Every finding on record at Masternick Memorial Health Care Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record reviews and staff interviews, the facility failed to ensure confidentiality of residents' protected health information. This affected 12 of 12 residents (#30, #57, #90, #91, #92, #93, #94, #95, #96, #97, #98 and #99) reviewed for confidentiality of records. The census was 84. Findings include:Review of an email dated 04/30/26 and timed at 4:41 P.M. to Administrator from Resident #20's son revealed he was notifying the facility of the breach of protected health information. He stated the facility sent a total of 786 pages on 04/29/26 at 3:34 P.M. that included information on 12 other residents. He did not disclose the names in this email. He requested the Administrator forward the email to the Privacy Office/Compliance Officer.Interview on 05/29/26 at 1:06 P.M. with Administrator and Quality Assurance Nurse (QAN) #220 verified there was a breach of protected health information of 12 residents on 04/28/26 when the facility scanned requested medical information for Resident #20 to his son. Resident #20's son discovered other residents' information amongst his father's medical record and informed the facility via email.A skilled progress note including protected health information for each of the following residents was sent to Resident #20's son along with his father's requested information: Resident #30, Resident #57, Resident #90, Resident #91, Resident #92, Resident #93, Resident #94, Resident #95, Resident #96, Resident #97, Resident #98, and Resident #99,Interview on 05/29/26 at 2:57 P.M. with Managed Care Coordinator (MCC) #250 verified she was the one who scanned other residents' information while fulfilling the release of medical records request from Resident #20's son. She stated she had printed a report from their electronic medical record (EMR) by typing the first few letters of Resident #20's name. She stated it printed to her printer and saw Resident #20's name on the top page. She scanned the information in a secured email to Resident #20's son. After discovering the breach, the facility determined multiple residents' were selected while printing the report. MCC #250 stated Resident #20's names was on top (alphabetically) and she did not think to look at the rest of the pages.Review of the facility policy titled Protected Health Information HIPAA Control Policy, dated 10/2013, revealed it was the policy of this facility to handle, store, and communicate our residents and employees protected health information (PHI) in accordance with current federal, state, and local regulations. The facility was to assure that release of PHI was only done by staff authorized to do so and that request/release were logged.The deficient practice was corrected on 05/06/26 when the facility implemented the following corrective actions: -Corporate QA (QAN #220) audited residents' documents on 04/30/26 to ensure only the resident's documents were in the chart.-Ad hoc QAPI completed on 05/01/26 which included the Medical Director to review the Abuse/neglect policy.-All staff were educated on HIPAA policy and abuse policy from 05/01/26 through 05/06/26.-Managed Care Coordinator (MCC) #250 was in-serviced by Administrator on 04/30/26 on HIPAA and Privacy policy.-All affected residents and resident representatives were notified of breach via phone and in writing by the facility and QAN #220 on 05/01/26. There were no concerns voiced by residents or resident representatives.-QAN #220 reported HIPAA breach to the Civil Rights Department on 05/05/26.-Medical Records #200 audited five days a week for four weeks to ensure medical records uploaded into EMR were uploaded to the correct resident.This deficiency represents non-compliance investigated under Complaint Number 3011361.

Based on review of facility policies, review of facility invoices, review of the Ohio Revised Code, and interviews, the facility failed to charge a reasonable price for request of medical records for Resident #3's representative. This affected one resident (#3) of three residents who requested records. The facility census was 86.Findings include:Review of the medical record for Resident #3 revealed he was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, anemia, and malignant neoplasm of the left lung with metastasis to the brain. Resident #3 was listed as his primary contact with his son listed as financial and medical power of attorney (POA).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had mild cognitive impairment. Resident #3 required moderate assistance for all activities of daily living.Review of the care plan dated 02/28/26 revealed Resident #3 desires to return to the community. Resident #3's son and daughter-in-law were involved in his care and discharge plans. Interventions included to involve resident and family in discharge planning and provide contact numbers for community resources.Review of the emails from Resident #3's son to the facility revealed he requested medical records on 04/13/26. He requested them electronically by completing the facility form electronically, and they were provided to him on 04/16/26 electronically. Resident #3's son requested more medical records on 04/27/26. On 04/28/26 he was provided with two invoices, both dated 04/28/26 stating he owed $315.21 for the first set of medical records and $334.35 dollars for the second set of medical records. The second set of medical records, the ones requested on 04/27/26, will not be provided until the invoices were paid.Interview on 04/29/26 at 11:15 A.M. with Regional Quality Assurance Manager #519 revealed she did send the first request of medical records to Resident #3's son on 04/16/26. She reported she was not aware Resident #3's son paid the fee for medical records as per the facility policy. So, he sent two invoices on 04/28/26, one for the medical records received on 04/16/26 and the ones requested on 04/27/26. She reported she was not going to send the records requested on 04/27/26 until Resident #3's son paid the invoices.Telephone interview on 04/29/26 at 12:48 P.M. with Resident #3's son revealed he did receive the first set of medical records he requested on 04/13/26 on 04/16/26. He reported he has only requested them electronically and only wanted to receive them electronically. He reported he requested more records on 04/27/26 and received two invoices totaling almost $800 and did not know why. He also reported staff informed them he would not receive the 04/27/26 records until the invoices were paid.Telephone interview on 04/29/26 at 2:55 P.M. with Corporate Medical Records #521 and Regional Quality Assurance Manager #519 revealed that Resident #3's son requested the medical records on 04/07/26 and the Corporate Medical Records #521 did not receive the request until 04/13/26. She sent the medical records electronically on 04/16/26. She also confirmed the second request was made on 04/27/26 and they were still processing that information awaiting the son to pay the invoices for the first set of medical records and they were not going to send the second set until the invoices were paid. Both parties confirmed the invoices totaled over $600 dollars based on their fee schedule and he did not receive those invoices until 04/28/26. Both parties also confirmed that Resident #3's son requested those forms by filling out the request electronically and only wanted electronic copies of the information.Review of the facility policy clinical records, revised May 2018, revealed a clinical medical record is maintained for each resident in accordance with accepted professional principles. All records pertaining to the residents will be provided within 48 hours (excluding weekends and holidays) upon written request from the residents. The charge for making photocopies will be in accordance with ORC Section 3701.742.Review of the facility authorization for release of medical information, revised February 2021, revealed in bold letters, please be advised that there may be fees for copies of the above items in accordance with Ohio Revised Code Section 3701.742.Review of the fee for copy of medical records, undated, revealed the first 10 pages $3.18 per page, next 40 pages $0.66 per page, and pages 51 and up are $0.27 per page.Review of the Ohio Revised Code 3701.742 fees for providing copies of medical records, effective 10/03/23, revealed if the request is made by a person identified in division (B)(1)(a) of this section and the request is for access to digital records or electronically transmitted records, the total cost for that access or for the electronic transmission, and all related services, shall not exceed fifty dollars.This deficiency represents non-compliance investigated under Complaint Number 2989431.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure catheters were maintained in clean and sanitary manner. This affected one resident (#10) of two residents reviewed for catheters. Facility census was 87.Findings include:Review of Resident #10's medical record revealed an admission date of 06/21/22 and diagnoses including dementia without behavioral disturbance, mood disturbance and anxiety, malignant neoplasm of sigmoid colon, low back pain, anorexia, insomnia, depression, obesity, and hemiplegia and hemiparesis following cerebral infarction. Review of Resident #10's physician's orders as of 03/11/26 revealed an order dated 01/03/25 for empty catheter collection bag when half full and each shift for catheter care and an order dated 03/20/25 to cleanse supra-pubic stoma with normal saline and apply a split sponge every night shift. Review of Resident #10's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had moderate cognitive impairment, did not reject care and had an indwelling catheter. Resident #10 required partial to moderate assistance with personal hygiene and was dependent on staff for toileting and bathing. Review of Resident #10's annual bladder incontinence evaluation dated 01/29/26 revealed Resident #10 needed staff assistance to get to the toilet, could not adjust his own clothing and required the use of briefs/pads. Resident #10 continued to have an indwelling catheter due to urinary retention that could not be treated or corrected medically or surgically and for which alternative therapy was not feasible. Review of Resident #10's care plans revealed a plan of care dated 11/01/24 and revised 01/06/25 revealed Resident #10 had a suprapubic catheter due to diagnosis of obstructive uropathy, benign prostatic hyperplasia and history of urinary tract infections and the need for antibiotic treatment.Observation on 03/11/26 at 9:32 A.M. revealed Resident #10 was up in his wheelchair in the activity room and his urinary collection bag, while attached to his wheelchair, was dragging on the ground.Interview on 03/11/26 at 9:34 A.M. with Restorative Registered Nurse (RRN) #112 verified the urinary collection bag was hanging too low on the bar of Resident #10's wheelchair and confirmed the bag was not to be on the floor.Observation on 03/11/26 at 2:37 P.M. revealed Resident #10 was resting in bed and his urinary collection bag was attached to the bed and dragging on the ground.Interview on 03/11/26 at 2:48 P.M. with Registered Nurse (RN) #121 verified the urinary collection bag was on the floor and should not have been. RN #121 stated the staff who put Resident #10 into bed was responsible for the appropriate positioning of his catheter bag at that time.During an interview on 03/11/26 at 2:53 P.M. the Director of Nursing (DON) was made aware of the above observations and confirmed the facility expectation was that urinary collection bags were not to be on the floor.Review of the facility policy, Catheter Management, Indwelling Urinary, revised November 2024 revealed the facility would administer routine care when indwelling urinary catheter is ordered and in place. The routine care protects and reduces the risk of infection, complications and therapy and promotes comfort. The policy did not address catheter bags being on the floor.

Based on observation, record review, and interview, the facility failed to ensure a pressure ulcer for Resident #35 received appropriate assessments and monitoring. This affected one resident (Resident #35) of one residents reviewed for pressure ulcers. The total census was 87.Findings includeRecord review of Resident #35 revealed he was admitted to the facility on [DATE] and had diagnoses including sepsis, dementia, Parkinson's disease, and a stage 4 (full thickness) pressure ulcer dated 02/09/26. He had an order from 01/22/26 to 02/02/26 for an alginate and gauze dressing to a lower spinal pressure ulcer daily, and a current order dated 02/10/26 for the lower spine pressure ulcer to be treated with Santyl and a foam dressing. His minimum data set assessment dated [DATE] revealed he had severe cognitive impairment, was dependent on staff for bed mobility, and had one stage 4 pressure ulcer which was not present on admission.Record review of Resident #35's wound assessments and progress notes revealed he was identified to have a new wound on 01/22/26 measuring 2 centimeters (cm) by 2 cm, with a depth of 0.2 cm. It was identified as a stage 2 (partial thickness) pressure ulcer covered by granulation (tissue characteristic of a healing wound). His wound assessment dated [DATE] identified it as an unstageable pressure ulcer measuring 5.5 cm by 6.0 cm and was covered by slough (devitalized tissue commonly found in non-healing wounds). No progress notes indicated the wound was noticed to have declined before the 01/29/26 assessments. He was hospitalized the same day for suspected sepsis. Hospital documentation revealed the wound was not septic, and he returned to the facility on [DATE]. The wound was assessed that day to be a stage 4 pressure ulcer measuring 6 cm by 5 cm with no measured depth. No depth was measured on the wound assessments following this on 02/17/26, 02/24/26, and 03/03/26. All of the assessments were documented done by only Licensed Practical Nurse (LPN) #111.Interviews with LPN #111 on 03/11/26 at 10:38 A.M. and 5:12 P.M. revealed she served as the facility's wound nurse. She said they did not know exactly how Resident #35 acquired his spinal wound, but she identified it as a pressure ulcer due to its location. She initially identified it as a stage 2 pressure ulcer. When she assessed it later it was larger and the resident had unstable vital signs so she had him hospitalized for possible sepsis. The hospital debrided the wound and it was a stage 4 pressure ulcer on his return. LPN #111 clarified Resident #35's primary physician saw the wound, but it was she who assessed its stage. The facility had not had a contracted specialist wound practitioner since the wound developed and none had seen Resident #35 during his stay. The facility was currently using the wound care orders sent back by the hospital. For the wound care prior to Resident #35's hospitalization, LPN #111 said the primary physician asked her opinion and agreed on her suggestion to use alginate. She confirmed multiple assessments were missing measurements for wound depth.Interviews with the Director of Nursing and Registered Nurse #120 on 03/11/26 at 11:31 A.M. revealed they did not know how long the facility had been without a wound practitioner. LPN #111 did all assessments and staging of pressure ulcers at the facility.Observation of wound care for Resident #35 by LPN #111 on 03/11/26 at 12:50 P.M. revealed his sacral wound appeared to be a stage 4 pressure ulcer which was clean and with no sign of infection. Orders and proper infection control were followed during the wound care. LPN #111 measured the wound as 5 cm by 5 cm. The surveyor prompted her to measure the depth, and found it to be 1 cm.Record review of the wound care policy dated 12/2025 revealed that when wounds were identified, the physician was to be notified, specialists were to be followed with as ordered, and any decline was to be reported.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, facility investigation review and facility policy review, the facility failed to ensure Resident #52 did not leave the facility without staff knowledge. This affected one (Resident #52) of three residents reviewed for elopement. The facility identified nine (Residents #6, #42, #52, #56, #64, #69, #70, #72 and #73) at risk for elopement. The facility census was 82.Findings include:Review of the medical record for Resident #52 revealed an admission date of 10/01/25. Diagnoses included dementia, hypertension, anxiety, and skin cancer.Review of the elopement risk evaluation dated 10/01/25 revealed Resident #52 was not at risk for elopement.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was severely cognitively impaired. He required help for eating, supervision for oral care, dressing, hygiene and toileting and partial assistance for showering. He was independently mobile.Review of the physicians' orders for January 2026 revealed Resident #52 had been wearing a Wanderguard (a bracelet worn on the wrist or ankle of a resident to alert staff if they try to leave the building) which was ordered on 10/02/25.Review of the nursing progress note dated 11/17/25 at 7:16 P.M. revealed at approximately 11:00 A.M., nursing staff received a phone call from a female who was driving in the area and spotted Resident #52 walking in the community. An elopement code was called, and two staff were sent by a car to the area where the resident was seen. Emergency services were also called and were en route to the location where the resident was last seen. At 11:14 A.M. the resident was located by police and emergency medical services (EMS), and the resident was returned to the facility. The physician was notified and a head-to-toe assessment was completed. Resident #52 was placed on one-to-one supervision. Resident #52's vital signs included blood pressure 149/75, heart rate 61, pulse ox 99% on room air, temperature 97.5 degrees Fahrenheit (F) and respirations 16.Interview on 02/05/26 at 7:47 A.M. with the Administrator revealed the facility received a phone call from the police that Resident #52 was walking down the street, and they were bringing him back. The facility assessed the situation and determined Resident #52 broke the screw that secured his window in his room, removed the screen from his window and placed it under his bed and climbed out his bedroom window. She revealed the last time he was seen was shortly after breakfast, at approximately 8:40 A.M. The call that he was found came in approximately an hour and a half later.Review of the facility investigation dated 11/17/25 revealed Resident #52 was last seen by a staff at approximately 8:40 AM. He was observed walking to his room, lying on his bed and shutting his door, which was his normal routine. Resident #52 resided on the secured memory care unit and had a Wanderguard in place beginning from admission. Resident #52 went out his bedroom window and broke the safety screw off the window and removed the screen. The temperature was identified as 40 degrees F. Resident #52 was wearing a sweatshirt and T-shirt, long pants and shoes. Resident #52 was located approximately 2.5 miles from the facility. The facility notified the local police department, the physician, the power of attorney (POA) and immediately conducted an elopement code. The resident was returned to the facility by local police, and a head-to-toe assessment was completed. No injuries were noted; Resident #52 was placed on one-to-one supervision. Resident #52 stated he went out the window and was going away. He returned to the facility with a pillowcase and shopping bag of personal items including washcloths, towels, and clothing.Interview on 02/05/26 at 12:41 P.M. with Licensed Practical Nurse (LPN) #201 says a friend of Resident #52's called the facility and said they saw him walking down the street. She revealed facility staff immediately started looking for him and called EMS who brought him back in. She revealed there was nothing remarkable about his behavior that day, he was calm, pleasant and cooperative. She said it was common for him to stay in his room with the door closed and was independent in most of his activities of daily living (ADL). She revealed he made no mention of being agitated or wanting to leave the day he eloped.Interview on 02/05/26 at 1:07 P.M. with the Certified Nurse Aide (CNA) #202 confirmed Resident #52 went to his room to lie down after breakfast at approximately 8:40 A.M. She also confirmed he was independent with most of his ADL, and was last seen at approximately 8:40 A.M.Interview on 02/05/26 at 1:26 P.M. with the Administrator confirmed the facility had been taking additional measures to address any future potential elopements.Review of the facility policy titled Wandering/Elopement, dated October 2025, revealed an elopement was defined as a resident leaving a home or safe area without the facilities knowledge or without supervision. If a resident eloped, the facility would immediately follow a missing person's procedure and document the elopement.The deficient practice was corrected on 11/18/25 when the facility implemented the following corrective actions: - Immediately upon return to the facility, Resident #52 was assessed by LPNs #201 and #204 and no negative outcomes or injuries were noted. - On 11/17/25, Resident #52's bedroom window was resecured by Maintenance Director #205 and Activity Director #206. - On 11/17/25, the facility interviewed all staff working at the time of the incident RN #207 and the Director of Nursing (DON).- On 11/17/25 all residents with Wanderguards were checked to ensure they were in place and functioning by Registered Nurse (RN) #207.- On 11/17/5, all windows on the secured unit were rechecked to ensure they were secured by the DON and Activity Director #206.- On 11/17/25, all residents' elopement evaluations were reviewed by the DON and LPN #208.- On 11/17/25, all elopement books were reviewed for accuracy by RN #207.- On 11/17/25, all facility staff were re-educated on the wandering/elopement and abuse/neglect policies by RN #207, the DON and the Administrator.- Beginning on 11/17/25, all windows on the secured unit were checked for security daily for five days per week for two weeks by the DON, the Administrator, and LPN #209. - Beginning 11/18/25, elopement drills were completed three times per week on varying shifts for four weeks by RN #207, the DON, and the Administrator.- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 11/18/25 to review the occurrence. This deficiency represents noncompliance investigated under complaint number 2684732.

Based on record review and interview, the facility failed to ensure Resident #146's allegation of misappropriation of personal property was promptly reported to the state agency as required. This affected one resident (Resident #146) of two residents reviewed for misappropriation of personal property. The facility census was 80. Findings include: Review of Resident #146's medical record revealed the resident was admitted on [DATE] and discharged home on 11/23/24 with diagnoses including displaced fracture of the olecranon process, bipolar disorder and need for assistance with personal care. Review of Resident #146's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #146's Missing Items Report form dated 11/22/24 revealed the Social Worker and Administrator spoke with the resident in his room. Resident #146 provided a description of a missing item as a gold chain with cross. Resident #146 stated a male aid was in his room around 7:00 P.M. on 11/19/24 and offered to move items from a nightstand to the bathroom. Resident #146 declined and used the restroom between 7:50 P.M. and 8:00 P.M. and stated the necklace was missing. Resident #146 stated the male Certified Nursing Assistant (CNA) never returned to his end table and he notified staff immediately by call light. Review of the Witness Statement form dated 11/21/24 and authored by Certified Occupational Therapy Assistant (COTA) #915 revealed at 2:00 P.M. on 11/19/24, Resident #146 was returned to his room, and his crucifix necklace was on the nightstand by the bed. Review of the Witness Statement form dated 11/21/24 authored by Nurse Aide Supervisor (NAS) #812 revealed CNA #859 was interviewed over the phone. CNA #859 stated the last time he had observed the crucifix necklace was when he had toileted the resident and noticed the resident's neck was extremely red and irritated. He asked the resident if he wanted to take off the necklace to relieve the irritation it caused, and the resident agreed. CNA #859 said the necklace was placed on the bathroom sink. CNA #859 stated the last time he was in Resident #146's room was around 7:00 P.M. to empty the bathroom trash. An interview with NAS #812 was unable to be obtained due to NAS #812 being on vacation at the time of the survey. Interview on 03/03/25 at 12:00 P.M. with the Administrator revealed she spoke to Resident #146's sister about the missing necklace and then spoke to Resident #146 who identified CNA #859 as the aid who misplaced or took the necklace as this was the last person to have the necklace. The Administrator stated she interviewed CNA #859 who had reported he took the necklace off Resident #146 because it was rubbing the resident's neck. The Administrator confirmed CNA #859 placed the necklace on the bathroom sink and then the necklace was moved for some reason to the resident's nightstand where it disappeared. The Administrator confirmed she was unable to find the necklace. An additional interview on 03/03/25 at 2:08 P.M. with the Administrator indicated she did not realize she was supposed to file a misappropriation Self-Reported Incident (SRI) with the state agency for Resident #146's missing necklace. Telephone interview on 03/03/25 at 2:51 P.M. with CNA #859 stated he helped Resident #146 take off his necklace and had observed the resident lay the necklace in the sink. CNA #859 denied he lost the necklace, threw the necklace away or took the necklace home. He was unaware of what happened to the necklace after his shift ended. Review of the facility policy titled Abuse Allegation Investigation, dated 10/2022, revealed the facility administrator or his/her designee will ensure the allegation was reported to the State Agency and if the allegation/incident was a suspected crime, reported to law enforcement as outlined in the Suspected Crimes policy. This deficiency represents non-compliance investigated under Complaint Number OH00161951.

Based on record review and interview, the facility failed to ensure an allegation of misappropriation of resident property was throughly investigated for Resident #146. The affected one resident (Resident #146) of two residents reviewed for misappropriation. The facility census was 80. Findings include: Review of Resident #146's medical record revealed the resident was admitted on [DATE] and discharged home on 11/23/24 with diagnoses including displaced fracture of the olecranon process, bipolar disorder and need for assistance with personal care. Review of Resident #146's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #146's Missing Items Report form dated 11/22/24 revealed the Social Worker and Administrator spoke with the resident in his room. Resident #146 reported a missing gold chain with cross. Resident #146 indicated a male Certified Nursing Assistant (CNA) was in his room around 7:00 P.M. on 11/19/24 and offered to move items from the nightstand to the bathroom. The resident declined and used the restroom between 7:50 P.M. and 8:00 P.M. and the necklace was missing. Resident #146 stated the male CNA never returned to his end table and he notified staff immediately by call light. Review of the facility investigation documents provided by the facility and dated 11/21/24 through 11/25/24 revealed no interviews with other residents were conducted to see if other residents may have had details regarding the allegation. The only resident interview conducted was with Resident #146. Review of the Witness Statement form dated 11/21/24 and authored by Certified Occupational Therapy Assistant (COTA) #915 revealed at 2:00 P.M. on 11/19/24, the resident was returned to his room, and his crucifix necklace was on the nightstand by the bed. Review of the Witness Statement form dated 11/21/24 and authored by Nurse Aide Supervisor (NAS) #812 revealed the CNA #859 was interviewed over the phone. CNA #859 stated the last time he had observed the crucifix necklace was when he had toileted the resident and noticed the resident's neck was extremely red and irritated. He asked the resident if he wanted to take off the necklace to relieve the irritation it caused, and the resident agreed. CNA #859 said the necklace was placed on the bathroom sink. CNA #859 stated the last time he was in Resident #146's room was around 7:00 P.M. to empty the bathroom trash. Interview on 03/03/25 at 12:00 P.M. with the Administrator indicated she spoke to Resident #146's sister about the missing necklace and then spoke to Resident #146 who stated CNA #859 misplaced or took the necklace as this was the last person to have the necklace. The Administrator stated she interviewed CNA #859 who had reported he took the necklace off Resident #146 because it was rubbing the resident's neck. The Administrator confirmed CNA #859 placed the necklace on the bathroom sink and then the necklace was moved for some reason to the resident's nightstand where it disappeared. The Administrator confirmed she was unable to find the necklace. An additional interview on 03/03/25 at 2:08 P.M. with the Administrator indicated she did not realize she was supposed to file a misappropriation Self-Reported Incident (SRI) with the state agency for Resident #146's missing necklace. She confirmed Resident #146 and the resident's family were the only resident interviews completed during the investigation. Review of the facility policy titled Abuse Allegation Investigation, dated 10/2022, revealed the facility would immediately investigate all allegations and interview all residents that may have details regarding the allegation. This deficiency represents non-compliance investigated under Complaint Number OH00161951.

Based on observation, interview and record review, the facility failed to ensure adequate infection control measures following a blood glucose test for Resident #79. This had the potential to affect any of the other 23 residents residing on the North C unit, Residents #5, #9, #17, #21, #23, #30, #31, #35, #36, #40, #41, #45, #46, #48, #50, #60, #68, #69, #72, #73 #74, #81 and #83. The facility census was 86. Findings include: An observation of a blood glucose (sugar) finger-stick test was completed on Resident #79 on 07/10/18 at 11:34 A.M. Registered Nurse (RN) #1 washed her hands, applied gloves and punctured the resident's finger. RN #1 obtained a drop of blood on a test strip and placed the strip into the glucometer. RN #1 obtained the reading. Without removing her gloves, RN #1 picked up the glucometer, lancet and soiled test strip, and exited the resident's room. RN #1 returned to the nurse's station and placed the glucometer on top of the medication cart. RN #1 discarded the lancet and test strip into the sharps container. RN #1 removed and discarded her gloves. RN #1 did not wash or sanitize her hands after removing the gloves. RN #1 opened the medication cart and removed two alcohol prep swabs. RN #1 cleaned the glucometer with the alcohol swabs and placed the glucometer inside the medication cart. RN #1 sanitized her hands. An interview was completed with RN #1 immediately following the observation 07/10/18 at 11:34 A.M. RN #1 verified the observation and concerns. RN #1 revealed she always cleaned glucometers with alcohol prep swabs after she used them. Review of the Handwashing/Hygiene Policy revised 06/2016 revealed: All personnel shall follow the established handwashing/hygiene procedures to prevent the spread of infection and disease to other residents, personnel and visitors. The policy directed staff to do handwashing after removal of gloves and before exiting a resident's room after providing personal care. Review of the facility Blood Glucose Monitoring policy revised 04/2018 revealed required equipment included alcohol wipes and Clorox germicidal wipes or Sanicloth Plus wipes. The same policy directed: wipe the glucometer with a germicidal wipe and use alcohol wipes to clean the resident's finger. Review of the undated manufacturer's information, Cleaning and Disinfecting the Easy Max LTC (Long Term Care) Meter revealed: After every use, follow both the cleaning and disinfection instructions, using the EPA (Environmental Protection Agency) registered disinfectant wipes to clean the glucometers.

Based on record review and interview the facility failed to provide showers for Resident #43 per her choice and preference. This affected one of three residents reviewed for bathing choices. The facility census was 94. Findings include: Resident #43 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident required extensive assistance with transfers and one assist with bathing. She was alert and oriented. On 01/24/18 at 1:30 P.M. interview with Resident #43 revealed she had a shower this morning (Wednesday). She said she was scheduled a shower on Monday, Wednesday and Friday. She said she got a shower Monday and today. She said last week she was ill and did not have a shower per her own request. The week prior she said she only had one shower. She said the staff would bring her bath water to bathe in bed if she missed a shower, but she did not get the three showers per week that she requested. The bathing preference dated 09/14/17 for Resident #43 revealed she chose a shower twice a week. The shower sheets revealed the resident was scheduled a shower on Monday, Wednesday and Friday. The documentation revealed the resident received two showers the first, second and third weeks in December from 12/03/17 through 12/23/17 and one shower the last week of December from 12/24/17 through 12/30/17. She received one shower the first and third weeks of January 2018 from 12/31/17 through 01/06/18 and 01/14/18 through 01/20/18. The resident did not receive the three showers per her choice for the past two months. This was verified with the director of nursing (DON) on 01/24/18 at 4:10 P.M. This deficiency substantiates Complaint Number OH 562.

Based on observation and interview the facility failed to ensure medications were stored with labels and in a safe manner. This had potential to affect 85 residents of 95 residents residing in the facility. Findings include: Observation on 05/16/17 at 4:01 P.M. with Licensed Practical Nurse (LPN) #10 revealed the medication cart for Resident room [ROOM NUMBER] through 131 on the north unit. Observation revealed five loose unpackaged and unlabeled pills in three of the four drawers in the medication cart. There were holes noted in the bottom of the medication cart drawers where the loose pills were found that were large enough for the pills to slip out. LPN #10 was present and confirmed this observation. Observation on 05/16/17 at 4:08 P.M. with Registered Nurse (RN) #11 revealed the medication cart for Resident room [ROOM NUMBER]-118 on the north unit. The medication cart was observed in the presence of RN #11 and eight loose unpackaged and unlabeled pills were found in the bottom of two of the three drawers of the medication cart. There were holes in the bottom of the drawers of the cart in which the loose pills were found that were observed to be large enough for the pills to fit through. RN #11 confirmed the observation. Interview on 05/16/17 at 4:09 P.M. with LPN #10 revealed the medication carts were checked for loose pills monthly on the sixth of the month when all the medication cards were removed and replaced in the cart. Observation on 05/16/17 at 4:15 P.M. with LPN #12 revealed the medication cart for the hall with Resident room [ROOM NUMBER] through 144 and Resident room [ROOM NUMBER]-154 on the south unit. The medication cart was observed with LPN #12 and one loose unpackaged and unlabeled pill in one of the four drawers of the medication cart was observed. There was a hole in the bottom of the drawer of the cart where the loose pill was laying which was large enough for the pill to slip through. LPN #12 confirmed this observation. The three carts that were observed with loose pills were contained in the north and south units in which 85 of the 95 residents residing in the building were located.

Based on observation, record review and interview the facility failed to maintain a medication error rate of less five percent. The medication error rate was calculated to be 5.88% with two medication errors of thirty-four opportunities. This affected one resident (Resident #74) of seven residents observed during medication administration. Findings include: Observation on 05/17/17 at 8:37 A.M. revealed Licensed Practical Nurse #13 was observed to prepare and administer 12 medications by mouth to Resident #74. The medications included Tylenol Arthritis extended release 650 milligrams (mg) and Potassium Chloride 20 milliequivalents (meq) extended release. LPN #13 was observed to crush the two medications and placed them in applesauce prior to administering the medications by mouth to Resident #74. Review of Resident #74's physician orders [REDACTED]. The resident also had a physician order [REDACTED]. Interview with LPN #13 and observation on 05/17/17 at 8:44 A.M. revealed the Potassium Chloride 20 meq packaging and the Tylenol Arthritis extended release 650 mg tablet packaging both indicated Do Not Crush. LPN #13 confirmed the medication packaging indicated to not crush the tablets. LPN #13 confirmed she crushed the medications and administered the medications (Tylenol arthritis 650 mg extended release and Potassium Chloride 20 meq extended release) to Resident #74 crushed in applesauce.

Based on observation, interview and review of the infection control and blood glucose monitoring policies, the facility failed to ensure proper infection control practices were followed during care. This affected three (Resident #92, Resident #26 and Resident #34) residents observed for infection control and had the potential to affect all 91 residents residing in the facility. Findings include: 1. Observation on 03/08/16 at 4:00 P.M. revealed glucometer testing (blood glucose testing) was conducted by licensed practical nurse (LPN) #105. LPN #105 took a glucometer out the top drawer of the medication cart and entered Resident #92's room. LPN #105 completed the procedure and returned the glucometer to the top drawer of the medication cart without cleaning the glucometer. On 03/08/16 at 4:26 P.M. an interview with LPN #105 verified she did not clean the glucometer before or after checking Resident #92's blood glucose levels. LPN #105 revealed she had a bad habit of not cleaning the glucometer between residents because sometimes she gets too busy. On 03/08/16 at 4:25 P.M. observation of the medication cart revealed that bleach germicidal wipes were available for use. Review of the policy and procedure for performing glucose monitoring dated April of 2013 revealed that step two of the procedure stated to wipe the glucometer with a germicidal wipe. Step eight stated to wipe the glucometer again with germicidal wipe after the procedure. Review of the policy for infection control dated March of 2011 revealed that all resident care items should be cleaned and disinfected before being used for another resident. Items should be cleansed according to the manufacturer's recommendations between resident uses. 2. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>Review of a physician's orders [REDACTED]. Observation on 03/09/16 at 9:24 A.M. revealed LPN #104 setting up a breathing treatment for [REDACTED]. LPN #104 poured the liquid medication into the chamber on the breathing mask and attached the lid. LPN #104 picked up the tubing for the breathing treatment of [REDACTED].#26's breathing mask. LPN #104 placed the mask over the resident''s mouth. Interview on 03/09/16 at 9:28 A.M. with LPN #104 verified she picked tubing up off of the floor, attached it to the resident's face mask and then applied the mask and started the breathing treatment. Review of the policy for infection control dated March of 2011 revealed that all items for resident care should be cleaned and disinfected and will be designated for that resident's use only. Items should be cleansed according to the manufacturer's recommendations. 3. Observation on 3/09/16 at 10:03 A.M. revealed Resident #34 getting catheter care from state tested nurse aide (STNA) #109. STNA #109 picked up a soap bottle while wearing soiled gloves and put the soap bottle into a backpack of supplies used for all of the residents. STNA #109 put all soiled linens into a bag and carried them to the dirty linen room. After leaving the dirty linen room, STNA #109 walked down the hallway, hugged a nurse and touched another resident before washing her hands. Interview with STNA #109 on 03/10/16 at 10:49 A.M. verified the above observations.

Based on observation and interview, the facility failed to ensure resident furniture and medical equipment was in good repair. This affected three (Resident #51, Resident #36 and Resident #94) of 34 residents residing on the South Unit. The facility census was 91. Findings include: 1. Observation on 03/07/16 at 9:14 A.M. revealed Resident #36's brown leather recliner had small tears on both arm rests, three tears on the seat, and one hole exposing the cushion. Resident #36's chair was in the common area of the South Unit. Interview on 03/09/16 at 2:23 P.M. with Housekeeping Supervisor #102 verified Resident #36's chair was torn. Housekeeping Supervisor #102 explained the chair was Resident #36's personal property. Interview on 03/10/16 at 9:35 A.M. with the Administrator verified the facility should notify family if a resident's chair is not in good condition. 2. Observation on 03/09/16 at 2:24 P.M. with Housekeeping Supervisor #102 revealed Resident #94's broda chair was cracked on the upper right corner. Housekeeping Supervisor #102 confirmed this observation. Interview on 03/10/16 at 9:35 A.M. with Administrator revealed the facility should have notified Hospice about Resident #94's broda chair being cracked. 3. Observation on 03/07/16 at 11:30 A.M. revealed the covering of the right arm of Resident #54's wheelchair was torn off, exposing the armrest padding. Interview on 03/09/16 at 2:25 P.M. with state tested nurse aide (STNA) #103 verified both armrests on Resident #36's wheelchair were torn exposing the armrest padding. Interview on 03/10/16 at 9:35 A.M. with the Administrator revealed the facility should replace a resident's wheelchair armrest if they are torn.

Based on observation, interview and record review, the facility failed to complete a significant change assessment. This affected one (Resident #92) of 16 residents reviewed for comprehensive assessments. The facility census was 91. Findings include: Resident #92 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #92 was discharged from the facility on 02/13/16 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #92's comprehensive assessments revealed the resident's last Minimum Data Set (MDS) assessment was completed on 01/22/16. Resident #92's record did not include a MDS assessment since the resident's readmission on 02/17/16. Interview on 03/09/16 at 8:58 A.M. with registered nurse (RN) #100 verified Resident #92 needed a significant change in condition assessment since the resident was readmitted on Hospice. RN #100 verified the assessment was not completed. Interview on 03/09/16 at 9:47 A.M. with Licensed Practical Nurse (LPN) #101 verified Resident #92 did not have an MDS assessment completed upon readmission and the assessment should have been completed on 03/01/16. LPN #101 explained she misread when Resident #92 was due for an assessment.

Based on record review and interview, the facility failed to provide restorative range of motion and ambulation programs as planned. This affected two (Resident #140 and #123) of three residents reviewed for activities of daily living. The facility census was 91. Findings included: 1. Review of the medical record for Resident #140 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assist for locomotion on the unit and off the unit. Review of admission physician orders [REDACTED]. Review of a facility Restorative Nursing Program evaluation for Resident #140 dated 12/09/15 revealed the resident was at risk of decline related to [MEDICAL CONDITION] joint disease and dementia. The Restorative Program to be initiated to maintain current function and prevent decline was identified as active range of motion (AROM) exercises to both upper and lower extremities six to seven days a week for 15 minutes and restorative ambulation six to seven days a week for 15 minutes. Review of Nursing Restorative Care Plan and Flow record revealed Resident #140 received restorative nursing care only four days in December 2015, five days in January 2016, one day in February 2016 and four days in March 2016 through the current date 03/10/16. There was no evidence the restorative program was offered or attempted at other times. Observation on 03/09/16 at 11:10 A.M. revealed Resident#140 seated in her wheelchair in the North hall resident lounge and the resident requested a ride to the dining room. An unidentified staff member propelled the resident in her chair to the dining room as requested. An interview with the restorative nurse, Licensed Practical Nurse (LPN) #107 on 03/09/2016 at 2:27 P.M. verified Resident #140 did not receive restorative services as planned. LPN #107 revealed frequently restorative aides were pulled from providing restorative care to replace call offs on the care units and then could not provide restorative to all the residents scheduled. LPN #107 revealed other facility staff were not assigned to provide the restorative programs on those days. 2. Record review for Resident #123 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of admission physician orders [REDACTED]. Review of the facility Restorative Nursing Program Evaluation for Resident #123 dated 02/23/16 revealed the resident was at risk for decline related to [MEDICAL CONDITION], arthritis of both hips and left knee and restorative care was initiated. The restorative program initiated to maintain current function and prevent decline was identified as active range of motion (AROM) exercises to both upper and lower extremities six to seven days a week for 15 minutes and restorative ambulation six to seven days a week for 15 minutes. Review of restorative documentation for Resident #123 revealed the restorative nursing program was initiated 02/23/16. The documentation revealed Resident #123 received the restorative AROM program only one day in February, on 02/27/15, and refused the ambulation on that day. Review of March restorative documentation revealed Resident #123 received restorative AROM nursing four times the first week between 03/01/16 and 03/07/16 and no restorative services to date between 03/08/16 and 03/10/16. Observation of Resident #123 on 03/08/16 at 1:50 P.M. revealed the resident in a movie activity seated in her wheelchair. Following the movie at 2:55 P.M., staff propelled the resident in her chair to her room for toileting and wound observation. Following the toileting at 3:15 P.M. Resident #123 self propelled her wheelchair out of the room using her feet only. The resident walked the chair approximately ten feet and then requested assistance from staff, stating she was tired. Interview with LPN #107 on 03/10/16 at 11:45 A.M. revealed Resident #123 received physical therapy services through 02/18/16 and then restorative nursing services started 02/23/16. LPN #107 verified Resident #123 did not receive services as per the restorative plan of care.

Based on record review and interview the facility failed to accurately assess pressure ulcer wounds. This affected two residents (Resident #39 and #42) of three residents reviewed for pressures ulcers of 18 assessments reviewed. Findings include: 1. Review of Resident #39's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further medical record review revealed on 07/31/14 Resident #39 developed a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough). Further review of the Pressure Ulcer Tracking Grid identified the wound declined on 08/14/14 to a Stage III pressure ulcer (full thickness skin loss, slough may be present but does not obscure the depth of tissue loss). Description of the wound on 08/14/14 identified the wound base as 100% slough (necrotic tissue in the process of separating from viable portions of the body). Interview with licensed practical nurse (LPN) #10 on 12/11/14 at 9:50 A.M., verified the wound was incorrectly staged as a Stage III wound on 08/14/14 as the correct stage was unstageable (depth is unknown as wound is obscured by slough) due to the wound base being 100% slough. 2. Review of Resident #42's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further medical record review revealed upon admission the resident had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) on the coccyx. Further review of the Pressure Ulcer Tracking Grid identified the wound declined on 07/11/14 to a Stage III pressure ulcer (full thickness skin loss, slough may be present but does not obscure the depth of tissue loss). Description of the wound on 07/11/14 identified the wound base as 100% slough (necrotic tissue in the process of separating from viable portions of the body). Interview with LPN #10 on 12/11/14 at 9:50 A.M., verified the wound was incorrectly staged as a Stage III wound on 07/11/14 as the correct stage was unstageable (depth is unknown as wound is obscured by slough) due to the wound base being 100% slough.

Based on observation, interview and review of residents' functional eating assessments, the facity failed to maintain adequate staffing in the south unit dining room to ensure residents who required assistance with meals were fed in a timely manner. This affected 10 residents, #53, 54, 56, 60, 64, 69, 71, 85, 86 and 87, observed eating on the South unit. Findings include : The breakfast meal was observed in the South unit on 03/30/14 at 8:40 A.M. Residents #56 and #85 were seated at a dining table with their breakfast in front of them. Resident #56 was sleeping and Resident #85 made no attempt to feed himself. There was no staff seated at the table to assist the residents. Review of eating assesssments revealed both residents were assessed to need the assistance of one or two staff to eat thier meal. Resident #87 was seated at a separate table with her breakfast in front of her, untouched. The resident was sleeping, and there was no staff seated at the table to assist the resident to eat. Review of the resident's eating assessment revealed she required the assistance of one or two staff members to eat. The three staff in the dining room were passing trays to other residents. The DON was interviewed on 03/30/14 at 9:00 A.M. and stated this was the typical staffing for every day with the exception of department heads who assisted during the week. On 03/30/14 at 9:03 A.M., Resident #87 remained asleep at the table, meal untouched in front of her and no staff seated with her to assist. On 03/30/14 at 9:03 A.M., Residents #53 and #86 were seated at an assist dining table, asleep, with their meals in front of them untouched. There was no staff seated at the table with them to feed them. Review of eating assessments revealed both residents were dependant on staff to eat their meals. State tested Nurse Aide (STNA) #1 was seated at the table next to the residents, feeding Resident #85 who had been moved there from another table. On 03/30/14 at 9:06 A.M., STNA #2 was observed standing and feeding and assisting Residents #54, #60, #64, #69 and #71. STNA #2 would feed each resident a few bites of food then move to the next resident. Resident #60 was seated at the next table over from the four other residents. All five residents had been assessed to require the assistance of one or two staff for eating. Licensed Practical Nurse (LPN) #3 was interviewed on 03/30/14 at 9:08 A.M. concerning the number of staff in the dining room and stated the staffing was typical for Sunday. On 03/30/14 at 9:09 A.M., STNA #1 moved over to next table to feed Resident #86, but did not attempt to feed Resident #53 who was seated at the same table with food untouched in front of her. On 03/30/14 at 9:13 A.M., STNA #4 entered the dining room to assist with feeding the residents and walked over to Resident #53 and stood while attempting to feed her. STNA #2 was interviewed at 9:15 A.M STNA #2 stated this was typical staffing for a Sunday morning. STNA #2 stated it was usually better in the afternoon because there were families to help with feeding. STNA #2 stated she realized it was not appropriate to stand and feed residents, but she had to make sure all the residents were fed. STNA #4 was interviewed on 03/30/14 at 9:18 A.M., and stated she usually worked in the main dining room, but the South unit said they needed help so she came over to assist. This deficiency substantiated Complaint Number OH 019.

Based on observation and interview, the facility failed to maintain appropriate temperatures for the washing machine to prevent the spread of infection. This had the potential to affect all residents residing in the facility. The facility census was 94. Findings include: On 06/07/12 at 8:45 A.M. the washing machines were observed in the laundry with Laundry Supervisor #4. One washer contained the residents' personal clothing. The highest water temperature reached during the wash cycle was 100 degrees Fahrenheit (F). There was no bleach added during the rinse cycle. On 06/07/12 at 8:55 A.M. the washer was observed for facility linens. The chlorine bleach was automatically dispensed into the machine. The highest temperature reached during the wash cycle was 132 degrees F. The temperatures were verified by the laundry supervisor at the time of the observations. The facility did not have a procedure to determine the bleach concentration in the washing machine. This was verified with corporate registered nurse (RN) #3 on 06/07/12 at 2:30 P.M.

Based on observation, interview and record review, the facility failed to ensure Resident #84 has a care plan to address his behaviors and that Resident #33's positioning was addressed in his plan of care. This affected two of twenty one residents reviewed for care plans. Findings include: 1. Resident #84 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Social service notes dated 01/11/12 revealed the resident had no behavioral concerns, and had a supportive family. The note also revealed the resident was severely cognitively impaired. The noted dated 04/10/12 stated the social worker would assist psychosocial services. It was brought to the social worker's attention the resident raised his fists to staff and had behaviors which included yelling at staff and being combative with the aids at times. The note revealed the resident would also tell family he had not been showered when he had been. The 05/25/12 social service note revealed the resident was a little depressed, and had behaviors which included yelling, being combative with hands on care, was short tempered and easily annoyed. The resident did not have a care plan to address the behaviors or the staff's response to them. The licensed social worker was interviewed on 06/07/12 at 1:50 P.M. and verified there was no care plan to address the resident's specific behaviors and how to address them. 2. Resident #33 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set assessment ((MDS) dated [DATE] indicated the resident was severely cognitively impaired, required extensive assistance of two people for bed mobility and dressing and was dependant for transfers. Review of physician orders [REDACTED]. front anti tippers to the recline chair and 05/25/12 for a contoured leg trough to the tilt and recline chair. The resident was observed in her tilt and recline chair with the chair tilted back on 06/06/12 at 11:13 A.M., 4:20 P.M. and 5:39 P.M. The chair was tilted back to approximately 100-110 degrees. The resident's head was forward and her chin was on her upper chest, neck hyperextended. There was a pillow attached to the top of the chair. The resident had a neck pillow positioned around the right side of her neck. At 5:40 PM, Registered Nurse (RN) #6 was called to the area. RN #6 verified resident positioning and reclined the resident's chair to the full tilt position (approximately 135 degrees). The resident's neck remained positioned on her chin and she did not relax. RN #6 notified the restorative nurse , RN #5. RN #5 stated the pillow was not supposed to be attached to the chair and the chair was supposed to be tilted all the way back. The resident's care plans were reviewed for information concerning what the resident's proper positioning was supposed to be. There was no information or care plan concerning proper positioning of the resident.

Based on observation, interview and record review, the facility failed to allow one resident to choose, and use, her preferred personal hygiene products. This affected one resident (Resident #139) of two residents reviewed for concerns with personal property. Findings include: Review of the medical record revealed Resident #139 was an alert and oriented resident with [DIAGNOSES REDACTED].M. revealed Resident #139 was admitted to the hospital for [MEDICAL CONDITION]. Review of a social service note dated 05/03/12 revealed Resident #139 returned to the facility on [DATE]. On 06/05/2012 at 3:51 P.M. an interview with Resident #139 revealed she had two containers of baby powder with her when she was admitted to the facility in February, 2012. The resident revealed one container of dusting powder was a gift from her great granddaughter, who was eight years old. Resident #139 revealed she was recently admitted to the hospital for a potassium imbalance and when she returned her powders were gone. Resident #139 revealed the staff told her she was not permitted to have powder because it could make the floor slippery and she could fall, the facility took her powder when she was in the hospital and now they could not find the powder that her great granddaughter gave her, which she described as "a fancy jar with a body puff." Resident #139 revealed she always used dusting powder at home and she wished she could still use it here. On 06/06/12 at 11:11 A.M. an interview with the director of nursing (DON) verified the facility staff took Resident #139's dusting powder out of her room when she was in the hospital. The DON verified the staff took all of the residents powder away because the powder could make the floor slippery and "cause falls". The DON also verified the facility lost Resident #139's dusting powder, did not consider this a "lost item" and did not replace the powder for the resident. On 06/06/12 at 1:15 P.M. an interview with the DON revealed dusting powder was taken from the resident because it could cause a fall or a respiratory issue. The DON admitted Resident #139 did not fall or incur respiratory difficulty because of her dusting powder. The DON stated an employee (the social worker) almost fell in some dusting powder in Resident #139's bathroom back in April, so they took all of the resident's dusting powders away. The DON stated "it is our policy to use lotion on the residents after a shower." On 06/06/12 at 1:15 P.M. an interview with the corporate registered nurse (RN #2) revealed the facility did not have a policy related to the use of dusting powder and each resident residing in the facility was permitted to use dusting powder if it was their preference. Review of the resident's physician orders [REDACTED]. Review of a missing items report dated 06/06/12 (the date of the survey investigation) revealed Resident #139 reported to the DON on 06/04/12 that she was missing her powder. The DON documented that the housekeeping supervisor took the resident's powder on 04/05/12 and gave the powder to nursing. The missing item report revealed nursing no longer had the powder. The DON verified the resident's dusting powder was taken by the facility staff on 04/05/12, so technically, the powder was not a "missing item." On 06/07/12 at 10:00 A.M. an interview with the DON verified the resident's medical record, including social service notes and nursing notes, did not contain any information about taking the resident's dusting powder, informing the resident when she returned from the hospital or contacting the resident's family to pick up the powder. The DON verified she did not attempt to educate the residents or provide an alternative way for them to apply the powder instead, she just did a "sweep" and took the dusting powder away from every resident in the facility.