Every finding on record at Ohio Living Breckenridge Village

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review and interview, the facility failed to conduct a safe resident transfer onto a transportation van to prevent a fall with injury for Resident #63. This affected one resident (#63) of three residents reviewed for falls. The facility census was 64. Actual harm occurred on 09/10/25 when Resident #63 fell forward out of his wheelchair onto the concrete ground while being transferred by staff onto a facility transportation van. This resulted in resident complaints of back pain and multiple skin tears and abrasions to the head, left elbow, and multiple fingers of each hand. The resident was transferred to the hospital and admitted with the presence of an acute re-bleed from a chronic subdural hematoma.Findings include:Review of the medical record for Resident #63 revealed an admission date of 07/16/24. Resident #63 had diagnoses including chronic lymphocytic leukemia of B-cell type, history of a traumatic subdural hemorrhage without loss of consciousness, spondylolysis of the cervical and lumbar region, and a subsequent encounter on 09/13/25 of a trace acute re-bleed of a subdural hemorrhage. Review of the John Hopkins Fall Risk Assessment Tool completed 02/10/25 revealed Reside t#63 was at low fall risk.Review of the care plans revealed Resident #63 had the potential for functional status deficit related to a recent hospital stay for traumatic subdural hemorrhage without loss of consciousness, subsequent encounter started 07/17/24. Interventions initiated on 07/17/24 included keep bed in lowest position with brakes locked, keep environment free from clutter, keep personal items and frequently used items within reach, keep call light in reach at all times, respond to call light promptly and provide toileting assistance every two to three hours and as needed.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The assessment revealed Resident #63 was dependent on staff for toileting, dressing, transfers, and locomotion in a manual wheelchair.Review of a nurse's note dated 09/10/25 at 2:15 P.M. revealed Resident #63 was sitting in a wheelchair being transported by a facility van to a dental appointment in the accompaniment of his daughter. As transportation staff tried to pull Resident #63 in the wheelchair up onto the van's ramp with the resident facing outward away from the van, Resident #63 fell forward out of the wheelchair onto the concrete. Skin tears and abrasions were noted on the back of the resident's head, left elbow, and multiple fingers on each hand. The resident complained of back pain. The note indicated all paperwork was sent with the Emergency Medical Technicians (EMT's).Review of a facility fall investigation dated 09/10/25 revealed Resident #63 experienced a fall with injury while being transported by facility transportation into a transport van via a wheelchair using the van's side entry inclined wheelchair ramp. The van driver was unable to push the resident in the wheelchair up the ramp facing toward the van, so the driver turned the resident around and attempted to pull the resident backward up onto the inclined wheelchair ramp from behind. When this action was taken, the resident fell forward out of the wheelchair onto the ground. The daughter yelled out audibly when the event occurred which alerted surrounding staff. Immediately nursing and therapy staff responded to the scene. Resident #63 was found on the ground lying on his left side in front of the facility with an empty wheelchair behind the resident. The wheelchair accessible van was present with the side door open, and the inclined ramp was down. Only the resident, Resident #63's daughter and the transportation driver were at the scene when first responders arrived. Immediate assessment of the resident resulted in Resident #63's complaints of back pain and first aid was provided to areas of skin impairment. Emergency Medical Services (EMS) quickly arrived on the scene and took over care. The resident was transferred onto a gurney by EMTs and taken to the hospital. The hospital completed multiple computerized tomography (CT) scans which confirmed Resident #63's history of a chronic subdural hematoma and the presence of an acute re-bleed.Additional review of the fall investigation dated 09/10/25 revealed staff witness statements, first-hand account by the Director of Nursing (DON) and verbal witness reports from the resident and his daughter were utilized for investigation and root cause analysis. Follow-up intervention and information included the van driver was immediately removed from the transport assignment. Statements were collected from witnesses. The van driver's past completed education was reviewed. Thereafter, the van driver and all other facility drivers were provided with new education on safe wheelchair transport. Upon Resident #63's return from the hospital, PT and OT were ordered for evaluation and treatment for safe transport. Therapy recommended to only use the bus for wheelchair transport needs and no longer use the wheelchair accessible van with the side ramp which was used during the incident.Review of the witness statement written 09/10/25 from Transportation Driver #204 stated she tried to take Resident #63 and the silver bars on the back of the wheelchair were too low and stopped the chair from going up. She turned the resident around and tried to pull him up. The resident leaned forward and fell out of the chair. He landed on his side.Review of the witness statement written 09/10/25 by the DON revealed the DONresponded to the outside front entrance of the facility on 9/10/25 after hearing someone yelling outside He fell! Oh my God. He fell. Resident #63 was noted laying on the concrete slightly on his left side. An empty wheelchair was behind him. The leg rests were on the bench to the left ofthe scene. Oxygen was on via nasal canula and connected to concentrator on back of the wheelchair. Resident #63's daughter standing to the resident's right side. Transport van with a right-side entry ramp was open behind the resident. Transportation Driver #204 was present and holding a cell phone. Multiple first responders arrived at the same time including employees from therapy, campus security and the front offices of the facility. On initial assessment Resident #63 was alert and responsive. Skin tears with active bleeding noted to left elbow and fingers on both hands. The charge nurse was notified. First aid supplies and vital signs equipment was obtained. Resident #63 complained of back pain from 'laying on the concrete'. The resident denied neck pain. Range of motion (ROM) was within normal limits. A towel for padding was placed under the resident's lower back for comfort. First aid to the skin tears was initiated. EMS responded while vital signs were being taken charge by the nurse, and EMS took over the assessment and treatment. Resident #63 was alert and oriented to person, place, and time, answering EMS responders' questions to time and place correctly. Resident #63 was transferred to the gurney by EMS and was taken to the emergency room (ER) for evaluation and treatment. Transfer paperwork was gathered and provided to EMS by the unit manager. Resident #63 remained alert and conversive through the interaction. The resident's daughter remained at the scene after Resident #63 was placed into the EMS ambulance. One to one was provided with the resident's daughter to offer support and obtain details of what she witnessed. The resident's daughter stated she saw her dad fall out of the wheelchair while the transporter was attempting to roll him in his wheelchair up the wheelchair ramp into the van. The resident's daughter stated Transportation Driver #204 first attempted to load the wheelchair into the van by approaching straight on and pushing him forward but the leg rests and metal pieces on the wheelchair prevented entry. The daughter stated Transportation Driver #204 then removed the wheelchair leg rests to try again. Resident #63's daughter stated the transporter then attempted to pull the resident backwards up the ramp and that is when he fell forward out of the wheelchair and she yelled out for help.Review of the witness statement written 09/10/25 from Business Office Coordinator (BOM) #214 revealed she heard a woman's scream, looked out the windows of the office, which she could see the outside area of the front door. I saw a man falling out of a wheelchair onto the ground. It appeared that he was being transferred into a vehicle from our transportation department. I responded immediately to the outside area of the front door. As I passed Receptionist #212, I asked her to call security. When I went through front doors to the outside area of the entrance, the elderly man was lying on his left side, his daughter was on his left side. Transportation Driver #204 was standing at the head of the resident about a foot behind. PT #215 was assessing the resident, when the DON and Admissions Coordinator #216 came out to assist. The DON went back into the building to obtain a vital signs machine. Resident #63 was asked if he hit his head, and he replied I don't think so but did state his back hurt. There was noticeable blood on the resident's left elbow, and fingers of left hand. The resident was rolled over to his back where a clearer assessment of his arm and hand could be seen. He had a large skin tear that from his elbow to approximately three to four inches up his arm. His fingers also had abrasions. When the DON returned to the scene along with Licensed Practical Nurse (LPN) #206, the DON further assessment was completed. Security Supervisor #217 was also was on the scene. Activities Director #203 was present consoling the daughter.Review of the witness statement written 09/10/25 from Receptionist #212 revealed she did not witness the actual incident.Review of the witness statement written 09/12/25 by PT #215 revealed she did not witness the event. She ran outside when she heard his daughter screaming. When she arrived, he was on the ground. The wheelchair was upright and off to side. She supported his head and assisted him to roll slightly off of his left arm that he reported hurt to be lying on. Resident #63 reported his arm felt better after he was able to get it out from under himself. Someone else brought pillows to support the resident's head. Once his head was supported, she returned to my resident indoors and let the others present take over.Review of the witness statement written09/15/25 by Certified Occupational Therapy Assistant (COTA) #213 revealed she did not witness the fall but heard the screams from the therapy gym. Resident #63 was on the ground next to the ramp, on his left side, alert and bleeding from the left forearm. Therapist, PT #215, was holding his head off the ground. Other people were around or on their way. She went back to therapy gym and got a pillow, a large bolster and a towel and brought them back to Resident #63. She placed the pillow under his head, others rolled Resident #63 onto his back and she placed the bolster under knees and the towel under his bleeding arm. Many people/nurses are around tending to him, so she retreated back to the therapy gym.Review of the witness statement written 09/15/25 from Activities Director #203 heard a loud scream and crash and ran out but did not witness the actual incident.Review of the hospital records for Resident #63's hospital stay from 09/10/25 to 09/13/25 revealed an acute re-bleed of the right frontoparietal subdural hematoma and the bilateral chronic subdural hematoma appeared slightly smaller than the prior exam eleven months ago with no significant global mass effect. Range of motion (ROM) was intact, and the right shoulder x-ray was negative. There was a left elbow skin tear with other superficial injuries.Interview on 11/17/25 at 11:53 A.M. with Resident #63 revealed on 09/10/25 the facility used a different van than usual and a different person loaded him onto the van. The resident revealed usually the staff pushed him up the ramp face first, but at that time he was pulled up backwards and fell. The resident said he hit his head and scratched and bruised his arm, mostly the elbow. The fall also made his back hurt, so he was taken to the hospital.Interview on 11/17/25 at 2:21 P.M. with Activities Director #203 revealed she saw Resident #63's daughter upset when the bus driver pulled up. The resident's daughter told the driver they had been waiting for an hour. Activities Director #203 did not witness the incident.She was inside the facility when she heard a loud noise from outside. She then went outside and saw Resident #63 lying to the side of the ramp. The DON and another nurse came running out and assessed the resident. Interview on 11/17/25 at 2:45 P.M. with Transportation Driver #204 stated she tried to push Resident #63 up the ramp, but the footrests did not clear the top, so she turned him around and pulled him up backwards. She told the resident to lean back, but instead he leaned forward and rolled out of the wheelchair onto the ground beside the ramp.Interview on 11/17/25 at 3:44 P.M. with Licensed Practical Nurse (LPN) #206 revealed she was assigned to care for Resident #63 on that day (09/10/25). The resident had a dentist appointment, and his daughter was accompanying him. The resident went out to catch the transportation van, and that was the last time she saw him until the daughter came running up after the fall. LPN #206 went outside, and the resident was on the concrete. He was bleeding from his elbow and fingers. LPN #206 saw blood on Resident #63's head. The resident complained of pain on his bottom which he had landed on. The resident's daughter called EMS and they arrived quickly.Interview on 11/17/25 at 4:01 P.M. with the DON revealed on 09/10/25 she heard Resident #63's daughter yelling, He fell. He fell. The resident was lying on ground with the wheelchair behind him. Transportation Driver #204 was in front of the van calling someone. The DON assessed Resident #63 and found the resident was bleeding on his elbow, but not from his head. No open areas were seen on the resident's head. After more people responded, staff tried to bandage the resident's elbow. EMS arrived and took Resident #63 to the hospital. The resident's daughter and the driver reported the resident fell when he was pulled backwards up the ramp. Thereafter, Resident #63 was diagnosed with an area of acute rebleed from the CT scan, and skin injuries.Upon hire, all transportation driver complete training using a computer learning module entitled Lift and Securement Review.The deficient practice was corrected on 09/22/25 when the facility implemented the following corrective actions: -Transportation Driver #204 was immediately removed from the assignment by Transportation Supervisor #210 on 9/10/25 and suspended by Human Resources #207 on 09/12/25.-Beginning 09/11/25, the DON completed observational audits of safe wheelchair transport was completed by the transportation drivers and continued three times weekly for four weeks, and then weekly for three weeks.-On 09/12/25, the Administrator and Transportation Supervisor #210 reviewed additional education and action items. As a result, Transportation Driver #204 received education on safe wheelchair procedures on 9/12/25 by Transportation Supervisor #210 and was permanently removed from future healthcare center transports. All campus drivers were educated on safe wheelchair protocols by Transportation Supervisor #210 by 9/15/25. The results of this meeting and plans of correction were then reviewed with the facility Quality Committee on 9/16/25.-On 09/13/25, Resident #63 was evaluated by therapy services upon return from the hospital for safe transportation which resulted in recommendation to only use the bus for future transports and not to use the van with a side entrance ramp.-By 09/15/25, safe wheelchair education was completed with all facility drivers by Transportation Supervisor #210 which included repeating the computer learning module entitled Lift and Securement Review and additional training titled Transportation Department Wheelchair Procedures which included:1) Must evaluate the wheelchair for proper size for transport vehicle.2) Must push wheelchair in from behind! At all times! Prevent from falling forward.3) If you feel you cannot accommodate safely, you must ask or call for help!4) Under no circumstances should a resident be facing forward on a slope without guidance!5) If process of transporting cannot be done in a safe manner, the driver has the right to refuse.6)The transporter needs to call the office for a final decision.-On 09/16/25, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the incident with the Interdisciplinary Team (IDT) and the Medical Director. The Administrator monitored compliance in a QAPI meeting monthly for three months and then on-going as needed.-On 09/17/25 and 10/02/25, Resident #63 had follow-up medical appointments.-On 09/22/25, a care conference and incident review was held with Resident #63's daughter and son-in-law with the DON, Administrator, and Executive Director.-Social services followed Resident #63 for psychosocial impact and offered support after returning from the hospital on [DATE]. -Resident #63's skin tear was followed by nursing staff and Wound Nurse #211 from Encore Wound Group weekly after return from the hospital on [DATE] and was healed on 10/09/25.-On 09/22/25 additional education was completed by Transportation Driver #204 using computer learning entitled Lift and Securement Review which was specific to the incident. Transportation driver #204 no longer transports facility residents. -Additional Driver education on Lift and Securement was then completed. Transportation Driver #204 was permanently removed from future transports for nursing home residents. Relias transcript of completed additional Relias training attached upon return from leave.-On 10/22/25, the Administrator reviewed results of the audits and investigation at the quarterly Quality Committee meeting.This deficiency represents non-compliance investigated under Complaint Number 2621195.

Based on observation, interview, record review, facility policy and staff training review, and review of the Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH, the facility failed to use a gown for required enhanced barrier precautions (EBP) while administering medications through a gastric tube for Resident #44, failed to clean a wrist blood pressure monitor between use on Resident's #44 and #52, and failed to maintain a clean wall-mounted fan while in use and directed toward clean linen in the laundry area. This affected two residents (#44 and #52) of 60 residents reviewed for infection control and had the potential to affect all 60 residents residing in the facility. The facility reported 13 residents (#17, #22, #25, #30, #32, #44, #48, #113, #120, #121, #125, #126 and #162) on EBP precautions. Findings include: 1. Observation on 05/13/25 at 8:06 A.M. with Licensed Practical Nurse (LPN) #615 of medication administration for Resident #44 revealed LPN #615 prepared three medications for administration into a gastric tube while at the medication cart then entered Resident #44's room which had a sign posted on the door to observe EBP with gowns and gloves stored in a door rack for staff use. LPN #615 donned gloves but did not put on the required gown before engaging Resident #44 and administering the medications through the gastric tube. Once completed, LPN #615 removed the soiled gloves, performed hand hygiene and then left the resident's room. Interview at the time of the observation with LPN #615 confirmed not wearing the required gown for EBP. Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including encephalopathy, diabetes mellitus type two, hypertensive heart disease with heart failure and gastrostomy status. The Admission Minimum Data Set (MDS) assessment completed on 03/06/25 indicated Resident #44 had moderate cognitive impairment, and the plan of care dated 02/28/25 specified a need for enteral feeding through a gastric tube. Review of CMS QSO Memo 24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, revealed EBP are indicated for residents with indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism (MDRO). The effective date for implementation of EBP under the guidelines was 04/01/24. Review of the facility policy, Enhanced Barrier Precautions, revised 09/14/23, revealed EBP required the use of gloves and a gown with residents who had an indwelling medical device during high-contact resident care. Review of the facility staff training completed on 05/13/25 revealed the use of a gown and gloves for high-contact resident care activities was indicated for residents with indwelling medical devices. 2. Observation on 05/13/25 at 8:06 A.M. with LPN #615 of medication administration for Resident #44 revealed LPN #615 obtained a blood pressure reading using a wrist monitor prior to medication preparation then placed the monitor on top of the medication cart without cleaning it after use. LPN #615 then prepared Resident #44's medications, administered them as ordered and then moved the medication cart to where Resident #52 was located. LPN #615 picked up the soiled blood pressure monitor and used it to obtain Resident #52's blood pressure prior to preparing the resident's medications. Once completed, LPN #615 returned to the medication cart and set the soiled blood pressure monitor on top of the medication cart without cleaning it after use. Interview at the time of the observation with LPN #615 verified the wrist blood pressure monitor was not cleaned after use between Resident's #44 and #52. Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including encephalopathy, diabetes mellitus type two, hypertensive heart disease with heart failure and gastrostomy status. Review of the medical record for Resident #52 revealed an admitted [DATE] with diagnoses including chronic kidney disease, palliative care, dementia, atrial fibrillation and congestive heart failure. Review of facility staff training completed on 05/13/25, entitled Infection Control Review - Shared Medical Devices, revealed cleaning and disinfecting shared medical devices between residents are crucial for preventing the spread of infections, reducing healthcare-associated infections, and protecting residents' safety. 3. Observation on 05/14/25 at 11:19 A.M. with Housekeeping Supervisor (HS) #610 of the laundry room revealed in the clean laundry area there were two unknown laundry workers actively folding linen out of a large mostly filled clean linen cart. In proximity was a large wall mounted fan blowing air toward the two laundry workers and the clean linen. The fan had visible dirt buildup with accumulated dirt seen flapping from the air flow out of the fan toward the clean linen. Interview at the time of the observation with HS #610 confirmed the wall mounted fan being used in the clean laundry area was visibly dirty and blowing toward the clean linen.

Based on record reviews and interviews the facility failed to ensure as needed medication orders for [CONDITION(S)] drugs were limited to 14 days. This affected three (Residents #3, #23, and #34) of six residents reviewed for unnecessary medication. The census at the time of the survey was 90 residents. Findings include: 1.Record review for Resident #34 revealed the resident was readmitted to the facility on [DATE]. Pertinent diagnoses for the resident included unspecified dementia, other dissociative and conversion disorders, cognitive communication deficit, chronic pain, anxiety disorder, and major depressive disorder. The brief interview for mental status (BIMS) from MDS dated [DATE] revealed the resident had a score of five indicating severe cognitive impairment. Review of physician orders for Resident #34 revealed on 03/09/22 the physician had ordered the antipsychotic medication [MEDICATION(S)] one 50 milligram (mg) tablet by mouth every six hours as needed (PRN) for unspecified dementia with behavioral disturbance with no end date. The medication administration record (MAR) for Resident #34 was reviewed for the month of June 2022 and had documented administrations of the PRN antipsychotic medication [MEDICATION(S)] as followed: one administration on 06/04/22, one administration on 06/05/22, one administration on 06/10/22, one administration on 06/20/22, one administration on 06/24/22, and one administration on 06/28/22. The facility failed to provide evidence the physician had reviewed the continued and frequent use of the PRN psychotic medication for Resident #34. No evidence was presented to confirm the 14 day re-assessment and reorder interval was completed. These findings were verified during interview with the Director of Nursing on 06/29/22 at 10:21 A.M. Review of the facility policy titled, [CONDITION(S)] Medications, with a revised date of 03/01/21, revealed PRN orders for [CONDITION(S)] drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she will document their rationale in the resident's medical record and indicate the duration for the PRN order. 2. Review of the medical chart for Resident #3 revealed an admitted [DATE]. Diagnoses include but not limited to vascular dementia without behavioral disturbance, [CONDITION(S)], and brachial [MEDICATION(S)] disorders. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/22/22, revealed Resident #3 had severely impaired cognition and required extensive assistance with two staff for activities of daily living except eating required supervision with set up only. Review of the physician's orders for June 2022 revealed Resident #3 was ordered 1.0 milligrams (mg) of [MEDICATION(S)] on 03/16/22 for muscle spasm as needed (PRN) with a maximum dose of three tablets with no stop date. Interview on 06/30/22 at 8:07 A.M. with Registered Nurse (RN) #538 verified that there was no stop date for [MEDICATION(S)] PRN. Review of the facility policy titled, [CONDITION(S)] Medications, with a revised date of 03/01/21, revealed PRN orders for [CONDITION(S)] drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she will document their rationale in the resident's medical record and indicate the duration for the PRN order. #3: Record review of Resident #23 revealed she was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease, cognitive communication deficit, restlessness and agitation, and acute [CONDITION(S)]. She had an active order for 25 milligrams of [MEDICATION(S)] (an antipsychotic) to be given twice per day as needed (PRN) for behaviors including hitting, scratching, and screaming. The order was dated 12/02/21. A psychiatric service visit dated 05/26/22 noted her PRN [MEDICATION(S)] order was to be continued. The surveyor could not find evidence the PRN [MEDICATION(S)] was specifically reviewed and renewed every 14 days. Record review of Resident #23's medication administration record revealed she received the PRN [MEDICATION(S)] twice in April 2022 on 04/11/22 and 04/15/22, and no times in May or June 2022 as of the time of the record review. Review of a pharmacy record review for Resident #23 dated 01/28/22 revealed the pharmacy recommendation that the PRN [MEDICATION(S)] order be made to only last 14 days, and to be renewed every 14 days. The provider checked 'disagree' on the response list at the bottom and wrote to continue the medication as-ordered. Review of the facility's [CONDITION(S)] medication policy dated 03/01/21 revealed antipsychotic medications were limited to 14 days and could not be renewed unless the physician evaluated the resident for appropriateness for another 14 days. The surveyor confirmed the above findings with the Director of Nursing on 06/29/22 at 10:25 A.M.

Based on record review and staff interview, the facility failed to ensure the most recent state survey results were readily available for public review. This had the potential to affect all 90 residents residing in the facility. Findings included: Review of the facility folder titled Ohio Department of Health Survey Results located in the main lobby in clear view revealed the last survey in the folder and available to be reviewed by the public was the annual survey conducted on 06/27/19. The Ohio Department of Health conducted a complaint survey at the facility on 01/04/22 resulting in a certification deficiency and licensure violation being issued to the facility: Interview with the Administrator on 06/28/22 at 9:53 A.M. confirmed the last survey in the book was 06/27/19 for public review.

Based on interview and record review the facility failed to prevent misappropriation for Resident #1 and #2 by agency State tested Nurse Aide (STNA) #3. This affected two of two residents reviewed for misappropriation. Findings include: 1. Resident #1 was admitted to the facility on [DATE] for skilled therapy with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/02/21 she was admitted to the hospital for complications related to the blood clot and returned to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) 3.0 dated 10/31/21 revealed the resident was alert and oriented and able to make her own decisions. On 12/08/21 she informed her husband she noticed charges she did not make on her credit card made on 12/06/21 and 12/07/21. The husband contacted the Administrator and a police report was filed #21- . The Administrator suggested the police question agency STNA #3. Police questioned STNA #3 who confessed to taking pictures of the credit card numbers and using the credit card for personal use. Resident #1 was discharged home from the facility on 12/30/21. 2. Resident #2 was admitted to the facility on [DATE] for skilled therapy due to weakness related to [CONDITION(S)]. Review of the admission MDS 3.0 dated 10/22/21 revealed the resident was alert and oriented and able to make her needs known. On 12/10/21 she informed her husband she noticed charges of #1,300.00 on her credit card from 12/06/21 and 12/07/21 that were not hers. The husband contacted the Administrator who contacted the police and a report was filed #21- . The Administrator suggested the police question agency STNA #3. The police questioned STNA #3 who confessed to taking pictures of the credit card numbers and using the credit card for personal use. Resident #2 was discharged home from the facility on 12/14/21. On 01/04/22 at 11:20 A.M., interview with the Administrator confirmed Resident #1's husband called him on 12/08/21 to inform him of the concerns and Resident #2's husband called him to inform him of the concerns on 12/10/21. On both occasions all staff were interviewed related to misappropriation without knowledge. STNA #3, was from an agency, and had only worked at the facility on 12/05/21, 12/07/21, 12/10/21, 12/11/21 and 12/12/21. The Administrator confirmed all agency staff had their background checks and license verification at the agency they worked for. Also, the agencies completed their own education on abuse and misappropriation. The Administrator verified the police informed him STNA #3 confessed to making unauthorized purchases for both residents. The Administrator had not spoken to STNA #3 but she would definitely not be be returning to the facility. The Administrator added he had spoken to Residents #1 and #2. Both had contacted their credit card companies. They were being reimbursed for the unauthorized charges and said they were satisfied with how things were handled by the facility. The police investigation was ongoing. Review of the abuse, neglect, misappropriation and crime reporting policy, revised 12/21/21, revealed the facility would take measures to prevent misappropriation of resident's property. Any allegations would be immediately investigated. All facility staff were trained on initially on hire during orientation with ongoing training related to misappropriation. All facility staff would be screened prior to hire to eliminate personas with a past history of misappropriation of residents. This deficiency substantiates Complaint Number OH 434.

Based on observation, interview, and record review, the facility failed to ensure facial hair was covered and utensils and gloves were used when plating and serving foods. This had the potential to affect 45 residents who received meals served in the second floor dining room, as well as Residents #52 and #91. The facility census was 93 residents. Findings include: 1. Observation on 06/24/19 at 12:30 P.M. of lunch service in the second floor dining room revealed Dietary Aide (DA) #150 setting up the food on the steam table. DA #150 had a full beard without a hair restraint. On 06/24/19 at 12:30 P.M. with the Director of Dining Services (DDS) #160 confirmed DA #150 had a long beard and wasn't wearing a hair restraint to cover it. Observation on 06/24/19 at 12:30 P.M. of the start of meal service revealed DA #150 used gloved hands to plate quiche. DA #150 held the serving utensil in one hand and with the other hand directly touched the quiche to help slide it from the serving utensil and then position it on the plate. Using the same gloves with visible particles of quiche on them, DA #150 also handled lettuce and tomato, and assembled and plated sandwiches. On 06/24/19 at 12:57 P.M. DA #150 confirmed he used his gloved hands to directly handle and serve quiche, lettuce and tomatoes and sandwiches. DA #150 verified he should have used serving utensils. Review of the facility policy titled Employee Sanitary Practices dated 2013 revealed all employees shall wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food and use utensils to handle food. 2. Observation of the Courtyard dining room during the lunch meal on 06/24/19 at 11:45 A.M. revealed State tested Nursing Aide (STNA) #201 used her bare hands to place lettuce and tomato on Resident #52's sandwich, and then held the sandwich in place to cut it in half. STNA #201 then repeated these actions for Resident #91's food. Interview with STNA #201 on 06/24/19 at 11:51 A.M. confirmed the above observations. Review of the facility's bare hand contact with food policy dated 2013 revealed single-use gloves were to be worn by staff when handling food directly, and bare handed contact with food was prohibited to staff.

Based on record review and interview the facility failed to ensure accurate assessments regarding falls for Resident #16 and regarding medications for Resident #84. This affected one resident (Resident #16) of three residents reviewed for falls and one resident (Resident #84) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the record revealed the resident had a fall on 01/12/18 when she sustained bruises and a compression fracture. A fall on 01/13/18 resulted in a laceration. She had falls on 01/15/18, 01/25/18 and 01/26/19 that did not result in injuries. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had sustained only two falls with no injury. An interview with the assessment nurse, Registered Nurse (RN) #600, on 05/17/18 at 11:50 P.M. confirmed the assessment was inaccurate and the fall on 01/12/18 should have been coded as a major injury and the fall on 01/13/18 should have been coded as an injury (except major). She also verified the falls with no injury should total three occurrences. 2. Review of Resident #84's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her record revealed she was diagnosed with [REDACTED]. She took the medication from 04/25/18 through 05/02/18. Review of the quarterly MDS 3.0 assessment, dated 04/23/18 revealed the resident was coded for taking an antibiotic six of seven days prior to the assessment date of 04/23/18. An interview with the assessment nurse, RN #600, on 05/17/18 at 11:50 A.M. verified the resident had not received an antibiotic in the 7 days prior to the assessment date and had been coded in error.

Based on record review and staff interview the facility failed to develop a care plan for elopement for Resident #68, who was assessed to be at moderate elopement risk. This affected one resident (Resident #68) of seven residents identified to be at moderate or high risk for elopement. Finding include: Review of the medical record for Resident #68 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. The resident required extensive assistance for transfers, dressing, toilet use and personal hygiene and was totally dependent on staff for locomotion. Review of the elopement risk assessment, dated 04/24/18 revealed the resident was at moderate risk for elopement. Review of the care plans for Resident #68 on 05/15/18 revealed there was no care plan for elopement/wandering behavior. Review of physician orders [REDACTED]. The order indicated to check placement every shift. Review of the nurse's notes dated 04/24/18 at 4:00 P.M. revealed wanderguard was applied to resident's wheelchair. Interview on 05/16/18 at 3:53 P.M. with the director of nursing (DON) verified there was no care plan developed for Resident #68 related to elopement risk.

Based on record review and interview the facility failed to ensure pharmacy recommendations were addressed timely by the physician for Resident #84 and Resident #47. This affected two residents (Resident #84 and #47) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #84's medical record revealed the resident was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Review of a consultation report, summary of a pharmacy recommendations made on 08/28/17 revealed a recommendation for Resident #84 to have a fasting lipid profile (laboratory testing) to be done since the resident was taking Atorvastatin, a medication to treat high cholesterol. The director of nursing (DON) verified during an interview on 05/17/18 at 12:50 P.M. she could not locate the form that would have been signed by the physician indicating his desire to comply with the recommendation or not, but verified the lab work had not been obtained since the recommendation was made 08/28/17. 2. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Record review on 05/17/18 at 10:00 A.M. revealed the consultant pharmacist recommended on 04/20/18 that a specific [DIAGNOSES REDACTED].# 47. The doctor failed to document and sign pharmacist's recommendation. An interview with the DON on 05/17/18 at 10:19 A.M. verified there was no [DIAGNOSES REDACTED].

Based on record review and interview the facility failed to an adequate indication for use of the antipsychotic medication, [MEDICATION NAME] for Resident #84 and failed to ensure gradual dose reductions were attempted for the medication. This affected one resident (Resident #84) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #84's medical record revealed the the resident was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of a pharmacy recommendation dated 07/01/17 revealed the pharmacist had recommended the medication be gradually reduced. The form provided by the pharmacist with the recommendation was check marked as declined and indicated its continued use was in accordance with the current standard of practice and a dose reduction is like to impair the residents stability. The statement was followed with an indication that further documentation was required to explain why the attempt was likely to impair function or cause psychiatric instability in the resident. This area was not completed. There was no further documentation indicated as to the reason for not attempting a gradual dose reduction as required. This was verified by the director of nursing during an interview on 05/17/18 at 12:50 P.M. The director of nursing did provide a form signed by the physician indicating monthly documentation of restraints, [MEDICAL CONDITION] medication and pressure ulcers. This form, dated by the physician monthly, indicated the [MEDICATION NAME] was used for agitation, yelling, restlessness, and delusional disorder and indicated the reduction was contraindicated per psych note dated 08/29/17. The director of nursing verified the resident did not see a psychiatrist, there was no documentation in the record with that date regarding gradual dose reductions and there was no documentation as required to indicate the reason a gradual dose reduction was not attempted. In addition, record review revealed consultant pharmacist recommended on 04/20/18 that a specific [DIAGNOSES REDACTED].# 47. The doctor failed to document and sign pharmacist's recommendation. An interview with the DON on 05/17/18 at 10:19 A.M. verified there was no [DIAGNOSES REDACTED].

Based on record review and interview the facility failed to medicate Resident #1 for pain according to the physician's orders. This affected one of three residents reviewed for pain medication administration. Facility census was 103. Findings include: Record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired, required assist of one person for transfers, dressing and toileting and had no pain in the 5 days prior to the date of the MDS. The care plan dated 09/04/12 and updated 05/13/16 revealed the resident had a potential for pain/alteration in comfort with interventions including administering pain medications as ordered by the physician. Review of the facility Self Reported Incident (SRI) # 3 completed by the Director Of Nursing (DON) dated 02/14/17 revealed Resident #1 called five times requesting a pain pill on 02/04/17 starting at 5:48 P.M. and did not receive one. Licensee Practical Nurse (LPN) #21 was immediately removed from the patient care area and the supervisor spoke with her. She was informed her that she was being suspended pending investigation. LPN #21 exited the building. The report revealed the LPN assigned to the resident, LPN #21 did not adhere to professional standards of conduct or obligations related to professional standards of conduct or obligations related to profession/licensure, failed to follow doctor's orders and had a breach of duty due to not addressing pain relief promptly and not adhering to Resident #1's request. LPN #21 was presented disciplinary action and her position was terminated as a result of the disciplinary action. Review of the facility's documentation for SRI # 3 confirmed the investigation details and interviews with LPN #21, LPN #23, LPN #24 and STNA #20. All interviews confirmed the facility's investigation except LPN #21 stated although she did not medicate the resident timely she denied any willful intent of neglect of care for Resident #1. Review of Resident #1's MAR for February confirmed he was medicated with [MEDICATION NAME] 50 mg on 02/04/17 at 5:30 A.M. and 7:00 P.M. by LPN #23 for complaints of pain. Record review revealed LPN #21 was hired on 08/31/16, terminated by phone on 02/07/11 at 3:00 P.M. by the DON, Administrator and the human resources manager related to this incident. An interview with Resident #1 on 02/21/17 at 9:35 A.M. confirmed the facility's reporting of the incident. A phone interview with LPN #23 on 02/21/17 at 11:23 A.M. confirmed the facility's reporting of the incident. Interview with the DON and Assistant Director of Nursing (ADON) confirmed LPN #21 did not medicate Resident #1 in a timely manner when the resident started requesting pain medication from LPN #21 at 5:45 P.M. on 02/04/17 and also confirmed the resident was not medicated for the pain until LPN #23 medicated him with [MEDICATION NAME] 50 mg at 7:00 P.M. This deficiency substantiates Complaint Number OH 524.

Based on record review, investigation report review, and interview, the facility failed to ensure Resident #43 was free from abuse during a transfer to his recliner, when a state tested nurse aide (STNA) pulled him away from another staff assisting with the transfer and threw him into his chair. Actual Harm of pain and mental anguish occurred for Resident #43, who said he had increased pain after the incident and felt the staff member had treated him like dirt. This affected one of five residents reviewed for care. Findings include: Review of the record revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An order dated 11/02/16 indicated he was to be transferred to the right side only with the assist of two staff and a gait belt. Review of his 11/08/16 Minimum Data Set 3.0 (MDS) assessment revealed the resident was cognitively intact, did not have behaviors and required the extensive of two staff for his bed mobility and transfers. Review of a facility self reported incident report dated 11/12/16 revealed possible abuse occurred to Resident #43 on 11//11/16 when the resident was transferred. The incident indicated STNA #9 ripped the resident out of the hands of STNA #8, who was helping with the two person transfer and threw him into the chair. STNA #8 immediately reported the incident to the nurse, who then interviewed the resident. The resident said STNA #9 was visibly upset, grabbed him under his arm and just dropped him in the recliner without warning. Review of the statement of STNA #9 dated 11/12/16 revealed no unusual incident had occurred. She was interviewed by phone and stated she transferred the resident with the assistance of STNA #8. Review of a statement by the Director of Nursing (DON) revealed she talked with Resident #43 on 11/14/16 and he said STNA #9 elbowed her way in, pushing (STNA #8) out of the way. She put her arms around me, lifted me and threw me into the recliner chair. He stated she did not talk to him or tell him what was happening but stated he did not want the aide to care for him anymore during his stay and hoped this did not happen to any other resident. He stated he was not upset or fearful, and that he didn't think she was trying to hurt him. She just wanted to get the job done. He did say it was a little frightening to be lifted like that and not know what was happening. Review of the statements of Licensed Practical Nurses (LPNs) #6 and #7 and STNA #8 completed during the investigation confirmed the incident had occurred. STNA #9 was no longer employed by the facility and could not be reached, and Resident #43 had been discharged from the facility on 11/22/16 to another facility and could not be interviewed. Review of the summary of the investigation completed by the facility and submitted to the state agency revealed the facility issued a correcting warning to STNA #9 for failure to follow protocol for resident transfers and for not acting in a [MEDICATION NAME] manner. The summary indicated STNA #9 denied the allegations and immediately quit without notice. Interview with the DON on 11/28/16 at 9:40 A.M. revealed LPN #6 texted her on 11/11/16 around 10:00 P.M. but she did not see the text until the next morning. She stated she began to investigate the incident when she came in the next morning. After receiving statements from LPN #6 and STNA #8, she called STNA #9 to come in to give a statement. She stated STNA #9 had given notice several days prior that she was quitting, but after the interview with the DON, she resigned immediately. The DON stated STNA #9 denied any wrongdoing in the incident, stating she had transferred the resident with STNA #8 with no concerns. She denied pulling the resident away for STNA #8 and throwing him in the chair. Interview with STNA #8 on 11/28/16 at 3:10 P.M. revealed she was the only aide on the hall on 11/11/16 around 5:45 or 6:00 P.M. when Resident #43 asked to move from his wheelchair to his recliner. She said the resident was weak on his left side and required two staff to transfer. She stated she saw STNA #9 sitting at the nursing station and asked her to help with the transfer. She said STNA #9 sighed as though she did not want to help but got up and went with her down the hall. She told STNA #9 on the way to the room that he was weak on one side and was a heavy transfer. She said they entered the room and she took the resident's right (strong) side, also holding onto his gait belt. She said STNA #9 initially took the resident's left arm to help him up, but once he was up, STNA #9 pulled him out of my arms and threw him in the recliner by herself. She stated STNA #9 then left the room without speaking. She said she saw a look of shock on the face of Resident #43 and saw tears in his eyes. She said she asked if he was okay and he said he was in a lot of pain from the transfer and wanted to see the nurse. She told LPN #6 what had happened and the nurse went in the room. She said later in the shift, when she went into his room, she asked if he was okay and he said, She (STNA #9) better never touch me again. STNA #8 said she had never witnessed staff treat a resident like this before. She said she saw STNA #9 continue working that night, but knew the nurse knew about the situation. She said she was busy and didn't know what came of the incident, except the nurse had her write a statement. Interview with LPN #6 on 11/28/16 at 3:50 P.M. revealed STNA #8 came to her on 11/11/16 at around 6:00 P.M. and told her Resident #43 was having pain. She denied STNA #8 told her anything about an improper transfer at that time. She said she went in the room and the resident said he was having pain but did not mention anything about the transfer incident. She said she could not medicate him, as he had just had pain medication, but she went back and gave him medication for pain at 8:00 P.M. She said she was unaware of the incident with STNA #9 until 9:45 P.M., when STNA #8 mentioned it to her. She stated she then went to Resident #43's room and asked him about the incident. She said he told her that STNA #9 had picked him up and threw him into the chair. She said he was upset, and said the action had caused him pain and made him feel like a piece of dirt. She stated she reassured the resident and asked for an interview statement from STNA #8. She said she texted the DON, but did not receive an response. She told the night shift supervisor about the incident. She said the STNA shifts were almost over (worked until 10:30 P.M.) and because STNA #9 wouldn't have any more contact with residents and since she was afraid STNA #9 would get loud and angry so late at night, she did not send her home. She said she knew now that she should have removed STNA #9 from resident care immediately. LPN #7 was interviewed on 11/28/16 at 3:40 P.M. He stated he worked on the day shift on 11/12/16 and interviewed Resident #43 when he heard what had happened. He stated the resident was scared and surprised by what had happened the night before and said STNA #9 was visibly upset when she came in the room to transfer him. LPN #7 stated she was probably upset because that room was not on her assignment. He said STNA #9 frequently had an attitude. He stated by visibly upset, the resident meant that she looked angry and mean. Interview with the DON on 11/29/16 at 11:00 A.M. verified all of the events and interviews related to the incident on 11/11/16 with Resident #43. She verified the report by STNA #8 that the resident stated he had pain and felt he had been treated like dirt, and the report by LPN #7 that the resident was scared and surprised by the incident. She verified her interview with the resident on 11/14/16 was several days after the interview. This deficiency substantiates Complaint Number OH 049.

Based on interview, review of investigation report and record review, the facility failed to ensure suspected abuse was reported immediately and that other residents were protected from possible abuse. This affected Resident #43, one of five residents reviewed for care. Findings include: Review of the record revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An order dated 11/02/16 indicated he was to be transferred to the right side only with the assist of two staff and a gait belt. Review of his 11/08/16 Minimum Data Set assessment revealed the resident was cognitively intact, did not have behaviors and required the extensive of two staff for his bed mobility and transfers. Review of a a facility self reported incident report dated 11/12/16 revealed possible abuse occurred to Resident #43 on 11//11/16 when the resident was transferred. The incident indicated State tested Nurse Aide (STNA) #9 ripped the resident out of the hands of STNA #8, who was helping with the two person transfer, and threw him into the chair. STNA #8 immediately reported the incident to the nurse, who then interviewed the resident. The resident said STNA #9 was visibly upset, grabbed him under his arm and just dropped him in the recliner without warning. Interview with the Director of Nursing (DON) on 11/28/16 at 9:40 A.M. revealed Licensed Practical Nurse (LPN) #6 texted her on 11/11/16 around 10:00 P.M. but she did not see the text until the next morning. She stated she began to investigate the incident when she came in the next morning. After receiving statements from LPN #6 and STNA #8, she called STNA #9 to come in to give a statement. She stated STNA #9 had given notice several days prior that she was quitting, but after the interview with the DON, she resigned immediately. The DON stated STNA #9 denied any wrongdoing in the incident, stating she had transferred the resident with STNA #8 with no concerns. She denied pulling the resident away for STNA #8 and throwing him in the chair. Interview with STNA #8 on 11/28/16 at 3:10 P.M. revealed she was the only aide on the hall on 11/11/16 around 5:45 or 6:00 P.M. when Resident #43 asked to move from his wheelchair to his recliner. She said the resident was weak on his left side and required two staff to transfer. She stated she saw STNA #9 sitting at the nursing station and asked her to help with the transfer. She said STNA #9 sighed as though she did not want to help but got up and went with her down the hall. She told STNA #9 on the way to the room that he was weak on one side and was a heavy transfer. She said they entered the room and she took the resident's right (strong) side, also holding onto his gait belt. She said STNA #9 initially took the resident's left arm to help him up, but once he was up, STNA #9 pulled him out of my arms and threw him in the recliner by herself. She stated STNA #9 then left the room without speaking. She said she saw a look of shock on the face of Resident #43 and saw tears in his eyes. She said she asked if he was okay and he said he was in a lot of pain from the transfer and wanted to see the nurse. She told LPN #6 what had happened and the nurse went in the room. She said later in the shift, when she went into his room, she asked if he was okay and he said, She (STNA #9) better never touch me again. She said she had never witnessed staff treat a resident like this before. She said she saw STNA #9 continue working that night, but knew the nurse knew about the situation. She said she was busy and didn't know what came of the incident, except the nurse had her write a statement. Interview with LPN #6 on 11/28/16 at 3:50 P.M. revealed STNA #8 came to her on 11/11/16 around 6:00 P.M. and told her Resident #43 was having pain. She denied STNA #8 told her anything about an improper transfer at that time. She said she went in the room and the resident said he was having pain but did not mention anything about the transfer incident. She said she could not medicate him, as he had just had pain medication, but she went back and gave him medication for pain at 8:00 P.M. She said she was unaware of the incident with STNA #9 until 9:45 P.M., when STNA #8 mentioned it to her. She stated she then went to Resident #43's room and asked him about the incident. She said he told her that STNA #9 had picked him up and threw him into the chair. She literally picked me up and threw me into it. She said he was upset, and said the action had caused him pain and the STNA made him feel like a piece of dirt. She stated she reassured the resident and asked for an interview statement from STNA #8. She said she texted the DON, but did not receive a response. She told the night shift supervisor about the incident. She said the STNA shifts were almost over (worked until 10:30 P.M.) and because STNA #9 wouldn't really have any more contact with residents and since she was afraid STNA #9 would get loud and angry so late at night, she did not send her home. She said she knew now that she should have removed STNA #9 from resident care immediately. LPN #7 was interviewed on 11/28/16 at 3:40 P.M. He stated he worked on the day shift on 11/12/16 and interviewed Resident #43 when he heard what had happened. He stated the resident was scared and surprised by what had happened the night before and said STNA #9 was visibly upset when she came in the room to transfer him. He stated she was probably upset because that room was not on her assignment. He said STNA #9 frequently had an attitude. He stated by visibly upset, the resident meant that she looked angry and mean. Review of the statement of STNA #9 dated 11/12/16 revealed no unusual incident had occurred. She was interviewed by phone and stated she transferred the resident with the assistance of STNA #8. Review of a statement by the DON revealed she talked with Resident #43 on 11/14/16 and he said STNA #9 elbowed her way in, pushing (STNA #8) out of the way. She put her arms around me, lifted me and threw me into the recliner chair. He stated she did not talk to him or tell him what was happening but stated he did not want the aide to care for him anymore during his stay and hoped this did not happen to any other resident. He stated he was not upset or fearful, and that he didn't think she was trying to hurt him. She just wanted to get the job done. He did say it was a little frightening to be lifted like that and not know what was happening. Review of the statements of LPNs #6 and #7 and STNA #8 completed during the investigation confirmed the interviews conducted. STNA #9 was no longer employed by the facility and could not be reached, and Resident #43 had been discharged from the facility on 11/22/16 to another facility and could not be interviewed. Review of the summary of the investigation completed by the facility and submitted to the state agency revealed the facility issued a correcting warning to STNA #9 for failure to follow protocol for resident transfers and for not acting in a [MEDICATION NAME] manner. The summary indicated STNA #9 denied the allegations and immediately quit without notice. Interview with the DON on 11/29/16 at 11:00 A.M. verified all of the events and interviews related to the incident on 11/11/16 with Resident #43. She verified the report by STNA #8 that the resident stated he had pain and felt that he had been treated like dirt, and the report by LPN #7 that the resident was scared and surprised by the incident. She verified her interview with the resident on 11/14/16 was several days after the interview. The DON verified STNA #8 had knowledge of the inappropriate treatment by STNA #9 around 6:00 P.M. on 11/11/16 and STNA #9 was not sent home or removed from direct resident care, putting other residents at risk. She indicated by the punch out detail, STNA #9 did not clock out until 11/11/16 at 10:40 P.M. She verified the investigation did not contain interview of other residents who may have been treated in an abusive manner by STNA #9 on 11/11/16. This deficiency substantiates Complaint Number OH 049.

Based on interview, review of investigation report, record review and policy review, the facilty failed to ensure policies were followed regarding reporting and protection of residents when abuse was suspected. This affected Resident #43, one of five residents reviewed for care. Findings include: Review of the facility's Abuse and Neglect policy, last updated December 2016, revealed all allegations of abuse, neglect and misappropriation will be reported immediately and will be investigated, and that staff should immediately provide for the safety of the resident by removing from service any suspected employee until the investigation is complete. Review of the record revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An order dated 11/02/16 indicated he was to be transferred to the right side only with the assist of two staff and a gait belt. Review of his 11/08/16 Minimum Data Set assessment revealed the resident was cognitively intact, did not have behaviors and required the extensive of two staff for his bed mobility and transfers. Review of a a facility self reported incident report dated 11/12/16 revealed possible abuse occurred to Resident #43 on 11//11/16 when the resident was transferred. The incident indicated State tested Nurse Aide (STNA) #9 ripped the resident out of the hands of STNA #8, who was helping with the two person transfer, and threw him into the chair. STNA #8 immediately reported the incident to the nurse, who then interviewed the resident. The resident said STNA #9 was visibly upset, grabbed him under his arm and just dropped him in the recliner without warning. Interview with the Director of Nursing (DON) on 11/28/16 at 9:40 A.M. revealed Licensed Practical Nurse (LPN) #6 texted her on 11/11/16 around 10:00 P.M. but she did not see the text until the next morning. She stated she began to investigate the incident when she came in the next morning. After receiving statements from LPN #6 and STNA #8, she called STNA #9 to come in to give a statement. She stated STNA #9 had given notice several days prior that she was quitting, but after the interview with the DON, she resigned immediately. The DON stated STNA #9 denied any wrongdoing in the incident, stating she had transferred the resident with STNA #8 with no concerns. She denied pulling the resident away for STNA #8 and throwing him in the chair. Interview with STNA #8 on 11/28/16 at 3:10 P.M. revealed she was the only aide on the hall on 11/11/16 around 5:45 or 6:00 P.M. when Resident #43 asked to move from his wheelchair to his recliner. She said the resident was weak on his left side and required two staff to transfer. She stated she saw STNA #9 sitting at the nursing station and asked her to help with the transfer. She said STNA #9 sighed as though she did not want to help but got up and went with her down the hall. She told STNA #9 on the way to the room that he was weak on one side and was a heavy transfer. She said they entered the room and she took the resident's right (strong) side, also holding onto his gait belt. She said STNA #9 initially took the resident's left arm to help him up, but once he was up, STNA #9 pulled him out of my arms and threw him in the recliner by herself. She stated STNA #9 then left the room without speaking. She said she saw a look of shock on the face of Resident #43 and saw tears in his eyes. She said she asked if he was okay and he said he was in a lot of pain from the transfer and wanted to see the nurse. She told LPN #6 what had happened and the nurse went in the room. She said later in the shift, when she went into his room, she asked if he was okay and he said, She (STNA #9) better never touch me again. She said she had never witnessed staff treat a resident like this before. She said she saw STNA #9 continue working that night, but knew the nurse knew about the situation. She said she was busy and didn't know what came of the incident, except the nurse had her write a statement. Interview with LPN #6 on 11/28/16 at 3:50 P.M. revealed STNA #8 came to her on 11/11/16 around 6:00 P.M. and told her Resident #43 was having pain. She denied STNA #8 told her anything about an improper transfer at that time. She said she went in the room and the resident said he was having pain but did not mention anything about the transfer incident. She said she could not medicate him, as he had just had pain medication, but she went back and gave him medication for pain at 8:00 P.M. She said she was unaware of the incident with STNA #9 until 9:45 P.M., when STNA #8 mentioned it to her. She stated she then went to Resident #43's room and asked him about the incident. She said he told her that STNA #9 had picked him up and threw him into the chair. She literally picked me up and threw me into it. She said he was upset, and said the action had caused him pain and the STNA made him feel like a piece of dirt. She stated she reassured the resident and asked for an interview statement from STNA #8. She said she texted the DON, but did not receive a response. She told the night shift supervisor about the incident. She said the STNA shifts were almost over (worked until 10:30 P.M.) and because STNA #9 wouldn't really have any more contact with residents and since she was afraid STNA #9 would get loud and angry so late at night, she did not send her home. She said she knew now that she should have removed STNA #9 from resident care immediately. LPN #7 was interviewed on 11/28/16 at 3:40 P.M. He stated he worked on the day shift on 11/12/16 and interviewed Resident #43 when he heard what had happened. He stated the resident was scared and surprised by what had happened the night before and said STNA #9 was visibly upset when she came in the room to transfer him. He stated she was probably upset because that room was not on her assignment. He said STNA #9 frequently had an attitude. He stated by visibly upset, the resident meant that she looked angry and mean. Review of the statement of STNA #9 dated 11/12/16 revealed no unusual incident had occurred. She was interviewed by phone and stated she transferred the resident with the assistance of STNA #8. Review of a statement by the DON revealed she talked with Resident #43 on 11/14/16 and he said STNA #9 elbowed her way in, pushing (STNA #8) out of the way. She put her arms around me, lifted me and threw me into the recliner chair. He stated she did not talk to him or tell him what was happening but stated he did not want the aide to care for him anymore during his stay and hoped this did not happen to any other resident. He stated he was not upset or fearful, and that he didn't think she was trying to hurt him. She just wanted to get the job done. He did say it was a little frightening to be lifted like that and not know what was happening. Review of the statements of LPNs #6 and #7 and STNA #8 completed during the investigation confirmed the interviews conducted. STNA #9 was no longer employed by the facility and could not be reached, and Resident #43 had been discharged from the facility on 11/22/16 to another facility and could not be interviewed. Review of the summary of the investigation completed by the facility and submitted to the state agency revealed the facility issued a correcting warning to STNA #9 for failure to follow protocol for resident transfers and for not acting in a [MEDICATION NAME] manner. The summary indicated STNA #9 denied the allegations and immediately quit without notice. Interview with the DON on 11/29/16 at 11:00 A.M. verified all of the events and interviews related to the incident on 11/11/16 with Resident #43. She verified the report by STNA #8 that the resident stated he had pain and felt that he had been treated like dirt, and the report by LPN #7 that the resident was scared and surprised by the incident. She verified her interview with the resident on 11/14/16 was several days after the interview. The DON verified STNA #8 had knowledge of the inappropriate treatment by STNA #9 around 6:00 P.M. on 11/11/16 and STNA #9 was not sent home or removed from direct resident care, putting other residents at risk. She indicated by the punch out detail, STNA #9 did not clock out until 11/11/16 at 10:40 P.M. She verified the investigation did not contain interview of other residents who may have been treated in an abusive manner by STNA #9 on 11/11/16. This deficiency substantiates Complaint Number OH 049.

Based on record review and interview the facility failed to ensure Resident #77 was properly transported in her wheelchair to prevent an injury. Harm occurred when the resident's leg fell from the wheelchair leg rest during transport by Activity Assistant #303 and her foot, per the resident's statement, jammed under the chair causing a fractured tibia. This affected one resident (Resident #77) of five residents reviewed for falls/accidents. Findings include: A review of the medical record for Resident #77 revealed a nurse's note, completed by Registered Nurse (RN) #205 dated 09/11/16 at 3:40 P.M. when the resident complained of pain to her right ankle and calf. The resident stated her foot jammed while being transported back from an activity the previous evening and did not think it hurt at the time. The nurse noted that although the resident, who had a Brief Interview for Mental Status (BIMS) of 7, reflecting moderate cognitive impairment, could not recall if her leg rests had been on the previous day, the nurse had seen them on at breakfast and at lunch the previous day. Review of the Investigative Summary revealed the resident had reported an injury on 09/11/16 that occurred on the previous day. The report stated the resident was complaining of pain in the right calf and ankle that she believed was due to her leg being jammed during a wheelchair transport on the previous day while being transported back from activities. The report indicated the RN was unable to identify the person who completed the transport and legs rests in place to wheelchair (w/c). The report stated an x-ray was completed which showed a fractured tibia (right). It is surmised per resident's statement that her leg fell from the rest while she was being pushed in her w/c and her leg caught the floor and met resistance and caused injury. The report was signed on 09/12/16 by Registered Nurse #203. Review of the facility investigation revealed no statements from staff or other residents regarding the incident, other than the nurse's note by RN #205 in which she gave the resident's description of her leg having been jammed and that the nurses had seen the leg rests on the wheelchair the previous day at breakfast and lunch. An interview with Resident #77 on 10/11/16 at 1:05 P.M. revealed she recalled an incident in which her leg was hurt. The resident stated someone was pushing her wheelchair and her leg slipped off the foot rest and it got run over. The resident stated she did not know who was pushing the wheelchair or where she was going at the time and was uncertain about the date of the actual incident. An interview with RN #203 on 10/11/16 at 2:11 P.M. revealed she reviewed the nurse's documentation for any incident that she investigated and if necessary she would clarify any questions she had by talking to the staff. She stated she had completed the investigation summary for Resident #77 and the facility believed that Resident #77's leg had fallen off the leg rest and had gotten her foot caught when it fell but could not identify who had been transporting the resident at the time of the incident. She stated she did not talk to any activity assistants or any State tested Nursing Assistants (STNAs) about the incident but did talk Activities Director #300. RN #203 stated she did not have any documentation of statements that she had interviewed staff. An interview with Activity Director #300 on 10/11/16 at 3:00 P.M. revealed only one Activity Aide worked on the weekend and on 09/10/16 it had been Activity Aide #303. She stated he had told her that Resident #77's leg had slipped off the foot rest during transport and he had put it back on the leg rest. The activity director stated Activity Aide #303 did not think there had been any injury from it and did not report the incident to anyone at the time it occurred. An interview with Activity Aide #303 on 10/11/16 at 3:10 P.M. revealed he had been the activity aide working on 09/10/16 and had in fact transported Resident #77 back to her unit after activities himself. During the transport, he noticed her leg had slipped off the leg rest and he had placed it back on the leg rest. He stated that he had not been interviewed by RN #205, RN #203 or anyone else regarding the resident's claim that her leg got caught during a transport on 09/10/16 and surmised nothing must have come of it. This deficiency substantiates Complaint Number OH 134.

Based on interview and record review, the facility failed to ensure interventions to prevent pressure ulcers were documented as in place for Resident #75. The facility also failed to ensure accurate and timely assessments of a residents skin condition were documented in the record, and treatments were completed as ordered for Resident #103. This affected two of three residents (Residents #75 and #103) reviewed for pressure areas. The facility census was 97 residents. Findings include: 1. Review of Resident #75's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was admitted with a pressure area to the buttocks, which healed by 08/22/15. He was assessed as high risk for pressure areas and had a care plan in place to prevent skin breakdown to include a pressure redistributing mattress and cushion to his wheelchair, turn and reposition as needed and to keep heels elevated in bed to prevent pressure. Review of the record revealed dietary notes dated 08/02/15 and 08/06/15 indicating the resident had a poor appetite and had nutritional supplements in place. Review of a skin assessment dated [DATE] revealed no impaired skin areas, other than the surgical area to his left hip. A skin assessment dated [DATE] revealed the resident refused a skin assessment. A note on 08/20/15 at 10:41 P.M. revealed the resident had an open blister to the right heel found by staff, measuring 4.5 centimeters (cm) by 4.5 cm by 0.1 cm. The note indicated the area had scant serosanguinous drainage and was red in color. An order was written to cleanse the area to the right heel with normal saline, apply ointment, [MEDICATION NAME] (an absorbent pad), cover with a pad, and wrap with Kerlix daily. An order was written to apply a foam heel protector to the left heel at all times. Review of the treatment orders revealed the left heel protector order was written, but not initialed as in place, despite areas for each shift to initial that the treatment was in place as ordered. Review of the nursing notes revealed no information about the left heel treatment. The care plan for skin impairment revealed the treatment in place for the right heel, but did not indicate the new order for the left heel foam protector. A nursing note dated 09/01/15 at 12:13 P.M. revealed a new pressure area was found on the residents left outer foot, measuring 2.0 cm by 1.5 cm with a dark area noted in the middle. An interview with the director of nursing on 01/11/16 at 11:40 A.M. verified the resident had been assessed as high risk for pressure areas. She verified the resident developed a pressure area to the right heel, despite orders in place to keep heels elevated when in bed. She stated the resident frequently changed positions in bed on his own and would bend his knees to put pressure on his heels. She verified the order for the left heel protector to prevent skin breakdown was not marked off as in place or documented in the nursing notes or care plan. She verified no other interventions were documented as in place after the development of the first pressure area to prevent pressure to the heels, or ensure the heels not rest directly on a surface. She verified the resident developed a pressure area to the right heel on 09/01/15 and that the wounds were still present at the time of the survey. 2. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment revealed the resident had a surgical site on the right hip area and had a reddened area to her coccyx measuring 2 centimeters (cm) by 2 cm. She was assessed as at moderate risk for skin impairment and interventions put in place were a salve to her buttocks, and pressure reducing mattress, and cushion to her wheelchair. The resident was to have a skin check weekly on Wednesdays. An assessment by the wound nurse on 12/16/15 revealed the resident had no reddened areas at that time, and was at risk for pressure areas related to impaired mobility and her current health status. She was to be encouraged to turn and reposition frequently but was reluctant due to pain. Review of physician orders [REDACTED]. Nursing notes from 12/16/15 through 12/19/15 revealed the resident with a poor appetite and a low hemoglobin level reported to the physician. The physician recommended a transfer to the hospital for a blood transfusion, but the resident's daughter instead requested a hospice consult. Review of a shower sheet for 12/23/15 revealed the resident with a red bottom. A shower sheet for 12/27/15 revealed the resident refused a shower on that date. Review of physician orders [REDACTED]. There was no nursing note in the record indicating the reason for the new treatment. Review of the treatment record revealed the treatment was applied on 12/27/15, but was not changed again until 01/02/15. Review of a nursing note dated 01/02/16 at 1:26 P.M. revealed the resident with new open areas to the sacrum and coccyx, with reddened areas noted to the spinal bony prominences. The note indicated the resident had pain to the sacrum and coccyx areas. Review of the weekly tracking of pressure wounds revealed a pressure ulcer assessment indicating week one (dated 01/02/15) revealed the area to sacrum was a stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed with no slough present). The part of the note dated 01/02/16 revealed the sacrum with two areas midline measuring 4 cm by 1.5 cm by 0.1 cm. The area had a small amount of serosanguinous drainage. Additional information revealed the sacrum as red with two open areas present. The top area measured 1.5 cm by 1.0 cm by 0.1 cm and the bottom area measured 1.5 cm by 1.0 by 0.1 cm. The area was 50% [MEDICATION NAME] and 50% moist yellow slough. Review of the pressure ulcer assessment week 2, dated 01/05/16, revealed the area remained as a stage 2, and measured 2.0 cm by 0.7 cm by 0.1 cm (top) and bottom area 1.2 by 1.2 cm by 0.1 cm. with moist yellow slough to wound bed. The area was observed on 01/11/16 at 10:00 A.M. by the surveyor during a dressing change and was measured by the nurse as two areas. The lower area measured 1.0 cm by 1.5 cm by 0.1 cm, and the upper area measured 1.6 cm by 0.5 cm by 0.1 cm. An interview with the assistant director of nursing on 01/07/16 at 4:00 P.M. verified that an assessment of the area was not completed on 12/27/15 when the order was written for a treatment. She verified the treatment was not completed as ordered on [DATE] and a full assessment of the area was not completed until 01/02/15. She further verified the assessment indicated slough was present at that assessment, which would classify the wound as a stage 3 (full thickness tissue loss that may have slough present) and that the staging, according to the assessment, was inaccurate. An interview with the director of nursing on 01/11/16 at 11:40 A.M. verified the assessment was not completed timely and accurately and that the dressing change had not been completed as ordered. This deficiency substantiates Complaint Number OH 744.

Based on observation, interview and record review, the facility failed to ensure infection control guidelines were followed during medication pass for Resident #107. This affected one of four residents observed for medication pass, and had the potential to affect all 97 residents in the facility. Findings include: On 01/07/16 at 9:30 A.M. Licensed Practical Nurse (LPN) #10 prepared medications for Resident #107. LPN #1 attempted to remove a [MEDICATION NAME] (narcotic pain medication tablet) from a blister pack and the tablet missed the cup and landed on the medication cart. LPN #1 picked up the tablet with a spoon and put it in the cup with the other pills. She administered the medication to the resident. LPN #1 was approached after the medication pass and asked about the dropped medication. She stated the top of the cart was clean, and would only come into contact with items in the medication cart, which should also be clean. She verified the top of the med cart had a sticky spilled substance noted on it's surface and there could be no assurance the medication cart was clean, with med books, and other items on it's surface. An interview on 01/07/16 at 11:50 A.M. with the assistant director of nursing (Registered Nurse #2) verified the infection control concern for LPN #1, and she verified the medication should have been discarded after it touched the medication cart. Review of the medication administration policy did not reveal specifics related to infection control, but an interview with the director of nursing on 01/11/15 at 11:40 A.M. verified LPN #10 should have discarded the tablet after it fell on to the medication cart surface. This deficiency is an incidental finding discovered during the investigation of Complaint Number OH 744.

br>Based on policy review, Self Reported Incident (SRI) review and interview the facility failed to ensure a staff member did not verbally abuse one resident (Resident #103) of two residents reviewed in SRIs. The facility census was 101. Findings include: Review of the facility SRI dated 04/07/15 revealed an allegation of witnessed verbal abuse by staff against Resident #102 that was investigated by the facility. The facility investigation results revealed the allegation of verbal abuse was substantiated. The investigation revealed a state tested nursing assistant (STNA) #1 was assisting Resident #102 with personal care when Resident #102 dropped a washcloth. STNA#1 verbally yelled and cursed at Resident #102 causing her to be fearful and upset when interviewed. This was observed by STNA#2 who had STNA #1 removed from the room and reported the incident immediately. The facility appropriately submitted the self reported incident (SRI), suspended the alleged perpetrator , STNA#1 and completed the investigation as required. During the investigation STNA #1 admitted the verbal/emotional abuse and was terminated on 04/08/15. Review of the facility from titled : Abuse and Neglect dated 12/2013 revealed the following: The use of oral, written or gesturing language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless or their age, ability to comprehend, or disability. On 11/05/15 at 4:40 P.M. an interview was conducted with the Administrator along with review of the SRI verifying the emotional/verbal abuse did occur to Resident #102 and that she felt fearful and upset about the incident. The staff member involved was immediately suspended and afterwards terminated. This certification deficiency was cited as an incidental finding to Complaint Number OH 176.

Based on record review and interview, the facility failed to complete accurate comprehensive assessments related to falls and pressure ulcers. This affected two (Resident #45 and #52) of ten residents reviewed for assessments. The facility census was 92. Findings include: 1. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessments dated 03/12/15 and 12/12/14 revealed Resident #52 had two Stage II pressure ulcers. The 03/12/15 MDS also indicated Resident #52 had a pressure ulcer at a lesser stage or that was not present on the last assessment, 12/12/14. The director of nursing (DON) was interviewed on 06/22/15 at 2:12 P.M. and these MDS's were reviewed. The DON indicated this resident had several pressure ulcers and she would get the wound tracking for the pressure ulcer areas. The DON returned at 2:55 P.M. on 06/22/15 and verified that the question under section M on the 03/12/15 MDS which indicated Resident #52 had a pressure ulcer that had worsened or had a new pressure ulcer not present on the previous assessment was inaccurate. The DON indicated a correction MDS would be completed. 2. Review of Resident #45's nursing notes dated 04/24/15 at 8:25 A.M. revealed Resident #45 was lowered to floor from the stand up lift by one staff member and she stained no injuries. The nursing notes contained further information on the fall. Review of the MDS dated [DATE] revealed Resident #45 had no falls in the last month and no falls in the last two to six months prior to admission/entry or reentry. Review of the MDS dated [DATE] revealed Resident #45 had no falls since admission/entry or reentry or the prior assessment. Interview with Registered Nurse (RN) #72 on 06/23/15 at 8:57 A.M. verified the fall of 04/24/15 was not documented on 05/25/15 MDS.

Based on record review and interview, the facility failed to develop an individualized, comprehensive care plan related to antipsychotic medication. This affected one (Resident #50) of ten residents reveiwed for care plans. The facility census was 92. Findings include: Review of the medical record revealed Resident #50 was admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the medications ordered by the physician on admission included [MEDICATION NAME], an antipsychotic medication, to be administered to the resident every day. Resident #50 was still receiving [MEDICATION NAME] every evening according to the physician orders. Record review revealed no plan of care to address the use of this antipsychotic medication including the monitoring for side effects and other non-pharmacological interventions that could be helpful for Resident #50. This concern was verified with assessment nurse, Registered Nurse (RN) #72 on 06/23/15 at 11:25 A.M. RN #72 indicated they had only developed a care plan related to depression and the medication Resident #50 took for that disorder. This nurse indicated she would initiate a plan of care this day.

Based on medical record review, staff interview, and review of the facility's Incident and Accident Protocol, the facility failed to supervise residents and monitor the facility exit safety system to prevent a cognitively impaired resident (Resident #48) from exiting the facility unknown to staff on 08/06/13. Resident #48 exited the building again without staff knowledge on 09/28/13, and sustained a fracture of the left upper leg. This resulted in Immediate Jeopardy for one (Resident #48) of nine sampled residents. The facility census was 105 residents. On 10/03/13 at 3:25 P.M., the Administrator was notified that Immediate Jeopardy began on 08/06/13 at 4:00 P.M., when Resident #48 propelled a wheelchair (with an alarm sensor in place) to the ground floor elevator, traveled to the first floor past the reception desk, and exited the building through the main entrance. The main entrance was equipped with the Sensormatic Tagging System (electronic system utilized by the facility to alert staff when a resident with a device exits the facility). Resident #48 was subsequently found outside the entrance and heading away from the facility by the grounds keeping staff. On 09/28/13 at 5:38 P.M., Resident #48 exited the facility again from the ground floor elevator to the first floor, through the electronic alarm device, past the reception desk and through the front doors of the facility. Licensed Practical Nurse (LPN) #10 observed Resident #48 outside the building, traveling in a wheelchair along the downslope at the side of the building. The resident was yelling for help, and ran into a parked vehicle, sustaining a fracture of the left upper leg. The Immediate Jeopardy was removed on 10/07/13 at 11:35 A.M., when the facility implemented the following corrective actions: ? Resident #48 was transferred to the hospital on [DATE] at 6:03 P.M. No additional residents at the facility were identified as being at risk for elopement. ? On 09/28/13 and 09/30/13, the Administrator educated reception desk staff on the elopement policy, and pictures of residents with sensors were placed at the reception desk for easy identification. ? On 09/28/13, the evening and night shift checked all resident sensors and identified non- working sensors that were replaced. ? On 10/02/13, the facility ordered equipment to secure the elevator with a programmable alarm and instructed staff to secure the front door in the event of an alarm malfunction. ? On 10/03/13 at 2:15 P.M., an interview with the Assistant Maintenance Director revealed that the Sensormatic Tagging System was checked weekly by security staff to verify it can read the sensors. ? On 10/03/13 the DON and ADON reassessed all residents using a sensor for elopement risk. ? On 10/03/13, Resident #48 returned to the facility from the hospital and was placed on 24 hour supervision for three weeks. The facility was discussing transferring the resident to another facility with the resident's family. ? On 10/04/13 the night shift State tested Nurse Aides (STNA) began daily checking of the sensors used by residents. ? On 10/05/13 through 10/07/13 all direct care staff were educated by the Assistant Director of Nursing (ADON) on the elopement risk assessment policy and procedure (revised 10/04/13) and the use/purpose of the Sensormatic Tagging System. ? On 10/07/13 an interview with Receptionist #12 revealed pictures were readily available at the reception area for easy identification of residents with sensors. The interview also revealed knowledge of the receptionist role in the elopement risk process. ? On 10/07/13 at 11:15 A.M. and 11:25 A.M., interviews with LPN #13 and STNA #14 (direct care providers for Resident #48) revealed knowledge of facility practice for identifying residents at risk for elopement and coordinating interventions. On 10/08/13 additional interviews with LPN #15, LPN #16, LPN #17, LPN #18, STNA #19, LPN #20, RN Supervisor #21, and STNA #22 verified their understanding of identifying and implementing facility interventions for residents who are an elopement risk. Although the Immediate Jeopardy was removed when the facility established measures to address adequate supervision of cognitively impaired residents to prevent elopement, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility has yet to implement measures to secure the elevator to prevent unsupervised resident exit. Findings include: A review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE], and had a medical history of [REDACTED]. A review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a functional level of dependence on staff for activities of daily living, use of a wheelchair for ambulation and cognitive impairments. A behavioral problem care plan, most recently revised on 07/06/13, included a problem of attempting to elope. Interventions on the care plan included "Intervene as necessary" for behaviors that endanger the resident or others; contact daughter for assistance; and attempt to discover cause of behavior, and alleviate if possible. A review of the nursing progress notes for July 2013 through the resident's hospitalization on [DATE] revealed a history of exit seeking behavior (12 documented episodes) and restless self-propelling in a wheelchair throughout the facility. A progress note dated 08/06/13 at 4:46 P.M. revealed Resident #48 was, "Observed by grounds keeping staff outside the facility near the entrance of the health center trying to head towards the garage." The note indicated Resident #48 was redirected back to the facility and staff would continue to monitor. A progress note dated 09/28/13 at 5:47 P.M. revealed LPN #10 witnessed Resident #48 hit a parked car while in a wheelchair outside the facility. The note indicated LPN #10 had to call for help. Further assessment of the resident revealed pain, swelling and discoloration of the left leg. The physician was notified and Resident #48 was transferred to the hospital and received surgery for [REDACTED]. On 10/03/13 at 3:40 P.M., interview with LPN #10 revealed on 09/28/13 at 5:47 P.M., she observed Resident #48 outside of the facility, alone and seated in a wheelchair rolling down the pavement at the side of the building. The resident was yelling "Help me." LPN #10 stated she was at the employee entrance at the side of the building and unable to reach Resident #48 in time to keep her from colliding with a parked van. LPN #10 further stated after attending to the resident she called out for help, and had to use her cell phone to get staff to locate them at the side of the building and provide assistance. LPN #10 verified that the side door was always locked and the resident must have exited from the reception area at the front of the building. LPN #10 said Resident #48 was screaming in pain and had an injury to the left leg. LPN #10 said she was not aware that Resident #48 had exited the building unsupervised the previous month, and that residents with sensors usually need a closer eye kept on them. Resident #48 retuned to the facility the evening of 10/03/13. Observations of Resident #48 revealed the facility had implemented 24 hour supervision of the resident upon her return to the facility on [DATE]. Review of the facility protocol for Incident and Accident Occurrences (revised August 2009) revealed the purpose of the protocol was to prevent repeat incidents and accidents. The protocol indicated that a direct care nurse would document the event and initiate an investigation. On 08/06/13, the facility initiated an investigation for the elopement of Resident #48. The investigative summary of the event concluded that sensor placement on the wheelchair of Resident #48 was too low and needed to be placed higher. The placement was altered and the sensor was verified as working. There was no evidence that the plan of care for Resident #48 was updated to include interventions to check/monitor placement and function of the sensor. On 09/28/13 the facility initiated an investigation for the elopement of Resident #48 and concluded that the sensor did not alarm in the reception area at the main entrance. On 10/03/13 at 12:50 P.M., interview with the DON verified that the care plan for Resident #48 did not identify individualized interventions for supervising and monitoring exit seeking behaviors, interventions to reassess the risk for elopement, and verifying that the resident's sensor was positioned properly and working as designed. On 10/08/13, further review of the care plan for Resident #48 revealed revisions to include monitoring the resident and sensor function. On 10/03/13 at 2:15 P.M., an interview with the Assistant Maintenance Director revealed that the Sensormatic Tagging System was checked weekly by security staff to verify it can read the sensors, however, they do not use resident sensors to test the system. Monitors used by residents were now checked by nursing staff. The interview further revealed that the system was experiencing problems reading sensors on 08/05/13 that was not corrected until 08/14/13 and that the problem was communicated to nursing staff. Additionally, the interview revealed that the facility was adding alarms and updating locking mechanisms to the main entrance and elevator. The elevator security was scheduled to be completed on 10/12/13. The Assistant Maintenance Director also provided evidence of routine completed work orders for monitoring of the alarm system from 08/06/13 through current that were verified by review. On 09/28/13 after the elopement of Resident #48, all sensors in use were checked by nursing staff and non-working sensors were replaced. On 10/04/13 the facility initiated daily sensor checks for each sensor in use with a resident. This was verified on 10/08/13 by review of the Daily Wanderguard Checklist. On 10/03/13 the DON and ADON reassessed all residents with sensors for elopement risk. There were no residents currently in the facility at risk. Interview with the DON on 10/03/13 at 4:00 P.M., revealed there were currently three sensors in use for residents who wander but were not exit seeking. This was verified by review of the medical records for Resident #17, Resident #55 and Resident #69. The interview also revealed that Resident #48 was expected to return to the facility on [DATE] and would have 24 hour supervision for three weeks. The DON said the facility was in discussion with the family about possible relocation of the resident to another facility that would better meet the resident's needs. A review of facility documents for staff education revealed that the reception staff was provided education on 09/28/13 and 09/30/13 on identifying residents at risk for elopement by having pictures of residents with sensors to prevent unsupervised exit from the building. Interview with Receptionist #12 on 10/07/13 at 12:00 P.M. verified the placement of resident pictures and the knowledge of the receptionist role in maintaining resident's safety. A review of staff education on the Elopement Risk Assessment Policy and Sensormatic Tag System (revised 10/04/13) revealed the facility staff were educated from 10/04/13 through 10/07/13. Interviews were completed with facility staff on 10/07/13 (LPN #13 and STNA #14) and 10/08/13 (LPN #15, LPN #16, LPN #17, LPN #18, STNA #19, LPN #20, RN Supervisor #21 and STNA #22) verified knowledge and understanding in the use of the Sensormatic Tag System and the revised Elopement Risk Assessment Protocol. This deficiency substantiates Complaint Number OH 094.