Every finding on record at Hampshire Center

Based on record review and staff interviews, the facility failed to provide care and services in accordance with professional standards of practice by crushing extended-release medications. This failed practice was found true for (1) one of (3) residents reviewed for weight loss during the complaint survey process. Resident identifier #45. Facility Census: 59. Findings Include:a) Resident #45A record review, completed on 05/05/26 at 10:30 AM, revealed a physician order for Resident #45, dated 09/24/19, that read as follows: Generic substitution is authorized unless otherwise indicated. Center may participate in therapeutic interchange program, where permitted by state regulations. May crush crushable meds.Further record review found that Resident #45 was ordered:-Tolterodine Tart Extended Release 4 milligram (MG) tablet one time a day on 05/10/25 to present-Potassium CL extended release 10 milliequivalent (MEQ) tablet from 07/27/22 to 03/31/26-Potassium CL extended release 20 MEQ tablet from 04/01/26 to presentDuring an interview on 05/05/26 at 1:10PM, Registered Nurse (RN) #29 stated, We crush all of her medications. A review of the blister pack for the Tolterodine Tart Extended release was completed with RN #29. The blister pack read, Do not chew or crush. The blister pack for the Potassium Extended release, read, Do not crush. Further record review of pharmacy recommendations for Resident #45, from 10/2025 to present, found the pharmacist did not mention the crushed medications as an irregularity. However, the Food and Drug Administration (FDA) web site warns about crushing the extended-release medications and put out the following information about the specific medications in question:-Crushing extended-release (ER) potassium chloride tablets is dangerous and warned against by the FDA and manufacturers, as it destroys the sustained-release mechanism. This causes an immediate release of the entire dose, leading to severe gastrointestinal irritation, bleeding, ulceration, and potential life-threatening hyperkalemia (high potassium)-Tolterodine tartrate extended-release (ER) capsules/tablets must never be crushed, chewed, or opened. FDA-approved labeling warns that tampering with these formulations destroys their sustained-release properties, causing a rapid release of the entire dose, which increases the risk of serious side effects and reduces drug effectiveness.Key Concerns with Crushing These Medications: Potassium Extended-Release: Crushing allows all the potassium to be released at once, rather than over time. This can cause severe gastrointestinal distress, stomach pain, vomiting, and potential stomach ulcers. Tolterodine Extended-Release: Crushing or chewing these tablets can cause too much medication to be absorbed at once, increasing the risk of side effects like dry mouth, constipation, and stomach pain. Indirect Weight Loss Factors: The gastrointestinal irritation from both medications (especially a damaged digestive tract from high-dose potassium) can lead to vomiting, diarrhea, or a reduced appetite.During an interview on 05/05/26 at 1:10PM, RN #29 confirmed what the blister packs read and further stated, We have always crushed them [resident's extended-release medications]. She would not even be able to swallow the potassium whole.

Based on record review and staff interview, the facility failed to maintain complete and accurate medical records in accordance with standards of practice. This was a random opportunity for discovery during a complaint survey process, with the ability to affect more than a limted amount of residents. Resident Identifier: Resident #45. Census 59.Findings Included: a) Resident #45 During the routine complaint investigation process, performed on 05/04/26, it was discovered that the physician orders, care plan, and Kardex for Resident #45 did not contain the same information. They (orders, care plan and Kardex) were updated as the status of the resident changed, however, they simply added the new information to what was already there and did not remove outdated information. The care areas that were not matching were the sections pertaining to transfers, eating and hygiene. Orders in chart:12/17/25 - Non weight bearing (NWB) post fall R ankle for one day12/26/25 - R ankle ORIF (Open Reduction and Internal Fixation) surgery12/30/25 - NWB Right lower extremity (RLE) at all times01/15/26 - CAM (Controlled Ankle Motion) boot RLE at all times02/11/26 - Weight bearing as tolerated (WBAT) post ORIF R ankle ** No mention of sling in orders or total lift / Hoyer use ** These orders were changed and updated as the needs of the resident changed and were maintained per MD and in agreement with the resident and IDT teams discussions. Care plans:Current active - Transfer - CAM boot as needed and GAIT belt for transfers. Page 1Weight - WBAT RLE Page 1Weight - NWB RLE Page 31 The current care plan still is showing non weight bearing to right leg as well as weight bearing as tolerated on right leg. Depending on what page and section was reviewed, it had contradictory information. Care plan dated 03/09/26:Transfer - CAM boot as needed (prn) and full lift w/ purple sling. Page 1 - 1/5/26Weight - WBAT RLE Page 2Transfer - NWB RLE, call for staff help Page 16Weight - NWB RLE Page 31 This was the care plan in place during Resident #45's post surgical fix of the right leg. Depending on what page or section was reviewed, it had contradictions in how the resident was able to move and transfer. Kardex - for 05/04/26:Ambulation/transfers - (no mention of CAM boot or if the resident is weight bearing or non weight bearing)Other devices - CAM boot as need with transfers per orthopedicDressing / bathing - GAIT belt for transfers The Kardex is where the staff goes to sign off on tasks as well as see what a resident's ADL (activities of daily living) needs and transfer status is currently. There is a transfer section and it was left blank and did not match what information was in the orders or care plan. These three documents show staff how to care for a resident and how to provide that care in certain ways to maintain the safety and healing potential of residents. They should be updated and old information removed. In an interview with the Administrator, on 05/05/26 at approximately 2:00 PM, they confirmed that those records should all pretty much match and not have information that was no longer relevant. We have some clerical house keeping to do.

Based observation and staff interview, this facility failed to ensure food was procured, stored, served in a sanitary way, this failed practice was a random opportunity for discovery during the Long Term Care survey process. Facility census: 61. Findings include: a) 2/07/2025 11:45AM observation upon entering the kitchen revealed a mop bucket, chemicals on floor next to bread rack, mops and brooms out leaning near the wall next to manager office- [NAME] #71,confirmed these items are out and need to be behind the janitor closet. Wet nesting to pans on shelf and x2 pans not inverted. [NAME] #71, confirmed the wet nesting and pans needed to be inverted. Spices were spilled on a shelf. [NAME] #71, confirmed. Hand sink trash can with brown liquid spilled on top of a lid. [NAME] #71 confirmed this needed cleaned. Food debris noted on bottom shelves of 2 of 3 tables. A sticky substance was also observed. [NAME] #71 confirmed this needed corrected. 12/07/2025 12:30 PM during dining room observation the following was observed:Cook # 71 was handling items with gloves during tray line then picked up dinner roll with gloved hand not utensil. [NAME] #71 did not wash her hand or utilize a utensil. When questioned [NAME] #71 confirmed she did not change gloves or use utensils to obtain the dinner roll. 12/07/25 12:15 PM an observation in the nourishment room revealed no temperature logs noted in the room, peanut butter container outdated as of 12/06/25. [NAME] #71 confirmed and removed, Floor, sink area with food debris noted, some paper cups- butter cups, jelly cups on floor near trash can and refrigerator. [NAME] #71 confirmed these findings. [NAME] #71 informed this surveyor I think housekeeping cleans here daily On 12/07/25 at 1:30 PM observation revealed a refrigerator that had a container of boiled eggs with open date of 12/02/25 with no use by date. [NAME] #17 confirmed and removed the item. Observation also revealed food debris on the wall behind the trash can and food debris on the trash can lid. Cook#17 confirmed and said, This should have been done yesterday. [NAME] #17 said, I guess something came up and they didn't get to it

Based on observation, resident interview, and staff interview, this facility failed to ensure a safe, comfortable homelike environment. This failed process was a random opportunity of discovery during Long Term Care Survey Process. Facility census: 61. Findings include a) Resident #43 12/08/25 at 8:45AM observation of Resident #43 sitting in her wheelchair with a blanket wrapped around her, visibly shaking. Throughout interview with Resident #43, she informed this surveyor, I am so cold they just gave me a shower and it was so cold, I like to go early so its warm. 12/08/25 at 8:50A M interview with maintenance director and observing shower room temperature through maintenance director checking shower water temperature which read 94 degrees and room temperature reading 69.8 degrees. Maintenance director informed this surveyor, recovery for the water is usually 20 to 30 minutes, they need to wait in between showers. Maintenance director informed this surveyor, I have the parts ordered just waiting, I do have the tanks separated to try and keep the water warmer to the shower room. The maintenance director turned the heat up in the shower room to aide with warming the entire room. 12/08/25 at 8:55AM during an interview with Nurse Aide (NA) #44 was waiting to give a resident a shower. She informed the surveyor One resident said it was really cold this morning, sometimes I let them know what the temperature is, if they want me to continue with the shower, if not, we do bed bath. 12/08/25 at 8:55AM observation while in shower room, Nurse Aide (NA) #28 was in a stall with a resident when she turned the water on and began shower the resident informed her, Oh that's cold, NA #28 asked this resident if she wanted to stop, however the resident informed the nursing assistant no let's get it over with. 12/08/25 at 9:05AM interview with director of nursing, she informed this surveyor We offer alert residents to check the temperature of the showers before giving. We space the showers out to ensure recovery time. We also have two spa aides that work 6 AM to 2 PM, we will start offering later in the day as well until the parts come in to be corrected. b) Resident #32, Resident #29 During interviews on 12/07/25 at approximatley 12:25 PM with Resident #32 and at approximatley 1:15 PM with Resident #29, both had stated they have received multiple cold showers and or bed baths over the last week or two. Resident #32 stated I have had to take two showers now in cold water. The water heater has been broken for weeks I think and the water is cold even after waiting a long time. While Resident #29 stated Water has been cold and since I get bed baths (residents choice) it makes it hard on me. On 12/08/25 at approximately 9:57 AM Maintenance Director temped the two rooms water, with hot side fully open and the highest recorded temp was 98 degrees Fahrenheit. During an interview with Maintenance Director on 12/08/25 at approximately 10:10 AM they stated Water heater has parts on order and the facility will cycle through showers to ensure water temp stays hot enough for the comfort of residents. Parts are on back order and delayed so we will make some adjustments to let the water tank recover better. c) Dirty Floor and Trash bags in activity area During entrance to the facility on [DATE] at approximately 11:40 AM it was observed that the Activities area at the end of the 400 hallway floor was visibly dirty with old food items and paper garbage. There were also around twenty-two (22) white garbage bags stacked in the right hand corner of the room from the floor all the way onto the table near the wall. While interviewing the Senior Administrator on 12/08/25 at approximately 11:11 AM the Senior Administrator stated they were aware of the white trash bags in the activity room. Senior Administrator said, They are Christmas donations that are on floor and back desk areas. The Senior Administrator also stated that the Health services group cleans all non resident common areas and office space. They usually follow a specific schedule and check twice a day on those areas, at least. Review of facility policies on 12/09/25 titled ENV205 cleaning of offices and non resident/common areas, showed cleaning should have been done prior to being observed upon entry to facility on that day. It is cleaned twice a day and as needed when visibly soiled. Review of a document titled OPS200 safe and homelike environment stated the environment refered to any area of the center frequented by patients but not limited to. OPS200 said the area shall remain clean and free of clutter at all time. It also stated Orderly an uncluttered physical environment shall be kept at all times.

Based on staff record review, staff interview, the facility failed to ensure all kitchen staff were up to date with their food handler cards. Two (2) of Eight (8) employees did not have food handler's cards. Interview with Dietary Manager, he confirmed these food handler cards were not obtained by expiration dates. This failed practice was a random opportunity for discovery during the Long Term Care Survey Process. Employee identifiers: #20 and #7. Facility census: 61.Findings include a) food handler cards ,record review for all staff in dietary department b) [NAME] #20 date of hire-05/03/2025, did not obtain Food Handler Card until 12/01/2025 c) [NAME] #71 date of hire 08/09/2025, did not obtain Food Handler Card until 12/01/2025

Based on observation, resident interview, and staff interview, this facility failed to ensure menus were properly displayed with correct meal and that residents receiving meals were given the correct diet type. This failed practice had the potential to affect more than an isolated number of residents. Resident identifier: #49. Facility census: 67. Findings include: a) 12/07/25 at 11:40AM an observation of a menu board revealed an incorrect menu. Lunch on the board was listed as: Cheeseburger, cucumber salad, French fries, and peaches. Lunch served was maple sage turkey, stuffing, peas, dinner roll and pumpkin pie. During an interview [NAME] #17 confirmed meal was to be maple sage turkey, stuffing, peas, dinner roll, and pumpkin pie. 12/07/25 12:30PM Resident #49 received a menu for regular diet and needed one for consistent carbohydrate 12/07/25 2:30 PM during an interview with the Dietary Account Manager regarding the display menu next to the dining room entrance the Dietary Account Manager confirmed the correct menu was not on display. The Dietary Account Manager confirmed evening shift before they leave are to ensure menus are hung. Also reviewed with Dietary Account Manager that Resident #49 menu for the three week cycle was not correct diet, he reviewed and confirmed she needed one for Consistent Carbohydrate diet. F-803 Based on observation and interview with staff, and residents(Resident #49) This facility failed to ensure menus were followed and ensure residents needs. 12/07/25 1:00PM Met with resident #49, during interview, resident complained of meals usually not warm, cold at times, meals are not consistent, They do a lot of substitutions Resident #49 informed this surveyor, I received a three week menu but not for my diet, they gave me one for regular diet and I need a consistent carbohydrate Observed the three week menu was for a regular diet with Resident #49 name. Observed lunch meal ticket for Resident #49 was for consistent carbohydrate diet, noting certain items: 1/3 cup cornbread dressing and 1/2 cup broccoli florets marked out with cauliflower written, also no stuffing and mashed written. Resident #49 reported the vegetables are always mushy, potatoes too hard, not cooked enough. Sometimes the meat is tough 12/07/2025 2:00 PM Reviewed with Dietary Account Manager that Resident #49 complained her menu for the three week cycle is not correct diet, he reviewed and confirmed she needed one for Consistent Carbohydrate diet. 12/08/25 3:30PM Interview with Dining Account Manager regarding correct 3 week menu cycle for Resident #49 was given. F804 Following observation, resident interview and staff interview this facility failed to ensure meals were prepared to ensure nutritional value, palatability and preferred temperature. 12/08/25 11:45AM Review of tray line set up/ temperatures: [NAME] #71 confirmed temperatures as follows: Ground meat- 172.5, California Blend vegetable 198, Peas 192.2, Scallop potato- 168.8, Mashed potato- 169, Regular Salisbury steak-176.6 and Puree Salisbury Steak- 161.2. District Manager also on line and confirmed temperatures. 11:50AM Tray line begun12:00 PM First Cart to Unit12:03 PM Cart arrived to Unit , staff immediately begun tray deliveries 12:15PM Test Tray obtained: District Manager verified temps for test tray via taking the temperatures:Test tray temps: Salisbury steak- 103.6 Scallop Potato- 101.4 California Blend Vegetable- 97.7District Manager verified the plate was cool to touch. 12:40PM Resident #49 called this surveyor to room, upon entering she informed this surveyor the food is a little warmer today, however the potatoes are hard and the vegetable is mush.: Resident #49 handed this surveyor a potato- was firm to touch. 12:50PM Taste tray :Salisbury steak- bland, seasoningScallop potato- bland seasoning, potatoes were firm to touch, with bite.Vegetable- California blend mushy- overcooked in appearance

Based on observation, resident interviews, and staff interview, the facility failed to ensure food was prepared and served in a palatable, and attractive appearance for the residents that received their nutrition from the kitchen. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 61. Findings include a) Resident #49 12/08/25 12:40 PM Resident #49 called this surveyor to room, upon entering she informed this surveyor the food is a little warmer today, however the potatoes are hard, and the vegetables are mush. Resident #49 handed this surveyor a potato. This potato was observed to be firm to touch. 12/08/25 12:50 PM a test tray was obtained from the kitchen The following was observed from tasting the items on the test tray:Salisbury steak- bland, seasoningScallop potato- bland seasoning, potatoes were firm to touch, with bite.Vegetable- California blend mushy- overcooked in appearance A review of the policy on 12/08/25 at 1:00PM, Titled [Food Temperatures], under purpose in part reads as follows :To serve food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Based on observations and interviews, the facility failed to maintain and provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Areas of concern were the dirty laundry room, Hallway 100, Hallway 300/400, and the Shared bathroom for room [ROOM NUMBER]/109. Facility Census: 61. b) 300 and 400 hall soiled lift slings On 12/07/25 at approximately 11:40 AM upon entrance to the facility, it was observed that four slings were left draped over lifts and chairs in both the 300 and 400 hallways. The 300-hall had one (1) sling that was visibly dirty left hooked to the lift and thrown over the main lifting arm left in hall. The 400-hall had one (1) sling left out draped over the lift after being used, as well as lift slings that were dirty left in chairs down at the end of the 400 hallways. Slings once used are not to be left out in the hallway as this can increase risk of spreading contaminates around the facility. Clean slings are to be stored under a covered area if left in hallways or in clean storage rooms, so they stay as sanitary as possible in between uses. During an interview with the Senior Administrator (SA) at approximately 11:00 AM on 12/08/25 the SA stated, Those slings do not belong on the lifts, they have a proper area to be stored and should not be left out dirty ever. Review of a policy on 12/09/25 titled OPS200 safe and homelike environment it was noted under the sanitary requirement definition that Preventing the spread of disease-causing organisms by keeping patient care equipment clean and properly stored. was not followed. c) 100 hall Open Brief On 12/07/25 at approximately 11:40 AM upon entrance to the facility, it was observed that one (1) package of resident briefs were opened and left on a chair out in the main hallway of the 100 section. Review of a policy on 12/9/25 titled OPS200 safe and homelike environment revealed:Orderly uncluttered physical environment shall be kept; this was not followed and Items for resident are not to be stored out in hallways.Sanitary Preventing the spread of disease-causing organisms by keeping patient care equipment clean and properly stored. The facility did not follow their policy on keeping resident use items clean and sanitary. Exposing them to anything out in the hallways once the packs were open. d) cleaning wipes in bathroom On 12/07/25 at approximately 11:40 AM upon entrance to the facility, it was observed that one (1) container of cleaning wipes (Cauiwipes, pink top wipes) were on the floor of the bathroom that was shared with room [ROOM NUMBER] and #109. During an interview with the Senior Administrator (SA) the SA stated that those Cleaning supplies are not supposed to be left in any areas where residents and families can get into them. Findings Include the following: a) Dirty Laundry Room During an inspection of the Dirty Laundry Room on 12/09/25 at approximately 9:35 AM, accompanied by the Laundry Manager (LM), the room was found to be very warm and humid. Further inspection revealed that the venting system was not operational. The venting system maintains negative pressure in the dirty laundry room and prevents the movement of pathogens into the corridors and the Clean Laundry Room. The Maintenance Director (MD) was notified of the issue by the LM and was unable to restart the venting system. The MD stated that he would inspect the system and report back. At approximately 11:40 AM on 11/09/25, the MD confirmed the vent motor was not working. He stated he was in the process of replacing it. The MD said he was unaware of how long the system had been not operational.

Based on medical record review and staff interview, this facility failed to ensure care plans were updated to reflect current resident needs. This practice affected (1) of 20 care plans reviewed during Long Term Care Survey. Resident identifier #10. Census 61.Findings include a) Resident #10 A medical review for Resident #10 found a care plan and minimum data set (MDS) for bowel and bladder continence, reviewed and last updated on 06/06/20. The care plan was documented, Usually continent of bladder and bowel uses toilet. Recent MDS annual dated 06/24/24 revealed the resident was frequently incontinent of bladder and always incontinent of bowel. During an interview with the MDS coordinator, she verified this should be updated to reflect the change with bladder continence.

Based on record review and interview, the facility failed to follow a physician's order for the administration of insulin. This was a random opportunity for discovery. Resident identifier: #3. Facility Census: 61.Findings Includea) Resident #3During record review on 12/10/25 it was noted that Resident #3 had been administered fifty-four (54) units of short-acting insulin, instead of the prescribed fifty-four (54) units of long-acting insulin on 01/20/25 at approximately 8:00 pm. The Change-in-Condition documentation noted that the Clinician was notified at 8:40 PM.The record review also revealed that the resident had been prescribed the following medications:A short-acting insulin -NovoLog Flex Pen Subcutaneous Solution Pen-Injector 100/Unit/ML. (Insulin Aspart). Inject subcutaneusly before meals for DM (diabetes mellitus).A long action insulin - Basaaglar Kwik Pen-Subcutaneous Solution Pen Injector 100 Unit/ML (Insulin Glanrgine). Inject 54 units subcutaneously two times a day for DM II.Further record review revealed a physician's note dated 01/20/5 which stated: [Resident] is a [AGE] year-old female who I am acutely evaluating as accidental administration of short-acting insulin and instead of long-acting insulin at 54 units occurred this evening. I have ordered dextrose-containing fluids, high-glucose-content oral supplements, vigilantly monitoring blood glucose levels. The resident has been notified to let staff know if she feels weird in any way. Nursing has been instructed to hold all diabetic medications. If failure of IV occurs, she drops below 130 at any point, or becomes symptomatic, she will require urgent presentation to the ED. While interviewing Resident #3, on 12/10/25 at 8:32 AM, the resident stated that she had been made aware of the medication error after the facility began implementing interventions on 01/20/25. The resident stated that she had been scared and complied with all the interventions prescribed by the physician. During an interview with the Director of Nursing (DON) at approximately 9:55 AM, on 12/10/25, the DON confirmed that the nurse had not administered the medication as prescribed by the physician.

Based on observation, resident interview, staff interview the facility failed to ensure diet needs were being provided correctly (1) one of (7) seven reviewed for diets and nutrition. Resident identifier: #49. Facility census: 61. Findings include a) Resident #49 12/07/25 12:30PM, met with Resident #49 during interview, the resident complained of meals not usually being warm, cold at times, and not consistent, Resident #49 said, They do a lot of substitutions Resident #49 informed this surveyor, I received a three week menu but not for my diet, they gave me one for regular diet and I need a consistent carbohydrate Observation of the three week menu revealed it was for a regular diet with Resident #49 name. Observation of the lunch meal ticket for Resident #49 revealed it was for consistent carbohydrate diet, noting certain items: 1/3 cup cornbread dressing and 1/2 cup broccoli florets marked out with cauliflower written, also no stuffing and mashed written. Resident #49 reported Vegetables are always mushy, potatoes too hard, not cooked enough. Sometimes the meat is tough. 12/07/25 2:30PM during an interview with Dietary Account Manager for Resident #49 the Dietary Account Manager confirmed her menu for the three (3) week cycle was not the correct diet. Dietary Account Manager reviewed and confirmed Resident #49 needed one for Consistent Carbohydrate diet.

Based on observation and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of Resident #7's bed safety. Resident Identifier: #7. Facility census: 61. a) Resident #7 During an observation of Resident #7's bed, a 6-inch gap was found between footboard & mattress. Resident #7 was observed in bed with a blanket rolled up and put on one side of the footboard and a mattress gap for his feet to rest on. During an interview 12/09/25 at 1:35 PM the DON verified the footboard and mattress gap could cause entrapment. She stated that she would call the maintenance department to get it fixed immediately. No further information was provided prior to the end of the survey on 12/10/25 at 11:30 AM.

Based on record review, and staff interview, the facility failed to prevent significant unintended weight loss for Resident #8. This failed practice was found true for (1) of (3) residents reviewed for weight loss during the survey process. Resident identifier: #8. Facility Census 62. The State Agency (SA) determined harm was caused to Resident #8 when significant unintended weight loss occurred of 11.6 percent within 60 days. The failure to identify a decrease in meal intake, which resulted in a significant unintended weight loss from failure to document all meall intake and not providing physician ordered fortified snacks. Findings included: a) Resident #8 A record review on 08/12/24 at 10:00AM revealed the following weights for Resident #8: 7/28/24 106.6 pounds (Lbs) 7/24/24 108.7 Lbs 6/23/24 119.5 Lbs 6/19/24 114.5 Lbs 6/3/24 114.0 Lbs 5/24/24 120.4 Lbs 5/24/24 120.4 Lbs Further record review showed a note by the Registered Dietician (RD) on 07/25/24 with the following recommendations: Re-weight, fortified pudding daily at 2:00PM. The fortified pudding daily at 2:00PM was ordered by the physician on 07/26/24 . Further record review of Resident #8's Medicine Administration Record (MAR) for the month of August 2024 revealed Resident #8 did not receive her fortified pudding (4) out of 12 days. An observation on 08/12/24 at 2:30PM, found Resident #8 asleep with no fortified pudding in her room. During an interview on 08/12/24 at 2:35 PM, Registered Nurse ( RN) stated, Her pudding usually does not come up with the 2:00 snacks. I don't know why. We sometimes go to the pantry and get her something. She did not have it today. During an interview on 08/12/24 at 3:00 PM, The Certified Dietary Manager (CDM) stated, I don't have access to Point Click Care (PCC), it pulls into my system and this is how I know what snacks to send out. A record review on 08/12/24 at 3:30 PM of the facilities ordered snacks revealed that Resident #8 is not listed to receive a snack. Further record review of Resident # 8's Physician Orders for Scope of Treatment (POST) form revealed under section D {Medically Assisted Nutrition}, it is marked to provide feeding through new or existing surgically -placed tubes. During an interview by phone on 08/13/24 at 11:45AM the RD stated, She is aware that she is marked for a feeding tube, but her intakes are still high with monitoring her meal intake and feels some of the weight loss is coming from TSH levels, but feels like they now have that under control During a record review on 08/14/24 at 12:30 PM of Resident #8's meal intake from 06/16/24 to 08/12/24, it revealed that out of a possible 174 meals, 42 of those had no documentation. 0n 08/14/24 at 2:07 PM, The Director of Nursing (DON) confirmed the meal intakes were not documented properly.

Based on observation and staff interview, the facility failed to serve meals at a palatable temperature. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the survey process. Resident identifiers #54 and #60. Facility Census 62. Findings Included: a) Food temperatures Resident #53 and #60 According to the meal timesheet hall 400 trays were brought out to the hallway at 7:45 AM During an observation on 08/13/24 at 8:00 AM, of hallway 400 it was revealed, Resident #54 and #60 were sitting in the hallway in reclining wheelchairs and their breakfast meal trays were still on the food cart. No staff were noted to be nearby and were down hall 200 passing breakfast trays. Further observation at 8:10AM of hallway 400 showed that Residents #54 and #60's breakfast trays were still on the food cart and no staff were present on the hallway. During an interview on 08/13/24 at 8:25 AM, while Residents #54 and #60's food was still on the meal cart, Nurse Aide (NA) #69 stated, We pass all trays on all halls first and then go back and assist them. During an observation on 08/13/24 at 8:26 AM, The Certified Dietary Manager (CDM) checked the temperature of Resident #54's breakfast tray at the surveyors request. The food temperature was as follows: Puree sausage: 83.3 degrees Fahrenheit (F) Puree pancakes: 90.5 degree F. Oatmeal: 94.1 degrees During an interview on 08/13/24 at 8:30 AM, The CDM stated, Serving temperature should be 145 degrees. I think the danger zone is 41 to 135 degrees. I will get them another tray. A review of Healthcare services Group Policy titled [Food Distrubution} on 08/13/24 at 10:00 AM, number (6) six reads as follows: Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining. Further policy review of the policy titled {Food: Preparation} Number 11, 12 and 13 reads as follows: 11. When hot pureed, ground or diced food drops into the danger zone (below 135 degrees F.), the mechanically altered food must be reheated to 165 degrees F for 15 seconds if holding for hot service. 12. When reheating foods will be rapidly heated to 165 degree F. for 15 seconds. If the food is not reheated within (2) two hours it must be discarded. 13. All foods will be held at appropriate temperatures, greater than 135 degrees F. (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding.

Based on record review and staff interview, the facility failed to provide an accurate and complete record for an acute transfer for Resident #9 and meal intake for Resident #8. This was true for two (2) of 16 residents reviewed during the survey process. Resident Identifiers: #9 and #8. Facility Census: 62. Findings Include: a) Resident #9 On 08/12/24 at 12:00 PM, a record review was completed for Resident #9. The review found the resident had been transferred to an acute care facility on 02/22/24 . The transfer form listed the date as 07/08/23. On 08/12/24 at 12:30 PM, the Director of Nursing was notified of the incorrect transfer date. The DON stated, I will have to look into this. b) Resident #8 During a record review on 08/14/24 at 12:30 PM of Resident #8's meal intake from 06/16/24 to 08/12/24, it revealed that out of a possible 174 meals, 42 of those had no documentation. 0n 08/14/24 at 2:07PM the Nursing Home Administrator confirmed the meal intakes were not documented properly. 49465

Based on observation, and staff interview, the facility failed to provide privacy to residents when providing assistance for showers. This was a random opportunity for discovery during the Survey process. Resident identifier #8. Facility Census 62. Findings Included: a) Resident #8 An observation on 08/12/24 at 9:45 AM, of the shower room located on hall 200 revealed the shower room had no lock or in use signage. Noticing there was no sign or lock the Surveyor knocked on the door. There was no answer, so the Surveyor entered the shower room. Further observation of the shower room revealed Nurse Aide (NA) #38 standing undressing Resident #8, who only had a brief on at this time. During an interview on 08/12/24 at 9:50 AM, NA #59, Stated, We just usually knock. I agree there isn't much privacy. During an interview on 08/12/24 at 10:00 AM, The Administrator stated, Well, us who work here know when shower time is. We just usually know when it is in use. The Administrator confirmed that there was no lock on the door, or in use signage.

Based on observation, record review and staff interview, the facility failed to follow physician's orders regarding wound care for Resident #9 and #36, follow a physician's order regarding adaptive equipment for Resident #8, and completing an intervention per the physician for a possible resident to resident altercation for Resident #35. This was true for three (3) of 16 residents reviewed during the survey process. Resident Identifiers: #9, #36, #8 and #35. Facility Census: 62. Findings Included: a) Resident #9 On 08/13/24 at 10:30 AM, a record review was completed for Resident #9. The review found physician's orders were not being followed regarding treatments, including wound care. The following physician's orders were not completed on the following dates: --Clotrimazole-Betamethasone External Cream 1-0.05% apply to affected area topically every day shift for itching. --06/20/24 --07/02/24 --07/10/24 --Hydrocortisone External Cream 1% apply to affected areas topically every day and evening shift for itching/rash. --06/20/24 --07/02/24 --07/10/24 Kerlix Gauze Roll Large Miscellaneous apply to peri-anal topically every days shift for surgical wound. Moisten with saline and pack wound. Cover with bordered gauze. --06/20/24 --07/02/24 --07/10/24 Lidocaine External Cream 3% apply to affected area topically every day shift for pain. --06/20/24 --07/02/24 --07/10/24 Triad Hydrophilic Wound Dress External Paste apply to affected areas topically every day shift for wound care. --06/20/24 --07/02/24 --07/10/24 On 08/14/24 at 1:00 PM, the Director of Nursing (DON) was notified. The DON confirmed the treatment orders were not followed. b) Resident #36 An observation on 08/13/24 at 10:30AM, revealed, Resident #36 had a bandage on her left shin dated 08/11/24. A record review on 08/13/24 at 11:00 AM, of Resident #36's orders revealed an order which read as follows: Skin tear: Cleanse left shin with Skintegrity Wound Cleanser and apply Sureprep No-Sting to periwound skin and adhesive contact area. Approximate edges when possible with moistened swab. Apply Optifoam Gentle. Every day shift. The Director of Nursing (DON) confirmed, the bandage was dated for 08/11/24 and had not been changed as ordered on 08/12/24. c) Resident #8 During an observation on 08/12/24 of the noon meal, Resident #8 was eating lunch and had pink liquid in a regular cup. Resident #8's meal ticket read: Provide [NAME] Cup with all meals. During an interview on 08/12/24 at 12:15 PM, NA #12 stated, Usually on the hall if they have that cup they are on their tray. I don't know why they don't do it that way in the dining room. I am really not sure. I am new here. I will get her the cup. She confirmed, Resident #8 did not have the Kennedy cup as ordered. A record review on 08/12/24 at 1:00 PM revealed an order for Resident #8 which read as follows: Kennedy cup with all meals. d) Resident #35 A record review on 08/14/24 at 10:30 AM of Resident # 35's E Interact Change in Condition form dated 02/15/24 revealed, she had a possible altercation with another resident. The (5) five day follow up revealed, she was put on 15 minute checks for 72 hours. Further record review showed, the 15 minute checks were completed on 02/15/24 and 02/16/24 but no 15 minute checks could be found for 02/17/24. On 08/14/24 at 11:00 AM, The DON confirmed, the 15 minute checks for Resident #35 had not been completed for the full 72 hours. 49465

Based on record review, and staff interview, the facility failed to do a complete and thorough investigation on a possible resident to resident altercation resulting in death. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers #63 and #35. Facility Census 62. Findings Included: a) Resident # 63 A record review on 08/13/24 at 9:00 AM, of Resident # 63's E Interact Change in Condition dated 01/20/24 read as follows: Another resident grabbed at this resident's sleeve and this resident lost balance and fell down. Resident landed on buttocks and the staff member caught head in hands before hitting the floor. Four staff members witnessed the fall. Further record review revealed another E Interact Change in Condition form dated 02/14/24 that read as follows: Found resident on floor in room [ROOM NUMBER], blood noted from back of head. Helmet, elbow pads, and hip pads on. 911 called, neck supported by nurse. Helmet removed. Further Record review revealed an Interdisciplinary team (IDT) note that lists staff in attendance and reads as follows: Resident found on floor by staff in room [ROOM NUMBER]. Helmet, elbow pads and hip pads in place as ordered when found. Bleeding noted underneath the helmet. Helmet removed by staff and neck supported by nurse. Blood noted on the floor from the posterior head wound. 911 called and the resident was transported immediately via ambulance to (local hospital named). Resident returned from hospital with a CVA and cerebral hemorrhage diagnosis. Resident has 4 staples to the back of head with minimal bleeding noted. Resident now on comfort care due to decline in condition . No response to stimuli noted. Several interventions were removed from the care plan due to resident state. Most interventions do not apply to resident currently due to recent diagnosis. According to the (5) five day follow up Resident #36 passed away from the head injury on 02/16/24. b) Resident #35 A record review on 08/13/24 at 9:10 AM of Resident #35's E Interact Change in Condition form dated 01/20/24 reads as follows: Resident saw another resident attempting to converse with a third resident. This resident attempted to stop another resident from conversing with the third. She grabbed the sleeve of the resident attempting conversation. That resident lost balance and fell . Four staff members witnessed an altercation. Further record review revealed an E Interact Change in Condition form dated 02/15/24 that reads as follows: Another resident was observed on the floor in Resident #35's room on 02/24/24. Resident #35 originally reported to staff She fell . Later Resident #35 stated to staff I did it, thief [sic] Staff did not witness the incident. Neither resident demonstrates capacity. Other resident was transferred to hospital for evaluation. A review of the (5) five day follow up on the incident Resident # 35 was put on 15 minute checks for 72 hours. c) The investigation A review of the five day followup on 08/13/24 at 12:30 PM, revealed that no staff or residents had been interviewed for the incident resulting in death. During an interview 0n 08/14/24 at 1:00 PM, The Director of Nursing stated, There were no witnesses. The residents shared a bathroom and we are assuming she came in through the bathroom door. Neither resident could tell us what happened. When the surveyor asked why staff was not interviewed, The DON stated, Because no one saw the fall. I was told by the corporate to put the Change in Condition in for (Resident #35 named) just because she had said that and I guess for precaution.

Based on record review and staff interview, the facility failed to update a care plan regarding an actual fall for Resident #42. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #42. Facility Census: 62. Findings Included: a) Resident #42 On 08/14/24 at 9:20 AM, a record review was completed for Resident #42. The review found the resident had an actual fall on 07/10/24 due to the bathroom floor being slippery from powder which is being used with another resident who shares the bathroom. The care plan was reviewed at this time. The care plan focus area stated, Resident is at risk for falls, R/T (related to) Weakness, Osteoarthritis, Chronic Pain, HTN (hypertension). The need for assistance with ADLs, (activities of daily living) use of meds (medications) that could cause drowsiness/dizziness. On 08/14/24 at 9:48 AM, the Director of Nursing was notified the care plan had not been revised to show an actual fall had occurred on 07/10/24. The DON stated, the care plan has not been revised to show an actual fall.

Based on record review and staff interview, the facility failed to implement an intervention regarding pressure ulcers for Resident #54 and implement an intervention of wearing personal protective equipment (PPE) for Resident #50. This was true for two (2) of 16 residents reviewed during the survey process. Resident Identifiers: #54 and #50. Facility Census: 62. Findings Included: a) Resident #54 On 08/13/24 at 11:00 AM, a record review was completed for Resident #54. The review found the resident was receiving wound care for an unstagable pressure ulcer on the left heel. The care plan was reviewed regarding the wound care and pressure ulcer. The care plan listed an intervention of assist resident in turning and repositioning every 1 (one) hrs (hours) and PRN (as needed). The Director of Nursing (DON) was interviewed regarding this intervention on 08/13/24 at 1:00 PM. At this time, the DON was asked where is the documentation of the one (1) hour turning and repositioning? The DON stated, there is no documentation to verify this intervention was completed. b) Resident #50 On 08/14/24 at 5:07 PM, an observation of Nurse Aide (NA) #71 and NA #17 entering room [ROOM NUMBER] without wearing the appropriate PPE for enhanced barrier precautions for Resident #50 due to an indwelling medical device (feeding tube). At this time, the resident stated, he needed changed. When a resident is under enhanced barrier precautions, the nurse aides should have worn a gown and gloves while performing high contact activities. On 08/14/24 at 5:11 PM, both NA #71 and #17 were asked, Isn't the resident on enhanced barrier precautions? NA #17 stated, no .there isn't a cart in front of his door. Signage was posted on the door stating enhanced barrier precautions were in place. On 08/14/24 at 5:35 PM, the DON was notified. The DON stated, they know there is only one cart on each hallway .they know.

Based on record review, staff interviews, resident interviews, and policy review, the facility failed to prevent four (4) residents from being mentally and physically abused by another resident (Resident #29); five (5) residents from experiencing verbal abuse by the same resident; and two (2) visitors from being abused verbally by the same resident. The facility failed to complete incident reports for three (3) of the four (4) physical abuse incidents and/or to investigate them. Although physical harm could not be substantiated, the residents involved and other residents are afraid of Resident #29, as evidenced by documentation in the records, confidential resident interviews, and staff interviews. The administrator was notified of the immediate jeopardy at 12:10 p.m. on 07/10/12. The administrator presented an Immediate Plan of Action, at 12:35 p.m. on 07/10/12, that stated Resident #29 would receive one on one 24 hour observation until the facility could secure appropriate discharge. This plan was immediately put into action and was observed by this surveyor. The plan was relayed to the OHFLAC office. Findings include: A review of the medical record for Resident #29 revealed that he was a [AGE] year old male admitted to the facility on [DATE], for therapy after severe multiple traumas related to a motorcycle accident. His [DIAGNOSES REDACTED]. On admission, the resident was ambulating well, alert but confused at times, and had short term memory loss. The Admission minimum data set (MDS), with an assessment reference date (ARD) of 09/15/1,1 indicated in section E0900 that the resident did NOT wander and his only behavior was "physical abuse", which was modified to include "refusal of care". When the Quarterly MDS was done on 12/06/11, this resident had been assessed to have the behaviors of "verbal abuse"; "other behavioral symptoms not directed toward others"; "refusal of care" and now was "wandering. " The Quarterly MDS on 06/02/12, indicated under Behavioral Symptom (section E0200) that Resident #29 exhibited physical, verbal, and other behaviors 1 - 3 days of the assessment period. He also rejected care 1 - 3 days and wandered daily. A review of the Mood Monitoring Forms for June and July 2012, revealed the following incidents of Resident to Resident aggression initiated by Resident #29: 06/01/12 " Resident went into other residents rooms; resident smacked C.N.A. ' s hands; Resident cussed a lot. " 06/06/12 " Resident yelled at another resident ' You are overweight ' . " 06/08/12 " Making inappropriate comments to other residents. " 06/22/12 " Yelling out making inappropriate remarks and comments to others. " 06/25/12 " Resident refused care several times, hit aid several times, threatened staff several times. " 06/26/12 " Resident pushing another resident up hall yelling and hooping, while resident being pushed YELLING ' Help me ' . (frightened). " 07/01/12 " Resident shoved another resident (in w/c) (in wheelchair) down hall fast, let go, yelled and laughing ' Look at her go ' . " This was the only incident that was reported on an incident report. The affected resident was a [AGE] year old female (Resident #54). She was pushed into the back of another wheelchair striking her knees, although no injury was reported. The nurses notes stated: " Resident pushed elderly resident up hallway while in w/c hard and stated, ' Look at her go ' . No injury occurred, but resident was upset. " 07/01/12 " Resident kicked another resident in back " She was sitting in front of him in w/c. " The nurses ' notes identified this resident as Resident #42 and stated, " Resident pushed resident #42 from back of w/c with his ft (feet) while he was in sitted position in chair at nurses ' station. " 07/01/12 " Pulled out privates in front of another resident. Making inappropriate comments. " 07/04/12 " Resident was arguing with another resident trying to pick a fight with him ... " Nurses ' notes stated, " ...resident verbally aggressive and threatening other residents, hard to redirect at times. " 07/05/12 " grabbing private area, laughing told visitor in D. Room (dining room) that he had two nuts he ' d give him. Making sexual comments to C.N.A. ' s and nurses ... " 07/09/12 During a confidential interview, on 07/10/12, a staff member stated that on the prior day the resident had yelled at a child visiting Resident #58 and it had taken two aides to deter him. The resident is also an exit - seeker and had exited the building 36 times from 06/01/12-07/09/12, although he was on visual checks every ? hour around the clock. He had a psychiatric consult on 06/28/12 and his [MEDICATION NAME] dosage was increased. During an interview with the director of nurses and the social worker. at 9:15 a.m. on 07/09/12, they agreed that his behaviors were increasing and that the interventions do not deter them. This was verified by confidential interviews with four (4) staff members. The social worker stated that she had met with the resident ' s wife and sister recently and that they were concerned that he was still wandering about. The sister had demanded one to one care 24 hours daily. The facility had told them this was beyond their scope of care and suggested they consider other types of facilities, but they refused and nothing further was done. In interviews with six (6) alert residents, all of them identified the resident by description and/or name as a resident who: comes and goes as he wants, sets off alarms, scares people, argues loudly, shoves wheelchairs and people out on his way, and goes in and out of rooms. Four (4) of the six (6) stated that when he was in a mood or loud they avoided being out of their rooms. During the interview with the administrator, at 12:10 p.m. on 07/10/12, she stated that they (staff) had discussed the resident ' s increasing needs several times, but as the wife would not consider transfer, they had continued trying to care for him. She stated her understanding that there was a safety risk to the resident when he eloped from the building. At the end of the facility drive-way is a busy highway as the hospital entrance is directly across from the nursing home entrance. The administrator stated that she was unaware of the increase in the resident to resident conflicts being initiated by Resident #29, and agreed that it was a problem that must be addressed. .

Based on staff interview, medical record review, and review of facility elopement logs, the facility failed to provide adequate interventions and/or supervision to prevent one (1) of ten (10) sampled residents from repeatedly exiting the building and increasing the risk of physical harm to a physically and cognitively impaired resident. Resident identifier: #29. Facility census 60. Findings include: a) Resident #29 A review of the medical record for Resident #29 found he was recognized as an "exit-seeker" and "wanderer" shortly after admission. However, these actions were limited by his physical weakness which limited him to a wheelchair at that time. As his physical status improved to independent ambulation, the wandering and episodes of elopement increased. He had incidents involving self-injury due to falls on two occasions. The driveway to the facility exits onto a paved two-lane highway on a curve. The entrance to a hospital is directly across from the entrance to the facility. In May 2012, this resident was placed on visual monitoring every 30 minutes around the clock. A log documenting the successful exit attempts when he actually exited the building was started on 05/23/12, as part of a plan of correction required by a previous survey. When this log was reviewed on 07/09/12, it revealed the resident had successfully exited the building 36 times from 05/23/12 to 07/09/12, although he had continued on visual checks every 1/2 hour around the clock. During an interview with the social worker and the director of nurses, at 9:15 a.m. on 07/09/12, they acknowledged that Resident #29 was continuing to wander and/or attempt to exit the building repeatedly throughout each day, although they added that with the monitoring he had no further injuries and had been returned quickly. They both stated the resident required more intense care than they could give on a long-term basis. The social worker stated they had met with the wife and a sister recently, who wanted the facility to increase the supervision to one-on-one, which they explained was more care than the facility could provide except on a short term basis. The social worker stated that she suggested the family could provide this or they may want to consider a facility with a higher level of care. The wife refused to consider transfer. The social worker stated that no other steps had been initiated to this date. When asked how far away from the building he had gotten, they had no answer and there was no documentation to reflect this. The log did indicate the number of staff required to redirect the resident back into the building. This varied from one (1) to seven (7) and the observation was made that there were shifts when there were not seven (7) staff members available. The administrator acknowledged this in an interview at 11:00 a.m. on 07/10/12, although she stated that assistance from the police was available if needed. A psychiatric evaluation of the resident had been completed on 06/28/12, but had resulted only in an adjustment of medication and no other suggestions. The previous preadmission screening (PAS) (to determine whether a resident is a candidate for nursing home placement), dated 08/22/11, had no mention of the present behaviors and a new PAS had not been completed. The physician's progress notes did not address behaviors at all. During an interview with the administrator, at 1:00 p.m. on 07/11/12, she announced that the resident had been placed on one-on-one constant supervision until transfer could be arranged to a more appropriate facility that could provide the level of care necessary for the safety of the resident. The physician had been contacted and a new PAS was being completed. .

Based on staff interview, medical record review, observation, review of incident reports, and review of fall investigations, the facility failed to provide adequate supervision to prevent one (1) of four (4) sampled residents from accessing a window, removing the screen, and falling to the ground while exit-seeking. The fall resulted in a fracture of his arm, requiring medical treatment. The facility was aware the resident displayed exit-seeking behaviors, but failed to implement interventions, including supervision, consistent with the resident's identified needs, to reduce the risk of an accident. Resident identifier: #30. Facility census 64. Findings include: a) Resident #30 A review of the medical record revealed this [AGE] year old male was admitted to the facility on [DATE], for therapy after severe multiple trauma related to a motorcycle accident. His [DIAGNOSES REDACTED]. On admission the resident was ambulating well, alert but confused at times, and had short term memory loss. The admission minimum data set (MDS), with an assessment reference date (ARD) of 09/15/11, indicated, in section E0900, that the resident did NOT wander and his only behavior was "physical abuse," which was modified to include "refusal of care." When the quarterly MDS was done on 12/06/11, the resident was assessed with [REDACTED]." The nurses' notes revealed the following incidents: -11/25/11: (1:58 p.m.) Resident was wandering in halls when he found an unsecured door, went into the mechanical room and turned his wheelchair over, sustaining a skin tear. -11/25/11: (8:24 p.m.) "...he exited the door X 2 returned without incident." -02/27/12: The monthly summary nurse's note stated: "Pt. (patient) still wanders around @ times he leaves the building." -03/28/12: The monthly summary nurse's note stated: "Pt. (patient) still wanders around a lot. At times he leaves the building." -04/16/12: (9:30 p.m.) Staff were unable to locate resident who had been asleep on a couch in the WV room (a day room) and after a search was found sitting on the ground outside a window. During an interview with a nurse, Employee #29, at 10:45 a.m. on 05/21/12, she acknowledged Resident #30 had exited the building several times, but came back in without a quarrel when they went after him.. An interview was conducted with the Director of Nurses, Employee #2, at 12:45 p.m. on 05/21/12. She was asked why there were no incident reports relating to the times Resident #30 had exited the building. These reports would have been useful in assessing, tracking, and planning necessary supervision and interventions to reduce the risk of an accident. Employee #2 stated they did not think the reports were necessary since the resident was always returned quickly. She said she did not know how many times he had exited, but acknowledged it happened often and had been happening since his admission. This was verified by reviewing the nurses' notes. The administrator was interviewed at 11:50 a.m. on 05/22/11. She stated the facility would reconsider their policy about not completing incident reports when a resident exited the building unauthorized. Two (2) of the incidents recorded involved falls which had a high probability of prevention, if the facility's policy to secure rooms containing hazardous equipment and/or appropriate monitoring and supervision by staff had been implemented. At 11:30 a.m. on 11/25/11, Resident #30 wandered into the mechanics room, down the hall from the dining room, in his wheelchair and was found sitting on the floor with the wheelchair tipped over. He sustained a 4.5 cm. skin tear to the lateral aspect of his left lower arm. During an interview with Employee #14 (Maintenance Supervisor) at 3:45 p.m. on 05/21/12, he accompanied the surveyor to the mechanics room, at the end of the hall between the dining room and a side exit of the facility. It was secured by a locked door. Employee #14 stated the door should have been locked at the time of the resident's entrance and fall. He had no explanation for why it had not been locked. Employee #2 was interviewed at 11:30 a.m. on 05/22/12. She acknowledged the resident had entered the mechanics room unobserved. Employee #2 could not confirm whether or not the resident's chair alarm had sounded, and this information was not documented in the report. She stated staff checked on this resident often, but acknowledged these checks were not care planned at the time of the fall and were not documented. At 9:30 p.m. on 04/16/12, Resident #30 could not be located during rounds. The investigation report stated he had been asleep on a couch in the WV Room ( a large day room located at the end of a hall) at 9:00 p.m.. During a search of the grounds outside of the facility, the window screen was noticed to have been removed from a window and the resident was seen sitting on the ground. The initial assessment revealed a 3cm x 1cm skin tear on the right forearm which began to exhibit swelling on 04/17/12. The swelling was brought to the attention of the nurse by the resident's wife. The arm was x-rayed on 04/19/12, due to continued swelling. The x-ray revealed a fracture of the left radial head. The resident was treated in the emergency roiagnom on [DATE], a splint was applied, and a follow-up was scheduled with an orthopedist. The WV Room was a building addition, put into use in December 2011 as a day room/lounge area. It was located at the end of a hall and was not observable from the nurses' station. Three (3) walls were lined with windows. There was an outside exit door that was secured and had an alarm. At the time of the incident, there were screens and locks on the windows, but they could be opened from the inside. The windows were about 4 - 5 feet above the ground. An air conditioner was located under the window the resident used for exit. The facility surmised the resident exited the window onto the air conditioner and then fell to the ground. There was no documentation regarding how often the resident was being checked by staff, other than the statement on the incident report that he had been seen at 9:00 p.m. asleep on the couch. During an interview with Employee #14, at 3:45 p.m. on 05/21/12, he stated window stops that prevent full opening were ordered the day after the incident and were put in place within 72 hours. They were all in place on the day of the survey. Employee #20, a nurse, accompanied the surveyor to the WV Room at 3:55 p.m. on 05/21/12, and demonstrated where the resident had exited. On 05/22/12 at 11:30 a.m., Employee #2 verified the resident was a known exit-seeker and agreed he should not have been left in the room alone. The physician issued an order, when informed of the fall, for "Visual checks every 1/2 hour, until further notice." This order had been added to the care plan and had not been discontinued; however, there was no evidence of implementation of these checks. The care plan for Resident #30 was reviewed. It showed evidence his wandering and exit seeking behaviors were recognized by the facility. Under the heading of "Focus": "Resident exhibits behavior: ... and is prone to exit seeking behaviors. He wanders throughout the building...." There was a goal which stated, "Resident will not wander into other residents rooms less than daily." There was no goal established for the "exit-seeking" behavior. A review of the care plan interventions revealed only one (1) intervention related to exit seeking. The intervention was, "Staff will attempt to redirect when exit seeking behaviors occur." There were no interventions related to how to reduce the resident's exit seeking behaviors or what individualized methods of redirection should be used. A review of the "Care Plan Kardex Report," which provided care information to direct caregivers, revealed only the following information, specifically regarding the resident's exit seeking and behaviors: --"Secure Care--Check integrity and operational function of secure care bracelet q (every) week. Secure Care bracelet to monitor for wandering outside facility. Check placement q shift." --"Complete behavior monitoring flow sheet." Neither of these instructions were included in the resident's care plan. During an interview with Employee #2, at 11:30 a.m. on 05/22/12, she acknowledged, after reviewing the care plan that these instructions should have been in the care plan. .