bruising and swelling to her lower lip/chin. The resident denied pain or discomfort. A new order was received to send the resident to the emergency room (ER) for evaluation and treatment. The POA was called and a message was left to call the facility for an update on new orders. Resident #308 was transported to the ER. Review of the progress notes dated 02/14/23 at 3:12 P.M. revealed Resident #308 returned from the ER with no new orders. The physician was aware, and a new order for a urinalysis with culture and sensitivity due to altered mental status was received. The resident was moved to a room closer to the nurse's station. Review of the progress note dated 02/15/23 at 10:30 A.M. revealed new orders to increase Resident #308's medication due to increased delusions. Review of the progress note dated 02/15/23 at 11:10 A.M. revealed Resident #308 complained of increased pain. The Medical Director (MD) was notified and a new order was received. Review of the hospital discharge summary dated 02/15/23 revealed Resident #308 was sent to the hospital for evaluation related to a fall. Resident #308 complained of acute shoulder pain, acute hand pain, acute knee pain and neck pain. No fractures were identified and the resident returned to the facility on [DATE]. Review of the progress note dated 02/16/23 at 6:33 A.M. revealed Resident #308 stated she was still sore from the fall, but the pain medication was helping. Review of the elopement assessment dated [DATE] revealed Resident #308 was cognitively impaired and ambulated independently. The resident had no history of elopement at home or leaving prior facility without supervision. Resident #308 had not verbally expressed the desire to go home. Resident #308 has packed belongings or stayed near the exit door. Resident #308 has not wandered aimlessly nor have family or responsible party voiced concerns that would indicate the resident might have wandering tendencies or try to leave the facility. Resident #308 was considered at minimal risk for elopement. Interview on 02/15/23 at 11:17 A.M. Social Worker (SW) #204 stated Resident #308 scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, however SW #204 verified Resident #308 had cognitive issues. SW #204 verified the resident would tell others that she was married to a famous singer and they had a home in another state together. Interview on 02/15/23 at 11:33 A.M. with Activity Director #54 revealed Resident #308 preferred to remain in her room for activities. The resident was asked to participate and would often state she will next time but it was very rare she would leave her room. Resident #308 did not like groups at all. Activity Director #54 stated the resident believed she was married to a famous singer and conversations were nonsensical most of the time. Additionally, Activities Director #54 stated the resident was confused most of the time and staff must navigate the conversation to determine the true intent of the message. Interview on 02/16/22 at 8:31 A.M. with LPN #17 verified a progress note was entered late regarding the incident with Resident #308 on 02/15/23 at 7:37 A.M. because she was not sure what needed to be included in the note. LPN #17 verified she completed a risk management report in the electronic health record and filled out a paper form documenting the details of the fall involving Resident #308 on 02/14/23 at 12:30 A.M. LPN #17 verified she was working the night of the incident with Resident #308. LPN #17 stated the alarm was going off at the end of the hall where Resident #308 resided. LPN #17 stated the door had an alarm and when you push on the door long enough (approximately 15 seconds), the door would open. LPN #17 verified the alarm was not very loud. LPN #17 stated she was helping another resident at the front of the unit and off to the side so she did not see Resident #308 leave her room initially. The aide went one way, and she (LPN #17) went the other way on the stairs, as they did not have sight of Resident #308 and did not know which way she went. LPN #17 stated when she made it to the door, Resident #308 had already made it down the stairs to the first floor and was pushing on the exterior door at the landing setting off the alarm and had fallen. LPN #17 stated when she arrived, she observed the resident on the ground against the door. Resident #308 had abrasions on her knees, hands, and her chin and the exterior door alarm was sounding but she did not get out of the facility. LPN #17 stated she was unsure who actually set the alarm off because she was helping the resident and they were both leaning on the door. The door did pop open because it had the same type of alarm on it as the other door, when you push on it long enough it will open. LPN #17 stated at first, Resident #308 had a small scratch on her chin and there was no swelling. As time passed the swelling to her lower lip and chin worsened. LPN #17 called for another LPN to assist with assessment to make sure nothing was missed. LPN #17 stated the third floor LPN (#57) assisted her after Resident #308 was found on the ground. LPN #17 stated LPN #57 stayed with Resident #308 while she went to get the supplies to clean up Resident #308's abrasions. After LPN #17 and LPN #57 assessed Resident #308 for injuries, LPN #17 called the Nurse Practitioner (NP) on call and was advised to wait until they were able to get to the facility in the morning, and they would evaluate Resident #308 then. LPN #17 stated she monitored the resident with neuro checks and watched the swelling increase, but all her vital signs were normal. The dark discoloration and swelling on Resident #308's face just started worsening over time. LPN #17 stated she did not witness the resident fall and did not realize that she hit her head until the swelling occurred to her face and chin. LPN #17 stated they implemented 1:1 care because Resident #308 had never left her room before that night. LPN #17 stated the resident was waiting for a ride to go to Tennessee and was more confused than usual. Resident #308 denied pain at the time of the incident. Observation on 02/16/23 at 8:54 A.M. with the Director of Nursing (DON) revealed when the 2nd floor door to the stairwell was pushed to activate the alarm, the alarm 'beeped' but was not very loud. The DON verified the alarm only beeps at the door and is hard to hear from the nurse's station. The DON then opened the exterior door at the bottom of the stairwell to the outside and the alarm went off loudly. The DON stated Resident #308 fell at the threshold of the door. The DON stated the nurse from the second floor responded to the exterior door alarm when Resident #308 fell . Interview on 02/16/23 at 2:45 P.M. with NP #202 verified she assessed Resident #308 on 02/14/23 after the fall occurred and stated she did not have any more than usual cognitive loss. Resident #308 was sent to the hospital for evaluation and returned with no acute injuries. NP #202 verified she was not notified at the time of the fall, but the physician was notified. NP #202 stated Resident #308 reported she fell down a hill when asked how the fall occurred. During a phone interview with the Administrator on 02/16/23 from 2:50 P.M. to 3:30 P.M., Resident #308's fall investigation from a fall on 02/14/23 was requested. The Administrator refused to provide the fall investigation for Resident #308's fall which occurred on 02/14/23. However, after further discussion with the Administrator a fall investigation was provided but further review of the document revealed there was no documentation of a root cause analysis. Further review revealed no witness statements were provided to the surveyors for review to clarify medical record documentation and staff interview discrepancies. Review of the facility's incident and accident log indicated Resident #308's fall occurred outdoors. Review of the facility's paper fall investigation revealed the fall occurred in the hall. There were no witness statements and no documentation if the fall was witnessed by a staff member, or unwitnessed. There were no details related to observation of the incident by staff, the residents' statements at the time of the fall, the severity of the injuries, staff interviews related to incident, fall interventions in place at the time of the fall or potential faulty equipment. Additional information regarding the risk management document included in the facility's electronic health record completed at the time of the incident (as reported by LPN #17) was refused by the Administrator. The Administrator reported the investigation provided was all that was needed, and the risk management document was an internal quality assurance document, and she did not have to provide the document. The Administrator verified the fall investigation utilized by the facility did not use the word root cause analysis and was unable or unwilling to provide any additional information that a thorough fall investigation had been completed by the facility to determine the underlying cause of the fall and current plans for prevention. Review of the summary of investigation dated 02/14/23 and signed by the Administrator, DON, and on the signature line for the Medical Director was handwritten via telephone, was presented to the surveyors just prior to exit conference on 02/16/23 at 5:20 P.M., revealed a root cause analysis of Resident #308 stated she was going to Tennessee. Resident #308 stated she owns a home in Tennessee and was married to a famous singer who lives there. A medication review was completed and medication changes were noted in the resident's medication administration record. Resident #308 refused room move and the resident was sent to the ER to rule out injury. The Administrator was unable and/or unwilling to provide a rationale as to why the document was not provided when requested. Interview on 02/17/23 at 11:08 A.M. with Physician #203 stated she was notified of a fall on 02/14/23 involving Resident #308. Physician #203 stated she was told it was a witnessed fall and the fall location was on the side of the building in a stairwell landing in front of an exterior door. The Surveyor advised Physician #203 the facility had provided a document at exit conference in which identified Physician #203 had participated in a meeting about Resident #308 to determine a root cause analysis for the fall on dated 02/14/23. Further Physician #203 was the Surveyors had requested this information during the survey and was told it was a protected document and the facility did not have to provide the risk management investigation related to Resident #308. Physician #203 was advised the facility never collected any witness statements, and the Surveyors were unable to collaborate the events, as the documents provided were not consistent. Physician #203 verified she spoke with the DON regarding Resident #203's fall but was unaware of the document indicating a root cause analysis was completed. Physician #203 verified she did not have a copy of the document, and does not know what the document states. Physician #203 was unaware the facility document had a signature line on it for her signature and was unaware the facility completed and dated the physician participated via phone along with the DON and the Administrator on 02/14/23. Physician #203 verified Resident #308 had not moved to a room closer to the nurse's station due to the fact the resident refused. Physician #302 verified she completed a medication review for Resident #203 on 02/17/23 during her visit to the facility. A request for a policy related to the completion of incident investigations was requested during the survey and not provided for review. Review of the facility policy titled, Resident Falls, undated, revealed under the title of documentation, in the nurses notes, the facility will record a head to toe assessment of the resident, the position observed, and describe any injury.

Based on record review, staff interview, and review of facility policy, the facility failed to provide each resident or resident representatives with education regarding the risks and benefits of influenza immunizations on an annual basis, when influenza vaccines were offered. This affected three (Residents #10, #23 and #27) of five residents reviewed for immunizations. The facility census was 57. Findings include: 1. Medical record review revealed Resident #10 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus with other circulatory complications, atrial fibrillation, gastro esophageal reflux disease without esophagitis, major depressive disorder and hypertensive retinopathy. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #10 required supervision with eating. Review of Resident #10's immunization record revealed on 10/10/22, the resident was administered the influenza vaccine by the Director of Nursing (DON). Review of Resident #10's consent to administer influenza vaccine form dated 09/11/19 revealed Resident #10 wished to receive an annual influenza vaccine. There was no indication Resident #10 received or signed the influenza consent form on 09/11/19. Additionally, there were no other consent forms completed. 2. Medical record review revealed Resident #23 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, bradycardia, retention of urine, insomnia, constipation, major depressive disorder, schizophrenia, and bipolar disorder. Review of Resident #23's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, and eating. Resident #23 also required total dependence with transfers, toileting, and personal hygiene. Review of Resident #23's immunization record revealed on 10/10/22, the resident was administered the influenza vaccine by the DON. Review of Resident #23's consent to administer influenza vaccine form dated 09/19/19 revealed Resident #23 wished to receive an annual influenza vaccine. There was no indication Resident #23 nor the resident's representative received or signed an influenza consent on 09/19/19. Additionally, there were no other consent forms completed. 3. Medical record review revealed Resident #27 admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, unspecified dementia, depression, insomnia, epilepsy, convulsion, cataract, glaucoma in diseases classified elsewhere, unspecified psychosis not due to a substance or known physiological condition, and disorientation. Review of Resident #27's quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, dressing, toileting, transfers, eating and personal hygiene. Review of Resident #27's immunization record revealed on 10/10/22, the resident was administered the influenza vaccine by the DON. Review of Resident #27's consent to administer influenza vaccine form dated 09/19/19 revealed Resident #27 wished to receive an annual influenza vaccine. There was no indication Resident #27 nor the resident's representative received or signed an influenza consent on 09/19/19. Additionally, there were no other consent forms completed. Interview on 02/14/23 at 10:37 A.M. with the DON verified Residents #10, #23, and #27 did not have updated influenza consents since 2019, and Residents #10, #23, and #27 were administered influenza vaccines on 10/10/22. Review of the facility's flu and pneumococcal vaccine policy dated 08/09/19 revealed all residents of the facility will be offered the flu vaccine on admission and annually.

Based on medical record review, review of facility correspondence with a nurse staffing agency, staff, nurse staffing agency staff and Ohio Board of Nursing staff interviews, review of nursing schedules, review of facility policy, and review of facility self-reported incidents (SRI's), the facility failed to ensure a resident was free from misappropriation of medications. This affected one (#41) out of three residents reviewed for misappropriation and had the potential to affect 16 (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents. The census was 47. Findings include: Review of letter sent per email to a nursing staff agency revealed on 11/24/21 a small medicine cup with five narcotic pills were found in the top of a medication cart by an oncoming nurse. The nurse alerted management. An investigation was started tracing back all nurses who had had possession of that cart. All claimed no knowledge. On 11/29/21 items were missing from the supply closets on first floor administrative unit and from the medication room. As a result, the video tapes for dates of 11/23/21 into 11/24/21, and third shift on 11/27/21 were reviewed. In very plain view of the video camera Licensed Practical Nurse (LPN) #100 could be seen removing narcotics from pill packets for individual residents, but not going into those resident rooms to administer those narcotics. On 11/27/21 the same nurse (LPN #100) was witnessed on video camera removing and entire narcotic card from narcotic box, and then removing the corresponding narcotic count sheet and placing all in her purse at the nurse's station. LPN #100 was also witnessed preparing a syringe of liquid [MEDICATION(S)] (narcotic pain medication), placing it on the medication cart, and never entering the room of the resident that receives that medication. LPN #100 later appeared to dispense the syringe into a water cup sitting on the medication cart and drink the contents of the cup. These videos were viewed by the Administrator, the Director of Nursing (DON), and Licensed Social Worker (LSW) #150. This letter was signed by the Administrator. This letter was on the facility letterhead. During an interview on 01/25/22 at 11:00 A.M. the Administrator stated that their had been no resident misappropriation or misappropriation of resident medications reported or suspected in the past several months. Follow-up interview with the Administrator on 01/25/22 at 11:50 AM. revealed a facility staff member (entrance screener) had reported a nurse (LPN #100) had entered a supply closet on the first floor. LPN #100 would keep her purse in the supply room and go out to her car and back to the supply room. The Administrator thought this was odd because supplies were available on third floor where LPN #100 was working. The Administrator reviewed video surveillance and LPN #100 was observed at a medication cart with the narcotic box open and flipping through narcotics for a longer time than she should have been. It was unable to be determined what LPN #100 was actually doing. The Administrator stated she tried to start pulling videos, but had difficulty and contacted information technology (IT) staff and they were working on it. Videos were unable to be watched by surveyor because the facility was using two different systems and IT was working on. Interview with the Director of Nursing (DON) on 01/25/22 at 1:21 P.M. revealed a thorough investigation was not completed when LPN #100 was suspected of misappropriation. The DON stated she had casual conversations with some of the residents. The DON did not interview LPN #100, or any other staff members. The DON stated another staff member (entrance screener) alerted management staff that LPN #100 was entering a supply closet on the first floor and thought it looked strange. The DON looked for obvious discrepancies in medication records. There was no documentation of any completed investigation. LPN #100 was an agency nurse, and was asked not to come back to the facility. Phone interview with an Ohio Board of Nursing Enforcement Agent (OBNEA) #300 on 01/26/22 at 10:08 A.M. revealed she was made aware of suspected misappropriation by LPN #100 by the nursing agency that employed her. OBNEA #300 was not made aware by the facility. OBNEA #300 had contacted the facility and talked with the Administrator and DON, but the have not been very forthcoming with any information. Phone interview with nursing agency Chief Nursing Officer (CNO) #200 on 01/26/22 at 11:20 A.M. revealed she was made aware of the facility's report of suspected misappropriation of narcotic medications by one of their agency nurses (LPN #100) when a nurse recruiter associated with the facility contacted her. CNO #200 stated that the facility said it was the nursing agency's responsibility to report LPN #100 to authorities because she was there staff and not the facility's. Facility correspondence was first received 12/03/21. Phone interview with nursing agency Accounts Coordinator (AC) #250 on 12/03/21 at 1:49 P.M. revealed he was first contact by the facility on 12/03/21. Facility staff reported that LPN #100 was seen on videos stealing medications. Phone interview with the Administrator on 01/26/22 at 2:54 P.M. confirmed that the facility had not submitted a SRI to the state survey agency, had not contacted local law enforcement, and had not reported LPN #100 to the state board of nursing for suspected misappropriation of narcotic medications. The Administrator confirmed a thorough investigation had not been completed on LPN #100's suspected misappropriation of narcotic medications. The Administrator stated LPN #100 would have had access to all resident narcotic medications on the dates she worked at the facility. The Administrator confirmed LPN #100 was observed on video removing a narcotic card containing narcotic medications and a narcotic count sheet. The Administrator confirmed the number of residents affected had not been identified but the misappropriation had the potential to affect 16 (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents that LPN #100 had access to their narcotics. The Administrator identified Resident #41 as the only resident that was ordered a liquid form of narcotic during the timeframe that LPN #100 worked at the facility. The Administrator confirmed Resident #41 was not documented as receiving any liquid narcotic on 11/27/21, the date LPN #100 was observed on video with a liquid narcotic bottle on her cart. The Administrator confirmed the facility's pharmacy services provider was not called to help investigate/reconcile any resident medications. The Administrator confirmed when asked by surveyor about any reported misappropriation or suspected misappropriation the past several months she stated she was not aware of any incidents. Review of Resident #41 medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #41 was assessed as being severely cognitively impaired, being totally dependent with activities of daily living (ADL's), and as receiving Hospice services in a quarterly Minimum Data Set assessment dated [DATE]. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication administration records (MAR's) revealed Resident #41 was not documented as receiving MS solution on 11/27/21 by LPN #100. Review of facility provided information revealed LPN #100 would have had access to 16 other (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents narcotic medications during the timeframe that she worked at the facility. Review of facility nursing schedules revealed LPN #100 worked at the facility on 11/01/21, 11/02/21, 11/03/21, 11/05/21, 11/06/21, 11/07/21, 11/09/21, 11/10/21, 11/11/21, 11/12/21, 11/13/21, 11/14/21, 11/15/21, 11/19/21, 11/22/21, 11/23/21, 11/26/21, 11/27/21, and 11/28/21. Review of SRI's submitted by the facility to the state survey agency revealed the facility had not filed a SRI in 2021. Review of the facility's undated policy titled Abuse, Neglect, and/or Misappropriation of Resident Property revealed the facility will not tolerate verbal, sexual, physical or mental abuse, or involuntary seclusion, neglect, or misappropriation of resident funds or property by anyone. This policy applies to all facility employees and contracted personnel. This deficiency substantiates Complaint Number OH 103.

Based on medical record review, review of facility correspondence with a nurse staffing agency, staff, nurse staffing agency staff and Ohio Board of Nursing staff interviews, review of nursing schedules, review of facility policy, and review of facility self-reported incidents (SRI's), the facility failed to report a suspicion of a crime involving misappropriation of medications to the proper authorities. This affected one (#41) out of three residents reviewed for misappropriation and had the potential to affect 16 (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents. The census was 47. Findings include: Review of letter sent per email to a nursing staff agency revealed on 11/24/21 a small medicine cup with five narcotic pills were found in the top of a medication cart by an oncoming nurse. The nurse alerted management. An investigation was started tracing back all nurses who had had possession of that cart. All claimed no knowledge. On 11/29/21 items were missing from the supply closets on first floor administrative unit and from the medication room. As a result, the video tapes for dates of 11/23/21 into 11/24/21, and third shift on 11/27/21 were reviewed. In very plain view of the video camera Licensed Practical Nurse (LPN) #100 could be seen removing narcotics from pill packets for individual residents, but not going into those resident rooms to administer those narcotics. On 11/27/21 the same nurse (LPN #100) was witnessed on video camera removing and entire narcotic card from narcotic box, and then removing the corresponding narcotic count sheet and placing all in her purse at the nurse's station. LPN #100 was also witnessed preparing a syringe of liquid [MEDICATION(S)] (narcotic pain medication), placing it on the medication cart, and never entering the room of the resident that receives that medication. LPN #100 later appeared to dispense the syringe into a water cup sitting on the medication cart and drink the contents of the cup. These videos were viewed by the Administrator, the Director of Nursing (DON), and Licensed Social Worker (LSW) #150. This letter was signed by the Administrator. This letter was on the facility letterhead. During an interview on 01/25/22 at 11:00 A.M. the Administrator stated that their had been no resident misappropriation or misappropriation of resident medications reported or suspected in the past several months. Follow-up interview with the Administrator on 01/25/22 at 11:50 AM. revealed a facility staff member (entrance screener) had reported a nurse (LPN #100) had entered a supply closet on the first floor. LPN #100 would keep her purse in the supply room and go out to her car and back to the supply room. The Administrator thought this was odd because supplies were available on third floor where LPN #100 was working. The Administrator reviewed video surveillance and LPN #100 was observed at a medication cart with the narcotic box open and flipping through narcotics for a longer time than she should have been. It was unable to be determined what LPN #100 was actually doing. The Administrator stated she tried to start pulling videos, but had difficulty and contacted information technology (IT) staff and they were working on it. Videos were unable to be watched by surveyor because the facility was using two different systems and IT was working on. Interview with the Director of Nursing (DON) on 01/25/22 at 1:21 P.M. revealed a thorough investigation was not completed when LPN #100 was suspected of misappropriation. The DON stated she had casual conversations with some of the residents. The DON did not interview LPN #100, or any other staff members. The DON stated another staff member (entrance screener) alerted management staff that LPN #100 was entering a supply closet on the first floor and thought it looked strange. The DON looked for obvious discrepancies in medication records. There was no documentation of any completed investigation. LPN #100 was an agency nurse, and was asked not to come back to the facility. Phone interview with an Ohio Board of Nursing Enforcement Agent (OBNEA) #300 on 01/26/22 at 10:08 A.M. revealed she was made aware of suspected misappropriation by LPN #100 by the nursing agency that employed her. OBNEA #300 was not made aware by the facility. OBNEA #300 had contacted the facility and talked with the Administrator and DON, but the have not been very forthcoming with any information. Phone interview with nursing agency Chief Nursing Officer (CNO) #200 on 01/26/22 at 11:20 A.M. revealed she was made aware of the facility's report of suspected misappropriation of narcotic medications by one of their agency nurses (LPN #100) when a nurse recruiter associated with the facility contacted her. CNO #200 stated that the facility said it was the nursing agency's responsibility to report LPN #100 to authorities because she was there staff and not the facility's. Facility correspondence was first received 12/03/21. Phone interview with nursing agency Accounts Coordinator (AC) #250 on 12/03/21 at 1:49 P.M. revealed he was first contact by the facility on 12/03/21. Facility staff reported that LPN #100 was seen on videos stealing medications. Phone interview with the Administrator on 01/26/22 at 2:54 P.M. confirmed that the facility had not submitted a SRI to the state survey agency, had not contacted local law enforcement, and had not reported LPN #100 to the state board of nursing for suspected misappropriation of narcotic medications. The Administrator confirmed a thorough investigation had not been completed on LPN #100's suspected misappropriation of narcotic medications. The Administrator stated LPN #100 would have had access to all resident narcotic medications on the dates she worked at the facility. The Administrator confirmed LPN #100 was observed on video removing a narcotic card containing narcotic medications and a narcotic count sheet. The Administrator confirmed the number of residents affected had not been identified but the misappropriation had the potential to affect 16 (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents that LPN #100 had access to their narcotics. The Administrator identified Resident #41 as the only resident that was ordered a liquid form of narcotic during the timeframe that LPN #100 worked at the facility. The Administrator confirmed Resident #41 was not documented as receiving any liquid narcotic on 11/27/21, the date LPN #100 was observed on video with a liquid narcotic bottle on her cart. The Administrator confirmed the facility's pharmacy services provider was not called to help investigate/reconcile any resident medications. The Administrator confirmed when asked by surveyor about any reported misappropriation or suspected misappropriation the past several months she stated she was not aware of any incidents. Review of Resident #41 medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #41 was assessed as being severely cognitively impaired, being totally dependent with activities of daily living (ADL's), and as receiving Hospice services in a quarterly Minimum Data Set assessment dated [DATE]. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication administration records (MAR's) revealed Resident #41 was not documented as receiving MS solution on 11/27/21 by LPN #100. Review of facility provided information revealed LPN #100 would have had access to 16 other (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents narcotic medications during the timeframe that she worked at the facility. Review of facility nursing schedules revealed LPN #100 worked at the facility on 11/01/21, 11/02/21, 11/03/21, 11/05/21, 11/06/21, 11/07/21, 11/09/21, 11/10/21, 11/11/21, 11/12/21, 11/13/21, 11/14/21, 11/15/21, 11/19/21, 11/22/21, 11/23/21, 11/26/21, 11/27/21, and 11/28/21. Review of SRI's submitted by the facility to the state survey agency revealed the facility had not filed a SRI in 2021. Review of the facility's undated policy titled Abuse, Neglect, and/or Misappropriation of Resident Property revealed the facility will not tolerate verbal, sexual, physical or mental abuse, or involuntary seclusion, neglect, or misappropriation of resident funds or property by anyone. This policy applies to all facility employees and contracted personnel. When the accused or suspected person is not a staff member, the facility will [MEDICATION(S)] to protect the resident including, but not limited to, contacting the third party and addressing the issue with him/her, or referring the matter to the proper authorities. Once the Administrator or designee becomes aware of an allegation of abuse, neglect, or misappropriation, the allegation must be immediately reported to the Ohio Department of Health (ODH), and any other officials mandated by Ohio law, including local law enforcement as necessary. Immediately means as soon as possible. It is irrelevant whether the facility investigated thee occurrence and determined that the allegations were unfounded: all alleged violations must be reported immediately. After the facility submits an immediate report of alleged violation, the facility must conduct a thorough investigation. The results of the investigation must be reported to the Administrator, ODH, and other state officials as mandated by by state law within five working days of the incident. However, if the facility learns of an occurrence more than five days after the event occurred, the facility is still required to report the incident. Review of the facility's undated policy titled Crime Reporting Policy revealed if you have reasonable suspicion that a crime has occurred against a resident or a person receiving care at the facility, federal law requires that you report your suspicion directly to both law enforcement and the state survey agency. This deficiency substantiates Complaint Number OH 103.

Based on medical record review, review of facility correspondence with a nurse staffing agency, staff, nurse staffing agency staff and Ohio Board of Nursing staff interviews, review of nursing schedules, review of facility policy, and review of facility self-reported incidents (SRI's), the facility failed to report an allegation of misappropriation of medications to the state survey agency. This affected one (#41) out of three residents reviewed for misappropriation and had the potential to affect 16 (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents. The census was 47. Findings include: Review of letter sent per email to a nursing staff agency revealed on 11/24/21 a small medicine cup with five narcotic pills were found in the top of a medication cart by an oncoming nurse. The nurse alerted management. An investigation was started tracing back all nurses who had had possession of that cart. All claimed no knowledge. On 11/29/21 items were missing from the supply closets on first floor administrative unit and from the medication room. As a result, the video tapes for dates of 11/23/21 into 11/24/21, and third shift on 11/27/21 were reviewed. In very plain view of the video camera Licensed Practical Nurse (LPN) #100 could be seen removing narcotics from pill packets for individual residents, but not going into those resident rooms to administer those narcotics. On 11/27/21 the same nurse (LPN #100) was witnessed on video camera removing and entire narcotic card from narcotic box, and then removing the corresponding narcotic count sheet and placing all in her purse at the nurse's station. LPN #100 was also witnessed preparing a syringe of liquid [MEDICATION(S)] (narcotic pain medication), placing it on the medication cart, and never entering the room of the resident that receives that medication. LPN #100 later appeared to dispense the syringe into a water cup sitting on the medication cart and drink the contents of the cup. These videos were viewed by the Administrator, the Director of Nursing (DON), and Licensed Social Worker (LSW) #150. This letter was signed by the Administrator. This letter was on the facility letterhead. During an interview on 01/25/22 at 11:00 A.M. the Administrator stated that their had been no resident misappropriation or misappropriation of resident medications reported or suspected in the past several months. Follow-up interview with the Administrator on 01/25/22 at 11:50 AM. revealed a facility staff member (entrance screener) had reported a nurse (LPN #100) had entered a supply closet on the first floor. LPN #100 would keep her purse in the supply room and go out to her car and back to the supply room. The Administrator thought this was odd because supplies were available on third floor where LPN #100 was working. The Administrator reviewed video surveillance and LPN #100 was observed at a medication cart with the narcotic box open and flipping through narcotics for a longer time than she should have been. It was unable to be determined what LPN #100 was actually doing. The Administrator stated she tried to start pulling videos, but had difficulty and contacted information technology (IT) staff and they were working on it. Videos were unable to be watched by surveyor because the facility was using two different systems and IT was working on. Interview with the Director of Nursing (DON) on 01/25/22 at 1:21 P.M. revealed a thorough investigation was not completed when LPN #100 was suspected of misappropriation. The DON stated she had casual conversations with some of the residents. The DON did not interview LPN #100, or any other staff members. The DON stated another staff member (entrance screener) alerted management staff that LPN #100 was entering a supply closet on the first floor and thought it looked strange. The DON looked for obvious discrepancies in medication records. There was no documentation of any completed investigation. LPN #100 was an agency nurse, and was asked not to come back to the facility. Phone interview with an Ohio Board of Nursing Enforcement Agent (OBNEA) #300 on 01/26/22 at 10:08 A.M. revealed she was made aware of suspected misappropriation by LPN #100 by the nursing agency that employed her. OBNEA #300 was not made aware by the facility. OBNEA #300 had contacted the facility and talked with the Administrator and DON, but the have not been very forthcoming with any information. Phone interview with nursing agency Chief Nursing Officer (CNO) #200 on 01/26/22 at 11:20 A.M. revealed she was made aware of the facility's report of suspected misappropriation of narcotic medications by one of their agency nurses (LPN #100) when a nurse recruiter associated with the facility contacted her. CNO #200 stated that the facility said it was the nursing agency's responsibility to report LPN #100 to authorities because she was there staff and not the facility's. Facility correspondence was first received 12/03/21. Phone interview with nursing agency Accounts Coordinator (AC) #250 on 12/03/21 at 1:49 P.M. revealed he was first contact by the facility on 12/03/21. Facility staff reported that LPN #100 was seen on videos stealing medications. Phone interview with the Administrator on 01/26/22 at 2:54 P.M. confirmed that the facility had not submitted a SRI to the state survey agency, had not contacted local law enforcement, and had not reported LPN #100 to the state board of nursing for suspected misappropriation of narcotic medications. The Administrator confirmed a thorough investigation had not been completed on LPN #100's suspected misappropriation of narcotic medications. The Administrator stated LPN #100 would have had access to all resident narcotic medications on the dates she worked at the facility. The Administrator confirmed LPN #100 was observed on video removing a narcotic card containing narcotic medications and a narcotic count sheet. The Administrator confirmed the number of residents affected had not been identified but the misappropriation had the potential to affect 16 (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents that LPN #100 had access to their narcotics. The Administrator identified Resident #41 as the only resident that was ordered a liquid form of narcotic during the timeframe that LPN #100 worked at the facility. The Administrator confirmed Resident #41 was not documented as receiving any liquid narcotic on 11/27/21, the date LPN #100 was observed on video with a liquid narcotic bottle on her cart. The Administrator confirmed the facility's pharmacy services provider was not called to help investigate/reconcile any resident medications. The Administrator confirmed when asked by surveyor about any reported misappropriation or suspected misappropriation the past several months she stated she was not aware of any incidents. Review of Resident #41 medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #41 was assessed as being severely cognitively impaired, being totally dependent with activities of daily living (ADL's), and as receiving Hospice services in a quarterly Minimum Data Set assessment dated [DATE]. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication administration records (MAR's) revealed Resident #41 was not documented as receiving MS solution on 11/27/21 by LPN #100. Review of facility provided information revealed LPN #100 would have had access to 16 other (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents narcotic medications during the timeframe that she worked at the facility. Review of facility nursing schedules revealed LPN #100 worked at the facility on 11/01/21, 11/02/21, 11/03/21, 11/05/21, 11/06/21, 11/07/21, 11/09/21, 11/10/21, 11/11/21, 11/12/21, 11/13/21, 11/14/21, 11/15/21, 11/19/21, 11/22/21, 11/23/21, 11/26/21, 11/27/21, and 11/28/21. Review of SRI's submitted by the facility to the state survey agency revealed the facility had not filed a SRI in 2021. Review of the facility's undated policy titled Abuse, Neglect, and/or Misappropriation of Resident Property revealed the facility will not tolerate verbal, sexual, physical or mental abuse, or involuntary seclusion, neglect, or misappropriation of resident funds or property by anyone. This policy applies to all facility employees and contracted personnel. When the accused or suspected person is not a staff member, the facility will [MEDICATION(S)] to protect the resident including, but not limited to, contacting the third party and addressing the issue with him/her, or referring the matter to the proper authorities. Once the Administrator or designee becomes aware of an allegation of abuse, neglect, or misappropriation, the allegation must be immediately reported to the Ohio Department of Health (ODH), and any other officials mandated by Ohio law, including local law enforcement as necessary. Immediately means as soon as possible. It is irrelevant whether the facility investigated thee occurrence and determined that the allegations were unfounded: all alleged violations must be reported immediately. After the facility submits an immediate report of alleged violation, the facility must conduct a thorough investigation. The results of the investigation must be reported to the Administrator, ODH, and other state officials as mandated by by state law within five working days of the incident. However, if the facility learns of an occurrence more than five days after the event occurred, the facility is still required to report the incident. Review of the facility's undated policy titled Crime Reporting Policy revealed if you have reasonable suspicion that a crime has occurred against a resident or a person receiving care at the facility, federal law requires that you report your suspicion directly to both law enforcement and the state survey agency. This deficiency substantiates Complaint Number OH 103.

Based on medical record review, review of facility correspondence with a nurse staffing agency, staff, nurse staffing agency staff and Ohio Board of Nursing staff interviews, review of nursing schedules, review of facility policy, and review of facility self-reported incidents (SRI's), the facility failed to thoroughly investigate an allegation involving misappropriation of medications. This affected one (#41) out of three residents reviewed for misappropriation and had the potential to affect 16 (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents. The census was 47. Findings include: Review of letter sent per email to a nursing staff agency revealed on 11/24/21 a small medicine cup with five narcotic pills were found in the top of a medication cart by an oncoming nurse. The nurse alerted management. An investigation was started tracing back all nurses who had had possession of that cart. All claimed no knowledge. On 11/29/21 items were missing from the supply closets on first floor administrative unit and from the medication room. As a result, the video tapes for dates of 11/23/21 into 11/24/21, and third shift on 11/27/21 were reviewed. In very plain view of the video camera Licensed Practical Nurse (LPN) #100 could be seen removing narcotics from pill packets for individual residents, but not going into those resident rooms to administer those narcotics. On 11/27/21 the same nurse (LPN #100) was witnessed on video camera removing and entire narcotic card from narcotic box, and then removing the corresponding narcotic count sheet and placing all in her purse at the nurse's station. LPN #100 was also witnessed preparing a syringe of liquid [MEDICATION(S)] (narcotic pain medication), placing it on the medication cart, and never entering the room of the resident that receives that medication. LPN #100 later appeared to dispense the syringe into a water cup sitting on the medication cart and drink the contents of the cup. These videos were viewed by the Administrator, the Director of Nursing (DON), and Licensed Social Worker (LSW) #150. This letter was signed by the Administrator. This letter was on the facility letterhead. During an interview on 01/25/22 at 11:00 A.M. the Administrator stated that their had been no resident misappropriation or misappropriation of resident medications reported or suspected in the past several months. Follow-up interview with the Administrator on 01/25/22 at 11:50 AM. revealed a facility staff member (entrance screener) had reported a nurse (LPN #100) had entered a supply closet on the first floor. LPN #100 would keep her purse in the supply room and go out to her car and back to the supply room. The Administrator thought this was odd because supplies were available on third floor where LPN #100 was working. The Administrator reviewed video surveillance and LPN #100 was observed at a medication cart with the narcotic box open and flipping through narcotics for a longer time than she should have been. It was unable to be determined what LPN #100 was actually doing. The Administrator stated she tried to start pulling videos, but had difficulty and contacted information technology (IT) staff and they were working on it. Videos were unable to be watched by surveyor because the facility was using two different systems and IT was working on. Interview with the Director of Nursing (DON) on 01/25/22 at 1:21 P.M. revealed a thorough investigation was not completed when LPN #100 was suspected of misappropriation. The DON stated she had casual conversations with some of the residents. The DON did not interview LPN #100, or any other staff members. The DON stated another staff member (entrance screener) alerted management staff that LPN #100 was entering a supply closet on the first floor and thought it looked strange. The DON looked for obvious discrepancies in medication records. There was no documentation of any completed investigation. LPN #100 was an agency nurse, and was asked not to come back to the facility. Phone interview with an Ohio Board of Nursing Enforcement Agent (OBNEA) #300 on 01/26/22 at 10:08 A.M. revealed she was made aware of suspected misappropriation by LPN #100 by the nursing agency that employed her. OBNEA #300 was not made aware by the facility. OBNEA #300 had contacted the facility and talked with the Administrator and DON, but the have not been very forthcoming with any information. Phone interview with nursing agency Chief Nursing Officer (CNO) #200 on 01/26/22 at 11:20 A.M. revealed she was made aware of the facility's report of suspected misappropriation of narcotic medications by one of their agency nurses (LPN #100) when a nurse recruiter associated with the facility contacted her. CNO #200 stated that the facility said it was the nursing agency's responsibility to report LPN #100 to authorities because she was there staff and not the facility's. Facility correspondence was first received 12/03/21. Phone interview with nursing agency Accounts Coordinator (AC) #250 on 12/03/21 at 1:49 P.M. revealed he was first contact by the facility on 12/03/21. Facility staff reported that LPN #100 was seen on videos stealing medications. Phone interview with the Administrator on 01/26/22 at 2:54 P.M. confirmed that the facility had not submitted a SRI to the state survey agency, had not contacted local law enforcement, and had not reported LPN #100 to the state board of nursing for suspected misappropriation of narcotic medications. The Administrator confirmed a thorough investigation had not been completed on LPN #100's suspected misappropriation of narcotic medications. The Administrator stated LPN #100 would have had access to all resident narcotic medications on the dates she worked at the facility. The Administrator confirmed LPN #100 was observed on video removing a narcotic card containing narcotic medications and a narcotic count sheet. The Administrator confirmed the number of residents affected had not been identified but the misappropriation had the potential to affect 16 (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents that LPN #100 had access to their narcotics. The Administrator identified Resident #41 as the only resident that was ordered a liquid form of narcotic during the timeframe that LPN #100 worked at the facility. The Administrator confirmed Resident #41 was not documented as receiving any liquid narcotic on 11/27/21, the date LPN #100 was observed on video with a liquid narcotic bottle on her cart. The Administrator confirmed the facility's pharmacy services provider was not called to help investigate/reconcile any resident medications. The Administrator confirmed when asked by surveyor about any reported misappropriation or suspected misappropriation the past several months she stated she was not aware of any incidents. Review of Resident #41 medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #41 was assessed as being severely cognitively impaired, being totally dependent with activities of daily living (ADL's), and as receiving Hospice services in a quarterly Minimum Data Set assessment dated [DATE]. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication administration records (MAR's) revealed Resident #41 was not documented as receiving MS solution on 11/27/21 by LPN #100. Review of facility provided information revealed LPN #100 would have had access to 16 other (#3, #4, #7, #10, #11, #18, #28, #31, #33, #35, #41, #42, #44, #43, #45, and #48) residents narcotic medications during the timeframe that she worked at the facility. Review of facility nursing schedules revealed LPN #100 worked at the facility on 11/01/21, 11/02/21, 11/03/21, 11/05/21, 11/06/21, 11/07/21, 11/09/21, 11/10/21, 11/11/21, 11/12/21, 11/13/21, 11/14/21, 11/15/21, 11/19/21, 11/22/21, 11/23/21, 11/26/21, 11/27/21, and 11/28/21. Review of SRI's submitted by the facility to the state survey agency revealed the facility had not filed a SRI in 2021. Review of the facility's undated policy titled Abuse, Neglect, and/or Misappropriation of Resident Property revealed the facility will not tolerate verbal, sexual, physical or mental abuse, or involuntary seclusion, neglect, or misappropriation of resident funds or property by anyone. This policy applies to all facility employees and contracted personnel. When the accused or suspected person is not a staff member, the facility will [MEDICATION(S)] to protect the resident including, but not limited to, contacting the third party and addressing the issue with him/her, or referring the matter to the proper authorities. Once the Administrator or designee becomes aware of an allegation of abuse, neglect, or misappropriation, the allegation must be immediately reported to the Ohio Department of Health (ODH), and any other officials mandated by Ohio law, including local law enforcement as necessary. Immediately means as soon as possible. It is irrelevant whether the facility investigated thee occurrence and determined that the allegations were unfounded: all alleged violations must be reported immediately. After the facility submits an immediate report of alleged violation, the facility must conduct a thorough investigation. The results of the investigation must be reported to the Administrator, ODH, and other state officials as mandated by by state law within five working days of the incident. However, if the facility learns of an occurrence more than five days after the event occurred, the facility is still required to report the incident. Review of the facility's undated policy titled Crime Reporting Policy revealed if you have reasonable suspicion that a crime has occurred against a resident or a person receiving care at the facility, federal law requires that you report your suspicion directly to both law enforcement and the state survey agency. This deficiency substantiates Complaint Number OH 103.

Based on review of the Board of Nursing license look up report and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were completed by a Registered Nurse (RN) who had an active license. This had the potential to affect all 73 residents who reside in the facility. Findings included: Review of the Board of Nursing look up license report for MDS RN #45 revealed her license was inactive and had lapsed. The document revealed the license had an expiration date of 10/31/19. Interview on 12/03/20 at 12:15 P.M., MDS RN #45 revealed she found out about a month or so ago her license had lapsed. She stated she had renewed her licensed, and had her receipts she was unable to retrieve them. She said she was unable to reach anyone at the Board of Nursing even though she had sent emails, and made phone calls. She denied she was working as an RN after the time she was made aware of her inactive license. This deficiency substantiated allegations in Complaint Number OH 1.

Based on medical record review, staff interview, review of the fall investigation, and policy review, the facility failed to follow care planned interventions to prevent a resident from falling out of bed. This affected one Resident (#71) of three reviewed for falls. The facility census was 73. Findings included: Review of the medical record revealed Resident #71 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 12/24/18 revealed Resident #71 has an activities of daily living (ADL) self-care performance deficit related to [MEDICAL CONDITION] and required extensive assistance of one to two staff members for ADL care. The resident also had limited physical mobility related to [MEDICAL CONDITIONS] with left sided [MEDICAL CONDITION] and was dependent on staff. Review of the plan of care updated 11/27/19 revealed Resident #71 was at risk for falls related to deconditioning, incontinence, left sided [MEDICAL CONDITION] and use of [MEDICAL CONDITION] medications. Interventions were to anticipate and meet resident's needs in a timely manner. Be sure the call light was within reach and cue/remind/encourage resident to use it for assistance as needed. Resident required prompt response to all requests for assistance. Place a scoop mattress to bed. Staff were to ensure resident was positioned properly in the middle of the bed and therapy to evaluate for bed positioning and staff training. On 06/13/20 updated interventions revealed the resident was bedfast all or most of the time. He was totally dependent on staff for toileting needs, and total assistance with bathing/showering as necessary. Review of quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #71 had severe cognitive impairment. He was totally dependent for bed mobility and toilet use with two-person physical assistance, and total dependence for eating with one-person physical assistance. The resident was coded to have a Gastrostomy tube ([DEVICE]). Review of the care Kardex undated revealed Resident #71 required one to two staff assistance for positioning every two hours. He was incontinent for bladder and bowel and required total care. He was alert, oriented, and agitated at times. Review of the fall investigation dated 11/11/20 at 6:05 A.M. revealed Resident #71 had a fall in his room while receiving care when he became resistive to staff and grabbed the State tested Nursing Aide (STNA) #7 by the gown and pulled himself out of the bed. Immediate intervention was for neurological tests were initiated and were within normal limits at the time of the incident. The resident was sent to the hospital later in the morning due to abnormal respiration sounds and altered mental status. Review of a witness statement dated 11/11/20 at 10:00 A.M. revealed STNA #7 went into the resident's room to change him and as turning him towards the door he pulled at his [DEVICE] and when she tried to stop him from pulling it out, she lost him and the resident fell to the floor. Review of progress notes dated 11/11/20 at 7:04 A.M. Licensed Practical Nurse (LPN) #12 revealed she was notified Resident #71 fell out of bed while being turned and changed. The resident was assessed and vital signs were taken, neurological assessment was completed and the resident was alert and talking. Family, physician and administrator were notified. Interview on 12/08/20 at 11:26 A.M., STNA #7 revealed she went in the room to complete her last check and change for Resident #71 by herself and had the bed up waist high for her and she was 5 foot 7 inches in height. He had a scoop mattress on the bed. She turned him towards the door and away from her onto his left side. She was behind him and when she turned him he grabbed his [DEVICE] and was pulling it out of his abdomen, but didn't succeed in pulling it all the way out. She stated during this she freaked out and lost him and he fell on to the floor. It looked like he had a scratch on the middle part of his forehead, she denied any blood on the resident. She called for the nurse and an assessment was completed, vital signs, and neurological checks were initiated. She said it was her fault and she should have taken another staff member in with her to change him, but had been doing this for 30 some years and this never happened before. She further stated she was disciplined for the fall by the facility. Review of policy titled Providing Activities of Daily Living Care undated revealed the STNA should review Care Plan & Kardex of each assigned resident prior to providing care. STNA will follow recommended care plan for all ADL care. This deficiency substantiated allegations in Complaint Number OH 938 and Complaint Number OH 341.

Based on medical record review and staff interview, the facility failed to accurately code a quarterly Minimum Data Set (MDS) assessment for Resident #7. This affected one (#7) of twenty resident reviewed for MDS accuracy. The facility census was 78. Findings include: Review of Resident #7's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 05/30/19, revealed section N indicated Resident #7 received an anticoagulant for seven days. Further review of Resident #7's medical record revealed Resident #7 was not prescribed, and did not receive an anticoagulant since admission to the facility. Interview on 09/05/19 at 3:38 P.M. with MDS Registered Nurse (RN) #477 verified Resident #7's quarterly MDS assessment, dated 05/30/19, verified the MDS was inaccurate reflecting the resident was on anticoagulant medication. The RN verified the resident was never on a anticoagulant.

Based on medical record review, observations, interviews with facility staff, residents, the fire department, and coroner's office, review of the Emergency Medical Services (EMS) report, and review of the facility's smoking policy, the facility failed to ensure the residents environment remained as free of accident hazards as is possible when one resident (#95), who utilized oxygen therapy and had an identified history of smoking in bed with oxygen on, was permitted to keep smoking materials, including a cigarette lighter, in the room. This facility practice resulted in Immediate Jeopardy and the potential for serious-injury and life-threatening harm when a fire occurred in the resident's room and the oxygen concentrator, oxygen tubing, and a section of the vinyl floor were observed on fire when staff entered the room. Consequently, the resident sustained [REDACTED]. This affected one (#95) of three residents reviewed for accident hazards. The facility identified eight residents (#10, #40, #42, #53, #56, #69, #86, #92), currently residing in the facility, who smoke and receive oxygen therapy. The facility census was 91. On 06/04/18 at 2:00 P.M., the Administrator was notified Immediate Jeopardy began on 05/29/18 at approximately 12:07 A.M. when Resident #95 was observed on a video surveillance recording coming out of the resident's doorway (room [ROOM NUMBER]) into the hallway and yelling for help. Interview with the Director of Nursing on 05/31/18 at 8:55 A.M. revealed she was working on the floor as a staff nurse the night of the incident and was caring for Resident #95. She stated there was smoke coming from the resident's room and into the hallway and when she looked in the room there were three small fires. She verified the oxygen concentrator was on fire and there were two small fires on the vinyl flooring. She stated she yelled for help, went back into the room and put a blanket on the fire to smother it. The DON stated State tested Nurse Aide (STNA) #40 came into the resident's room and took the roommate (Resident #89) out of room [ROOM NUMBER]. The DON stated she then went to Resident #95 who was seated in a wheelchair in the hallway and was complaining she couldn't breathe. The DON called nine-one-one (911), put oxygen on Resident #95, but was unable to get a pulse oximetry reading. The DON stated the resident was a DNR and once EMS arrived, they took over the resident's care. Further investigation revealed the facility permitted Resident #95 to keep smoking materials while utilizing oxygen. The Immediate Jeopardy was removed on 06/05/18 when the facility implemented the following corrective actions: · On 05/29/18 at approximately 12:09 A.M., Resident #95 was out of her room and in a wheelchair at the nurses' station with staff until EMS arrived. STNA #40 removed Resident #89 (Resident #95's roommate) from the room and the DON checked on both residents for injuries. · On 05/29/18 at 4:00 A.M., the DON, Administrator, STNA #40 and STNA #43 collected smoking materials from all residents. · On 05/29/18 at 7:00 A.M., all resident rooms were assessed for potential fire hazards by the Administrator, the DON, Maintenance Director #86, and Housekeeping Supervisor (HKS) #84. The facility maintenance staff checked all contracted oxygen equipment for any visible signs of concerns such as frayed cords with no concerns noted. · On 05/29/18 from 9:00 A.M. until 10:15 A.M., a representative from the oxygen concentrator company ([NAME]C #2) arrived at the facility and inspected all the oxygen equipment. All equipment was in good working order with no need for repairs or replacement. · On 05/29/18 at 9:00 A.M., Registered Nurse (RN) #45 and Social Worker (SW) #80 completed smoking assessments and updated care plans on all residents who smoke which included, Residents #01, #02, #05, #06, #09, #10, #12, #16, #19, #23, #31, #34, #35, #40, #42, #45, #48, #50, #51, #53, #54, #55, #56, #58, #64, #69, #71, #72, #77, #78, #80, #81, #86, #87, #89, #90, #91, and #92. · On 05/29/18 at 10:00 A.M., Maintenance Director #86 and SW #80 began in-servicing staff present in the facility and telephone in-servicing for staff not present in the facility. The in-service topics included fire drills, oxygen safety, and the new smoking policy and procedure. The education of all staff concluded on 06/05/18 at 2:00 P.M. · On 05/29/18, The facility developed and implemented a new smoking policy/procedure with revisions including; all smoking materials would be kept at the nurses' station and a staff member would distribute and light all cigarettes. Smoking times would no longer be 24 hours a day. It would be hourly throughout the day with no smoking between 10:00 P.M. to 7:00 A.M., 12:00 P.M. to 1:00 P.M., and 5:00 P.M. to 6:00 P.M. · On 05/29/18 at 1:00 P.M., the Quality Assurance (QA) Team meeting was held by the Administrator, DON, SW #77, SW #80, RN #83, Activities Director (AD) #74, Business Office Staff (BOS) #78, HKS #84, Medical Record's staff #72, Human Resource (HR) staff #81 and Medical Director (MD) #93. The Interdisciplinary Team (IDT) met to discuss the event details and the corrective actions. · On 05/29/18 at 2:00 P.M., the Administrator educated all residents who smoke on the new smoking policy/procedures, and offered smoking cessation classes and [MEDICATION NAME]. · On 05/30/18, facility staff began monitoring each designated smoking area and will continue to round in rooms checking for violations of the new policy. Staff will use the monitoring tool to record hourly smoking times. The Administrator, DON, and or designee will audit the monitoring tool weekly which will continue unless the policy changes. · On 05/30/18 at 11:00 A.M., a letter was mailed to family members and next of kin regarding changes in the smoking policy/procedure. 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 in the process of implementing their corrective action plan, including their new policy, and were monitoring to ensure on-going compliance. Findings include: Review of Resident #95's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #95's progress notes dated 08/04/16 revealed the resident was found lying in bed smoking a cigarette while oxygen was on. The cigarette was put out with water, and two packs of cigarettes and a lighter were removed from the resident's room and placed at the nurse's station. The dangers of smoking in rooms with oxygen were explained and the resident voiced her understanding. Review of the Smoking assessment dated [DATE] revealed the resident had cognitive loss, a visual deficit and dexterity problems. The frequency of smoking per day was noted as 10 plus and the time of day was checked marked for Morning, Afternoon, Evenings, and Nights. Under the safety section, the resident was identified as able to light own cigarette and the need for adaptive equipment was marked as Supervision. The assessment indicated the facility needed to store the lighter and cigarettes and the residents' plan of care is used to assure the resident is safe while smoking. Review of Resident #95's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #95's (MONTH) (YEAR) physician's orders [REDACTED]. Staff could titrate the oxygen to keep her oxygen saturation above 92%. Review of Resident #95's smoking assessment dated [DATE] indicated Resident #95 could light her own cigarettes and the facility did not need to store the resident's lighter and cigarettes. Review of Resident #95's care plan dated 05/25/18 revealed Resident #95 had a potential for injury due to a smoking habit. Interventions included to allow her to smoke in designated areas, monitor for compliance with the smoking policy/schedule, monitor need for smoking apron, and to complete a smoking assessment quarterly and as needed. Review of the EMS report dated 05/29/18 at 12:09 A.M. revealed Resident #95 was found sitting in the hallway in a wheelchair with agonal breathing (gasping for air) with [MEDICAL CONDITION] the feet. The report indicated fire department personnel was on the third floor with light haze of smoke present in the hallway, Resident #95 was found in a hallway wheelchair with agonal breathing at approximately four times per minute with no pulse. EMS noted [MEDICAL CONDITION] both feet, started with the application of a non-rebreather oxygen mask and placed the resident on a cardiac monitor which showed sinus [MEDICAL CONDITION] at 30 beats per minute and slowing. EMS was given a Do Not Resuscitate (DNR) order by facility staff and additional care was stopped. Resident #95 was monitored by EMS staff until breathing stopped and the heart monitor showed asystole at 12:29 A.M. EMS confirmed Resident #95 was pulseless and the time of death was called at 12:29 A.M. The Coroner was notified at the time and was noted to be responding to the scene. Review of Resident #95's progress notes, late entry dated 05/30/18 at 11:47 A.M. for 05/28/18 at approximately 11:45 P.M., revealed the resident asked for help and was shouting fire. The resident sat in a wheelchair in the hallway. The DON responded and entered the residents room where the concentrator was on fire. The DON yelled for help and tried to extinguish the fire. STNA #40 arrived and got the roommate out of bed and into her wheelchair. The DON then took the roommate out of the room and into the hallway while STNA #40 extinguished the fire with a water pitcher. Interview with the DON on 05/31/18 at 8:55 A.M. revealed she was working on the floor the night of the incident as a staff nurse and was caring for Resident #95. She stated Resident #95 came out her room, sat down in a wheelchair and was asking for help. The DON stated there was smoke, she looked in the room and noted three small fires. The DON verified the oxygen concentrator was on fire and there were two small fires on the floor. She stated she yelled for help, went back into the room and put a blanket on the fire to smother it. She stated STNA #40 came in and took the roommate out of the room. The DON stated she went to Resident #95 who was complaining she couldn't breathe, called 911, put oxygen on her and was unable to get a pulse oximetry reading. The DON stated the resident was a DNR and once EMS arrived, they took over the resident's care. Observation on 05/31/18 at 9:00 A.M., during tour of the facility, noted the appearance of the oxygen concentrator machine #1935 located in the Administrator's office. The oxygen concentrator was noted with burn and char marks at the oxygen hose connector and at the bottom side of the machine. Attached oxygen tubing was noted burned and melted on a charred bed blanket. Additionally, a three-foot section of the vinyl floor was observed in the office with black soot marks. During an interview with the Administrator at the time of the observation she stated the section of the floor was replaced and the damaged sections were stored with the damaged oxygen concentrator. The electrical appliance cord and plug were observed intact with no visible signs of damage. An inspection tag was noted on the machine for electrical safety on 06/2017 by Maintenance Director #86. During an interview on 05/31/18 at 9:05 A.M. with Resident #89, who was the roommate of Resident #95, she stated she was asleep and didn't know what occurred. She stated she was waking up to an orange flash of light and the fire alarm was going off. She was awakened by a staff member and was evacuated out of the room. A telephone interview on 05/31/18 at 10:53 A.M. with the local Fire Department Chief (FDC) #91 revealed crews responded to a fire alarm at the facility. He stated Resident #95 had a couple of burn marks on her thumb. He stated there [MEDICAL CONDITION] the floor and a burned lighter was found on the floor next to the resident's bed. Interview on 05/31/18 at 1:05 P.M. with the DON verified the fire department found a burned lighter in Resident #95's room. The DON also verified Resident #95 was on oxygen therapy at two liters per minute via nasal cannula. Telephone interview on 06/01/18 at 11:33 A.M. with STNA #40 revealed he was in another resident's room and heard someone yelling. He saw smoke in the hallway and went to Resident #95's room. He stated when he went into the room, Resident #95's oxygen concentrator was on fire and the DON was trying to put the fire out with a blanket. STNA #40 verified he threw a couple little cups of water on the fire flames and unplugged the concentrator. He stated he then took the roommate out of the room. STNA #40 stated the facility had taken Resident #95's cigarettes and lighters away over a year ago because they felt like she would smoke in her room. STNA #40 stated she had a fire in her room on the 2nd floor a year or two ago but did not know the details. Telephone interview on 06/01/18 at 12:49 P.M. with LPN #9 stated Resident #95 should never have had a lighter or cigarettes because she had caught something on fire before. Interview and review of policies with the DON on 06/01/18 at 3:15 P.M. verified they did not follow their fire drill policy during the fire by not removing the roommate first and by not using a fire extinguisher. On 06/04/18 at 2:15 P.M., interview with a representative from the oxygen concentrator company ([NAME]C #1) revealed the concentrator was an Invacare Platinum five-liter oxygen concentrator and was checked weekly and monthly. Maintenance logs were submitted for review from (MONTH) (YEAR) to (MONTH) (YEAR) with no deficiencies noted. Further interview with [NAME]C #1 noted the company does inspect the machines weekly and filters are checked and replaced as needed per the manufacturer's instructions and recommendations. A copy of the manufacturer's manual was also obtained. A room to room assessment was completed on 05/29/18 at 9:00 A.M. to ensure all machines were in working order by a technician from the oxygen supply company. Interview on 06/05/18 at 9:58 A.M. with RN #83 verified Resident #95 had been caught smoking in her bed with oxygen according to the progress note dated 08/04/16. Interview with SW #80 on 06/05/18 at 5:54 P.M. verified the facility had knowledge of Resident #95 keeping smoking materials including cigarettes and lighters inside her room in the dresser drawer. A photo was obtained from SW #80 which showed one cigarette was inside Resident #95's dresser drawer. Telephone interview on 06/06/18 at 9:00 A.M. with the local County Coroner Investigator (CCI) #92 verified the resident [MEDICAL CONDITION] both feet and the top of her left toes. CCI #92 also verified Resident #95 had soot deposits on her thumb. Review of the facility's undated smoking policy that was in effect at the time of the fire revealed residents had the right to smoke independently whenever possible in order to maintain independence and choice. The policy documented residents would be assessed quarterly for safety. Interventions for unsafe smoking may include the staff maintaining some or all smoking materials. The policy also documented residents were permitted to smoke in the facilities designated areas and/or outside. This deficiency substantiates Complaint Number #OH 258