Every finding on record at Otterbein Springboro

Based on observation, staff interview, and policy review, the facility failed to ensure medication carts were locked. This affected one of four medication carts observed and had the potential to affect 11 Residents (#5, #7, #14, #15, #18, #33, #34, #52, #54, #55, and #57) whose medications were stored in the cart. The facility census was 57.Findings include: Observation of the 300 cottage medication cart on 04/30/26 at 8:10 A.M. revealed it was unlocked and a nurse was not visible near the unsecured medication cart. Interview and observation on 04/30/26 at 8:12 A.M., the Administrator verified the 300 cottage medication cart was unlocked and a nurse was not present in the cottage. The Administrator verified Residents' (#5, #7, #14, #15, #18, #33, #34, #52, #54, #55, #57) medications were stored in the cart. Review of the facility policy titled Medication Storage in the Facility dated May 2022 revealed medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, staff interview and review of the week at a glance menu, the facility failed to ensure the menu portion sizes were followed. This affected twelve (Resident #09, #10, #16, #19, #20, #32, #35, #37, #39, #40, #41 and #51) out of 57 residents that resided in the facility. The facility census was 57. Findings Include:Review of the facility's a week at a glance menu for house 9349 dated 04/27/26 revealed residents on a regular and bite sized diets were to receive five ounces of grilled chicken, four ounces of broccoli, a half of a cup of rice pilaf and one breadstick for lunch on 04/27/26.Observation of the kitchen in house 9349 on 04/27/26 at 12:36 P.M. revealed Certified Nursing Assistant (CNA) #166 was serving residents on regular diets two scoops of broccoli using an unlabeled spoon, a scoop of rice using an unlabeled spoon, a piece of chicken that she cut in half and a breadstick. The CNA #166 was serving residents on bite size diets two scoops of broccoli using an unlabeled spoon, a scoop of rice using an unlabeled spoon, a piece of chicken that she cut in half and then cut into bite size pieces with a pair of kitchen scissors and a breadstick. Interview with the CNA #166 on 04/27/26 at 12:36 P.M., revealed CNA #166 did not know any information about portion sizes for regular or bite size diets. CNA #166 stated she just scooped the rice and broccoli using a metal spoon and gave the residents a piece of chicken and a breadstick. CNA #166 verified she was not following the menu for portion sizes. Interview with the Registered Dietitian (RD) #502 on 04/27/26 at 12:47 P.M., verified there were portion sizes listed on the facility's menu but stated the facility had an open concept kitchen and they did not follow exact portion sizes.

Based on observations, staff interviews, facility documentation, review of manufacturers recommendations, and policy review, the facility failed to serve food in a manner that protected against cross-contamination. This affected 21 (Residents #5, #7, #14, #15, #18, #27, #33, #34, #52, #54, #55, #56, #57, #64, #65, #66, #68, #69, #70, #71, and #72) residents. Additionally, the facility failed to maintain appropriate dishwashing equipment. This had the potential to affect 12 (Residents #2, #6, #8, #22, #23, #28, #30, #31, #46, #48, #49, and #50) residents in unit 9335. The facility census was 57.Findings include: 1. Observation on 04/27/26 from 12:13 P.M. to 12:23 P.M. revealed Certified Nursing Assistant (CNA) #124 donned blue disposable gloves and prepared food plates for ten (#27, #56, #64, #65, #66, #68, #69, #70, #71, and #72) residents on the rehab unit including one sloppy joe sandwich, one scoop of macaroni and cheese, one prepared garden salad, and one prepared cup of canned fruit. CNA #124 prepared each sandwich by reaching into a bag with her gloved hands, retrieving a hamburger bun, and opening bun on the plate. She scooped one serving of sauced ground beef on the bottom portion bun and used her gloved hand to place the top bun over the meat to complete the sandwich. After preparing the sandwich, she used her gloved hands to pour canned fruit from the can into a small round, fluted serving dish, and placed one dish on the resident tray. She used her gloved hand to cover the plate with a round metal plate cover on the tray. After preparing three additional trays in the same manner without changing her gloves or sanitizing her hands, she walked in to the pantry, opened a cabinet below the counter and removed a stack of three sliver lids and placed them on the kitchen counter next to the stack of trays. She did not change her gloves or sanitize her hands before preparing four additional trays. CNA #124 changed her gloves without sanitizing her hands before preparing two additional trays in the same manner. During an interview on 04/27/26 at 12:23 PM., CNA #124 verified she was touching buns with gloves after touching other surfaces and utensils without changing gloves or sanitizing hands. 2. On 04/27/26 at 12:13 P.M. CNA #149 was observed preparing meals in the 300 cottage kitchen. CNA #149 was wearing gloves. CNA #149 went to the sink scrubbed dirty dishes and then went to the cupboard for a plate. CNA #149 took the plate and scooped a portion of spaghetti and salad onto the plate. CNA #149 then picked up two breadsticks using gloved hands and put them onto the plate. CNA #149 did not remove gloves and wash hands after scrubbing the dirty dishes and before touching breadsticks and plating food items. Interview with CNA #149 on 04/27/2026 12:16 P.M., verified she had not removed her gloves or washed her hands after scrubbing dirty dishes at the sink. CNA #149 verified she had used the same gloves to wash dirty dishes, plate food items, and touch the breadsticks. Review of facility documentation revealed 11 Residents (#5, #7, #14, #15, #18, #33, #34, #52, #54, #55, #57) eat food from the 300 cottage kitchen. Review of the facility policy titled Food Handling and Preparation Policy & Procedure, dated May 2013 revealed hands are washed before and after handling food, between glove change, and as often as necessary to keep them clean. 3.Observation of the kitchen in House 9336 on 04/27/26 at 10:28 A.M. revealed there was a pack of expired buns in the kitchen dated 04/25/26. Interview with Household Aide (HA) #128 on 04/27/26 at 10:28 P.M., verified there was a pack of expired buns in the kitchen dated 04/25/26. 4.Observation on 04/27/26 at 10:39 A.M. of the kitchen in House 9320 revealed the dishwasher wash temperature was 134 degrees Fahrenheit and the dishwasher rinse temperature was 185 degrees Fahrenheit. Interview on 04/27/26 at 10:39 A.M., with Dietary Technician (DT) #142 verified the dishwasher wash temperature was 134 degrees Fahrenheit and the dishwasher rinse temperature was 185 degrees Fahrenheit. The DT #142 verified the dishwasher wash temperature should be above 155 degrees Fahrenheit. Review of the dishwasher's manufacturer instructions dated September 2024 revealed the dishwasher should have a wash temperature of 155 to 160 degrees Fahrenheit and a rinse temperature of 180 to 195 degrees Fahrenheit.

Based on medical record review, staff interview, review of the resident funds accounting record and policy review, the facility failed to ensure resident funds were conveyed within 30 days of discharge from the facility. This affected one (Resident #73) out of five residents reviewed for resident funds. The facility census was 57.Findings Included:Review of Resident #73's medical record revealed Resident #73 admitted to the facility on [DATE]. Diagnoses included cerebral infarction, adult failure to thrive, osteoarthritis, hypertension, chronic kidney disease, dementia moderate with agitation, and anxiety disorder. Resident #73 discharged from the facility on 10/13/25. Review of Resident #73's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #73's resident funds authorization dated 10/03/22 revealed Resident #73's Power of Attorney (POA) authorized Resident #73 to have a resident funds account at the facility. Review of Resident #73's resident funds account quarterly statement from 07/01/25 to 09/30/25 revealed Resident #73 had a beginning account balance of $69.14 and an ending balance of $49.14.Review of Resident #73's resident funds account quarterly statement from 01/01/26 to 03/31/26 revealed Resident #73 had a beginning account balance of $49.14 and an ending balance of $0. Further review of the quarterly statement revealed Resident #73 had a debit of $49.14 on 01/14/26 to close the account.Review of a check to the Treasure of the State dated 01/14/26 revealed a check in the amount of $49.14 was issued to the Treasurer of the State for Resident #73.Interview with Business Office Manager (BOM) #500 on 04/29/26 at 11:07 A.M., verified Resident #73 discharged from the facility on 10/13/25 and Resident #73's resident funds account was not conveyed within 30 days of discharge from the facility. Review of the resident trust policy dated 10/04/18 revealed the facility will close and refund resident trust accounts per regulatory guidelines.

Based on medical record review, staff interview and policy review, the facility failed to ensure a resident had an activities care plan. This affected one (Resident #23) out of 20 residents sampled. The facility census was 57.Findings Included: Review of Resident #23's medical record review revealed Resident #23 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease with late onset, paroxysmal atrial fibrillation, incisional hernia with obstruction without gangrene, hypertension, pure hypercholesterolemia, sleep apnea, atherosclerotic heart disease of native coronary artery without angina pectoris, generalized anxiety disorder, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance, acute kidney failure, restlessness and agitation, other vitamin B12 deficiency, iron deficiency anemia, anxiety disorder and major depressive disorder. Review of Resident #23's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and Resident #23 required set up assistance with eating, oral hygiene, and personal hygiene. The interview for daily and activity preferences was conducted on the MDS and Resident #23 reported it was very important to have books, newspapers and magazines to read and to keep up with the news. Resident #23 reported it somewhat important to listen to music he liked.Review of Resident #23's care plan dated 04/28/26 revealed Resident #23 did not have an activities care plan and Resident #23's activities preferences were not listed in the care plan.Interview with the Administrator on 04/29/26 at 11:36 A.M., verified Resident #23 did not have an activities care plan and Resident #23's activities preferences were not listed in the care plan.Review of the policy titled Comprehensive Care Planning, dated 11/13/17 revealed an interdisciplinary team was responsible for developing, implementing and evaluating a comprehensive person centered plan of care.

Based on medical record review, staff interview, and policy review, the facility failed to ensure care plans reflected resident's needs regarding tube feeding. This affected one (Resident #3) out of four residents reviewed for care planning. The facility census was 57.Findings Included:Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, neurocognitive disorder with Lewy Bodies and dysphagia oropharyngeal phase. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #3 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 00. Resident #3 was dependent for activities of daily living (ADLs) and required a Hoyer lift for transfers.Review of Resident #3's physician's orders and medication administration record revealed the resident was receiving Jevity 1.5 at 30 milliliters (ml) per hour via gastrostomy tube.Review of the care plan dated 02/07/26 revealed Resident #3 was on hospice care/comfort care. Resident does not eat enough to prevent decline. Resident does not want tube feed or intravenous (IV).Review of the same care plan dated 02/07/26 revealed Resident #3 was receiving Jevity 1.5 at 30 ml per hour times 24 hours with 150 ml water flush every four hours.Interview on 04/29/26 at 2:08 P.M., the MDS Nurse #108 and the Director of Nursing (DON) #106 verified the Care Plan dated 02/07/26 documented Resident #3 does not want a tube feeding and also stated Resident #3 was receiving Jevity 1.5 tube feeding. The interviews also revealed Resident #3's daughter does want a tube feeding administered.Review of the policy titled Comprehensive Care Planning Procedure, dated 11/09/17 revealed an interdisciplinary team is responsible for developing, implementing and evaluating the comprehensive, person-centered plan of care. Person-centered is defined as a focus on the resident as the locus of control and support the resident in making their own choices; having control over their daily lives. The care plan is updated on a quarterly basis and with any significant change in resident status.

Based on medical record review, observation, staff interview, review of manufacturer's instructions, and policy review, the facility failed to ensure insulin pen administration devices were primed. This affected one (Resident #37) out of three residents observed during medication administration. The facility census was 57.Findings include:Review of Resident #37's medical record revealed an admission of 05/14/25. Diagnoses included type two diabetes mellitus, anxiety disorder, chronic kidney disease, and dementia.Review of an annual minimum data set (MDS) dated [DATE] revealed Resident #37 had moderately impaired cognition and received insulin injections.Review of physician orders revealed an order dated 09/26/25 for Admelog SoloStar (a rapid acting insulin) 100 units per milliliter (unit/ml) solution pen-injector. Inject six units subcutaneously before meals related to type two diabetes mellitus with hyperglycemia. Observation on 04/29/26 at 7:31 A.M. revealed Registered Nurse (RN) #312 prepared Resident #37's Admelog SoloStar by attaching a new needle and dialing the dose to six units. RN #312 had not primed the new needle. RN #312 then administered Admelog SoloStar six units to Resident #37's right arm at 7:38 A.M.During an interview on 04/29/26 at 7:41 A.M. RN #312 verified she had not primed Resident #37's Admelog SoloStar pen needle before dialing up the ordered dose of six units. RN #312 stated the needle did not need to be primed.Review of the manufacturer's instructions for an Admelog SoloStar pen-injector revealed a safety check should be performed to ensure the pen is working and getting the correct dose by dialing up two units and pressing the injection button all the way in. Repeat the procedure up to three times until insulin appears. Then select the desired dose.Review of the facility policy titled Insulin Pen Use, dated 05/19/25 revealed to attach a new, appropriately sized insulin pen needle to the insulin pen by screwing or clicking it into place following the manufacturer's instructions. Remove the cap from the pen needle and prime the insulin pen by pointing it up in the air, dialing one or two units on the insulin pen and then fully pressing the plunger or by following the manufacturer's instructions. A drop of insulin should appear at the needle tip. Repeat the priming procedure until a drop appears. Turn the dial on the insulin pen to match the patient's prescribed dose.

Based on medical record review, observation, staff interviews, and policy review, the facility failed to provide Enhance Barrier Precautions (EBP) for residents with wounds. This affected two (Residents #67 and #68) of four residents observed for infection control. In addition, the facility failed to ensure appropriate hand sanitization during wound treatments. This affected one (Resident #51) of two residents sampled for wound care. The facility census was 57.Findings include: 1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included unspecified fracture of the lumbar vertebra, rheumatoid arthritis, and obstructive sleep apnea.admission Minimum Data Set (MDS) assessment not yet completed. Review of the care plan dated 04/24/26 revealed Resident #67 had impaired skin integrity related to surgical wound to back. Interventions included applying back brace for comfort, administering treatments as ordered, completing weekly skin checks, providing pressure-reducing mattress, and turning/repositioning frequently and as needed. Review of the medical record revealed Resident #67 had no orders for Enhanced Barrier Precautions (EBP). Observation on 04/29/26 at 8:53 A.M. revealed there was no sign hanging outside the door to Resident #67's room to alert staff and visitors that Resident #67 was in enhanced barrier precautions. During an interview on 04/29/26 at 8:54 A.M. Registered Nurse (RN) #122 verified Resident #67 had a surgical wound to back with the dressing changed every day and had no order or sign on the door for EBP. 2. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included adult failure to thrive, unspecified anxiety disorders, trigeminal neuralgia, recurrent major depressive disorder, moderate protein calorie malnutrition, and chronic kidney disease stage II. Review of the care plan dated 04/25/26 revealed Resident #68 had impaired skin integrity related to pressure injuries to right lateral hip, coccyx, and right ankle from fall at home. Interventions included administering treatments as ordered, completing weekly skin screens, providing a pressure-reducing mattress, and turning/repositioning frequently and as needed. Review of the medical record revealed Resident #68 had no orders for Enhanced Barrier Precautions. Observation on 04/29/26 at 8:46 AM revealed there was a plastic bin with drawers containing Personal Protective Equipment (PPE) including isolation gowns and boxes of non-latex gloves. There was an EBP sign magnetically attached to the door frame. Certified Nursing Assistant (CNA) #201 entered the room to provide morning care without donning PPE. During an interview on 04/29/26 at 9:01 A.M. RN #122 verified Resident #68 had an ankle wound with treatment and had no order for EBP. During an interview on 04/29/2026 at 9:03 A.M. CNA #201 stated Resident #68 was not on any precautions. CNA #201 verified she had just provided Resident #68 assistance with transferring, dressing, and toileting without wearing any PPE other than procedure gloves. Review of policy titled Isolation Precautions Process revised 03/26/25 revealed Enhanced Barrier Precautions were utilized for residents with wounds for their entire stay. Gowns and gloves were worn during high-contact resident care activities including dressing, bathing, changing linens, transferring in the resident room, providing hygiene, toileting, device care, and wound care with a skin opening requiring a dressing. 3. Review of the medical record revealed Resident #51 admitted to the facility on [DATE]. Diagnoses included senile degeneration of the brain, anxiety disorder, mild protein calorie malnutrition, constipation, atherosclerosis of aorta, weakness, osteoarthritis of left knee and other retention of the urine. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and Resident #51 required set up assistance with eating. Resident #51 required moderate assistance with oral hygiene and maximal assistance with toileting, upper body dressing, lower body dressing, personal hygiene, rolling left and right, sitting to lying, lying to sitting, sitting to standing, and chair transfers. Resident #51 was dependent with showering, putting on and taking off footwear, toilet transfers, and tub transfers. Review of a physician order dated 04/09/26 revealed Resident #51 was ordered to cleanse the left heel with normal saline, apply skin prep and a bordered gauze every day and as needed. Review of a wound care note dated 04/23/26 revealed Resident #51 was seen by Nurse Practitioner (NP) #501. Resident #51 was on hospice and was being followed by management of her left heel. Resident #51 had in house acquired Skin Changes at Life's End (SCALE) wound to her left heel that was 3.1 centimeters (cm) in length by 2.5 cm in width by 0.1 cm in depth. Observation of Registered Nurse (RN) #132 completing wound care on Resident #51's left heel on 04/29/26 at 4:12 P.M. revealed RN #132 donned her gown and entered Resident #51's room. RN #132 washed and dried her hands and donned her gloves. RN #132 used the bed remote that was previously in Resident #51's hands to raise the bed. RN #132 then stated that she left her biohazard bag outside of the room. RN #132 lowered the bed using the bed remote and left the room to get the biohazard bag. RN #132 returned to the room without changing her gloves and placed the biohazard bag on the bed. RN #132 raised Resident #51's bed up using the bed remote and RN #132 removed Resident #51's sock and a dressing that was dated 04/28. RN #132 placed the dressing in the biohazard bag. Resident #51 had a circular dime sized wound on her left heel that was scabbed over with a red and white border around the wound. Without changing gloves RN #132 cleansed Resident #51's wound with normal saline and patted the wound dry. RN #132 wiped the wound with skin prep and applied a foam bordered dressing. RN #132 removed her gloves and gown and washed her hands. Interview with RN #132 on 04/29/26 at 4:24 P.M., verified she had not washed her hands or donned new gloves after touching Resident #51's bed remote, leaving the room to get the biohazard bag or after removing Resident #51's soiled dressing. RN #132 verified she removed Resident #51's soiled dressing to her left heel wound, cleansed Resident #51's wound with normal saline, patted Resident #51's wound dry, applied skin prep to Resident #51's wound and applied a new bandage to Resident #51's heel wound without changing her gloves or washing her hands. RN #132 stated she only had to wash her hands and don new gloves at the beginning of wound care because it was not a sterile procedure. Review of the facility policy titled Foam Dressing Application revealed staff should complete wound care in the following order. Staff should verify the practitioner's orders, gather and prepare the necessary equipment and supplies, perform hand hygiene, confirm the resident's identity using at least two identifiers, provide privacy, explain procedures to the resident, screen for and assess for pain, treat for pain, raise the head of the bed to waist level before providing care, perform hand hygiene, position the resident in a way that maximizes comfort while allowing easy access to the wound site, open the packages of supplies, perform hand hygiene, put on gloves and other personal protective equipment as needed, remove the existing dressing gently, discard the soiled dressing in an impervious plastic trash bag to help avoid spreading infection, assess the wound, clean the resident's wounds using a technique that is appropriate for the wound type and location, remove and discard gloves, perform hand hygiene, put on a new pair of clean gloves, blot the surrounding dry skin using a sterile gauze pad, apply a topical agent using a sterile cotton tipped swab following safe medication administration practices if prescribed, remove the protective film from the foam dressing, lay the dressing gently over the resident's wound and smooth the dressing over the wound without stretching the dressing following the manufacturer's instructions for use, return the bed to the lowest position, discard used supplies in appropriate receptacles, remove and discard your gloves and other personal protective equipment if worn, and perform hand hygiene.

Based on medical record review, staff interview and review of the Centers for Disease Control and Prevention (CDC) recommendations, the facility failed to ensure a pneumococcal vaccine was offered to a resident. This affected one (Resident #43) out of five residents reviewed for vaccinations. The facility census was 57.Findings Included:Review of the medical record revealed Resident #43 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, dysphagia, hyperlipidemia, spinal stenosis, heart failure, constipation, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, epilepsy, generalized anxiety disorder and insomnia.Review of Resident #43's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required set up assistance with eating. Resident #43 required supervision with oral hygiene and personal hygiene and maximal assistance with toileting, showering, and lower body dressing. Review of Resident #43's pneumococcal vaccine consent dated 06/25/25 revealed Resident #43's power of attorney (POA) neither consented or declined the pneumococcal vaccine. The consent stated Resident #43 had received the PPSV23 (Pneumovax 23) vaccine on 04/23/14.Review of Resident #43's medication administration record (MAR) from 04/06/25 to 04/30/26 revealed Resident #43 was not provided any additional pneumococcal vaccines. Interview with the Administrator on 04/28/26 at 4:25 P.M., verified Resident #43's POA neither consented or declined the pneumococcal vaccine on 06/25/25. The Administrator also verified there was no information related to Resident #43 being offered or declining the PCV20, PCV21 or the PCV15.Review of the CDC's pneumococcal vaccine timing for adults job aid dated March 2025 revealed adults over the age of 50 years and over that have received the PPSV23 at any age should have the option to receive the PCV20 or PCV21 in more than one year or the option to receive the PCV15 in more than one year.

Based on observation, staff interview, and review of employee orientation documents, the facility failed to ensure a safe environment in the kitchen. This had the potential to affect four facility-identified cognitively impaired and independently-mobile (Residents #4, #6, #18, #22) of 12 residents residents residing in the house. The facility census was 58 residents. Findings include: Observation on 09/22/25 at 9:12 A.M revealed there was pot of eggs cooking in a boiling water on top of gas stove in the house kitchen. The gates to prevent entry to the kitchen were opened, and the kitchen was unattended by staff. Interview on 09/22/25 at 9:13 A.M with the Administrator confirmed there was an unsupervised gas stove on with a pot of eggs cooking with the kitchen gates opened. The Administrator also confirmed that the stove should never be left unattended while on and that the kitchen gates are supposed to be closed when the kitchen is left unattended or when the stove is in use.Interview on 09/22/25 at 9:55 A.M with Certified Nursing Assistant (CNA) #105 confirmed staff never leave the stove unattended while cooking and kitchen gates should be closed when the kitchen was left unattended or when the stove was in use.Review of the facility orientation education document titled Food Handling and Preparation revealed staff members should lock the gates to the kitchen when cooking or not in the common area and ensure the stove is off when not in use.This deficiency represents noncompliance investigated under Complaint Number 1364148 (OH00167224.)

Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods were stored properly to potentially prevent spoilage. This had the potential to affect 24 (Residents #19, #5, #46, #32, #11, #16, #48, #30, #54, #50, #25, #38, #40, #23, #37, #6, #49, #33, #12, #47, #21, #9, #35, and #155) who resided in House #49 and House #35. The facility's census was 57. Findings include: Observation on 10/11/22 at 10:32 A.M. in House #49's kitchen revealed following sanitation violations: 1. Open container of juice was unlabeled 2. Pitcher of dark liquid was unlabeled and undated 3. Opened package of cream cheese with no date 4. Container of bacon and turkey with no open date Interview on 10/11/22 at 10:32 A.M. with State tested Nurse Aide (STNA) #14 working in House #49, verified food should be labeled and dated. Observation on 10/11/22 at 10:45 A.M. in House #35's kitchen revealed following sanitation violations: 1. Opened bologna package undated 2. Container applesauce undated 3. Opened juice bottle not dated Interview on 10/1122 at 10:45 A.M. with State tested Nurse Aide, (STNA) #85 working in House #35, verified foods should be labeled and dated. Review of facility policies, Food Labeling and Dating, dated 06/01/08 and Food Storage Best Practice, dated August 2022 revealed once food is removed, the bulk foods may be stored in approved container, identified by name and dated. Once opened, foods should be marked open and dated.

Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to reflect the resident's risk for Urinary Tract Infections (UTIs). This affected one (Resident #18) of three residents reviewed for comprehensive care plans. The facility census was 57. Findings include: Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Resident #18 required extensive two person assist for all activities of daily living. The MDS also revealed Resident #18 was frequently incontinent of urine and bowel. Review of the hospital discharge documents dated 07/19/22 revealed Resident #18 was admitted to the hospital for [CONDITION(S)] due to a [CONDITION(S)], with acute [CONDITION(S)]-related organ dysfunction, acute hypoxic, and respiratory failure. Review of Resident #18's care plan dated 07/22/22 revealed the facility failed to address the resident's risk for UTIs. There were no goals or interventions in place to potentially prevent UTIs. Interview on 10/12/22 at 1:00 P.M. with the Director of Nursing (DON) verified the facility failed to address the Resident #18's history of urinary tract infections or urosepsis in the resident's care plan.

Based on review of Centers for Medicare and Medicaid Services (CMS) Quality Safety & Oversight (QSO) Memo ,d+[DATE]-ALL Attachment A for Long Term Care (LTC) Facilities issued [DATE], medical record review, review of a Coronavirus Disease 2019 (COVID-19) line listing, interview with staff, review of the COVID-19 vaccination matrix, review of staff schedules, observations, review of a facility floor plan, review of information from CMS and review of a facility policy and procedure, the facility failed to ensure 100% of their staff had received at least one dose of the COVID-19 vaccine or had a pending request for, or had been granted a qualifying exemption, or were identified as having had a temporary delay as recommended by the Centers for Disease Control (CDC). This resulted in Immediate Jeopardy and the potential for serious life-threatening negative health outcomes and/or death when the facility permitted unvaccinated agency State tested Nursing Assistants (STNA's) to work on multiple dates from [DATE] through [DATE]. The following residents tested positive for COVID-19: Resident #45 on [DATE], Resident #03, #17, and #32 on [DATE], and Resident #22 on [DATE]. Resident #17 was sent to the emergency roiagnom on [DATE] due to displaying COVID-19 symptoms, was treated at the hospital and returned to the facility on [DATE]. Resident #17 was sent to the hospital again on [DATE] and was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #45 developed a fever of 104.1 degrees Fahrenheit (F) on the day she tested positive for COVID-19 and was sent to the hospital on [DATE] and was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was not aware of the vaccination status of the agency staff they hired to care for the residents and did not include them in their vaccination matrix. On [DATE], the facility determined the vaccination status of 50 agency staff who had worked in the facility from [DATE] through [DATE]. When this information was added to the facility vaccination matrix, the vaccination rate was 98 percent (%). The facility census was 42. On [DATE] at 11:08 A.M., the Administrator was notified Immediate Jeopardy began on [DATE] when the facility failed to ensure the facility's COVID-19 vaccination policy was implemented resulting in three agency STNA's (#520, #515 and #505) being unvaccinated against COVID-19 and without a pending/granted medical or non-medical exemption while continuing to provide care and services to the residents in the facility since [DATE]. Five (#45, #03, #17, #32 and #22) residents have tested positive for COVID-19 since [DATE]. The facility was not aware of the vaccination status of the agency staff they hired to care for the residents and did not include them in their vaccination matrix. On [DATE], the facility determined the vaccination status of 50 agency staff who had worked in the facility from [DATE] through [DATE]. When this information was added to the facility vaccination matrix, the vaccination rate was 98 percent (%). The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], the facility conducted COVID-19 outbreak testing in House #20 (the buildings where Resident #17 and #45 resided) with no other positive tests. · On [DATE], the Vice President of Neighborhood Operation (VPNO) #100 educated the Administrator, Assistant Administrator #115, Director of Nursing (DON) and the Minimum Data Set (MDS) Nurse #105 on the COVID-19 Policy and Procedure, and the COVID-19 Partner Vaccine Policy and Procedure and reviewing agency staff vaccination status prior to being permitted to work in the facility. · On [DATE], VPNO #100 educated the Administrator on updating the COVID-19 Vaccination Mandate information reported to the National Healthcare Safety Network (NHSA) weekly to ensure numbers are correct. · To ensure that the deficient practice does not recur, the Administrator or designee will audit daily beginning [DATE] to ensure agency staff meet the requirements of the COVID-19 Vaccine Mandate and those who do not meet are removed from the schedule and not permitted to work. · Starting [DATE], the Administrator or designee, will audit the COVID-19 Vaccination Mandate information reported to NHSN weekly to ensure numbers are correct. The previous NHSN reporting information will be corrected and resubmitted on or before [DATE] dating back to [DATE]. · The Quality Assurance Performance Improvement (QAPI) Committee met on [DATE] to review the Immediate Jeopardy removal plan. Areas of deficiency will be submitted to the QAPI Committee and corrected immediately. · Staff interview on [DATE] at 1:00 P.M. with the Administrator confirmed VPNO #100 provided her with in-person education on [DATE] on the COVID-19 Policy and Procedure, and the COVID-19 Partner Vaccine Policy and Procedure and reviewing agency staff vaccination status prior to being permitted to work in the facility. Administrator further confirmed VPNO #100 provided education on updating the COVID-19 Vaccination Mandate information reported to NHSA weekly to ensure numbers are correct. · Staff interview on [DATE] at 1:02 P.M. with Assistant Administrator #115, at 1:03 P.M. with the DON, and at 1:04 P.M. with MDS Nurse #105 confirmed VPNO #100 provided them education on [DATE] on the COVID-19 Policy and Procedure, and the COVID-19 Partner Vaccine Policy and Procedure and reviewing agency staff vaccination status prior to being permitted to work in the facility. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: A review of QSO Memo ,d+[DATE]-ALL Attachment A issued on [DATE] revealed, within 30 days after the issuance of the memorandum, policies and procedures were to be developed and implemented for ensuring all facility staff, regardless of clinical responsibility or resident contact were vaccinated for COVID-19, including all required components of the policies and procedures (e.g., related to tracking staff vaccinations, documenting medical and religious exemptions, etc.). The facility was also to demonstrate 100% of staff have received at least one dose of COVID-19 vaccine or have a pending request for, or have been granted a qualifying exemption, or were identified as having a temporary delay as recommended by the Center for Disease Control (CDC). Less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or were identified as having a temporary delay as recommended by the CDC, the facility was non-compliant under the rule. Review of the medical record for Resident #45 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment for Resident #45 dated [DATE] revealed the resident was cognitively intact and required extensive assistance of one staff with Activities of Daily Living (ADL's). Review of the MDS for Resident #45 dated [DATE] revealed the resident was discharged to the hospital. Resident #45's return to the facility was anticipated. Review of the immunization record for Resident #45 revealed the resident had declined offers of COVID-19 vaccination on [DATE] and [DATE] and was unvaccinated for COVID-19. Review of a quarterly care conference note for Resident #45 dated [DATE] revealed the resident continued to be alert and exhibited no significant changes in status the prior quarter and demonstrated no cognitive decline. Resident #45 had support of her family who visited her often. Review of the physician note for Resident #45 dated [DATE] revealed the resident was in stable condition and was awake and alert, up in her wheelchair and participating in therapy and was in no apparent distress. Review of her social history revealed Resident #45's husband was planning to move into the facility with her. Review of a nurse progress note for Resident #45 dated [DATE] revealed the resident had a fever of 104.1 degrees F. The resident's temperature was rechecked three times with the same high temperature noted. Resident #45 also complained of a cough and congestion and was administered as needed Tylenol. After administration of Tylenol, Resident #45's temperature went down to 102.3 degrees F. The resident was rapid tested for COVID-19 with a positive result and the on-call physician gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse progress note for Resident #45 dated [DATE] revealed the nurse spoke to an emergency room (ER) nurse who said the resident was receiving intravenous (IV) fluids, additional COVID-19 testing, flu test, blood work and diagnostic tests. Review of a nurse progress note for Resident #45 dated [DATE] revealed the resident was being transferred from the ER to a larger hospital for further evaluation and treatment. During the survey, hospital and hospice records were requested for Resident #45 but were not received. Review of facility COVID-19-line listing revealed Resident #45 tested positive for COVID-19 in the facility on [DATE] per rapid test and had passed away in the hospital. Further review of the COVID 19-line listing for the four weeks prior to the survey revealed the following residents also tested positive for COVID-19: Residents #03, #17, and #32 on [DATE], and Resident #22 on [DATE]. Resident #17 was sent to theER on [DATE] due to displaying COVID-19 symptoms, was treated at the hospital and returned to the facility on [DATE]. Resident #17 was sent back to the hospital on [DATE] and was admitted with pneumonia and COVID-19 and remains in the hospital with a return to the facility expected. Interview on [DATE] at 12:02 P.M. with VPNO #100 confirmed Resident #45 was transferred to the hospital after developing signs and symptoms of COVID-19. VPNO #100 further confirmed Resident #45 passed away in the hospital presumably of COVID-19. VPNO #100 further confirmed the facility tracked vaccination status of staff and contracted staff on the vaccination matrix and all staff were either partially vaccinated, fully vaccinated, or had a medical or religious exemption. The facility did not track agency staff because the facility presumed the agency did this. Review of the facility COVID-19 vaccination matrix dated [DATE] presented at the beginning of the survey revealed the facility had confirmed the vaccination status of 82 staff and 12 contracted staff, but the contracted staff did not include agency staff. Review of the staffing schedule dated [DATE] revealed agency STNA #505 was working from 7:00 A.M. to 3:00 P.M. in House #36. Observation on [DATE] at 11:40 A.M. in House #36 revealed STNA #505 was in the residents dining room with residents in the vicinity and was not wearing eye protection. Interview on [DATE] at 11:40 A.M. with STNA #505 confirmed she was in a resident area and was not wearing eye protection. STNA #505 further volunteered that she was not vaccinated and did not have a valid exemption to the COVID-19 vaccination, but she was trying to decide if she should get vaccinated. STNA #505 confirmed the facility had never asked her about her vaccination status but the nursing agency she worked through knew she wasn't vaccinated for COVID-19. Interview on [DATE] at 2:41 P.M. with VPNO #100 and the DON confirmed the facility contracted with only one agency and they scheduled nursing assistants and licensed nurses through the agency website. VPNO #100 and the DON confirmed they did not include agency staff who worked in the facility on the vaccination matrix because the agency told them all the agency employees were fully vaccinated or had a valid exemption on file. Review of the facility COVID-19 vaccination matrix updated during the survey on [DATE] revealed it included 50 agency staff who had worked in the facility since [DATE]. Three STNA's (#505, #515, and #520) were unvaccinated for COVID-19 and did not have a valid exemption to the vaccine. Review of the campus floor plan for the facility revealed it consisted of five houses with 10 rooms each: House #20, House #35, House #36, House #49, and House #50. Review of facility staffing records revealed all five houses had unvaccinated COVID-19 staff working in them on at least one date. Review of facility staffing records revealed the unvaccinated COVID-19 agency staff worked on the following dates in the following houses: STNA #520 on [DATE] in House #36, STNA #515 on [DATE] in House #49, [DATE] in House #49, [DATE] in House #50, and [DATE] in House #50, STNA #505 on [DATE] in House #35, [DATE] in House #49, [DATE] in Houses #35 and #50, [DATE] in House #36, [DATE] in House #20, and [DATE] in House #36. Interview on [DATE] at 3:37 P.M. with VPNO #100 confirmed STNA's #505, #515, and #520 were not vaccinated for COVID-19, did not have valid exemption to the vaccine and worked in the facility providing direct resident care multiple times since [DATE]. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a moderate spread (yellow) of COVID-19 with a positivity rate of 6.5% for the week ending in [DATE]. Review of the facility policy titled COVID-19 Partner Vaccine Policy and Procedure dated [DATE] revealed the facility would ensure all partners were vaccinated against COVID-19 unless they had a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID-19. Further review of the policy revealed agency staff who provided services under arrangement were subject to the policy and the facility would maintain information regarding the vaccination status of all partners including agency staff. This deficiency substantiates Complaint Number OH 749.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure staff wore hair nets/coverings during food preparation. The had the potential to affect the 10 (#5, #7, #16, #18, #21, #23 #24, #34, #35 and #36) residents residing in House 35. The census was 42. Findings include: Observation on 03/11/22 at 11:48 A.M. revealed State tested Nursing Assistants (STNA) #155 and #510 were in the House 35 plating and finishing preparation of lunch plates for delivery the residents and were not wearing hairnets or hair coverings. Interview on 03/11/22 at 11:48 A.M. with State tested Nursing Assistants (STNA) #155 and #510 confirmed they were in the House 35 plating and finishing preparation of lunch plates for delivery the residents and were not wearing hairnets or hair coverings. Interview on 03/11/22 at 12:10 P.M. with the Vice President of Neighborhood Operations (VPNO) #100 confirmed the STNA's in the houses functioned as universal workers and preparing resident meals was part of their job duties. VPNO #100 further confirmed the STNA's followed safe food preparation practices which included wearing a hair net or hair covering at all times while in the House Kitchen preparing or plating food. The facility confirmed there are 10 (#5, #7, #16, #18, #21, #23 #24, #34, #35 and #36) residents residing in House 35 that receive food from the kitchen within this kitchen. Review of the facility policy titled Partner Hair Control in Kitchen dated May 2013 revealed anyone who is in the kitchen preparing food, serving food, washing dishes, or putting dishes away must wear a hat, hair covering or hairnet. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, observation, staff, private caregiver and physician interview, review of facility policy and review of online resources per the Centers for Disease Control (CDC), and the Center for Medicare and Medicaid Services (CMS), the facility failed to ensure staff wore eye protection in resident areas to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19) which had the potential to affect eight (#1, #8, #10, #11, #28, #37, #42 and #42) residents residing in House 36, nine (#9, #13, #15, #20, #25, #26, #29, #31 and #33) residents residing in House 49 and one (#22) resident residing in the COVID-19 unit. The facility failed to ensure staff wore masks properly to cover the nose when working directly with residents which affected one (#43) of the ten residents residing in House 36. The facility failed to ensure nurses cleaned and sanitized the glucometer after use which had the potential to affect two (#11 and #30) residents who received medications from the House 36 cart with orders for fingerstick blood sugar monitoring and who shared a glucometer device. The census was 42. Findings include: 1. Observation on 03/11/22 at 8:25 A.M. in House 36 revealed Physician #525 was making rounds in the house and going from room to room and was not wearing eye protection. Interview on 03/11/22 at 8:25 A.M. with Physician #525 confirmed she was not wearing eye protection while conducting resident examinations and eye protection was only required on the COVID-19 unit. 2. Observation on 03/11/22 at 11:30 A.M. House 49 revealed State tested Nursing Assistant (STNA) #385 was in resident dining area and was not wearing eye protection. Several random residents were out of their rooms and were in the vicinity. Interview on 03/11/22 at 11:30 A.M. with STNA #385 confirmed she was not wearing eye protection and was not required to do unless she came within six feet of a resident. STNA #385 confirmed she was in a resident care area. The facility nine (#9, #13, #15, #20, #25, #26, #29, #31 and #33) residents residing in House 49. 3. Observation on 03/11/22 at 11:40 A.M. in House 36 revealed STNA #505 was in the resident dining room with residents in the vicinity and was not wearing eye protection. Interview on 03/11/22 at 11:40 A.M. with STNA #505 confirmed she was in a resident area and was not wearing eye protection. 4. Review of the medical record for Resident #22 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 01/05/22 revealed resident was cognitively intact and required supervision and physical assistance with activities of daily living (ADL's). Review of nurse progress note for Resident #22 dated 03/03/22 revealed resident exhibited fever, cough, and general malaise. Resident #22 received a rapid test and was found to be positive for COVID-19. Resident #22's representative was notified by resident' private caregiver of resident's COVID status. Resident #22 was moved to the COVID -19 unit. Observation on 03/11/22 at 12:27 P.M. in the COVID unit revealed Private Caregiver #530 was inside Resident #22's room providing care and was not wearing eye protection. Interview on 03/11/22 at 12:27 P.M. with Private Caregiver #530 confirmed she had been providing care to Resident #22 since 9:00 A.M. on 03/11/22 and was not wearing eye protection. Review of the facility policy titled COVID-19 dated 02/07/22 revealed partners partners should wear appropriate personal protective equipment (PPE) in resident areas. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a moderate spread (yellow) of COVID 19 with a positivity rate of 6.5% for the week ending in 03/01/22. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. 5. Observation on 03/11/22 at 8:40 A.M. in House 36 revealed STNA #300 was feeding Resident #43 and was wearing a face shield and a surgical mask positioned below her mouth. Interview on 03/11/22 at 8:47 A.M. with STNA #300 confirmed she was wearing her surgical mask positioned below her mouth while feeding Resident #43 but she thought it was acceptable because she was wearing a face shield. The facility confirmed there are eight (#1, #8, #10, #11, #28, #37, #42 and #42) residents residing in House 36 Review of the facility policy titled COVID-19 dated 02/07/22 revealed partners working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic residents/elders with COVID-19 infection. Staff should wear eye protection in addition to their facemask to ensure the eyes, nose and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of online resource per the CDC titled Types of Masks and Respirators dated 01/28/22 at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html revealed masks should fit properly over nose, mouth, and chin. 6. Review of the medical record for Resident #11 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS assessment for Resident #11 dated 02/21/22 revealed resident was cognitively intact and required extensive assistance of two staff with ADL's. Review of the March 2022 monthly physician orders for Resident #11 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 03/11/22 at 8:36 A.M. in House 36 revealed Registered Nurse (RN) #110 checked Resident #11's blood sugar and then placed the glucometer inside the medication cart without cleaning or sanitizing it. RN #110 then went to the nurse's station to order medication from the pharmacy and administered Resident #11's oral medications with the glucometer still in the cart. Interview on 03/11/22 at 8:58 A.M. with RN #110 confirmed she had placed the glucometer in the cart without cleaning or sanitizing it after use. RN #110 confirmed Resident #30 who also had orders for blood sugar checks used the glucometer stored in the House 36 cart. RN #110 confirmed glucometer's should be cleaned and sanitized immediately after use with a bleach wipe. Review of the facility policy titled Glucometer cleaning dated 11/05/21 revealed upon completion of blood sugar check nurse will clean and disinfect glucometer with approved bleach wipe. Glucometer's should be cleaned prior to storing. This deficiency substantiates Complaint Number OH 749 and Complaint Number OH 734.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents received medications as ordered by the physician. This affected one (#40) of four residents reviewed for medication administration. The census was 42. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE] with diagnoses including acute [CONDITION(S)] (CHF), [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] (CKD), hypertension ([CONDITION(S)]), presence of pacemaker, [CONDITION(S)] heart disease, [CONDITION(S)], [CONDITION(S)], history of [CONDITION(S)], gastroesophageal reflux disease (GERD) Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 03/04/22 revealed resident was cognitively intact and required extensive assistance of two staff with activities of daily living (ADL's). Review of the admission nurses note for Resident #40 dated 02/25/22 revealed the resident was admitted to the facility in the evening and her admitting medication orders were verified with the nurse practitioner (NP) on call. Review of the nurse progress notes for Resident #40 dated 02/26/22 revealed the following medications were ordered to be administered to resident in the morning but were not available and resident did not receive them: [MEDICATION(S)] 25 microgram (mcg) one tablet for [CONDITION(S)], [MEDICATION(S)] 40 milligram (mg) one capsule for GERD, [MEDICATION(S)] Tablet 6.25 mg one tablet for [CONDITION(S)], lansoprazole 15 mg one capsule for GERD, [MEDICATION(S)] Tablet 100 mg one tablet for arthropathy, [MEDICATION(S)] 0.4 mg on capsule for CKD, potassium chloride 20 milliequivalent (meq) for [CONDITION(S)], [MEDICATION(S)] 20 mg two tablets for arthropathy, Mutlaq 400 mg one tablet for [CONDITION(S)], [MEDICATION(S)] 300 mg two capsules for neuralgia, [MEDICATION(S)] 20 mg two tablets for heart failure and aspirin 81 mg one tablet for heart failure. Further review of notes revealed facility was awaiting delivery of medications from the pharmacy. Review of the nurse progress note dated 02/26/22 revealed the following medications were ordered to be given to Resident #40 in the evening but were not given due to not being available: [MEDICATION(S)] 6.25 mg tablet, potassium chloride 20 meq and [MEDICATION(S)] 300 mg two capsules. Further review of the note revealed these medications were on hold per the physician due to not being available from the pharmacy. Review of the February 2022 Medication Administration Record (MAR) for Resident #40 revealed the resident did not receive ordered medications until 02/27/22. Interview on 03/11/22 at 12:00 P.M. with Registered Nurse (RN) #105 confirmed the pharmacy delivered medications once per day but if a resident was newly admitted the nurse should call for a immediate (STAT) delivery and the medications should arrive within four hours. RN #105 further confirmed the facility had an emergency box of medications for use until pharmacy could make a stat delivery. Interview on 03/14/22 at 10:23 A.M. with the Director of Nursing (DON) confirmed Resident #40 did not receive medications on 02/26/22 as ordered by the physician upon admission on 02/26/22. Review of the facility policy titled Medication Administration dated 07/09/21 revealed medications would be administered to residents as prescribed. This deficiency substantiates Complaint Number OH 556.

Based on record review, observation, staff interview, review of facility policy, and review of online resource Medscape, the facility failed to discard expired medication. This affected one (#11) of six facility identified residents with orders for insulin. The census was 42. Findings include: Review of the medical record for Resident #11 revealed and admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the [DATE] physician orders for Resident #11 revealed an order dated [DATE] for resident to receive insulin [MEDICATION(S)] solution via subcutaneous injection three times daily. Observation on [DATE] at 8:34 AM. with Registered Nurse (RN) #110 revealed Resident #11's insulin vial was opened and was dated [DATE]. RN #110 discarded the insulin. Interview on [DATE] at 8:34 A.M. with RN #110 confirmed insulin should be discarded 28 days after opening. Review of the facility policy titled Medication Administration dated [DATE] revealed medications will be administered consistent with good with infection control and standards of practice. Review of online resource Medscape at https://reference.medscape.com/drug/[MEDICATION(S)]-[MEDICATION(S)]-insulin-[MEDICATION(S)]- 1#11 revealed Insulin [MEDICATION(S)] solution could be stored at room temperature once opened for up to 28 days. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, review of facility policy, and review of Center for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff followed appropriate infection control techniques during medication administration. This affected four (#5, #11, #16, and #17) of the 15 residents observed during medication administration. Facility census was 42. Findings included: Observation of medication administration 11/09/21 at 408 P.M. with Licensed Practical Nurse (LPN) #31 revealed LPN #31 administered medications and completed a finger stick blood glucose (FSBG) on Resident #10. LPN #31 exited Resident #10's room, laid the glucometer on top of the medication cart, retrieved bleach wipes, wrapped the glucometer in wipes, removed his gloves, and placed the glucometer on the side of cart. LPN #31 performed no hand hygiene then touched numerous items on the cart with ungloved hands, touched the computer, handled his keys as he opened the medication cart and the narcotic locked cabinet inside the medication cart, and started prepping medications for Resident #05. Observation revealed LPN #31 removed Oxycodone and lorazepam from the locked bin. LPN #31 then popped out the Oxycodone from a medication card, using his fingers to guide the pill into the medicine cup. LPN #31 popped out the lorazepam from a medication card into his left hand and used his fingers to remove the lorazepam from his hand and placed it in the medicine cup. LPN #31 was removing [MEDICATION(S)] from a package when the medicine fell on top of the medication cart. LPN #31 picked up the [MEDICATION(S)] tablet with his ungloved hands and placed it in the medicine cup with other medications. At 4:21 P.M. LPN #31 administered these medications to Resident #05. Continued observation of with LPN #31 on 11/08/21 at 4:47 P.M. revealed LPN #31 after administering medications to Resident #05, LPN #31 donned gloves and completed a FSBG on Resident #17 while while the resident sat at the common dining room table. LPN #31 did not perform hand hygiene before approaching Resident #17. Observation revealed LPN #31 used an alcohol wipe on the resident's finger and laid it on the common dining room table, used a lancet to pierce Resident #17's skin and dropped it on the table, placed a glucometer strip in the machine and obtaining d a blood sample for reading. LPN #31 stated he needed to recheck Resident #17's FSBG again to be sure, so he removed the contaminated glucometer strip with blood on it, placed it on the table, and retrieved another glucometer strip. Once completed with the second FSBG for Resident #17, LPN #31 removed all trash and discarded it. Observation revealed there was blood on the table where LPN #31 laid the glucometer strip. Interview with LPN #31 immediately afterwards, indicated he was completed with all care for Resident #17 since he did not require any insulin coverage. Observation revealed LPN #31 removed and discarded his gloves and no observation of hand hygiene was completed and or cleaning of the common dining room. Continued observation at 4:50 P.M. following the FSBG for Resident #17 revealed LPN #31 did not perform hand hygiene before removing a glucometer and entering Resident #16's room. LPN #31 then donned gloves and completed a FSBG. LPN #31 stated Resident #16's FSBG was 208 and the resident required insulin coverage. LPN #31 returned to the medication cart, prepped two units of Novolog insulin, returned to Resident #16's room, donned gloves and administered insulin to Resident #16. LPN #31 exited resident's room discarded gloves and supplies and started to prepare medications for Resident #11 without any hand hygiene. Observation at 4:55 P.M. revealed LPN #31 administered medications to Resident #11. Interview with LPN #31 on 11/08/21 at 5:01 P.M. verified he did not complete any hand hygiene after he completed the FSBG on Resident #10 and before he started prepping medications for Resident #05. LPN #31 also verified he touched Resident #05's Oxycodone and Lorazepam with ungloved, dirty hands and verified Resident #05's [MEDICATION(S)] fell on top of the contaminated medication cart. LPN #31 stated he touched the lorazepam and Oxycodone due to being narcotics and wanted to make sure they fell in the medicine cup. LPN #31 stated he did not think about hand hygiene before he prepped medications for Resident #05 since he had gloves on when he checked Resident #10's FSBG. LPN #31 also verified he completed a FSBG on Resident #17 and laid the contaminated supplies on the common dining room table. LPN #31 stated he should have cleaned the blood off the table but did not think about it. LPN #31 verified he did not complete any hand hygiene between Resident #17's FSBG and Resident #16's insulin administration. LPN #31 also verified he did not complete any hand hygiene between Resident #16's FSBG and prepping and administering medications to Resident #11. LPN #31 stated he should have completed hand hygiene between the residents. LPN #31 stated he did not have any alcohol-based hand rub (ABHR) on his cart. Review of online resources from CDC titled Hand Hygiene Guidance (https://www.cdc.gov/handhygiene/providers/guideline.html) dated 01/30/20 revealed the core infection prevention and control practices for safe care delivery in all healthcare settings recommendations include the following recommendations for hand hygiene in healthcare settings: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, contaminated surfaces and immediately after glove removal. Review of the facility policy titled Infection Prevention and Control Program, dated 07/09/21, revealed the facility would prevent, recognize and control the onset and spread of infection. This was an incidental finding discovered during course of investigation for Complaint Number OH 117.

Based on record review, staff interview and review of facility policy, the facility notify the physician, the resident's representative, and administration when a resident choked when being given the wrong food consistency. This affected one (#10) of the three residents reviewed for notification. The facility census was 42. Findings included: Review of the medical record for Resident #10 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse's progress notes for Resident #10 created as late entry on 11/09/21 for 10/21/21 at 9:48 P.M. revealed approximately at 10:15 P.M. staff notified nurse the resident was choking. When the nurse entered the room the resident was visibly forcing air and turning blue. The nurse immediately raised the bed into a full sitting position and prepared to administer first aid. Resident was able to make sounds and forcibly cough. Notes indicated nurse was concerned the resident may not be able to clear object. The nurse removed dentures and looked into mouth and throat and did not notice any foreign objects. Emergency medical services (EMS) was called for help. Notes indicated nurse and the Elder Assistant (EA) continued to encourage elder to cough as hard as possible. The resident forcibly expelled object with the squad arriving shortly after. EMS wished to evaluate resident and requested the resident to go to hospital. There was no evidence the resident's representative, the facility physician, and /or the administrative staff was contacted after the choking incident. Review of EMS report, dated 10/21/21, revealed EMS was dispatched at 10:10 P.M. arrived at resident 10:15 P.M. for choking. EMS report indicated once they arrived, the facility indicated resident was no longer choking, resident presented conscious, breathing with patent airway, alert and oriented to her normal baseline and resident was not displaying any signs of distress. The resident voiced no complaints and resident refused to be transported to hospital. Resident #10 choked on a slice of apple with completed obstruction. Interview with Nurse Practitioner (NP) #100 on 11/09/21 at 7:45 A.M. indicated she was never informed and was not aware of a choking incident that involved Resident #10. Interview with Administrator on 11/09/21 at 11:47 A.M. indicated she recently learned Resident #10 had a choking incident on 10/21/21 when EA #46 gave the resident apple slices to eat. Administrator stated EA #46 went to give Resident #10 her cottage cheese snack and the resident begged EA #46 for some of the apple. Administrator stated Licensed Practical Nurse (LPN) #32 and EA #48 were able to get the apple dislodged. Interview on 11/09/21 at 1:50 P.M. LPN #32 stated he did not want to call Resident #10's representative because she had COVID and he did not want to upset her. LPN #32 verified he did not make a progress note, did not call the facility physician, did notify the administrative staff, and did not notify the resident's representative. Review of the facility policy titled Notification of Change of Condition, dated 12/06/16, revealed the facility would immediately inform the resident, consult with resident's physician, and notify the residents representative when an accident involving the resident which resulted in injury and/or had the potential of requiring physician intervention. This deficiency substantiates Complaint Number OH 130

Based on medical record review, observation, staff interview, review of Medscape.com drug information, and review of facility policy, the facility failed to administer medications in the proper form for one (#10) out of 15 residents observed during medication administration. Facility census was 42. Findings included: Review of the medical record for Resident #10, revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, depression, and [CONDITION(S)]. Review of physician orders for Resident #10, dated 04/28/21, revealed an order for [MEDICATION(S)] delayed release (DR) 250 milligrams (mg) three times daily for depression. Review of physician orders dated 05/19/21 revealed Resident #10 was ordered [MEDICATION(S)] tablet DR 125 mg by mouth there times daily for [CONDITION(S)] for total of 375 mg. Physician orders dated 10/18/21 revealed staff may crush crushable medications and administer medications in applesauce or pudding. Observation of medication administration on 11/08/21 at 4:04 P.M. revealed Licensed Practical Nurse (LPN) # 32 preparing medications for administration for Resident #10. LPN #31 opened and removed a [MEDICATION(S)] DR 125 mg and [MEDICATION(S)] DR 250 mg tablets, placed them in a clear sleeve, and crushed both medications. Observation at 4:08 P.M. revealed LPN #31 administered the crushed [MEDICATION(S)] DR tablets to Resident #10 in pudding. Interview on 11/08/21 at 4:12 P.M. LPN #31 verified he crushed the two [MEDICATION(S)] DR tablets. LPN #31 stated he always administered the [MEDICATION(S)] DR in a crushed consistency and never really thought about the pills being delayed release before today. Review of Medscape.com information for [MEDICATION(S)] DR revealed to swallow the medication whole, do not chew or crush. Review of facility policy titled Medication Administration Policy, dated 07/09/21 revealed medications would be administered to residents safely, as prescribed and in manner consistent with standards of practice. This deficiency substantiates Complaint Number OH 117

Based on observation, record review, staff interview, investigation review and medical director interview, the facility failed to ensure the residents received adequate supervision and care planned interventions to prevent falls. Resident #46 did not have a care planned functioning alarm to alert staff of her rising; she fell alone in the bathroom, resulting in hip fracture, pain and surgery. Resident #13 fell during a barefooted transfer when the state tested nurse aid (STNA) failed to provide non skid foot wear in accordance with the care plan. Resident #50 was left alone in the bathroom and fell to the floor from the toilet. This affected three of ten sampled residents reviewed for falls. Findings included: 1. Review of the medical record face sheet for Resident #46 revealed [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) quarterly assessment dated [DATE] revealed Resident #46 had memory problems, moderate cognitive impairment (required cues and supervision), required extensive assistance from staff with bed mobility, transfers, ambulation and toileting, was not able to attempt the balance test without physical help, was incontinent and on a bladder retraining program and fell in the past 30 days and the past 31 - 180 days. The MDS further documented Resident #46 received antipsychotic, antianxiety, antidepressant and diuretic medication daily. The fall assessment dated [DATE] assessed the resident was at risk for falling due to history of falling, cognitive impairment, limited vision, incontinence, ambulated with problems, unable to balance without physical help, drop in blood pressure after standing, three or more health conditions, and three or more medications. The fall assessment score was 19 and a resident was at high risk for falling with a score of 10. The care plan for falls dated 03/15/10 included an intervention of an alarm in the chair. The care plan did not include individualized resident supervision requirements to prevent falls. Review of the Progress Notes by Licensed Practical Nurse (LPN) #9 dated 05/29/10 at 12:38 P.M. revealed Resident #46 was sitting in her recliner with an alarm placed under her. STNA #4 found the resident on the floor in the bathroom. LPN #9 documented the alarm pad was not working properly at the time of the fall. The notes documented Resident #46 stated she was trying to get to the bathroom "to fix my hair." The notes did not state how she got to the bathroom or how long she was on the bathroom floor. LPN #9 further documented Resident #46 complained of right shoulder pain and right hip pain. Progress notes by LPN #5 on 05/29/10 at 10:43 P.M. stated the resident was admitted to the hospital at 7:00 P.M. for surgical repair of a right hip fracture. Review of the Incident Details Report dated 05/29/10 stated the resident's alarm did not work properly. Corrective action was education to STNA #4 to check all alarms prior to placing them in the chair or beds. The care plan dated 06/08/10 by Registered Nurse (RN) 7 documented Resident #46 returned from the hospital with impaired physical mobility related to a right hip fracture. The care plan required assistance of two staff for transfer, monitor for pain, provide physical therapy and siderails up in bed to assist with mobility. Progress notes by LPN #5 dated 06/09/10 at 12:37 A.M. revealed Resident #46 had a new order for routine Percocet (narcotic analgesic) and ativan as needed (for anxiety). The notes documented the resident complained of leg pain when up in the wheelchair for dinner. LPN #5 further documented the dressing changes was completed to the right hip wound, staples were intact. According to the significant change in status MDS assessment dated [DATE], Resident #46's condition declined upon readmission to the facility from the hospital. The MDS documented deterioration in activities of daily living function and limitations in range of motion an voluntary movement of one leg, the presence of a hip fracture and the presence of two Stage I pressure ulcers. Care plans did not include supervision requirements to prevent falls after the significant change assessment. Progress notes by LPN #6 dated 08/01/10 at 1:29 P.M. revealed the resident was found by the STNA on the floor with right arm pain and the alarm was sounding. The resident required evaluation in then emergency room . Progress notes by RN #10 dated 08/02/10 at 12:35 P.M. revealed Resident #46 was unable to state how the fall from the wheelchair occurred. During interview on 09/01/10 at 9:15 A.M., Registered Nurse (RN) #21 stated Resident #46's chair alarm was not functioning when she was found alone in her bath room on the floor on 05/29/10. RN #21 further stated there was no evidence the alarm's functioning was checked prior to the resident's fall. RN #21 was unable to describe when the resident was last toileted, if the call bell was available or what type of footwear the resident was wearing at the time of the fall. RN #21 also affirmed the resident, left unsupervised on 08/01/10, fell from the wheelchair. During observation on 09/02/10 at 3:00 P.M., dependent Resident #46 was seated in her recliner in the common area with feet elevated. She could not respond to questions during interview. On 09/03/10 at 10:30 A.M. the Medical Director was interviewed. The fall list from 05/10 through 08/31/10 was reviewed. There were 41 falls listed, involving 23 residents. The Medical Director stated she has concerns regarding the frequent falls in the home. During telephone interview on 09/13/10 at 3:30 P.M., Director of Nursing (DON) #2 affirmed the Resident #46 was at high risk for falling and the care plan did not specify Resident #46's requirements for staff supervision to prevent falls. DON #2 affirmed the alarm was used to alert staff to the resident's rising from the chair. DON #2 also affirmed Resident #46 should be observed by staff in a common area and provided meaningful distractions. DON #2 did not know why the resident was left alone in her room and was not in the common area with residents where staff observe. 2. Review of the medical record face sheet for Resident #13 revealed [DIAGNOSES REDACTED]. The fall assessment dated [DATE] determined the resident was at risk for falls. Review of the 05/10/10 care plan for fall prevention revealed an intervention of shoes or non-skid socks for ambulation and transfers. Review of Progress Notes dated 07/12/10 at 7:40 A.M. by the registered nurse revealed the STNA was toileting the resident and, when transferring the resident from the toilet to the wheelchair, the resident started to slip and the STNA lowered her to the floor. The note stated the STNA was reminded the resident needed to have non-skid socks or slippers on her feet during transfers. On 09/01/10 at 10:05 A.M., RN #21 was interviewed and affirmed Resident #13 was transferred from the toilet to the wheelchair without shoes or nonskid socks. RN #21 affirmed the fall care plan required the use of shoes or nonskid socks during transfers. RN #21 also affirmed the fall was avoidable. 3. Review of the medical record face sheet for Resident #50 revealed [DIAGNOSES REDACTED]. The fall assessment dated [DATE] assessed the resident at risk for falls. The MDS assessment dated [DATE] documented Resident #50 had moderate cognitive impairment and required two person physical assistance for toileting. Review of the care plan for falls included an intervention to provide assistance with transfers and mobility. Review of the Progress Notes dated 05/06/10 at 6:03 A.M. stated Resident #50 fell from the toilet. On 09/01/10 at 10:30 A.M., RN #21 was interviewed. She affirmed the resident was left alone on the toilet by the STNA and the resident fell to the floor. This deficiency substantiated Complaint Control Numbers OH 796 and OH 067. This deficiency is an example of continued noncompliance from the annual survey completed on 04/30/10 and the complaint investigation completed 05/18/10.

Based on observation, record review, and interview with facility staff, the facility failed to ensure residents had care planned fall interventions in place to ensure the environment was as free from accident hazards as possible and each resident received the required level of supervision to prevent an accident. Lack of implementation of accident prevention interventions and supervision affected six (#34, #15, #36, #24, #3 and #29) of eleven sampled residents and resulted in a fractured knee for Resident #34 and Findings include: 1. The [DIAGNOSES REDACTED]. The resident's initial Minimum Data Set (MDS) of 03/16/10 identified the resident as needing limited physical assistance with all activities of daily living including transfers and ambulation. The MDS identified the resident had a history of [REDACTED]. Quick notes (nursing notes) documented on 03/04/10 at 7:55 A.M. the resident was found on the floor next to her bed. The resident stated she had hit her head. She was sent to the emergency room for evaluation and returned at 8:54 P.M. The resident returned with new orders for a safety mat next to the bed and an alarm on when unattended as the resident was unreliabile in using the call pendent. On that date, these interventions were added to the resident's plan of care and included the use of an alarm in the bed and the chair at all times. Quick notes on 03/28/10 at 1:31 P.M. documented the resident was found on the living room floor complaining of left knee pain. She had a hematoma on her forehead. An Xray of the left knee was negative. On 03/29/10, notes from an Interdisciplinary Team meeting indicated the fall documentation stated the resident had been near the hearth area of the house when she stood up reaching for her walker. The walker rolled away and she fell . The note stated the personal alarm was only used at bedtime and it would be put into use at all times. The personal alarm was not on at the time the resident fell on [DATE]. At 10:31 P.M. on 03/29/10 the resident was sent to the hospital for mental status changes. She returned to the facility at 11:30 P.M. with a report of no fractures. On 03/30/10 at 11:00 A.M. a nurse called the hospital for a report on the resident's mental status changes. At this time, the hospital reported the X-rays taken the previous night revealed a left knee fracture. The hospital requested the resident return to the hospital as she had not been treated for [REDACTED]. The resident was observed during breakfast on 04/30/10 in a wheelchair with her left leg supported by an elevated leg rest. She was wearing a knee immobilizer. The resident had a large bruise visible between her eyebrows that extended to her forehead. On 04/30/10 at 11:30 A.M. State tested Nurse Aide (STNA) #82 , who was present when the resident fell on [DATE], was interviewed regarding the fall. She affirmed the chair alarm was not on the resident at the time of the fall as she felt the resident had been having a good day cognitively and did not need it. She stated she was the only nurse aide in the building at the time and she was busy toileting another resident. 2. Review of Resident #24's [DIAGNOSES REDACTED]. Review of the resident's current quarterly assessment dated [DATE] revealed the resident had fallen in the last 30 days and in the last 31-180 days. The quarterly assessment of 04/05/10 and the annual comprehensive assessment of 07/17/09 revealed the resident needed extensive assistance of staff with mobility and transfers and had a history of [REDACTED]. Additional interventions included placing the call pendent within the resident's reach and encourage the resident to call for assistance as needed. Instead of call lights, the facility utilized call pendants that resident's wore around their necks. Review of the resident's quick notes revealed the resident had a fall on 01/11/10 at 1:15 P.M. when she was sitting on the commode. The state tested nurse aide was not within the resident's reach when the resident attempted to stand and hold onto her wheelchair. The nurse aide had not locked the wheelchair and it rolled away causing the resident to fall. The resident sustained [REDACTED]. Quick notes dated 02/21/10 at 1:10 P.M. revealed the resident was found on the floor in front of her bed. The resident's bed alarm was not working. On 02/22/10 at 2:30 P.M. quick noted stated the resident got up from bed and fell . The note stated the staff failed to acknowledge the low battery warning of the alarm. An A/C adapter was ordered. Quick notes dated 03/18/10 at 2:37 P.M. documented the resident was found on the floor laughing. The box of the bed alarm was functioning but the pad was not sensing pressure appropriately. The alarm pad was changed. On 04/28/10 at 9:50 A.M. upon entering the room with STNAs #24 and #73, the resident was observed in bed without her pendant alarm on. The necklace alarm was out of the resident's reach and laying on her nightstand. Interview with both nurse aides at the time revealed the resident did not wear her pendant in bed at night. They confirmed the pendent was not within the resident's reach. Both STNA's stated the resident had personal alarms on when in bed and she was checked on frequently throughout the night. Therefore, if she needed anything they would know as the alarm would sound when she was trying to get up. 3. The [DIAGNOSES REDACTED]. The resident's initial comprehensive assessment of 07/20/10 revealed the resident had no problems with long term memory or the ability to make himself understood. The resident had no history of falls. The quarterly assessment of 04/07/10 revealed the resident had a history of [REDACTED]. Review of the resident's fall prevention care plan revealed interventions to have a Dycem mat in the dining room chair and to educate the resident on dining room chair safety. Quick notes revealed the resident fell from the dining room chair on 10/06/09 at 12:32 P.M. when he bent down to pick up a pencil when the chair slide out and he fell . Quick notes of 10/07/09 at 3:36 P.M. revealed the resident sustained [REDACTED]. Quick notes of 11/14/09 at 12:00 A.M. revealed the resident sat on the edge of the chair and fell sustaining a skin tear. Quick notes of 11/16/09 revealed the resident fell from the dining room chair when he sat on the edge of the seat and the wheels rolled. On 04/29/10 at 1:13 P.M. the resident was observed eating lunch sitting on a dining room chair. The chair had front wheels and did not have a Dycem mat in the seat. At that time, STNAs #13 and #43 were interviewed regarding the resident's falls from dining room chairs. Both STNA's stated they had not worked in this home very long and were unaware the resident had a history of [REDACTED]. They did not know the resident had fallen as a result of the wheels on the chair moving. They were unaware the resident should have a Dycem matt on the seat of the chair. Both nurse aides affirmed there was no Dycem in the resident's chair. 4. Review of Resident #15's last comprehensive fall assessment dated [DATE] revealed the resident was at risk for falls due to dementia, antidepressant and cardiovascular medication usage, and recently moving into the facility. Review of incident reports and progress notes revealed the resident had experienced two falls in the past year. According to these reports, the resident experienced a fall on 02/16/10 at 3:43 A.M. when she tripped over her slipper walking to the bathroom. The resident experienced a second fall on 04/16/10 at 11:59 A.M. when she was stood up from the toilet and fell . Review of the resident's plan of care revealed the use of a personal alarm was added to the plan of care after this fall. On 04/27/10 at 2:10 P.M. the resident was observed sitting in a wheel chair at the kitchen counter reading the newspaper. She was not wearing a personal alarm as directed by her current plan of care. STNA #38 was in the dining room at the time of the observation and was immediately informed the resident did not have a personal alarm in place. STNA #38 verified the alarm was not in place and went into the resident's room to check for the alarm. She returned less than two minutes later with the alarm and alarm pad. STNA #38 stated the resident was taken to the bathroom approximately 20 minutes prior and staff had forgotten to put the alarm pad back onto the wheel chair seat. 5. Review of incident reports revealed that on 08/07/09 at 5:30 P.M. a volunteer was pushing Resident #29 in her wheelchair on an outing to Cox Arboretum. According to the report the volunteer pushed the resident on an arched bridge that was steep and on the way down the other side of the bridge the volunteer turned the wheel chair around to back it down and it tipped over during the turn. The report documented the resident fell on her hands, knees, and elbows and received abrasions as a result of there fall. There was no nursing personal accompanying the residents on the outing so the resident was sent to the emergency room with a state tested nursing assistant. Interview with Social Worker #56 on 04/29/10 at 9:45 A.M. revealed that she had taken eight residents on this outing with one state tested nursing assistant , two adult volunteers and six teenage volunteers. She stated that a [AGE] year old volunteer was pushing Resident #29 at the time of the incident. Social Worker (SW) #56 stated the resident was not within sight of herself or the STNA. SW #56 stated that a passerby from the community assisted the [AGE] year old volunteer to push the resident in her wheel chair to the top of the bridge and then left the girl alone with the resident. When the girl attempted to push the resident back down the bridge she lost control of the wheel chair and the resident fell from the wheel chair. SW #56 stated the volunteer had no training related to pushing wheelchairs and she was not being supervised at the time of the incident. The list of the residents on the trip and the volunteers was reviewed with SW #56. She stated she did not have enough staff on this outing to adequately supervise the residents and stated no additional policies or interventions were put into place to ensure she had enough trained staff on the outing. She stated she continues to depend on untrained volunteers and family members to assist her with the outing. 6. Review of nursing notes in the medial record of Resident #3 revealed, on 01/06/10 at 9:15 A.M., Resident #3 experienced a fall while on an outing to a restaurant. According to the progress notes the resident's cane got caught on a furniture leg causing him to trip over an area rug in the restaurant lobby. According to the nursing documentation the activity staff were reminded to watch for possible hazards when this resident is on an outing due to his confusion. The best intervention was for staff to monitor the resident more closely. During interview on 04/29/10 at 9:45 A.M., SW #56 stated at the time of the fall she was outside moving the van to the front of the building so residents could board the van and return to the nursing facility. She did not witness the fall. She stated the STNA was present and did witness the fall. Review of outing information provided by SW #56 revealed there was only one STNA accompanying the nine residents taken on this outing. A family member of one of the residents was also present. SW #56 stated she could have used one more trained employee to ensure resident safety. SW #56 also stated she continues to depend on untrained volunteers for supervision of residents while on outings. She stated the facility did not have a policy to address what level of supervision was required during outings. On 4/30/10 at 8:55 A.M. the outing documentation was reviewed with the Director of Nursing and she also stated there should have been one more employee on the outing to ensure resident's safety. This deficiency substantiates complaint OH 177.