Every finding on record at Oak Grove Manor

Based on record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure food was palatable and appropriate temperature. This had the potential to affect all 75 residents residing in the facility who receive food from the kitchen. Findings include:Review of the resident council meeting for 09/08/25 revealed residents did not like most of the food due to having the same food, dry meat, and food not being seasoned. Under the area that reads status update on the resident council minutes revealed the concern was not resolved. Interview on 09/24/25 at 1:39 P.M. with Resident #53 revealed breakfast was always cold so he no longer eats breakfast. Resident #53 stated he has reported it to the Certified Nursing Assistants (CNAs); however, nothing has changed. Resident #53 stated the CNAs would offer to reheat the food; however that was not preferred. Interview on 09/24/25 at 2:00 P.M. with Resident #4 revealed the food was frequently cold by the times the trays were passed. Resident #4 stated she eats the food because she was hungry, however she would prefer her food to be warmer. Observation on 09/25/25 at 7:30 A.M. revealed Dietary Manager (DM) #529 taking food temperatures for breakfast. Temperature of sausage patties were 172 degrees Fahrenheit (F), waffles were 136 degrees F, and oatmeal was 165 degrees F. Observation on 09/25/25 at 7:55 A.M. revealed the hallway trays being transported to the 100-hallway. Trays began being distributed at 8:01 A.M. with the last tray being passed at 8:11 A.M. The last hallway tray temperature was obtained and revealed the sausage patties were 101 degrees F, and the waffles were 88 degrees F. A test tray was obtained at this time from DM #529. The sausage patty was lukewarm and was dry, and difficult to swallow. The waffles were cool to taste and dry as well. Interview on 09/25/25 at 8:20 A.M. with DM #529 confirmed the sausage and waffles were not warm and the sausage patties were dry. DM #529 stated they used to use plate warmers; however, the machine was too hot for the staff to handle. DM #529 stated special gloves were supposed to be ordered for staff to use but were never followed through. Interview on 09/25/25 at 11:15 A.M. with the Administrator revealed the staff should have been using plate warmers to keep the food warm. Review of the facility policy titled Food Temperatures dated 2021 revealed hot food items may not fall below 135 degrees F after cooking. Temperatures should be taken periodically to ensure hot foods stay above 135 degrees F during the holding and plating process. This deficiency represents non-compliance investigated under Complaint Number 2604984 and Complaint Number 2565327.

Based on medical record review, resident and staff interviews, and review of the facility policy, the facility failed to ensure medical appointments were timely scheduled as physician ordered. This affected one (Resident #36) of two residents reviewed for appointments. The facility census was 75. Findings include:Review of the medical record for Resident #36 revealed an admission on [DATE]. Diagnoses included chronic ischemic heart disease and acute diastolic (congestive) heart failure (CHF). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. Review of the care plan dated 08/18/25 revealed Resident #36 had altered cardiovascular status related to CHF and hypertension. Interventions included monitoring and reporting to medical providers any signs and symptoms of chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in capillary refill, color or warmth of extremities. Review of the progress note dated 05/26/25 revealed Resident #36 was having shortness of breath and chest pain. The facility called a triage Nurse Practitioner (NP), and the NP spoke to Resident #36 via video call. The NP determined Resident #36 did not need to be sent to the emergency room. The NP progress note dated 05/27/25 revealed Resident #36 was seen for chest pain and dizziness. An electrocardiogram (EKG) was ordered as well as follow up with cardiologist based on findings. The progress note dated 05/28/25 at 11:45 A.M. revealed new orders for Resident #36 to have an EKG due to orthostatic blood pressure and consultation with cardiology. The progress notes dated 07/28/25 revealed the facility faxed Resident #36's consultation to cardiology on 07/08/25 and 07/28/25. There was no evidence in Resident #36's medical record that a cardiology appointment was scheduled nor seen by a cardiologist from 05/28/25 to 09/23/25. During an interview on 09/24/25 at 8:59 A.M., Resident #36 revealed she was waiting to see a cardiologist due to having CHF. Resident #36 stated a couple months ago, the Director of Nursing (DON) told Resident #36 she needed to see a cardiologist, but the appointment had not been made. Interview on 09/24/25 at 9:37 A.M. with Transportation Aide (TA) #304 revealed prior to starting the position of appointments and transportation in June 2025, the facility had issues with residents missing appointments. TA #304 stated Resident #36 had a referral to cardiology; however, there were issues with cardiology receiving the referral from the facility. TA #304 confirmed that since 07/28/25, no further attempts were made to make the appointment. Interview on 09/24/25 at 9:50 A.M. with the DON confirmed Resident #36 should have had a cardiology consult scheduled due to concerns of chest pain, shortness and diagnoses of CHF. Review of the facility policy titled Transportation dated 04/28/25 revealed the facility staff will receive the appointment from the resident, family, transportation company or doctors' office. The staff will schedule transportation to and from the appointment as needed. This deficiency represents non-compliance investigated under Complaint Number 2604984.

Based on observation, staff interview, and policy review, the facility failed to ensure a kitchen did not have expired food, kitchen was clean and sanitary, and opened food items were not labeled or dated. This had the potential to affect all 73 residents residing in the facility who receive food from the kitchen. Findings include: A tour of the kitchen on 06/29/25 from 8:10 A.M. through 8:33 A.M. revealed in the dry storage room, there were 12 bags of raisins that had a best buy date of 07/14/24, red wine vinegar was opened and had a best if used 03/13/24, molasses was opened and had a best if used by date of 11/15/24, and ziti, penne and elbow pasta bags were opened with no label or date. In the walk-in refrigerator, the packages of biscuits, waffles, pepperoni, and sliced cheese were not labeled and dated. In the preparation area, there was grease on the floor behind the convection oven and the microwave had dried food on the top of the inside of the microwave. The stand up fan had food splatter on the base of the stand. Interview with Dietary [NAME] #340 on 06/29/25 at 8:34 A.M. verified there were several items including red wine vinegar, molasses, and pasta that had best if used by dates of 2024, there were food packages in the walk-in refrigerator that were no labeled and dated, and there was grease on the floor, a dirty microwave, and dirty fan in the preparation area. Review of the facility policy dated 2021 titled Food Safety and Sanitation revealed kitchen should be cleaned, open food items should be labeled and dated. Foods should be used prior to the use by date on the package.

Based on observation, record review, and interview, the facility failed to ensure they implemented their smoking policy by ensuring the facilities grounds were free from discarded cigarette butts. This finding had the potential to affect all 73 residents residing in the facility. Findings include: Observations on 06/29/25 at 1:05 P.M. revealed residents were on a supervised smoke break. Approximately 25 cigarette butts were noted in the rocks surrounding the smoking area. Fire proof receptacles and fire proof ashtrays were located in the smoking area. Interview 06/29/25 at 1:10 P.M. with Medical Records #1121 confirmed approximately 25 cigarette butts were in the rocks in the smoking area which were not cleaned up. A second observation on 06/30/25 at 9:52 A.M. revealed approximately five cigarette butts were lying on the ground surrounded by lint in front of the emergency exit off of the kitchen. Interview on 06/30/25 at 12:05 P.M. with the Administrator revealed it was every staff member's responsibility to pick up cigarette butts from the ground in the smoking areas. Review of the facilities Smoking Policy revised 04/28/25 revealed cigarette butts were to be discarded into the proper containers.

2. Observation on 06/29/25 at 11:16 A.M. revealed Registered Nurse (RN) #383 obtained a blood sugar using a blood glucose testing (BGT) machine for Resident #66. RN #383 then walked back down the hall and placed the contaminated BGT machine on top of the medication cart before placing the contaminated BGT machine in the top drawer of the medication cart without disinfecting the device. Interview on 06/30/25 at 11:51 A.M. with RN #383 with the Director of Nursing (DON) present revealed RN #383 obtained Resident #12's blood sugar just prior to obtaining Resident #66's blood sugar using the same BGT machine. RN #383 confirmed the multi-use BGT machine was not disinfected or decontaminated between residents because the medication administration cart did not have disinfectant wipes to disinfect or decontaminate the BGT machine to prevent the potential of cross contamination of blood borne pathogens. Interview on 07/01/25 at 9:20 A.M. with the DON confirmed nursing was not disinfecting the BGT machine after each use. The DON confirmed four residents (#34, #66, #223 and #224) shared the BGT machine on the 400-unit. Review of the Assure Prism Multi Blood Glucose Monitoring System Reference Manual dated 02/2026 revealed the meter should be cleaned and disinfected after use on each patient. The Assure Prism multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures were followed. The cleaning procedure was needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure was needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used environmental protection agency (EPA)-registered wipes had been tested and approved for cleaning and disinfection of the Blood Glucose Monitoring System. Based on observation, interview, review of Centers for Disease Control and Prevention (CDC) guidance, review of manufacturers instructions, policy review, and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place for residents who had indwelling medical devices or wounds, failed to ensure their infection control surveillance accurately reflected the resident's who required EBP, and failed to ensure blood glucometer machines were appropriately sanitized and disinfected between residents to prevent the potential for cross contamination of blood borne pathogens. This affected nine residents (#2, #48, #63, #65, #66, #122, #171 #172, and #223) reviewed for EBP and had the potential to affect four residents (#34, #66, #223, and #224) who share the same glucometer. The facility census was 73. Findings include: 1. Review of the facilities Order Listing Report dated 06/29/25 at 12:13 P.M. revealed Residents #2, #8, #9, #12, #17, #21, #29, #35, #44, #45, #46, #48, #52, #59, #63, #174, and #221 had orders for enhance barrier precautions (EBP). Tour of the facility on 06/29/25 at 12:36 P.M. revealed Residents #2, #9, #12, #21, #35, and #174 did not have any EBP signage on their doors and personal protective equipment (PPE) in the room or outside the room for staff to don when providing high contact direct care. Observation and interview with Director of Nursing (DON) on 06/29/25 at 1:20 P.M. stated the DON was the facilities Infection Preventionist. The DON confirmed there was no EBP signage or PPE cart available for Residents #2, #9, #12, #35 and #174 despite orders in place for EBP. Review of the updated Order Listing Report dated 06/29/25 at 2:49 P.M. revealed Residents #2, #17, #29, #44, #45, #46, #52, #59, #65, #66, #122, #171, #172, #221, and #223 had orders for EBP. Residents #8, #9, #12, #35, #48, #63, and #174 were removed for the updated list as originally provided on 06/29/25 at 12:13 P.M. Residents #65, #66, #122, #171 #172, and #223 were added to the updated list provided at 2:49 P.M. Review of Centers for Disease Control and Prevention (CDC) guidance titled Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021 revealed EBP was an approach of targeted gown and glove use during high contact resident care activities designed to reduce transmission of multi-drug-resistant organisms (MDROs). EBP should be applied to residents with wounds or indwelling medical devices regardless of MDRO colonization status and if a resident was infected or colonized with an MDRO. Effective implementation of EBP requires staff training on proper use of PPE and availability of PPE with hand hygiene products at point of care. Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 revealed EBP was indicated for residents with infection or colonization with a MDRO when contact precautions do not apply, for those with wounds, and for those with indwelling medical devices including central line, urinary catheter, feeding tubes, tracheostomy, nephrostomy, and ventilator.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure residents had accurate advance directive orders and consistent information in place throughout the medical record for Resident #121. This affected one (#121) of 23 residents reviewed for advanced directives. The facility census was 73. Findings include: Review of the medical record for Resident #121 revealed an admission date of 04/05/19 with diagnoses including dementia. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #121 was rarely understood. Review of the physician's orders for Resident #121 revealed an order dated 02/28/25 for a Do Not Resuscitate Comfort Care (DNRCC) code status (meaning only comfort measures would be initiated in the event of a medical emergency). Review of the plan of care dated 03/04/25 revealed Resident #121 was a DNRCC. Review of the hard medical chart for Resident #121 revealed there were two code statuses in the front of the chart. There was an undated Do Not Resuscitate Comfort Care (DNRCC) code status and a bright red card stock paper in front of the undated DNRCC that stated Do Not Resuscitate Comfort Care - Arrest (DNRCC-A) code status (meaning invasive or extreme life-supporting measures were allowed under any circumstance except for cardiac or respiratory arrest. In the event of cardiac or respiratory arrest only comfort measures would be initiated). Interview on 06/29/25 at 2:13 P.M. with Regional Registered Nurse (RRN) #500 verified Resident #121's code status was not consistent in the medical record. RRN #500 verified Resident #121 was DNRCC code status in the electronic medical record and the hard chart had a red paper that stated DNRCC-A and an undated DNRCC in the chart. Review of the facility's policy titled Advanced Care Planning/Advance Directive Policy and Procedure dated 08/2024 revealed it is the policy to support and facilitate a resident's right to discontinue medical treatment and formulate an advance directive.

Based on observation, record review and resident and staff interviews, the facility failed to complete a treatment for Resident #12. This affected one of one resident reviewed for wound treatments. The facility census was 73. Findings include: Review of the medical record for Resident #12 revealed an admission date of 06/03/25. Resident #12 was hospitalized from [DATE] through 06/11/25. Resident #12 was readmitted [DATE]. Diagnoses included unspecified fracture of upper end of left tibia, diabetes mellitus, and adult failure to thrive. Review of the care plan initiated 06/05/25 and revised on 06/17/25 revealed he had an open area on his right hand related to gout. One intervention was to assess, monitor and record wound healing. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was cognitively intact and received treatments and ointments to areas other than feet. Review of the Medication Administration Record (MAR) from June 2025 revealed an order to cleanse area to back of right hand with wound cleanser and apply a dry dressing daily and as needed starting 06/17/25. It was signed off daily except for 06/19/25. Observation and interview on 06/29/25 at 10:30 A.M. revealed Resident #12's dressing on his hand was dated 06/25/25. Resident #12 stated it was ordered to be changed daily but staff were not changing it daily. Interview on 06/29/25 at 10:50 A.M. with Certified Nursing Assistant (CNA) #392 verified the date of 06/25/25 on the dressing on Resident #12's hand. Review of the facility policy titled Wound Care dated 08/2023 revealed to apply the treatment as indicated. Dress the wound and mark tape or dressing with initials, date and time. Document in the electronic medical record. Indicate if the resident refused.

Based on record review, review of the Ohio Board of Nursing Administrative Code, and staff interview, the facility failed to ensure they had sufficient nursing staff with the appropriate skills to complete the resident's central venous line therapy procedures. This affected one (Resident #122) of one resident reviewed for intravenous (IV) access. Findings include: Review of Resident #122's medical record revealed the resident was admitted on [DATE] with diagnoses including osteomyelitis and chronic kidney disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #112 exhibited intact cognition. Review of Resident #122's hospital discharge documentation dated 06/13/25 revealed an central venous catheter (CVC) double lumen (DL) tunneled left internal jugular (IJ) was placed on 06/06/25 and a hemodialysis central line access permanent catheter left internal jugular was placed on 06/03/25. Review of Resident #122's physician orders revealed an order dated 06/11/25 to use 10 milliliters (ml) of normal saline (NS) intravenously (IV) as needed for an IV flush; flush each IV catheter lumen with 10 ml NS after each intermittent IV administration; use 10 ml IV every six hours for IV flush; flush each IV catheter lumen with 10 ml saline after each intermittent IV administration. The IV flushes were ordered at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of Resident #122's medication administration records (MARs) from 06/12/25 to 06/30/25 revealed Licensed Practical Nurse (LPN) #306 had documented the nurse flushed the resident's left chest CVC DL tunneled IJ IV access on 06/22/25 at 12:00 A.M. and 6:00 A.M.; 06/23/25 at 12:00 A.M. and 6:00 A.M.; 06/28/25 at 12:00 A.M. and 6:00 A.M.; 06/29/25 at 12:00 A.M. and 6:00 A.M. Review of Resident #122's MARS revealed the Director of Nursing (DON) had documented the nurse had completed the resident's flushes on 06/30/25 at 12:00 A.M. and 6:00 A.M. Interview on 06/30/25 at 6:27 A.M. with LPN #306 revealed Resident #122's left CVC DL IJ IV access was to be flushed four times per day including two on the nightshift at 12:00 A.M. and 6:00 A.M. LPN #306 confirmed she flushed Resident #122's IV access outside of the scope of practice for LPNs in Ohio on 06/22/25, 06/23/25, 06/28/25 and 06/29/25 at 12:00 A.M. and 6:00 A.M. because Registered Nurse (RN) coverage was not available to complete the task and the nurse did not want complications for the resident. Interview on 06/30/25 at 8:30 A.M. with the DON confirmed the Ohio Board of Nursing allows LPNs to flush peripheral access lines only and LPN #306 could not provide care to Resident #122's left CVC DL IJ IV. A second interview on 07/01/25 at 9:32 A.M. with the DON revealed she had flushed Resident #122's left DL IJ on 06/30/25 at 6:00 A.M. and confirmed the MAR shows she completed the left DL IJ on 06/30/25 at 12:00 A.M. The DON said she was was not sure why it was signed off as completed on 06/30/25 at 12:00 A.M. by the DON because she didn't complete it. An additional interview on 07/01/25 at 11:20 A.M. with the DON revealed she had documented Resident #122's left DL IJ FLUSH on 06/30/25 at 12:00 A.M. in error. Review of Rule 4723-4-02 of the Ohio Board of Nursing Administrative Code titled Intravenous Therapy Procedures for Licensed Practical Nurses revealed except as provided in paragraph (B) of this rule, a licensed practical nurse shall not perform any of the following intravenous therapy procedures including solutions administered through any central venous line or arterial line or any other line that does not terminate in a peripheral vein.

Based on observation, record review, facility policy review, and staff interview, the facility failed to ensure the medication error rate did not exceed medication error rate of five percent (%) or greater. Two errors occurred within 28 opportunities for an error rate of 7.14%. This affected two (Residents #35 and #41) of four residents observed for medication administration. Findings include: 1. Review of Resident 41's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes mellitus and edema. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had intact cognition. Review of Resident #41's physician orders dated [DATE] revealed an order for potassium chloride powder give 20 milliequivalents (meq) by mouth one time a day for a supplement. Observation on [DATE] at 8:15 A.M. revealed Licensed Practical Nurse (LPN) #308 administered Resident #41's morning medication administration. LPN #308 revealed she administered nine medications including a potassium 20 meq tablet. Interview on [DATE] at 11:55 A.M. with LPN #308 confirmed she administered a potassium tablet to Resident #41 instead of the potassium powder as ordered. Review of the facilities Administering Medications policy revised 12/2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. 2. Review of Resident #35's medical record revealed the resident had a re-admission on [DATE] with diagnoses including hyperlipidemia, essential hypertension and constipation. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #35 exhibited moderate cognitive impairment. Review of Resident #35's physician orders revealed an order dated [DATE] to inject Lispro 12 units subcutaneously (sq) before meals for diabetes mellitus and notify the physician of a blood sugar below 50 or greater than 400. Observation on [DATE] at 11:21 A.M. revealed Registered Nurse (RN) #383 obtained Resident #35's blood sugar via a blood sugar device and then administered eight medications including Lispro 12 units to Resident #35. The date written on the vial of Lispro indicated the insulin was opened on [DATE]. Interview on [DATE] at 11:38 A.M. with the Director of Nursing (DON) confirmed staff were to discard insulin once opened after 30 days. Interview on [DATE] at 12:10 P.M. with RN #383 confirmed Resident #35's Lispro insulin was opened on [DATE] and expired on [DATE] and the expired insulin was administered to the resident. Review of the Insulin Lispro Instructions for Use revised 07/2023 verified after insulin vials had been opened, store opened vials in the refrigerator or at room temperature up to 86 degrees Fahrenheit for up to 28 days. Keep vials away from heat and out of direct light. Throw away all opened vials after 28 days of use, even if there was insulin left in the vial.

Based on observation, staff interview, and record review, the facility failed to ensure the residents received the correct texture of diet and adaptive equipment as ordered by the physician. This affected one (Resident #53) of three residents reviewed for nutrition. The facility identified 18 residents on a mechanically altered diet. The facility census was 73. Findings include: Review of the medical record for the Resident #53 revealed an admission date of 03/08/25. Diagnoses included dementia and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had a memory problem and was on a therapeutic mechanically altered diet with no significant weight change. Review of the physician's orders for July 2025 revealed Resident #53 was ordered a regular diet, mechanically altered texture, and honey thick consistency liquids with finger foods as available. Review of Resident 53's diet ticket on 07/01/25 at 12:05 P.M. revealed Resident #53 was on a regular diet, mechanically altered texture, with honey thick consistency liquids. Resident #53 was to receive liquids in a sippy mug and plastic utensils. Observations on 07/01/25 from 12:10 P.M. through 12:25 P.M. revealed Resident #53 was sitting at a table in the dining room. Resident #53 was sitting at the table with a six-ounce regular cup of thin liquids in front of her. Resident #53's plate had ground turkey, scalloped potatoes and green beans. Resident #53 was was observed trying to eat the scalloped potatoes with her fingers. Certified Nursing Assistant (CNA) #309 noticed that Resident #53's liquids were not correct and replaced Resident #53's liquids with the correct consistency and in the appropriate cup. An interview on 07/01/25 at 1:45 P.M. with CNA #309 verified Resident #35 received the incorrect consistency of fluids and did not have the adaptive equipment of a sippy cup. CNA #309 stated she had a concern the newer CNAs not knowing the resident's diets and were not serving the correct juices and adaptive equipment to the residents. Interview on 07/01/25 at 1:55 P.M. with Regional Nurse #500 confirmed Resident #35's diet order and diet ticket included honey thick consistency liquids.

Based on record review and staff interview. the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) in a timely manner to the residents. This affected two (Residents #1 and #17) of three residents reviewed for NOMNC. The facility census was 73. Findings include: Review of Resident #1's NOMNC revealed the last covered day was 06/10/25. It was signed and dated on 06/09/25. Review of Resident #17's NOMNC revealed the last covered day was 06/12/25 and signed on 06/12/25. Review of the Advance Beneficiary Notice of Non-Coverage notice was dated 06/11/25. Interview on 07/01/25 at 8:10 A.M. with Social Service Designee (SSD) #416 verified Resident #1 and #17 did not receive two days notice before the end of a Medicare covered Part A stay or when all all of Part B therapies were ending. SSD #416 stated he was not aware NOMNC required at least a two-day notice.

Based on review of personnel files and staff interview the facility failed to ensure certified nursing assistants (CNA) received regular performance reviews as required. This had the potential to affect all 73 residents residing in the facility. Findings include: Review of the personnel file for CNA #1106 revealed a date of hire of 10/25/23 and there was no annual performance review. Review of the personnel file for CNA #1108 revealed a date of hire of 06/07/23 and there was no annual performance review. Interview with Human Resources Director (HRD) #415 on 07/01/25 at 10:59 A.M. verified there were no annual performance reviews completed for CNA #1106 and CNA 1108.

Based on review of personnel files and staff interviews, the facility failed to ensure certified nursing assistants (CNA), who were hired for more than one year, had 12 hours of in-services annually. This had the potential to affect all 73 residents residing in the facility. Findings include: Review of the personnel file for CNA #1106 revealed a date of hire of 10/25/23 and there was no evidence CNA #1106 had 12 hours of annual in-services. Review of the personnel file for CNA #1108 revealed a date of hire of 06/07/23 and there was no evidence CNA #1108 had 12 hours of annual in-services. Interview with Human Resources Director (HRD) #415 on 07/01/25 at 11:25 A.M. verified there was no evidence that CNAs #1108 and #1106 had 12 hours of in-service annually. HRD #415 stated he received an email from Corporate Human Resources (CHR) #700 that stated all employees were scheduled a minimum of 12 hours of in-services in the program. HRD #415 stated he was searching for a report from the software. Interview on 07/01/25 at 1:37 P.M. with the Administrator and Regional Nurse #500 verified they had no further evidence of 12-hour in-services were being completed annually for CNAs #1108 and #1106.

Based on observation and interviews, the facility failed to ensure residents had water at the appropriate temperature in their bathrooms. This affected three (Residents #3, #4, and #6) out of three reviewed for water temperatures. Facility census was 59. Findings include: Review of an invoice dated 10/16/24 revealed a fifty-gallon hot water tank was ordered. Review of a typed timeline provided by Maintenance Supervisor #104 revealed he was notified the hot water heater for Resident #3's room blew the seams out of the back. An order was placed for a new hot water heater. The new hot water heater was delivered late in the afternoon of 10/16/24. Maintenance Supervisor #104 installed the new hot water heater on 10/17/24. According to the timeline on 11/15/24, Maintenance Supervisor #104 was notified of the high limit switch and the breaker for the new hot water tank were tripping frequently. Maintenance Supervisor #104 replaced the upper thermostat on 11/15/24. On 11/22/24, Maintenance Supervisor #104 was notified that the water was cold again. Maintenance Supervisor #104 found the bottom heating element had burnt out. On 11/22/24, Maintenance Supervisor #104 replaced the heating element. On 12/09/24, the water was getting cold again and the bottom thermostat was replaced. Review of the water temperature logs for 10/23/24 and 11/13/24 revealed the rooms for Resident #3, #4, and #6, did not have water temperatures recorded. Review of the water temperature log for 12/09/24 revealed the rooms for Resident #3, #4, and #6, did not have water temperatures recorded. Interview on 12/23/24 at 10:04 A.M. Resident #4 stated the water in her bathroom would start to get warm and then would get cold. Resident #4 stated she would like to have hot water so she could take a bath in the tub in her bathroom. The water in the bathroom sink was turned on and started to feel warm but then felt cool. Interview on 12/23/24 at 11:23 A.M. Resident #6 verified there had been a problem with hot water. Interview on 12/23/24 at 11:34 A.M. Resident #3 verified there had been problems with hot water. A new hot water tank had been installed but the water did not stay hot. Resident #3 stated they had showered in their bathroom and had to finish their shower in cold water. Resident #3 stated they had bought their own shower chair so they could take showers in their personal bathroom and not go to the main shower room. The water in the bathroom sink was turned on. The water started to feel warm but then felt cool. Observation of water temperatures with Maintenance Supervisor #104 on 12/23/24 at 2:02 P.M. revealed the water in Resident #4's room reached 96 degrees Fahrenheit (F) and then started to drop. At 2:05 P.M. the water temperature in Resident #3's room was 98.2 degrees F and started to drop. At 2:07 P.M. the water in Resident #6's room was 92.7 degrees F. Maintenance Supervisor #104 verified the water temperatures for Resident #3, #4, and #6 were controlled by the same hot water tank and were not at the appropriate temperature. Maintenance Supervisor #104 found the mixing valve was at 100 degrees. When Maintenance Supervisor #104 tried to adjust the mixing valve, he discovered the valve was seized up. Maintenance Supervisor #104 called a plumbing company to bring a new mixing valve. The plumbing company said they would be out either late 12/23/24 or first thing 12/24/24. Maintenance Supervisor #104 also verified there was no documentation of water temperatures being checked in Resident #3, #4, and #6's rooms since October 2024. Review of the resident council meeting minutes for 11/11/24 revealed there was no hot water on the 400 hall. The concern was resolved by working with a plumber to get a new hot water heater. This deficiency represents non-compliance investigated under Complaint Number OH00160270.

Based on observation, record review, and interview, the facility failed to ensure treatments were put in place in a timely manner. This affected three (Residents #3, #6, and #7) of three residents reviewed for wounds. Facility census was 59. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included acquired absence of bilateral legs, peripheral vascular disease, chronic obstructive pulmonary disease, and chronic pain syndrome. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and had Moisture Associated Skin Damage (MASD). A skin condition/shower sheet dated 11/06/24 revealed Resident #3 had an open area that appeared to be an abrasion. Resident #3 requested to have an appointment made at the dermatologist. A skin monitoring/shower review sheet dated 11/12/24 revealed Resident #3 had an abrasion to buttock. Resident #3 did not want to see the facility Certified Nurse Practitioner (CNP). On 11/13/24 an order was received to cleanse bilateral buttocks with wound cleanser, pat dry, and apply triad (zinc-oxide based paste used on light to moderate wound exudate) paste every shift due to shearing. Review of the Treatment Administration Record (TAR) revealed the treatment was started on 11/13/24. On 11/19/24 a weekly wound assessment revealed Resident #3 had shearing to right gluteal fold that measured 0.5 centimeters (cm) long and 0.5 cm wide. A health status note dated 11/20/24 at 1:44 P.M. revealed per Resident #3's request a dermatology appointment was made for skin breakdown to gluteal area. The earliest appointment available was 12/09/24. Interview on 12/23/24 at 11:34 A.M. Resident #3 verified a treatment and appointment to the dermatologist was not done in a timely manner. Resident #3 stated the area to buttock was sore, but the paste seemed to help. Observation on 12/23/24 at 11:46 A.M. revealed Resident #3 had white colored paste to buttocks and peri area. A small open area with a red wound bed was noted to Resident #3's left gluteal area. Interview on 12/23/24 at 3:22 P.M. with Assistant Director of Nursing (ADON) #105 verified the abrasion to Resident #3's buttock was discovered on 11/06/24. ADON #105 verified there was no documentation of the physician being notified or a treatment order being put in place until 11/13/24 (seven days later). ADON #105 also verified Resident #3 requested to see a dermatologist on 11/06/24 and an appointment was not made until 11/20/24. Resident #3 was first seen by the dermatologist on 12/09/24. Interview on 12/23/24 at 5:49 P.M. the Director of Nursing (DON) verified the physician was not notified, orders were not put in place, and dermatology appointment was not done in a timely manner for Resident #3. 2. Review of the medical record revealed Resident #6 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, vascular dementia, and Parkinsonism. The annual MDS dated [DATE] revealed Resident #6 was cognitively intact. A weekly wound assessment dated [DATE] revealed Resident #6 had a newly identified venous ulcer to the right lower extremity that measured 3 cm long, 1.5 cm wide, and 0.1 cm deep. The treatment plan order included the wound to be cleansed with wound cleanser, patted dry, and calcium alginate with silver (wound dressing where silver acts as an antimicrobial and the alginate absorbs wound fluid) applied, covered with a super absorbent gauze and six-inch ace bandage to base of the knee. The treatment was ordered daily and as needed. A health status note dated 12/17/24 at 3:08 P.M. revealed Resident #6 was seen by the wound CNP. Wounds to bilateral lower extremities were cleansed and measured. The area to the right lower extremity was considered a reopened venous wound. Treatment was applied. Review of the December TAR revealed no evidence of the treatment to the right lower extremity being put in place or completed as ordered. Interview on 12/23/24 at 5:51 P.M. the DON verified the order and treatment for Resident #6's right lower leg was not put in place until 12/23/24. 3. Review of the medical record revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Parkinsonism, chronic pain, palliative care, and type 2 diabetes. The quarterly MDS dated [DATE] revealed Resident #7 had severe cognitive impairment. The weekly wound assessment dated [DATE] revealed Resident #7 had a new wound. The wound was classified as a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to sacrum that measured 3.5 cm long, 3 cm wide, and 0.1 cm deep. The treatment plan was to cleanse sacrum with wound cleanser, pat dry, and apply triad cream every shift and as needed. Review of the December TAR revealed no evidence of the treatment to the sacrum being put in place or completed as ordered. Interview on 12/23/24 at 3:16 P.M. ADON #105 verified the order and treatment for Resident #7 was not put in place until 12/23/24. This deficiency represents non-compliance investigated under Complaint Number OH00160270 and OH00160226.

Based on observation, staff interview, review of a cleaning task list, and policy review, the facility failed to store food in a safe and sanitary manner and failed to ensure food service equipment, storage areas, and kitchen floor were properly cleaned. This had the potential to affect all 67 residents. The facility census was 67. Findings included: 1. Observation of the kitchen on 10/24/24 at 9:55 A.M. with Dietary Aide #134 revealed walk-in cooler #1 was full of boxes. The boxes were stored directly on the floor inside the cooler and staff were unable to walk into the cooler due to the amount of boxes stacked four to five boxes high. Interview with Dietary Aide #134 at the time of the observation revealed the facility received the food delivery the day before and no one had time to unpack the boxes. Dietary Aide #134 verified the boxes containing food items were stored directly on the cooler floor. Review of the undated policy titled, Food Storage, revealed all refrigerated food should be stored off of the floor. 2. Observation of the kitchen on 10/29/24 at 7:50 A.M. revealed the shelf under the steam table was dirty with food crumbs and areas of dried brown and white liquid. The flooring near the walls in the dish room was observed to have a build up of dirt and some debris. Further observation revealed the bottom shelf of the clean dish rack had a thick layer of dust build up. Interview on 10/29/24 from 7:52 A.M. to 8:10 A.M. with Dietary Manager #119 verified the dirty dish room floor near the walls specifically near under the dishwasher, the dirty shelving under the steam table, and the dirty dish rack for clean pots and pans. Review of an undated cleaning task list revealed staff are to sweep and mop the dish room and under equipment daily, clean work tables and decrease clutter underneath daily, and dust pot and pan shelves as needed but at least weekly. Review of the policy titled, Cleaning and Sanitation of Dining and Food Services Areas, dated 2023, revealed the food and nutrition services staff will maintain the cleanliness and sanitation of the dining room and the food service areas through compliance with a written, comprehensive cleaning schedule This deficiency represents non-compliance investigated under Complaint Number OH00158146. 41528

Based on observation, staff interview, and review of a facility policy, the facility failed to maintain a pest free environment. This had the potential to affect all 67 residents. The census was 67. Findings include: 1. Observation on 10/28/24 at 10:00 A.M. revealed the dish washer room in the kitchen had, at minimum, four to five gnats and a fly. Further observation of the kitchen serving area revealed a fly was present in the area. Interview on 10/28/24 at 10:05 A.M. with Dietary Manager #119 verified the gnats and flies in the kitchen. 2. Observation on 10/29/24 at 9:30 A.M. revealed Resident #10 was sitting in a chair in his room. When Resident #10 moved, five (5) flies flew off of him. Interview on 10/29/24 at 9:32 A.M. with the Administrator verified the number of flies in Resident #10's side of the room. The Administrator removed the bag of garbage from the end of the resident's bed; however, no flies were observed near the garbage. Interview on 10/29/24 at 9:48 A.M. with Resident #23 revealed there are often flies in his room. Review of a policy titled, Pest Control Policy, dated August 2016, revealed the facility acknowledged the importance of pest and vermin control in providing a living environment of adequate health and safety for its residents. This deficiency represents non-compliance investigated under Complaint Number OH00158146 and Complaint Number OH00157659.

Based on medical record review, resident family interview, staff interview, orthopedic staff interview, review of hand written statements, review of the facility incident and accident log, and policy review, the facility failed to investigate an injury of unknown origin as required. This affected one (#24) of three residents reviewed for abuse, neglect, mistreatment, exploitation, and misappropriation. The facility census was 67. Findings included: Review of Resident #24's medical record revealed an admitted [DATE]. Diagnoses included infection and inflammatory reaction due to an internal left knee joint prosthesis, periprosthetic fracture around internal prosthetic right hip joint, atrial fibrillation, transient ischemic attack, and muscle weakness. Review of Resident #24's clinical admission note dated 10/17/24 revealed the resident required use of a wheelchair and knee immobilizer. She had a range of motion impairment of one unspecified lower extremity. Resident #24's gait was documented as unsteady and balance was poor. Staff were to maintain proper joint alignment while turning and positioning. Review of Resident #24's admission note dated 10/17/24 revealed a knee immobilizer to left leg was in place. Review of Resident #24's fall risk assessment dated [DATE] revealed the resident was at a high risk for falls. Review of Resident #24's medical record found no mention of a fall or injury noted from the date of admission until 10/25/24. Review of the facility incident and accident log revealed no falls or injuries were log for Resident #24 between 10/17/24 and 10/25/24. Review of a hand written statement dated 10/22/24, written by Registered Nurse (RN) #165 revealed Resident #24 and a certified nurse aide (CNA) were in the bathroom when RN #165 entered to administer medications. Further review of the written statement revealed Resident #24 indicated her knee popped and was given pain medication. Resident #24 was administer additional pain medication 30 minutes later and then denied any further pain or issues. Review of Resident #24's health status note dated 10/25/24 revealed the resident returned from an orthopedic physician appointment and the facility was then notified by the orthopedic office that the facility needed to send Resident #24 to the local hospital as a direct admission due to several femur fractures. Interview with Resident #24's family member on 10/29/24 at 9:10 A.M. revealed on 10/22/24 the resident informed the family that a CNA was assisting her to the bathroom when the resident's and CNA's legs became entangled in each other and the resident twisted her leg. The CNA sat Resident #24 on the toilet and the resident was in intense pain. Interview with the Director of Nursing (DON) on 10/29/24 at 8:23 A.M. revealed she was aware that Resident #24 bumped her leg in the bathroom but verified the chart was free of documentation regarding the incident. Interview with the DON and the Administrator on 10/29/24 at 11:05 A.M. revealed the facility did not initiate an investigation into Resident #24's femur fracture, and the DON stated she thought the resident's femur fracture was present on admission. Telephone interview with Orthopedic Nurse (ON) #160 on 10/29/24 at 11:08 A.M. revealed Resident #24 did not have a femur fracture prior to admission to the facility. ON #160 stated the fracture was identified on an x-ray during the resident's first post-operative appointment on 10/25/24. ON #160 stated the orthopedic surgeon's office then notified the facility of the femur fracture and requested Resident #24 be brought to the hospital for treatment. Interview with RN #165 on 10/29/24 at 11:10 A.M. revealed on 10/22/24 she witnessed Resident #24 with a CNA in the bathroom. The resident was sitting on the toilet and told RN #165 she heard something pop when her feet got tangled. The resident was assessed for pain and administered pain medication. The rest of the day Resident #24 denied pain until the nurse went off her shift. Interview with CNA #116 on 10/29/24 at 1:05 P.M. revealed on 10/22/24 she was assisting Resident #24 to the bathroom when the resident's foot got tangled up in her boot and it twisted her leg. CNA #116 sat the resident down on the toilet and untangled her legs. At that point the resident was crying in pain and the nurse was right outside the door and came and assessed her. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/06/22, revealed it is the facility's policy to investigate all alleged violations of abuse, neglect misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source. All incidents of injuries of unknown source must be reported immediately to the Administrator or designee and the Ohio Department of Health (ODH). Once notification is made, and investigation of the alleged violation will be conducted. This deficiency represents an incidental finding discovered during investigation of Master Complaint Number OH00159311.

Based on review of the facility menu, resident interview, staff interview, observation, review of the facility food temperature logs, and review of the facility policy the facility failed to ensure food temperatures were assessed to ensure safe ranges prior to resident consumption. This had the potential to affect all 64 residents in the facility who were identified by the facility to receive food from the facility kitchen. The facility census was 64 residents. Findings include: Review of the facility lunch menu dated 07/30/24 revealed the following items were listed: chicken parmesan, spaghetti noodles, cauliflower, garlic toast. Interview on 07/30/24 at 8:26 A.M. with Resident #23 confirmed the food at the facility was fair, sometimes the hot items were not hot enough for her liking. Interview on 07/30/24 at 10:13 A.M. with Staff Member (SM) #510 confirmed she heard food concerns from residents on a daily basis, including hot food items were not hot enough, food was too tough, and residents receiving food they did not order or items they disliked. Interview on 07/30/24 at 11:01 A.M. with Resident #39 confirmed sometimes when she got her meal tray, the food is lukewarm. The meat was of varying quality, sometimes too tough or chewy. Observation on 07/30/24 at 11:44 A.M. revealed [NAME] #242 and Dietary Manager (DM) #138 were at the steam cart in the kitchen preparing to serve the lunch meal. [NAME] #242 retrieved a calibrated food thermometer and proceeded to do her pre-meal food temperature checks. The chicken patty was 176 degrees Fahrenheit (F), the spaghetti noodles were 168 degrees F, and the cauliflower was 184 degrees F. [NAME] #242 did not record the temperatures on the designated food temperature monitoring log. [NAME] #242 and DM #138 did not obtain temperatures of the following items on the steam table: garlic toast, tomato sauce, mechanical soft chicken, pureed chicken, pureed noodles, pureed garlic bread, pureed cauliflower, green beans, hamburger patties. Further observation revealed [NAME] #242 and DM #138 did not obtain temperatures of pre-poured glasses of milk on approximately 50 resident meal trays. Interview on 07/30/24 at 11:48 A.M. with [NAME] #242 confirmed she typically only obtained temperatures of the main entrees prior to meal service. [NAME] #242 further confirmed she did not record the food temperatures for the main items she had temped. Interview on 07/30/31 at 12:53 P.M. with DM #138 following the conclusion of the lunch tray line confirmed [NAME] #242 should have checked food temperatures of all of the items on the steam stable prior to meal service to ensure they were at safe temperatures and [NAME] #242 should have checked the temperature of the milk and should have recorded all food temperatures on the log at this the temperatures were obtained. Review of the facility policy titled Food Preparation and Storage revised November 2022, revealed the danger zone for food temperatures was above 41 degrees F and below 135 degrees F. This temperature range would promote the rapid growth of pathogenic microorganisms that cause foodborne illnesses. Potentially hazardous foods included meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Proper hot and cold temperatures should be maintained during food distribution and service. The temperatures of foods held in steam tables should be monitored throughout the meal service by food and nutrition services staff. This deficiency represents noncompliance investigated under Complaint Number OH00155626.

Based on medical record review, resident interview, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Residents #39) of three residents reviewed for medication administration. The facility census was 64 residents. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses including parkinsonism, bipolar disorder, osteoarthritis, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #39 dated 07/08/24 revealed the resident was cognitively intact. Review of the physician's orders for Resident #39 revealed an order dated 09/15/23 for Gabapentin (an anti-seizure medication) 600 milligram (mg) tablets three times daily. The order included entries indicating the medication was reordered on 07/23/24 and 07/24/24. Review of the Medication Administration Record (MAR) for Resident #39 dated July 2024 revealed the resident did not receive Gabapentin on 07/23/24 and 07/24/24. Review of the progress notes for Resident #39 dated 07/23/24 at 9:08 A.M., 12:30 P.M., and 4:21 P.M. revealed the resident's Gabapentin was not administered because the medication was not available. The notes did not include documentation regarding physician or pharmacy notification of the omitted doses on 07/23/24. The progress notes for Resident #39 dated 07/24/24 did not include documentation of the omitted doses of Gabapentin. Review of the facility list of medications available in the emergency kit, undated, revealed Gabapentin 300 mg capsules (quantity of 6) and Gabapentin 100 mg capsules (quantity of 6) were available for administration if needed. Review of Resident #39's electronic and physical medical record contained no evidence Gabapentin was removed from the emergency kit and provided to the resident. Interview on 07/30/24 at 11:01 A.M. with Resident #39 confirmed on 07/23/24 and 07/24/24 she missed all three routine doses of her Gabapentin. Resident #39 stated she asked her nurses multiple times where her medication was, and they said the medication had been reordered but was not in the facility. Observation on 07/31/24 at 7:35 A.M. with Assistant Director of Nursing (ADON) #204 revealed the facility's emergency kit was stored in the medication room behind the nurses' station. Review of the log associated with the emergency kit revealed no doses of Gabapentin had been signed out for Resident #39. Interview on 07/31/24 at 8:24 A.M. with ADON #204 confirmed Resident #39 missed six consecutive doses of Gabapentin on 07/23/24 and 07/24/24. ADON #204 further confirmed Resident #39's record did not include documentation of notification of the pharmacy or attending physician of the missed doses and staff had not signed out doses of Gabapentin from the emergency kit for Resident #39. Review of the facility policy titled Medication Errors Reporting - Pharmacy Related undated revealed errors included medications not administered within the allowed time frame, failing to administer an ordered dose, and administration of medication which is greater/lesser than what is ordered. Review of the facility policy titled Emergency Pharmacy Service and Emergency Kits dated 03/28/18 revealed medications should be administered as ordered by the provider. A list of all medications and supplies should be posted on the kit and system and should include medication, quantity, expiration date and the pharmacy name and phone number. A method of recording use of items from the emergency kit should be in place. This deficiency represents noncompliance investigated under OH00156258.

Based on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews with staff and the transportation driver, the facility failed to provide adequate supervision and comprehensive individualized interventions to prevent Resident #14, who was identified at risk for elopement, from leaving the building when on an outside doctor's appointment, unaccompanied by facility staff or family, and prior to the transportation company picking her up and returning her to the facility after the appointment had concluded. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #14, who was assessed to be at risk for elopement, exited the doctor's office without staff knowledge when the appointment was completed. This affected one (#14) of two residents reviewed for elopement. The facility identified 11 residents (#7, #14, #19, #28, #31, #39, #42, #46, #51, #56, and #60) who were assessed as elopement risks that currently reside in the facility. Additionally, the facility failed to conduct a thorough investigation by doing a root cause analysis, and have evidence that neuro checks were completed, after Resident #49 fell on two consecutive days (01/07/24 and 01/08/24) in an effort to identify and implement measures to reduce the hazards/risks, including adequate supervision and assistive devices, as much as possible; and/or monitor the effectiveness of the interventions and modify the care plan as necessary to prevent further falls from occurring, placing the resident at risk for the potential for more than minimal harm that is not Immediate Jeopardy. This affected one (Resident #49) of three residents reviewed for falls. The facility census was 75. On 01/24/24 at 10:30 A.M., the Administrator, Regional Nurse Consultant (RNC) #384, Interim Director of Nursing (IDON) #390 and Assistant Director of Nursing (ADON) #336 were notified Immediate Jeopardy began on 12/15/23 at approximately 10:35 A.M. when Resident #14 left an outside doctor's office appointment, unsupervised and without staff knowledge, and prior to the transportation company picking her up and returning her to the facility following the appointment. Transportation Driver (TD) #378 reported to the facility that he was taking a person, who did not reside at the facility, to an appointment and as he was driving down the road he saw the resident walking on the sidewalk, pushing a rollator walker, next to a four-lane highway approximately 0.3 miles from the doctor's office with feces running down her leg, so he turned around and picked her up. TD #378 then returned her to the nursing home at 12:00 P.M. and talked to the Administrator. TD #378 stated that Resident #14 usually had an escort or staff would meet her at outside appointments. TD #378 stated that on 12/15/23, Resident #14 had neither. The Immediate Jeopardy was removed on 01/26/24 when the facility implemented the following correction actions: On 12/15/23 at 11:45 A.M., TD #378 called the facility and spoke to Business Office Manager #301 and explained that he picked up Resident #14 when he saw her walking from the appointment, and she had feces down her leg so he may need some help when Resident #14 arrives at the facility. On 12/15/23 at12:00 P.M., Resident #14 returned to the facility from her appointment with TD #378. ADON #336 walked Resident #14 and TD #378 to the nurses' station. The Administrator interviewed TD #378. TD #378 explained that he saw her walking on the road, stopped and asked her where she was going, and she told him that she was walking back to the facility. On 12/15/23 at 12:10 P.M., Resident #14 was taken to the shower room by State tested Nurses Assistant (STNA) #377 because she had feces on her legs, and at that time Licensed Practical Nurse (LPN) #329 did a skin assessment to check for any injuries and no new skin issues were noted. On 12/15/23 at 12:20 P.M., the Administrator spoke to RNC #384 regarding Resident #14. RNC #384 instructed the Administrator to document the skin assessment, ensure elopement care plan is in place, verify elopement risk assessment was previously completed and review care plan for previous elopement risk. Transportation policy was updated to include transportation form process noting if the resident needs accompanied to an appointment. RNC #384 also instructed the Administrator to complete education with nurses, State tested Nursing Assistants (STNAs), and department heads on the transportation form process and transporting residents with wanderguard to outside appointments and being accompanied by a staff member or family member. On 12/15/23 from 12:30 P.M. to 4:00 P.M., the Administrator in serviced nursing staff on the first shift in the building on the transportation form process and transporting residents with wanderguard to outside appointments and being accompanied by a staff member or family member. On 12/15/23 at 12:36 P.M., Medical Director (MD) #391 was notified of the resident leaving the doctor's office and walking down the street. He gave the order to send the resident for a psychiatric evaluation at the psychiatric hospital. On 12/15/23 at 1:30 P.M., the Administrator reviewed the Elopement Binder to ensure Residents #14 and #19, who were assessed as an elopement risk and previously ordered a wander guard, were included. The Administrator added the education about the new transportation form to the Elopement Binder. On 12/15/23 at 1:45 P.M., the Administrator added Wander Guard/Appointment Education to the Agency Binder/Nursing Staff book FYI for first shift staff. On 12/18/23 at 9:30 A.M., audits began to monitor if anyone had a wanderguard and has an appointment that there was someone to accompany them. These audits will continue five times a week for four weeks. On 12/26/23 from 10:40 A.M. to 4:56 P.M., the DON and/or Designee completed new elopement assessments for all current residents. Residents #7, #28, #31, #39, #42, #46, #51, #56, and #60 were identified as an elopement risk and assessed that no wanderguard is needed at this time. On 01/24/24 at 5:10 P.M., the Administrator and/or Designee updated the elopement book to reflect which residents were identified as an elopement risk with the criteria that these residents will be accompanied to future outside appointments. On 01/25/24 at 11:04 A.M., LPN #337 updated care plans to reflect elopement risk for Residents #7, #14, #19, #28, #31, #39, #42, #46, #51, #56, and #60. The facility ensured appropriate interventions were put in place if needed. On 01/25/24 from 5:30 P.M. through 8:00 P.M., the Administrator in serviced all staff in the building on both shifts including facility Transportation Driver #320 on the transportation form process and transporting residents with elopement risk to outside appointments. Residents with an elopement risk would be accompanied by a staff member or family member. Daily, the off going nurse will inform incoming nurse to review the Nursing FYI binder for any updates. On 01/25/24 at 7:45 P.M., the Administrator conducted an elopement drill with no issues noted and the process was evaluated with no concerns identified. On 01/26/24, the Administrator educated Agency staff via Clipboard messaging application and will continue to educate any new Agency staff working at the facility regarding the transportation form process and transporting residents with elopement risk to outside appointments and being accompanied by a staff member or family member. Ongoing, elopement assessments will be completed quarterly and as needed. The Elopement Binder will be updated as needed. Although the Immediate Jeopardy was removed on 01/26/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses including but not limited to diabetes mellitus, cognitive communication deficit, unspecified psychosis, and unspecified intellectual disabilities. Review of Resident #14's comprehensive care plan dated 08/22/23 revealed Resident #14 was an elopement risk but there were no interventions documented to address outside appointments. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was cognitively intact and was independent for walking with the use of a walker. The MDS also revealed that Resident #14 had verbal behaviors, rejected care, and wandered one to three days during the look back period. Review of the physician's orders for January 2024 revealed Resident #14 had an order for a wanderguard to be placed on the right wrist with a start date of 09/19/23. Review of the elopement assessment dated [DATE] revealed Resident #14 was at moderate risk for elopement. Review of the health status note dated 11/03/23 at 12:14 P.M. revealed Resident #14 was transported to an outside appointment by the transportation company and was accompanied by Former Central Supply #405 to her appointment. Review of the health status note dated 11/03/23 at 4:28 P.M. revealed STNA #403 reported to the nurse (LPN #329) the resident was packing up a few belongings. STNA #403 reported talking resident out of leaving facility. Physician aware, the nurse will continue to monitor resident for the rest of this shift. Review of the health status note dated 12/01/23 at 10:38 A.M. revealed Resident #14 expressed concerns with going to an appointment alone and requested that someone attend the appointment. This nurse (LPN #329) requested a staff nurse (LPN #327) to accompany the resident to the appointment. Staff nurse (LPN #327) meeting resident at scheduled appointment. Resident #14 transported to appointment by transportation company. Review of the health status note dated 12/04/23 at 10:49 A.M. revealed Resident #14 had packed up items on her wheeled walker. Resident #14 stated, I want to leave could someone cut this wrist band off of my arm please. This nurse (LPN #329) encouraged Resident #14 to stay and get unpacked and educated resident on the reasoning of the wander guard on her wrist. Resident #14 stated, I want to leave, no one wants me here, and I'm tired of the voice. This nurse (LPN #329) will continue to monitor Resident #14 for the rest of this shift. Review of the health status note dated 12/11/23 at 9:30 A.M. revealed Resident #14 threatened to remove her wanderguard band. ADON #336 assisted Resident #14 back to her room and reassured the resident that the facility would be the safest place to stay. Resident #14 is currently in room watching television with wanderguard in place. Fifteen-minute checks are in place. MD #391 notified. Review of the health status note dated 12/15/23 at 9:45 A.M. revealed Resident #14 left out for an appointment to the gynecologist, transported by transportation company. Review of the health status note dated 12/15/23 at 12:00 P.M. revealed Resident #14 returned to the facility soiled. TD #378 reported finding the resident walking down the road. Resident #14 told TD #378, I was heading back here. The Administrator, ADON #336, MD #391 were notified. MD #391 ordered to send the resident out to the psychiatric hospital to be further evaluated. Interview on 01/23/24 at 1:48 P.M. with TD #378 revealed that he dropped Resident #14 off at her doctor's appointment and gave his number to the office staff to call when she needed to be picked up. The doctor's office did not call TD #378 when Resident #14's appointment was completed. TD #378 stated that he was taking a person, who did not reside at the facility, to an appointment and he was driving down the road and saw her walking on the sidewalk. He turned around and picked her up. She had feces down her leg. TD #378 took her to the nursing home and talked to the Administrator. TD #378 stated that Resident #14 usually had an escort or staff would meet her at outside appointments. TD #378 stated that on 12/15/23, Resident #14 had neither. Review of the policy titled, Transportation Policy, dated 08/2021 with a revision date of 12/15/23, revealed that transportation will be arranged by central supply or designee for appointments. A transport form will be filled out by the nurse and notify central supply if an escort is needed. Review of the policy titled, Wandering and Elopement Policy, dated 08/2021 with a revision date of 08/2023, revealed the facility will identify residents that are at risk of unsafe wandering. Residents who are identified at risk for wandering or elopement, the resident's orders will include strategies and interventions to maintain the resident's safety. 2. Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included pressure ulcer and cellulitis. Review of the plan of care dated 01/02/24 revealed the resident was at risk for falls and potential injury related to impaired cognition, neurological impairment, and unsteady gait. Interventions included bed in lowest position, room moved closer to the nurses' station for safety, mat on floor by bed, and assist resident to toilet. Review of the progress note dated 01/08/24 at 3:54 P.M. revealed around 2:20 P.M. the resident was seen on the floor next to the bed on the floor mat. The resident had an abrasion to the right elbow. Resident #49 was currently on neuro checks from a previous fall on 01/07/24, so neuro checks will be continued. The family and ADON #336 were notified. Review of the medical record identified no fall assessment/investigation was completed on 01/08/24 and no neuro checks were available for the falls on 01/07/24 or 01/08/24. Interview on 01/29/24 at 10:45 A.M. with the Administrator revealed the facility was unable to find any fall investigation for Resident #49's fall on 01/08/24. The Administrator verified she was unable to provide neuro checks being completed on 01/07/24 or 01/08/24 for Resident #49. The Administrator verified that no fall investigation was completed for the fall on 01/08/24 for Resident #49. Review of the facility policy titled, Falls and Fall Risk, Managing, reviewed 08/2022, revealed staff will monitor resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. This deficiency represents non-compliance investigated under Master Complaint Number OH00150310 and Complaint Number OH00150105. 36650

Based on observation, staff interviews, resident interview, and record review, the facility failed provide ongoing assessment and monitoring of existing pressure ulcers, failed to complete treatments as ordered by the physician, and failed to notify the physician of the need to alter treatment when pressure ulcers increased in size and when new pressure ulcers developed. This affected two (Resident #63 and #69) of three residents reviewed for skin breakdown. Actual harm occurred when Resident #69 did not have any ongoing assessments of existing pressure ulcers and did not have treatments applied as ordered which resulted in the Stage 3 pressure to the resident's right buttock increasing in size from 7 centimeters (cm) by 5 cm to 12.1 cm by 8 cm by 2 cm. The facility census was 75. Finding include: 1. Review of the open medical record for Resident #69 revealed admission on 11/24/23. Diagnoses included multiple sclerosis, chronic pain syndrome and neuromuscular dysfunction of bladder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on toileting and needed assistance with repositioning. The assessment indicated Resident #69 had four stage 3 pressure ulcers (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) on admission. Review of the admission nursing assessment dated [DATE] revealed a pressure ulcer to the right gluteal fold (right buttock) that measured 7 centimeters (cm) by 5 cm, a right hip pressure ulcer that measured 5 cm by 5 cm and a right heel pressure ulcer that measured 7 cm by 5 cm. There were no wound depths documented for any of the three pressure ulcers. There were no other wound measurements documented in the resident's record. Review of the plan of care dated 11/24/23 revealed Resident #69 is at risk for impaired skin integrity related to pressure ulcers, eczema and osteomyelitis wound. Interventions included to administer antibiotic medication, apply barrier cream/ointment after each incontinent episode as needed, inspect skin during routine daily care, pressure reduction devices as needed and wound vac to right heel wound with treatment per physician orders. Resident #69 had a pressure ulcer or potential for pressure ulcer development related to stage 3 pressure ulcers to right hip, sacrum, and right heel. Interventions included assess/record/monitor wound healing, measure length, width, and depth. Assess and document status of wound perimeter, wound bed and healing progress. Review of physician orders revealed no orders for Resident #69 to be seen by the wound clinic for the pressure ulcer on the right hip or right buttock. Orders dated 11/26/23 included weekly skin checks on Friday, the right hip pressure ulcer was to be cleansed with normal saline, pat dry with non-sterile gauze, apply wet to dry dressing with Dakin's (sodium hypochlorite solution) (1/4 strength) and cover with foam, wound vac to right heel and changed on Monday, Wednesday and Friday, wound care to evaluate right hip treatment and skin condition as soon as possible (ASAP). Wound treatments orders changed on 01/12/24 to include right hip apply Prisma (semi-occlusive dressing, like a foam, to maintains a moist wound environment) to entire wound bed, cover with absorbent bandage dressing (ABD) daily, buttock and sacral wound apply triad cream (zinc oxide-based hydrophilic paste to adheres to moist wound beds and protects skin), cover with ABD daily, wound clinic to evaluate wounds/orders on 12/04/23. On 01/22/24 orders changed to cleanse with Normal Saline (NS), pat dry and apply wet to dry dressing daily and as needed. On 01/23/24 orders changed for right hip to cleanse with normal saline, pat dry, apply wet to dry dressing daily and as needed. Review of the Treatment Administration Record (TAR) for January 2024 revealed dressing changes for right hip and buttock/sacral wound was not documented as being completed 01/01/24, 01/09/24, 01/15/24, 01/19/24, 01/21/24, and 01/22/24. Interview on 01/22/24 at 11:47 A.M. with Resident #69 revealed he was to have a wound vac on his right heel but there were no new canisters for the wound vac after it was removed two days ago. A dressing was applied but has not been changed since it was put on two days ago. Observation on 01/22/24 at 1:45 P.M. of the pressure ulcer on Resident #69's right foot with Registered Nurse (RN) #377 revealed the wound vac was not on the right heel as ordered. An undated ABD dressing that was saturated with serosanguinous drainage (thin, watery, pale, red/pink drainage) was observed on the resident's right heel. The wound bed gauze that packed the wound had to be soaked to be removed. The wound was beefy red and covered with 25% slough (often presents as a soft, mucinous or stringy material in granulated wounds). The wound was cleansed with normal saline and gauze, wet with Dakin's quarter-strength solution was applied and covered with an ABD. The nurse did not take any measurements when the dressing was removed. Interview on 01/22/24 at 4:00 P.M. with RN #377 verified she did not have an order for the wet to dry dressing to the right heel. The order is for a wound vac to the right heel. Interview on 01/25/24 at 8:45 A.M. with RN #349 revealed she was the nurse that notified the physician that Resident #69 did not have wound vac supplies and needed an order for his right heel pressure ulcer. She verified the wet to dry dressing was not put in Resident #69's orders. Interview on 01/29/24 at 11:05 A.M. with Resident #69 revealed he was having more pain on his left hip/buttock area and that he has not been seen by the wound doctor for wounds on his bottom since he has been in the facility. Observation on 01/29/24 at 12:18 P.M. of Resident #69's coccyx wounds with RN #349 revealed the right buttock pressure ulcer measured 12.1 cm by 8 cm by 2 cm. The wound bed was necrotic with serosanguineous drainage. The necrotic tissue was located from 10 O'clock to 2 O'clock with undermining of 2 cm from 10 O'clock to 2 O'clock. The old dressing was saturated with a moderate amount of serosanguineous drainage. The wound was cleansed, wet to dry dressing, moistened with Dakin's solution was applied and ABD dressing applied. The right hip dressing was removed and revealed a stage 3 pressure ulcer wound measured 3.8 cm by 1.8 cm by 0.8 cm. The wound bed had granulation with serosanguineous drainage, and no odor noted. The resident was rolled to the right side and under a dressing to left buttocks was a stage 2 pressure ulcer measuring 4 cm by 3 cm by 0.1 cm with moderate serosanguineous drainage with no odor. The wounds were cleaned with normal saline and a wet to dry dressing was applied and covered with ABD. Interview on 01/29/24 at 4:00 P.M. with RN #349 verified the right buttock pressure ulcer appeared to have gotten worse since admission. RN #349 verified there was no order for the left buttock treatment. RN #349 stated she had not seen the left buttock wound prior to the dressing change. She stated she did not know when this wound was identified. RN #349 verified she has not measured any of Resident #69's wounds and thought the wound clinic was following these wounds. Interview on 01/29/24 at 4:15 P.M. with Regional Nurse Coordinator (RNC) #384 verified there was no order for the wound on Resident #69's left buttock and did not know when this wound appeared. RNC #384 verified Resident #69 had not been seen by any wound doctor for his pressure ulcers on his buttock or right hip since he was admitted to the facility on [DATE]. RNC #384 verified the facility was not measuring wounds weekly and the skin assessment dated [DATE] did not identify the new pressure ulcer on his left buttock. RNC #384 verified Resident #69 was being seen at an outside wound clinic for his right heel, but no other wounds. Resident #69 had not been to the wound clinic for his right heel since 12/18/23. RNC #384 verified no physician was notified of the worsening of the pressure ulcers to Resident #69's right buttock or the right hip, since he was admitted to the facility. RNC #384 verified the physician had not been notified of the new pressure ulcer on Resident #69's left buttock. Interview on 01/30/24 at 9:52 A.M. with State tested Nursing Assistant (STNA) #356 via phone revealed she has taken care of Resident #69 on 01/20/24 and 01/21/24. STNA #356 stated Resident #69 has bandages covering both sides of his buttock and the nurse was changing the dressing. Interview on 01/30/24 at 10:00 A.M. with STNA #361 revealed she has taken care of Resident #69 over the weekend, and he had bandages on both sides of his buttock that needed to be changed and the nurse changed the dressing. Interview on 01/30/24 at 10:45 A.M. with STNA #363 revealed she had seen the wound on Resident #69's left buttock a little over two weeks ago while assisting an agency nurse to change Resident #69's dressing. STNA #363 stated there was an open area on the left buttock. Interview on 01/30/24 at 11:00 A.M. with RN #380 revealed she is the nurse for Resident #69, and she has taken care of his wounds on his bottom. RN #380 stated she just thought the right buttock wound was getting bigger and the pressure ulcer on the left buttock had been identified and the physician had been notified. 2. Review of the open medical record for Resident #63 revealed an admitted on 11/22/23. Diagnoses included sepsis, pressure ulcer to the right buttock, sacral pressure and kidney failure. Review of a wound evaluation dated 01/16/24 revealed a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum that measured 11.7 cm x 10.4 cm x 3.7 cm, a stage 4 pressure ulcer to the left ischium that measured 9.5 cm by 10.5 cm by 2.5 cm, and a stage 4 pressure ulcer to the right ischium measuring 8.5 cm by 8.4 cm by 2.2 cm. Further review revealed a new order to apply quarter-strength Dakin's-moistened Kerlix to the wound beds and ABD pad twice a day for 16 days (01/16/24 - 02/01/24) (sacrum stage 4 pressure ulcer, stage 4 left ischium pressure ulcer, stage 4 right ischium pressure ulcer.) Review of January 2024 physician orders revealed orders for the coccyx and bilateral buttocks pressure ulcers to be cleansed with Dakins, apply Dakin's-soaked gauze and ABD secured with tape twice a day for wound healing for seven days, started on 01/16/24 and discontinued on 01/23/24. Review of the TAR for January 2024 revealed no order for the coccyx and bilateral buttocks pressure ulcers after 01/23/24, which should have continued until 02/01/24. Interview on 01/24/24 at 12:15 P.M. with Resident #63 revealed he does not see a wound doctor. His dressing was supposed to be changed twice a day but is only changed daily. Observation on 01/24/24 at 12:18 P.M. of Resident #63's dressing change to his coccyx wounds with RN #349 and LPN #328 revealed three stage four pressure ulcers. The old dressings that were removed were saturated with serosanguinous drainage and the pad underneath the resident had bloody discharge from the wound. The wounds were cleansed with normal saline and packed with normal saline-soaked Kerlix and then covered with ABDs. Interview on 01/24/24 at 1:00 P.M. with RN #349 verified the order was to use Dakins solution but she did not have any and used the normal saline instead. RN #349 stated she has never used the Dakins solution when providing wound care. This deficiency represents non-compliance investigated under Complaint Number OH00150105, OH00150034, OH00150030 and OH00149650.

Based on observations, medical record review, review of manufacture's instructions for passenger and wheelchair security and staff interviews, the facility failed to provide adequate supervision and security to a resident during a transport in the facility van. Actual harm occurred when Resident #80 and the wheelchair were not properly secured with safety straps in the facility van. This resulted in Resident #80's wheelchair tipping over in transport and Resident #80 suffering a fractured humerus. This affected one (#80) of three residents reviewed for accident/hazardous. The facility census was 56. Findings include: Review of Resident #80's medical record revealed an admitted [DATE]. Resident #80's medical diagnoses including: [CONDITION(S)] with [CONDITION(S)], gastrointestinal hemorrhage, [CONDITION(S)], [CONDITION(S)] and chronic obstructive pulmonary disease. Resident #80 required [CONDITION(S)] treatments out of the facility, every Monday, Wednesday and Friday. Resident #80 was to be transported to the [CONDITION(S)] center, by the facility, in a wheelchair accessible van. Review of the facility accident investigation report dated 11/10/21 at 6:40 A.M., identified Resident #80 suffered a fall in the transport van. The assessment of Resident #80 identified she was tender in the right shoulder and forearm. The facility obtained an X-ray of Resident #80's shoulder and arm. The investigation identified the physician and daughter were aware of her falling and were awaiting the results of the X-ray. Review of Resident #80's X-ray results dated 11/10/21, revealed the results were returned to the facility at 1:32 P.M. The results identified an acute displaced comminuted proximal humeral fracture of the right arm. Review of the nursing notes dated 11/10/21 at 2:47 P.M., revealed the physician was contacted regarding the X-ray results and ordered Resident #80 to be sent to the hospital. The resident was taken by squad to the closest hospital to the facility. Observation of the facility van was completed on 11/16/21 at 9:48 A.M., with Maintenance Man #100. The observation identified there is a wheelchair lift on the side of the van. The floor area inside the van is observed with multiple tie down areas, so a wheelchair does not move. The van is also observed with seat belts for the occupants in the wheelchair. Maintenance Man #100 confirmed all the items in the van are in working order and if used correctly a wheelchair could not tip over. Interview with Resident #80's family occurred on 11/16/21 at 10:11 A.M., revealed Resident #80 remains in the hospital and will have to undergo surgery to repair her fractured arm. Interview on 11/10/21 at 4:08 P.M., with State tested Nursing Assistant (STNA) #90, revealed she is the person who transported Resident #80 on 11/10/21. STNA #90 stated when she picked up Resident #80, the resident was in a different wheelchair then she usually was. STNA #90 stated when they almost reached their destination, she heard a noise in the back of the van. STNA #90 stated it was dark and she could not see exactly what occurred but yelled back to Resident #80 and asked if she was ok. STNA #90 stated Resident #80 stated no. STNA #90 stated she pulled the van over and found Resident #80 with the wheelchair tipped half way up on the floor. STNA #90 stated she immediately called the facility as she was not sure if she should call 911 or what to do. STNA #90 stated she spoke to the Director of Nursing (DON), who told her to take Resident #90 to the [CONDITION(S)] center, since they were so close to that location. STNA #90 stated the [CONDITION(S)] center staff took Resident #80's vital signs and told STNA#90 to take Resident #80 back to the nursing home. STNA #90 stated she returned Resident #80 to the nursing home where the DON was located. STNA #90 stated the staff had never sent Resident #80 in this particular wheelchair before. STNA #90 stated she was not sure why they had her in a different chair, but believes the chair was to narrow to properly be secured in the van. Observation on 11/16/21 at 11:19 A.M., with the DON, of the actual wheelchair involved in the incident, with Resident #80 on 11/10/21, revealed the wheelchair was observed to be narrow, firm, unbroken and sturdy. The head support to the back of the chair is tall and sturdy. The DON stated she was told the wheelchair tipped half way over when the incident occurred. DON stated the chair Resident #80 was in, could not have been appropriately secured, to the floor of the van, if it was tipped over. The DON stated Resident #80 could not have fallen, unless Resident #80 or the wheelchair was not properly secured. Review of the undated manufacture's instruction titled QRT-1 Series, user instructions revealed Part A of the instructions identified the wheelchair should be forward facing, attach the tie downs into the floor anchorages, ensure locked into place near the seat level and ensure proper tension. Part B of the instructions the resident should be secured with a lap belt and shoulder belt that are firmly in place. The instructions included pictures to demonstrate securing the chair and the passenger. This deficiency substantiated Master Complaint Number OH 455 and Complaint Number OH 379.

Based on surveyor observation, medical record review, resident and staff interviews, the facility failed to ensure leg rests were utilized on a manual wheelchair for one (#22) of five residents reviewed for assistive devices. This resulted in actual harm when Resident #22 sustained a left femur (leg) fracture, after her leg became entangled under the wheelchair, while being transported to the facility van for an outing. The facility identified 30 residents (#1, #6, #8, #9, #10, #11, #12, #13, #15, #16, #17, #19, #21, #22, #23, #24, #25, #26, #28, #29, #31, #32, #33, #35, #36, #42, #43, #45, #47, and #48) who are dependent on wheelchairs for locomotion. The facility census was 46. Findings include: Review of Resident #22's medical record revealed she was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #22 is cognitively intact. She has range of motion impairments to the upper extremities on one side and to the lower extremities on both sides. A limb prosthesis is utilized. Resident #22's plan of care initiated 04/09/10, revealed she requires assistance for mobility related to an impaired sitting balance. She is unable to ambulate due to left sided hemiparesis and bilateral lower extremity amputations. The plan identified Resident #22 uses an electric wheelchair for mobility. Interventions included the need for nursing staff and state tested nursing assistants to monitor the resident for safety while in her wheelchair. A second plan of care dated 01/18/11, revealed an intervention to closely monitor the resident's mobility in the wheelchair during outings and group activity. A third plan of care initiated on 02/09/12, revealed the resident is dependent on staff for activities. An intervention was to ensure adaptive equipment is provided and functional. Review of a facility incident investigation dated 05/24/12, identified Resident #22 had sustained an injury during transport to an activity. The injury was identified as a left femur fracture. Nurse's notes dated 05/24/12 at 3:30 A.M., identified Resident #22 complained of pain and discomfort below the left knee stump. The area was examined and an ecchymotic (bruised) area around the stump was present. The physician, family, and director of nursing were notified. At 10:00 A.M., Resident #22 complained of severe pain to left stump area. The physician was again notified and a new order was received for an x-ray. The x-ray was completed at 12:00 P.M., and results were obtained at 2:30 P.M. The results identified a fractured left femur. Resident #22 was then sent to the emergency room and later admitted related to the fracture. Review of the radiology report dated 05/24/12, confirmed Resident #22 had a fracture involving the distal femur with modest displacement. During interview with Activity Assistant #61 on 06/06/12 at 9:30 A.M., she identified Resident #22 was going out to eat as part of a planned facility activity. However, the resident was unable to be lifted into the van while in her electric wheelchair, because it was too heavy. Therefore, Resident #22 was transferred into a manual wheelchair. While pushing the resident's new wheelchair onto the van lift, Activity Assistant #61 verified Resident #22's prosthetic leg became wedged under the wheel of the wheelchair. Activity Assistant #61 stated Resident #22 never complained of pain, and they went to eat. Interview on 06/06/12 at 9:45 A.M., with the Director of Nursing (DON), revealed the lift on the van would not lift the resident while in her electric wheelchair. Therefore, State tested Nursing Assistant (STNA) #60 assisted the resident into a manual wheelchair and began pushing her toward the door. At this time, Resident #22's prosthetic leg became lodged under the chair. STNA #60 stopped pushing, instructed Resident #22 to pick her leg up, and continued pushing the resident to the front door. Then, while Activity Aide #61 assisted Resident #22 onto the van lift, her prosthetic leg dropped and became lodged under the wheelchair again. Resident #22 verbalized her leg hurt, but went on the outing with the rest of the residents and staff. On 06/06/12 at 10:35 A.M., during an interview with STNA #60, she revealed she had assisted Resident #22 via wheelchair to the van. STNA #60 verified there were no leg rests on the resident's manual wheelchair at the time, and Resident #22's prosthetic leg did get caught under the chair during the transport. Interview on 06/06/12 at 12:35 P.M., with Resident #22 revealed the lift was incapable of picking her up while in her electric wheelchair. Resident #22 stated STNA #60 transferred her into a manual wheelchair, which had no leg rests, and pushed her to the door. While STNA #60 was pushing her, her prosthetic leg dropped and turned under the wheelchair. Observation made on 06/06/12 at 12:35 P.M., revealed Resident #22 appropriately dressed and seated in an electric wheelchair. In the corner of Resident #22's room was a manual wheelchair with no leg rests present. Interview on 06/06/12 at 1:00 P.M., with Physical Therapist Assistant (PTA) #62, verified Resident #22 has an electric wheelchair for transport. PTA #62 stated Resident #22 is safe to transport in a manual wheelchair, as long as there are leg rests attached. The facility was unable to provide a policy related to the safe transport of residents in wheelchairs. This deficiency substantiates Master Complaint Number OH 743.