Every finding on record at Jefferson Healthcare Center

Based on record review, interview, review of hospital paperwork, and facility policy review, the facility failed to report an allegation of abuse from Resident #59's family to the appropriate parties. This affected one (Resident #59) of three residents reviewed for change in condition. The facility census was 87.Findings include:Review of the medical record for Resident #59 revealed an admission date of 11/01/25. Diagnoses included periprosthetic fracture around internal prosthetic left joint, fracture of the lower end of the left femur, dysphagia, dementia, and Alzheimer's disease.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had cognitive impairment with a memory problem. Resident #59 required extensive assistance for all activities of daily living.Review of the progress note dated 06/22/26 at 2:10 A.M. revealed an alarm was going off in Resident #59's room. Resident #59 was observed on the floor on the left side of her lift chair. A head laceration was noted to the left temporal region. Pressure was applied to the laceration, and vital signs were assessed with no concerns. 911 was called. Resident #59 went to the emergency room for evaluation. The physician and Resident #59's power of attorney (POA) were notified.Review of the nursing note dated 06/22/26 at 7:47 A.M. revealed Resident #59 returned to the facility from the emergency room with new orders for tramadol (pain medication) 50 milligrams every eight hours as needed for pain for seven days.Review of the hospital paperwork from 06/22/26 revealed an x-ray noted changes of the left knee replacement, with findings suggestive of a periprosthetic fracture of possible remote chronicity, although there was some soft tissue swelling present along the medial aspect of the left thigh, no sizable joint effusions were noted. No other orders or weight bearing status were noted. The discharge instructions reported her final diagnoses were closed head injury, simple bruising, and fall.Review of the physician note dated 06/23/26 revealed Resident #59 was treated and released from the emergency room on [DATE]. She had a follow up appointment with orthopedics related to left knee pain. The left knee x-ray showed periprosthetic fracture of possible remote chronicity. Staff reported Resident #59 would not bear weight on left leg, and the physician will wait for the follow-up appointment with orthopedics.Review of the nursing progress note dated 06/24/26 revealed Resident #59 was sent back to the emergency room for further evaluation of the left knee/hip/and pelvis. The physician was notified, and the x-ray showed same results.Review of the nursing progress note dated 06/26/26 revealed the nurse spoke with Resident #59's POA regarding the x-ray results that showed no acute fractures. The POA verbalized understanding. The orthopedics office confirmed no weight bearing to the left leg until the appointment on 07/15/26. Nursing to continue current plan of care, Ace wrap and ice as needed.Review of the nursing progress note dated 07/02/26 revealed Resident #59's daughter requested she be sent out to the emergency room due to left hip and knee pain. The nurse practitioner was notified and 911 was called. Resident #59 was found to have a left femoral fracture at the left knee prosthetic knee joint. She was readmitted to the facility on [DATE] after undergoing a left femur repair with insertion of an orthopedic implant at the left distal femur end.Review of the orthopedic history and physical dated 07/03/26 revealed Resident #69 was a [AGE] year-old female who suffered a fall at the nursing facility on 06/22/26 and found to have a left periprosthetic distal femur fracture. She was unable to manage pain at facility and now undergoing a distal femur replacement surgery on 07/06/26.Review of the care plan dated 07/06/26 revealed Resident #59 was at risk for alteration in comfort. Interventions included administering medications as ordered and monitoring for increased pain levels. The care plan also had a focus that Resident #59 was at risk for falls. Interventions included ensuring her environment was free from clutter and providing a pressure sensitive alarm to the bed to alert staff of unassisted transfer attempts.Review of the social services note dated 07/13/26 revealed a care conference was held with staff, the Ombudsman, POA, and family. Resident #59's treatments were discussed such as her leg brace, lab results, medications, code status, indwelling catheter, showers, recliner use, and possible camera being set up in her room. Goals of therapy were discussed and Resident #59's family reported they were pleased with care in the facility. During a telephone interview on 08/05/26 at 9:34 A.M., Resident #59's daughter reported they found her mother in bed with her leg wrap off and twisted in bed. The Director of Nursing (DON) came in and moved her leg and they heard crunching. She had to be taken back to the hospital and had to have emergency surgery where her kneecap was replaced. She confirmed she had spoken to the Administrator and the Ombudsman because they are blaming the DON for the fracture. She reported the DON did not come to the meeting and was hiding in an office listening to the meeting, and it was a closed meeting. The DON began screaming during the meeting when they discussed their concerns about her moving her leg calling the family liars.During a telephone interview on 08/05/26 at 11:01 A.M., the Ombudsman reported Resident #59's family expressed same concerns about the injury of and confirmed when the meeting was held with the Ombudsman and family with the facility over the phone, the DON was not a part of the conversation, but when it was brought up, she jumped into the conversation and became very defensive. The Ombudsman reported that she informed the family to call in a complaint to the Ohio Department of Health (ODH) due to her behavior.During a telephone interview on 08/05/26 at 12:21 P.M., Resident #59's other daughter reported she does not trust the facility because the DON never said she was sorry for breaking her mother's leg.During a telephone interview on 08/05/26 at 1:30 P.M., the Administrator and the DON revealed the Administrator was made aware of Resident #59's family accusing the DON of causing Resident #59's fractures when she assessed the leg on 07/02/26. The Administrator was made aware during a phone care plan meeting with Resident #59's family and the Ombudsman on 07/13/26. The Administrator reported she then went and spoke to staff who were present and decided no allegations of abuse were being made, so she did not file a self-reported incident (SRI). The DON reported on 07/02/26, Resident #59's family was insisting her mother was in a lot of pain and wanted her sent back to the hospital. The nurse called the DON in to assess the leg. The DON reported Resident #59's was up in her recliner chair, and her hip, legs, and toes were pointed inward towards her midline propped on some pillows. The DON reached for Resident #59's leg to move it to the center and readjust it on the pillows. She grabbed Resident #59's leg with two hands, one on her upper left thigh and one near her left ankle and slightly moved her leg from midline to center approximately 30 degrees. Resident #59 did not scream out in pain but did slightly moan with the movement, and she immediately stopped moving her leg placing it back down onto the pillows. The DON confirmed there were no twisting movements or popping sounds that happened when she readjusted her leg. Resident #59 was sent back to the emergency room because the family insisted that her pain was not controlled. The Administrator reported that when she was made aware of the allegation during the phone conference, the DON was not a part of the meeting, but her office was in the room where the meeting was taking place, and the DON confirmed she did chime in stating she did not cause the fracture. The DON confirmed that was not professional as she was not a part of the meeting. The Administrator reported she did get staff statements about the incident but did not file an SRI.Review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source. Additionally, the facility should immediately report all such allegations to the Administrator and the Ohio Department of Health. In cases where a crime is suspected, staff should also report the same to local law enforcement.This deficiency represents noncompliance identified under investigation of Complaint Number 3123564.

Based on observation, interview, and record review the facility failed to provide sufficient staff to meet the needs the residents. This affected Resident's #43, #69 and #78 and had the potential to affect all 87 residents residing in the facility. Findings include: Interview on 07/18/22 at 1:50 P.M. with Resident #78 stated there was not enough staff because there was only one State tested Nursing Assistant (STNA) for every resident on the hallway and could take up to 30 minutes for staff to respond to the call light. Interview on 07/18/22 at 2:44 P.M. with Resident #43 revealed there was not enough staff since there was only one STNA all the time available on the hallway. Interview on 07/20/22 at 12:26 P.M. with family of Resident #69 revealed it was necessary to visit daily before lunch until after dinner to assist Resident #69 with meals because there was not sufficient staff, especially on the weekends, to ensure Resident #69 received adequate meal intake. Resident #69's family stated it took longer for staff to answer call lights on the weekends, staff were more hurried, and Resident #69 was pressured to finish meals quicker. Interview on 07/21/22 at 4:30 A.M. with STNA #262 verified there was one STNA to each hallway but there was occasionally a float. STNA #262 stated it was more difficult without a float because the nurse had to be relied upon for the residents who required two staff assistance, so it took longer to complete work. STNA #262 verified without a float STNA residents did not receive showers but a bed bath instead. Interview on 07/21/22 at 4:54 A.M. with Licensed Practical Nurse (LPN) #230 confirmed there was only one STNA on each hallway but usually there was a float. LPN #230 stated when there was not a float, it was harder to get residents up in the morning or lay them down for bed, and showers were completed when there was a float but if there was not, the showers were delayed or rescheduled for the next shift. Observation on 07/21/22 at 6:00 A.M. with STNA #253 of the memory care secured unit, of which resided 22 residents, revealed the STNA was alone on the unit an alarm sounded for Resident #45 who attempted to self-transfer to bed. STNA #253 entered Resident #45's room, closed the door, provided personal care, and assisted Resident #45 to bed. Interview at the time of the observation with STNA #253 verified there was no other staff on the unit to monitor the other residents while she was providing personal care to Resident #45 behind the closed door because the nurse had floated to another hallway to pass medications, and there was not a float aide. STNA #253 indicated although tasks were completed with only one aide, it took longer and would stay if necessary to get things done. Review of Facility assessment dated [DATE] through 07/28/22 revealed there was no information on the number of staff needed to meet the needs for each resident. Review of Resident Council minutes from 01/31/22 through 06/30/22 revealed on 01/31/22 snacks were not always passed; on 02/25/22 a complaint of more staff was needed on 300 hallway; on 05/31/22 there was a staff delay returning a resident from dialysis; and on 06/30/22 a resident complained of a bed not being made. Review of staffing tool from 06/24/22 through 06/26/22, 07/03/22 through 07/09/22, and 07/15/22 through 07/17/22 revealed the facility was below the daily direct care requirement of 2.50 hours per resident on 06/25/22, 06/26/22, 07/03/22, 07/09/22, 07/15/22, 07/16/22, and on 07/17/22. Interview at the completion of the staffing tool on 07/20/22 at 10:27 A.M. with Human Resources #215 verified the staffing tool was accurate and the facility was under the staff requirements due to call offs, which the facility was unable to cover. Human Resources #215 stated the facility had a contract with an agency for temporary staff but did not used them.

Based on record review and interview, the facility failed to ensure staff needs were identified on the facility assessment as required. This had the potential to affect all 87 residents. Findings include: Review of the facility assessment, dated 07/07/22 to 07/28/22, revealed it did not contain an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet the needs of each resident. Interview on 07/22/22 at 9:39 A.M. with Director of Nursing, Administrator, and Corporate Nurse #296 verified the facility assessment did not contain facility staffing needs as required.

Based on observation and interview, the facility failed to ensure a homelike environment free of gouges and unpainted patched areas on the walls in resident rooms and common hallways. This affected 13 Residents (#10, #16, #26, #35, #37, #49, #54, #56, #60, #84, #87, #289, #290). The facility census was 87. Findings include: Observation during an environmental tour on 07/22/22 from 8:40 A.M. to 8:51 A.M. with Maintenance Director #207 revealed the following findings: · Resident #10 and #16's room had one large gouge on the bottom portion of the wall by the window with paint peeling away from the area. · Resident #26 and #84's room had one patched non-painted area on the bottom right side of the wall by the window and two large gouges behind the headboard. · Resident #35's room had 11 large gouges in the wall with drywall exposed behind the headboard of the bed. · Resident #56's room had two large gouges in the drywall, one on the bottom right-hand side of the wall with the window and one gouge halfway up on the left-hand side on the wall closest to the hallway. · Resident #60's room had five large gouges in the wall by the window. · Resident #87's room had one large hole in the drywall with a corner bead showing on the right bottom side of the wall by the bathroom door, and multiple chipped areas with drywall showing on bottom portion of the wall with the window. · Resident #289's room had 20 large gouges in the wall with drywall exposed behind the headboard of the bed. · Resident #290's room had five large gouges in the drywall between the bed and the chair. · Arbor Avenue common hallway had one large white patched strip from the ceiling to the handrail located on the left wall next to the double doors. · Buckeye Boulevard common hallway had a large square shaped area free of paint with drywall showing on the area to the right of the wall with the mounted hand sanitizer container near the hallway entrance. Interview at the time of the observation with Maintenance Director #207 verified the above findings.

Based on observation, interview, and the review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to maintain infection control practices for the spread of infectious diseases by not ensuring staff properly donned and maintained the wearing of facemasks while in resident care areas and hand hygiene was not performed after removing gloves. This affected two (Residents #295 and #413) and had the potential to affect all 87 residents residing in the facility. Findings include: 1. Observation on 07/18/22 at 10:04 A.M. of D wing hallway revealed State tested Nursing Assistant (STNA) #252 was observed exiting Resident #413's room, which required droplet precautions, while wearing the upper strap of the N95 respirator on back of head and the lower strap dangling under chin. STNA #252 also did not perform hand hygiene after removing her soiled gloves as she exited Resident #413's room. STNA #252 stated she normally wears both straps to the N95 but this time she did not and confirmed she did not wash her hands with soap or water or sanitize her hands with an alcohol-based sanitizer after removing gloves. At the time of confirmation, STNA #252 sanitized hands with an alcohol-based sanitizer. 2. Observation on 07/18/22 at 2:56 P.M. of D wing revealed Medical Records #205 entering Resident #295's room, which required droplet precautions, with a surgical mask underneath the N95 respirator. The upper strap of the N95 was secured on the back of the head and the lower strap was dangling under her chin. Medical Records #205 confirmed upon exit of Resident #295's room the N95 respirator was not worn properly. Review of facility policy titled Infection Control-Standard Precautions, dated 05/05/17, revealed after removing gloves, hand hygiene needs to be performed to avoid transfer of microorganisms to other residents or environments. Review of Personal Protective Equipment (PPE), reviewed 10/21/21, from the Centers for Disease Control and Prevention Healthcare-Associated Infections (HAIs), located at https://www.cdc.gov/hai/prevent/ppe.html, revealed to put on a mask or respirator, secure ties or elastic bands at the middle of the head and neck; fit the flexible band to the nose bridge; fit it snug to the face and below the chin; and place goggles or a face shield over the face and eyes and adjust to fit and to wash hands or use an alcohol based sanitizer immediately after removing PPE. 3. Observation on 07/21/22 at 4:30 A.M. of STNA #262 on B wing hallway was not wearing a facemask or eyewear. Interview at the time of the observation with STNA #262 verified a facemask or eyewear was not donned while in a resident care area. STNA #262 walked to the nurse's station where a facemask and goggles were setting on the countertop and donned the items. STNA #262 stated the facemask was removed because it was easier to breathe. Review of Personal Protective Equipment (PPE), reviewed 10/21/21, from the Centers for Disease Control and Prevention Healthcare-Associated Infections (HAIs), located at https://www.cdc.gov/hai/prevent/ppe.html, revealed to put on a mask or respirator, secure ties or elastic bands at the middle of the head and neck; fit the flexible band to the nose bridge; fit it snug to the face and below the chin; and place goggles or a face shield over the face and eyes and adjust to fit.

Based on record review, interview, facility policy review, and review of Self-Reported Incident (SRI) # 1, the facility failed to ensure Resident #43 was free from verbal abuse. This affected one Resident (#43) of one resident reviewed for abuse. The facility census was 87. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/04/22, revealed Resident #43 had mild cognitive impairment and required extensive assist of one staff for bed mobility, locomotion off unit, dressing, and toilet use. For transfers, Resident #43 required extensive assist of two staff. Review of the care plan, initiated on 08/06/18, revealed Resident #43 had alteration in mood or behavior by feeling bad or upset with self because of medical issues. Review of the nursing progress note dated 07/02/22 at 6:45 P.M. revealed Resident #43 yelled and used profanity toward State tested Nursing Assistant (STNA) #294 during smoke break. Review of SRI # 1 dated 07/02/22 revealed an allegation of emotional/verbal abuse with Alleged Perpetrator (STNA #294) and victim (Resident #43) which occurred on 07/02/22. The summary indicated on 07/02/22 staff witnessed Resident #43 and STNA #294 speaking to each other with raised tone of voice during smoke pass. Staff separated STNA #43 and Resident #43. STNA #294 reported during smoke pass Resident #43 used profane language towards her and attempted to run into her with his wheelchair. The facility unsubstantiated the allegation due to lack of evidence and STNA #294 was provided with education on resident rights and customer service. STNA #294 left facility, and Resident #43 did not request police involvement. Review of SRI # 1 witness statement for Resident #43 dated 07/02/22 revealed Resident #43 and STNA #294 were discussing their personal relationship and STNA #294 stated she left him because he preferred dirty girls. Resident #43 responded stating STNA #294 was a cheater and STNA #294's family were cheaters. STNA #294 yelled out I have been waiting to get this off my chest for [AGE] years. Resident #43 admitted to using profanity but stated it was mutual. STNA #294 told Resident #43 to put out his cigarette, he was done with his smoke break, and would not be smoking at the next smoke break. Resident #43 refused to leave, continued to smoke, and Resident #43 and STNA #294 continued to swear at each other until Resident #43 returned into the facility and went back to his room. Review of SRI # 1 witness statement for STNA #294 dated 07/02/22 revealed STNA #294 assisted residents out for smoke break at 6:30 P.M. STNA #294 stated Resident #43 was in a foul mood and tried to hurt her feelings by calling her and her sister names. STNA # 294 stated she had many domestic disputes with Resident #43 and had told all the nurses on night shift. STNA #294 stated she still took Resident #43 on smoke breaks but was just waiting because Resident #43 was going to do this. Review of SRI # 1 witness statement for Resident #12 dated 07/02/22 revealed STNA #294 started insulting Resident #43 and he responded by swearing and calling STNA #294 names. Resident #12 was unable to recall the exact phrases used but indicated STNA #294 made references to Resident #43's condition by saying Well look where you are now. Resident #12 also reported STNA #294 told Resident #43 that she had been holding this in for [AGE] years and now was going to get it off her chest. Resident #12 stated in her own opinion, STNA #294 could have ended the discussion but kept it going. Review of SRI # 1 witness statement for STNA #258 dated 07/02/22 revealed STNA #258 was in the pantry during the time of the incident and heard the arguing outside but could not make out the words. Upon going to check it out, Resident #43 and STNA #294 had separated. Review of SRI # 1 witness statement for Licensed Practical Nurse (LPN) #234 dated 07/02/22 revealed STNA #294 came to her and indicated Resident #43 and her had argued. STNA #294 stated Resident #43 was not a person, he is a monster. STNA #294 then continued to state Resident #43 should not receive a 9:00 P.M. smoke break. LPN #234 explained to STNA #294 that staff members should treat all residents the same and cannot punish or yell at residents. Interview on 07/19/22 at 11:40 A.M. with Resident #43 verified an incident occurred with STNA #294 on 07/02/22, who was once a girlfriend several years ago. Resident #43 stated STNA #294 stated he was a loser, talked in a loud voice first, and then started to yell. Resident #43 confirmed several residents who were smoking in the area witnessed the incident. STNA #294 reported the incident and then staff came and talked with him. Resident #43 indicated not wanting to contact police since STNA #294 left and went home. Resident #43 stated STNA #294 argued with him in the past when they dated. Further interview on 07/22/22 at 10:37 A.M. with Resident #43 revealed the incident which occurred on 07/02/22 embarrassed him and made him feel bad. Resident #43 stated STNA #294 had insulted and yelled at him in front of four to five residents who were smoking at that time. Resident #43 indicated being glad STNA #294 was no longer working at the facility and stated if she was it would happen again. Review of Alleged Perpetrator (STNA #294) personnel file revealed a hire date of 03/31/22. STNA #294 was educated on abuse, neglect, exploitation and misappropriation, customer service and professionalism upon hire. A criminal background check was completed on 03/21/22, and a review of the nurse aide registry was completed on 03/22/22. Review of disciplinary action form for Alleged Perpetrator (STNA #294) dated 07/08/22 revealed a violation of resident rights which resulted in suspension from 07/02/22 through 07/08/22, a written warning, and education on customer service and resident rights with employee signing the document on 07/08/22. Interview on 07/20/22 at 12:56 P.M. with Director of Nursing (DON) and Administrator stated STNA #294 had an emotional response from the previous relationship and therefore was in violation by not listening, discussing personal issues, not using an indoor voice, and that she chose to not reveal the past relationship to the facility. They confirmed STNA #294 did not reveal the past relationship with Resident #43 and was unprofessional. They also verified STNA #294 acknowledged what she did was wrong. Interview with Administrator on 07/19/22 at 2:34 P.M. verified STNA #294 was suspended 7/02/22 through 07/08/22 pending investigation, and it was decided for STNA #294 to return with the plan for STNA #294 not to work on the hallway where Resident #43 resided. STNA #294 asked for a transfer to a sister facility but did not return and did not go to a sister facility. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed all alleged violations involving abuse, neglect, exploitation, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, observation, and record review the facility failed to ensure a resident was supervised while smoking and that he did not have smoking material including cigarettes and lighter on his person per his smoking assessment and care plan. This affected one resident (Resident #5) of twelve residents identified as smoking residents residing at the facility. Findings include: Record review for Resident #5 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of care plan dated 07/30/18 for Resident #5 revealed he had health risks related to smoking. Interventions included staff were always to provide supervision for smoking and smoking items were to be kept at the nursing station. Review of quarterly Minimum Data Set (MDS) for Resident #5 dated 04/08/19 revealed he had cognitive impairments as his Brief Interview for Mental Status (BIMS) score was a ten. Review of smoking assessment labeled, Smoking Data dated 07/09/19 for Resident #5 revealed staff were to observe the resident while smoking as all residents would be supervised while smoking regardless of their capabilities. He required no appliances or assistance while smoking. Interview on 07/09/19 at 2:16 P.M. with State tested Nursing Assistant (STNA) #601 revealed all residents were to be supervised to smoke and no residents, per policy, can have cigarettes or lighters on them as they had to be stored in the nursing station. She revealed staff had to light all cigarettes for the residents when they are smoking. She revealed Resident #5 had to sign out in the leave of absence book and go to the new patio the facility recently built off the path if he wanted to smoke unsupervised outside of smoking times. Interview on 07/09/19 at 4:10 P.M. with Licensed Practical Nurse (LPN) #603 revealed all residents were to be supervised when smoking and were not to keep cigarettes or lighters on them as smoking materials were stored at the nursing station. She revealed if Resident #5 wanted to smoke in between smoking times he had to sign out on leave of absence and go to a patio off the path to smoke. She revealed he then was not supervised. Interview on 07/09/19 at 4:20 P.M. with Resident #5 revealed he goes a few times a day to the new outside patio the facility just built to smoke which was located down the path. Resident #5 revealed he does not need to be supervised while smoking and can go anytime throughout the day. Interview on 07/09/19 at 4:28 P.M. with the Maintenance Director #600 revealed he recently built the new patio located next to the paved path going around the facility. He revealed the patio was considered off facility property as technically the owner owns the property but was not part of the facility's property where the new patio was built. He revealed the residents use this area for smoking, but the residents had to sign out by leave of absence to be able to use the area unsupervised. Interview on 07/09/19 at 5:55 P.M. with the Administrator and Director of Nursing revealed in the past when the residents wanted to smoke outside of smoking times they signed out by leave of absence and went across the street off facility property to smoke. They revealed they felt this was a safety concern and recently the facility decided to have a cemented area with a picnic area built next to the path. They revealed this area was off facility property. They revealed all residents including Resident #5 was to be supervised while in the facility and no residents were to have smoking material on their person. Observation on 07/10/19 at 8:35 A.M. of Resident #5 revealed he opened the gait to the gazebo area and propelled in his wheelchair down the path to the newly cemented area. He then lit a cigarette that he pulled from a cigarettes case out of his pocket. No staff were in the area while he was smoking. Interview on 07/10/19 at 8:37 A.M. with STNA #602 verified Resident #5 was smoking unsupervised on the patio next to the paved path by the facility. She verified he had a lighter and four remaining cigarettes in a case on his person. Interview on 07/10/19 at 8:39 A.M. with LPN #603 verified she was Resident #5's nurse and he did not sign out in the leave of absence book and she verified he was to be supervised when he smokes at the facility. She verified that residents were not to have cigarettes or lighters on them per their facility policy. Review of undated form labeled, Release of Responsibility for Leave of Absence, for Resident #5 revealed he did not sign out on 07/10/19 at 8:35 A.M. when he went to smoke. Review of facility policy dated 07/17/18 labeled, Resident Smoking, revealed all residents would be supervised while smoking, and staff would light all smoking products. The policy revealed all smoking materials would be kept in a secured area and distributed by the facility staff and a resident would not be permitted to carry or have in their possession smoking material including cigarettes or lighters. The policy did not include residents signing out on leave of absence to smoke.

Based on interviews and record review, the facility filed to ensure medication was properly secured and disposed of. This affected one of 20 residents residing on the Buckeye wing, Resident #3. Findings include: Review of self-reported incident (SRI) # 5 revealed one dose of the antibiotic Bactrim traceable to the facility was confiscated by the county sheriff's department during a routine traffic stop on 07/31/17. The medication was found in the purse of State tested Nurse Aid (STNA) #18. The sheriff department notified the facility in person on 08/31/17 and an investigation was conducted by the facility. STNA #18 was suspended while the investigation was conducted and terminated at the conclusion of the investigation. Interview with the Director of Nursing (DON) on 09/29/17 at 9:19 A.M. revealed the investigation failed to identify any residents, prescribed Bactrim, who did not receive their medication. The investigation concluded the dose of Bactrim misappropriated by STNA #18 was an extra dose resulting from the use of the starter dose for Resident #3 and a full prescription of 10 doses being sent by the pharmacy. The misappropriated dose should have been destroyed once Resident #3 completed 10 doses of the antibiotic. The investigation failed to identify the date and nurse responsible for leaving the Bactrim unsecured. Review of the Medication Administration Record [REDACTED].M. The DON reported STNA #18 was interviewed and admitted picking up the medication which was setting outside of the medication cart in the nurses' station on the Buckeye wing. The DON stated the nurse stations, rooms with windows and a passcode entry door, were to be remain locked when the nurse was not inside the station and that all staff knew the passcode for entry into the nurse station. The facility was unable to provide documentation to verify how many doses of Bactrim were sent by the pharmacy for Resident #3. Interviews with the DON on 09/29/17 at 9:19 A.M. and the Assistant Director of Nursing (ADON) on 09/29/17 at 10:58 A.M. verified medications should be secured in the medication cart or the med room at all times and wasted immediately if they were no longer needed. Review of the 08/07/12 Policy 4.1, General Guidelines for Medication Storage for Remedi senior care (the facility pharmacy) revealed medications were to be stored securely, accessed only by licensed nursing personnel authorized to administer the medication and when removed from storage for wastage, immediately disposed of according to procedures for medication destruction.

Based on observation, interview and record review the facility failed to ensure a two-person transfer was provided to Resident #80 resulting in a fall. This affected one resident (#80) of three residents reviewed for falls. The facility census was 68. Findings include: Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] determined Resident #80 needed extensive assistance with transfers with at least two staff persons. The facility initiated a plan of care dated 12/17/2014 with a revision on 01/04/17 which addressed Resident #80 requiring two staff assist with transfers and the use of a Medi lift (a mechanical device with a body sling used to lift and move a person). Resident #80 sustained a fall on 03/20/17 resulting in an abrasion (a scraped spot) to her right side. Review of the fall investigation from 03/20/17 at 1:20 P.M. revealed Resident #80 stated she had to go to the bathroom and fell from her recliner. The cause of the fall was listed as lack of proper transfer by the state tested nursing assistant (STNA) who attempted to transfer Resident #80 without getting another staff member to assist her with the transfer and did not use the Medi lift. The Director of Nursing (DON) was interviewed on 04/12/17 at 10:13 A.M. and 04/13/17 at 9:59 A.M. and verified Resident #80 fell because the STNA did not follow the plan of care and attempted to transfer Resident #80 by herself and without the Medi lift. On 04/13/17 at 11:05 A.M., Resident #80 was observed being transferred with the Medi lift by STNA #10 and STNA #11. These staff both verified Resident #80 must be transferred with two staff and the Medi lift.

Based on observation and interview, the facility failed to ensure medication labels included complete information on the drug contained. This affected medication for one resident (Resident #75) out of 68 residents currently living at the facility. Findings include: Observation on 04/12/17 at 10:10 A.M. revealed a bag of 59 syringes filled with 0.5 milliliters (ml) of an unknown liquid located in the 200 hall medication refrigerator. The individual syringes were not labeled with any identifying information. The bag itself was labeled with Resident #75 ' s name, and identified the appropriate dose as 0.5 ml of the medication to be applied topically twice daily, and every six hours as-needed. The label did not identify the name or concentration of the drug. The bag contained no other label. This finding was confirmed with the Director of Nursing on 04/12/17 at 10:23 A.M.

Based on closed record review and interview, the facility failed to report injuries of unknown origin to the state agency as required. This affected one (Resident #1) of three residents reviewed for self reported incident reports. Findings include: Review of the closed record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurses notes dated 09/29/16 at 8:30 P.M. indicated Nurse #1 was called to resident's room by State tested Nurse Aide (STNA) #10. The nurse observed bruising that measured 10 centimeters (cm) by 12 cm on the front of the resident's upper right arm and bruising that measured 17 cm by 9.5 cm on the back of the resident's right arm. Both areas were dark purple. The resident denied pain to the areas. There was an abrasion that measured 1.5 cm long by 1.2 cm wide by 0.1 cm deep.on the resident's outside right elbow No drainage was observed and the wound bed was pink. The area was cleaned with normal saline, patted dry and left open to air. The resident denied pain to this area. Vital signs were taken. Review of nurses notes dated 09/30/16 at 12:35 A.M. indicated the physician was notified and ordered an x-ray of the right humerus (upper arm bone). The x-ray indicated a [MEDICAL CONDITION] humerus. Review of nurses notes for Resident #1 dated 10/02/16 at 12:00 P.M. indicated Nurse #2 was assisting STNA #11 with care and noted bruising on the resident's left ribs, left shoulder and left upper arm. The resident stated, I don't know what happened. Nurse #2 asked the resident if she was in pain and the resident stated, No. Nurse #2 notified the physician and obtained a new order for x-rays of the left ribs, left shoulder and left upper arm. Review of the x-ray results revealed they were completed on 10/02/16 at 2:20 P.M. and indicated early healing of the left humeral neck fracture and normal left rib series. The facility completed investigations of the resident's injuries, however there was no evidence that the injuries of unknown origin were immediately reported to the state agency as required. This was verified with the Director of Nursing on 10/26/16 at 11:40 A.M. Review of the the facility's Nursing Policy and Procedure dated 10/18/01 indicated the definition of an Injury of Unknown Source existed when the source of the injury was not observed by any person or could not be explained by the resident, and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time or incidence of injuries over time. The policy also indicated all injuries of unknown origin will be reported to the Ohio Department of Health immediately after the incident was discovered. This deficiency substantiates Complaint Number OH 546.

Based on observation, record review and interview, the facility failed to arrange care plan conferences to develop an interdisciplinary plan of care for Resident #56. This affected one of three residents whose families were interviewed . The facility census was 97. Findings include: Resident #56 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 05/04/13 revealed the resident had severe cognitive impairment. The resident required extensive assistance to meet her daily needs. The assessment nurse noted that no family/guardian or legally authorized representative participated in the assessment. Review of the psychosocial quarterly assessment dated [DATE], revealed a resident interview was attempted without success. Social Service Designee (SSD) #1 noted that the staff was interviewed and reported the resident was having periods of inattention, disorganized thinking, feeling tired (napping throughout the day), and trouble concentrating. The resident was referred to psychological services. On 07/23/13 at 10:00 A.M., during an interview, the resident's family member reported they were not invited to participate in the care planning conferences for Resident #56. On 07/23/13 at 11:50 A.M., during an interview with SSD #1 and the director of admissions and marketing, the director stated both he and SSD #1 were involved in social services. He stated they did have initial care conference meetings scheduled on admission. SSD #1 stated that prior to last week, she would offer the care conferences on a "need be basis". She stated that she was now calling resident families to ask if they want to participate in care conferences in July 2013. She stated there was no policy change. The administrator joined the meeting and provided a copy of the 08/06/06 policy regarding the Plan of Care meetings. Review of the policy revealed that on admission, the residents were offered an initial care conference meeting and were informed they may request a care conference meeting at any time. The policy stated that periodic letters would be sent to families /responsible parties. The administrator stated that meant the letters could be sent anytime. SSD #1 stated that the facility used to send out quarterly letters, but were instructed to stop sending those approximately two years ago. She verified the care plans were reviewed and updated quarterly by the care plan nurse. There was no evidence the resident/responsible parties were afforded the opportunity to participate in development of the individualized care plans that were reviewed and updated quarterly.

Based on record review and interview, the facility did not ensure the environment was free from accidents hazards for one resident (Resident #96). This affected one (Resident #96) of three resident records reviewed for accidents. The facility census was 92. Findings include: Review of the medical record revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's notes dated 05/07/13 at 7:45 P.M. revealed two state tested nuring assistants (STNA) transfered Resident #96 from the bed to her recliner chair, located at the foot of her bed. The STNA's used a mechanical lift (medilift) and the wheel of the lift caught on the cords from the specialty air mattress control box which was attached to the footboard. This caused the medilift to stop abruptly, the momentum caused the sling to shift forward and the resident struck her face on the medilift. Resident #96 suffered a hematoma on her forehead, discoloration to the bridge of the nose and an open area to her right lateral nose. An interview with the director of nursing (DON) on 06/17/13, at 3:30 P.M. verified STNA #100 and STNA #101 did not ensure the floor around and under the bed was clear of obstacles prior to transferring the resident. Review of staff inservice records revealed STNA #100 and STNA #101 attended an in-service on 10/15/12 for using mechanical lifts and "making sure the area between the bed and chair are free of obstacles." The DON revealed no in-services were provided to the staff after this incident. This citation substantiates the allegation under accidents in complaint number OH 440.

Based on observation and interview, the facility did not ensure residents had accurate information or awareness of the long term care ombudsman. This affected all residents in the facility. The census 113 residents. Findings include: On 04/16/12 at 2:30 P.M., interview with Resident #50 revealed she did not know about the ombudsman. On 04/16/12 at 5:00 P.M., Resident #81 was asked if she knew who the ombudsman was and what the ombudsman did. Resident #81 replied, "No never heard of that." On 04/19/12 at 10:10 A.M. a list of state agencies was observed on the bulletin board in the common hallway. The information regarding the Area Agency on Aging ombudsman program was outdated and did not contain the current toll free number to contact the long term care ombudsman program. Interview with the director of nursing and the administrator on 04/19/12 at 10:12 A.M. confirmed the posting on the bulletin board.

Based on observation, staff interview, policy review and medical record review, the facility failed to ensure a full tray lap board was properly assessed and care planned as a restraint and was the least restrictive device and required to treat the resident's medical symptoms. This affected one of six residents reviewed for restraints (Resident #57). The facility census was 111. Findings include: Review of the medical record for Resident #57 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physicians' orders revealed on 10/01/09 a full lap board tray was ordered to be placed on the resident's wheelchair for positioning and increase awareness of the right upper extremity. Review of the resident's care plans revealed no care plan was initiated for the care and use of the resident's full lap board tray. Review of the physical therapy discharge summary dated 02/04/10 revealed Resident #57 was good with her dynamic sitting balance. The resident was able to spontaneously right herself when needed in order to reduce the risk for falls and facilitate her upright posture. Resident #57 was able to ambulate in the parallel bars with moderate assistance and the use of a right upper arm sling and a right leg brace. Resident #57 showed improved technique with increased safety during ambulation. Review of the annual and quarterly rehabilitation service screenings dated 08/04/10, 11/04/10 and 02/03/11 revealed Resident #57 had no change in her status and no therapies were required at those times. Review of an assessment for the full lap tray dated 02/12/11 revealed the lap tray was not a restraint because it did not prohibit movement and the resident was unable to physically get up. Observations made on 02/15/11 at 11:10 A.M. and 2:32 P.M. and on 02/16/11 at 8:15 A.M. revealed Resident #57 sitting up in her wheelchair with a full lap tray table intact and fastened with a belt and clip around the back of the wheelchair. Observations revealed Resident #57's right side was flaccid but the resident was observed drinking water with her left hand. On 02/16/11 at 2:40 P.M., an interview with State-tested Nurse Aide (STNA) #2 verified Resident #57 was unable to release the full lap tray table without help from staff. STNA #2 revealed Resident #57's right side was affected by her stroke but her left side worked "very good." STNA #2 indicated the resident was able to feed herself, assist with her care and was able to stand and pivot on her left leg for transfers. On 02/17/11 at 9:19 A.M., an interview with the director of nursing (DON) and Registered Nurse (RN) #1 verified Resident #57 could not remove the lap table independently, a care plan for the care and use of the lap table was not initiated and the facility had no evidence to indicate a less restrictive device was attempted. Review of the facility's policy and procedure for restraints (dated 2006) revealed physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy continued to indicate the resident must be physically and cognitively able to self-release devices such as Velcro lap trays or tables, seat belts with Velcro or easy snap seat belts. If the resident cannot mentally or physically self-release, then the device is considered a restraint.

Based on observation, record review, facility policy and procedure review, Centers of Disease Control (CDC) 2007 guidelines for isolation precautions review, and staff interview, the facility failed to appropriately maintain contact isolation precautions for two of 24 sampled residents (Resident #1 and Resident #22). The facility census was 111. Findings include: 1. During tour of the facility on 02/15/11 at 8:45 A.M. through 9:00 A.M., Registered Nurse (RN) #1 identified two residents (Resident #1 and Resident #22) were in isolation. Resident #22 was found to have no personal protective clothing (gowns, gloves, masks, etc.) anywhere in the hallway by the resident's door or in the resident's room. Two large garbage cans with lids, one yellow and one red in color, were observed far inside of the room, far across from the entrance of the room. RN #1 verified there was no personal protective clothing equipment (PPE) in or out of the resident's room for staff to put on when entering. Resident #1's room was found to have no sign posted on the door before entering the room to indicate to see the nurse before entering. Two large garbage cans with red and yellow lids were noted in the resident's room, also located far away from the entrance of the room. PPE was noted, but was not at the entrance of the resident's door. The PPE was noted far in the resident's room on a counter at the back of the room. RN #1 verified both rooms as not being equipped with infection control items appropriately. 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 01/31/11, revealed the resident was severely impaired in cognition for decision making and required extensive assistance by two staff for all activity of daily living events including bed mobility, transferring and toileting. The MDS assessment revealed the resident was occasionally incontinent of both bowel and bladder function. Nursing notes on 02/01/11 at 3:09 P.M. revealed a physician who was covering for the resident's primary physician was made aware by staff of the resident's increased incontinence of bowel and that the resident was unaware of the incontinence. The physician ordered a stool specimen to be obtained and sent to the laboratory. The stool specimen results returned on 02/05/11 positive for [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE). On 02/07/11, the resident was ordered to be placed in contact precautions. A sensitivity was ordered from the physician and on 02/11/11 an antibiotic ordered, [MEDICATION NAME], 400 milligrams (mg) two times a day for 10 days for the resident. A plan of care for infection in stool, dated 02/08/11 revealed the resident was in contact precautions. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 12/08/10, revealed the resident was cognitively intact for decision making but required extensive assistance by two staff members for bed mobility, transferring and toileting. Resident #1 had a surgical debridement done to the right foot wound on 11/30/10 prior to admission in the facility. The wound to the right foot was found to have [MEDICATION NAME]-Resistant Staphylococcus Aureus (ORSA) in the wound. The resident was ordered for contact precautions on admission. A plan of care for an ORSA infection to the right foot wound dated 12/03/10 revealed interventions but did not indicate for the resident to be on contact precautions. On 02/15/11, the resident was started on a second antibiotic medication, [MEDICATION NAME] VK, 500 mgs four times a day for two weeks for the wound infection. Review of the facility policy and procedure for "Infection Control-Isolation, Initiating" (dated revision July 2006) revealed the following: When isolation precautions are implemented, the unit manger, the infection control coordinator or designee shall be sure an adequate array of PPE is maintained near the isolation room so that appropriate PPE clothing can be easily put on when entering the room. The policy also indicated to post appropriate isolation notice on the room entrance door and above the bed in a room with two residents so that all personnel will be aware of isolation precautions. Review of the facility "Drug Resistant Organisms: General Information" for ORSA revealed that for resistant strains of staphylococcus aureus, the primary means of transmission is contact. Elderly and debilitated people were particularly susceptible to these organisms. For VRE, certain populations were at greater risk; critically ill, immuno-compromised, recent surgery and prolonged hospital stay. It can be spread person-to-person or environmentally such as through contaminated equipment. The policy identified contact precautions as, in addition to standard precautions normally used on all residents for blood and body fluid precautions. Implement contact precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. On 02/17/11 at 10:00 A.M., review of the Centers of Disease Control (CDC) 2007 guidelines for isolation precautions revealed: Clinical and laboratory coats or jackets worn over personal clothing for comfort and/or purposes of identity are not considered PPE. When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces. During interview with the director of nursing (DON) on 02/17/11 at 9:15 A.M., she verified both rooms of Resident #1 and Resident #22 were not set up properly for contact isolation procedures. She verified that, if a resident in either room needed emergency assistance, no PPE would be available for the staff to put on if they needed to.