Every finding on record at Regency Care of Copley

Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate and timely activities of daily living (ADL) care for dependent residents. This affected one resident (#42) of three residents observed and reviewed for ADL care. The facility census was 51.Findings include: Review of Resident #42 ' s medical record revealed an admission date of 10/25/24. Diagnoses included quadriplegia, muscle weakness, and anoxic brain injury.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had no cognition score as the resident was noted to be rarely/never understood. Resident #42 was dependent with toileting and bed mobility and was incontinent of bowel and bladder.Review of the care plan dated 07/14/25 revealed Resident #42 was dependent with bathing and care. Interventions included to turn and reposition as needed and to provide two staff assistance with bathing.Observation on 12/01/25 at 8:41 A.M. reveled Resident #42 was in bed on her left side. Resident #42 was non-verbal and unable to be interviewed. Observation on 12/01/25 at 11:46 A.M. revealed Resident #42 was in same position as the previous observation.Observation and interview on 12/01/25 at 1:25 P.M. revealed Resident #42 had remained in same position as previous observations. Interview with Certified Nursing Assistant (CNA) #400 at the time of observation revealed CNA #400 confirmed she had not provided Resident #42 with ADL care, including hygiene or turning and repositioning, since the start of her shift at 7:00 A.M. CNA #400 further stated Resident #42 required total care which included turning and repositioning at least every two hours. At 1:40 P.M. CNA #400 had returned to Resident #42's room and had proceeded to provide incontinence care. Observation further revealed Resident #42's hair was severely matted and appeared to be greasy and unkempt. CNA #400 stated Resident #42 ' s showers were scheduled on night shift and she was unaware when Resident #400 had last received a shower or her hair had been washed. Review of the facility policy titled Activities of Daily Living (ADL) undated revealed care and services will be provided that included bathing and grooming.Review of the facility policy titled Turning and Repositioning revised 10/01/22 revealed turning and repositioning is a primary responsibility of nursing staff and routine repositioning schedules consisted of every 2-4 hours.

Based on observation, interview, record review, and facility policy review, the facility failed to provide timely incontinence care to residents. This affected two residents (#27 and #42) of three residents observed and reviewed for incontinence care. The facility census was 51.Findings include:1.Review of Resident #27's medical records revealed an admission date of 11/14/24. Diagnoses included stroke with left-sided weakness, muscle weakness, and need for personal care assistance.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had impaired cognition. Resident #27 was dependent on staff for toileting and was noted to be incontinent of bowel and bladder.Review of the care plan dated 11/17/25 revealed Resident #27 had activities of daily living deficits. Interventions included to provide toileting assistance as required.Observation on 12/01/25 at 8:45 A.M. revealed Resident #27's call light was active. Upon entering Resident #27's room, an odor of stool was detected and observation reveled a large dried brown stain underneath Resident #27. Resident #27 was not interviewable. Observation on 12/01/25 at 9:37 A.M. revealed Resident #27 remained incontinent of stool. At the time of observation, Certified Nursing Assistant (CNA) #400 approached and asked what type of assistance was required as Resident #27 was not her assigned resident. At the time of interview, CNA #400 had entered Resident #27's room and confirmed the odor of stool and the large dried stool on Resident #27's sheets. CNA #400 had exited Resident #27's room to obtain supplies to provide incontinence care. At 9:55 A.M., CNA #400 had returned and proceeded to provide Resident #27 with incontinence care. Continued observation revealed Resident #27 was incontinent of a large amount of green and black colored liquid stool. Further observation revealed an incontinence pad underneath Resident #27 that had dark colored urine that had extended up to the middle of Resident #27's back. Interview with CNA #400 at the time of observation confirmed the observations and stated she was unsure when Resident #27 had last received incontinence care. 2. Review of Resident #42's medical record revealed an admission date of 10/25/24. Diagnoses included quadriplegia, muscle weakness, and anoxic brain injury.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had no cognition score as the resident was noted to be rarely/never understood. Resident #42 was dependent with toileting and bed mobility and was incontinent of bowel and bladder.Review of care plan dated 07/14/25 revealed Resident #42 was dependent on staff for bathing and care and was incontinent of bowel and bladder. Interventions included to turn and reposition as needed and to provide incontinence care as needed.Observation on 12/01/25 at 11:46 A.M. revealed Resident #42 was in bed and had an odor or urine. Resident #42 was non-verbal and unable to be interviewed.Observation on 12/01/25 at 1:25 P.M. revealed Resident #42 had remained in same position as previous observation and still had an odor of urine. Interview with CNA #400 at the time of observation revealed she had not provided Resident #42 with incontinence care since the start of her shift at 7:00 A.M. CNA #400 further stated she had another resident she had to provide care for and then she would provide Resident #42 with care. At 1:40 P.M. CNA #400 had returned to Resident #42's room and had proceeded to provide incontinence care. Observation further revealed Resident #42's incontinence brief was heavily saturated with dark, pungent urine.Review of facility policy titled Incontinence revised 02/01/25 revealed all residents that are incontinent will receive appropriate treatment and services.

Based on observation, interview, medical record review, review of facility policies, and review of the facility investigation of self-reported incident (SRI) number 263186, the facility failed to ensure appropriate care and services were provided to Resident #4, who had a tracheostomy. This affected one resident (Resident #4) of two residents (residents #4 and #23) who were reviewed for appropriate tracheostomy care. The facility census was 46. Review of the medical record for Resident #4 revealed an admission date of 01/10/25 with diagnoses including acute respiratory failure with hypoxia, cerebral infarction, type two diabetes mellitus, atrial fibrillation, paranoid schizophrenia, post-traumatic subdural hemorrhage, lymphangioma, sepsis, encephalopathy, gastrostomy status, and encounter for attention to tracheostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/10/25 revealed Resident #4 had severely impaired cognition and was dependent for all activities of daily living (ADL), including, bathing, dressing, personal hygiene, oral hygiene, bed mobility, and transfers. Further review of the MDS revealed Resident #4 required oxygen therapy, suctioning, and tracheostomy (trach) care. Review of the plan of care dated 01/10/24 to 10/12/25, last reviewed 07/18/25, revealed Resident #4 had a tracheostomy secondary to encephalopathy, acute and chronic respiratory failure, subdural hygroma, and cerebrovascular accident. Interventions included ensuring the trach ties were always secured, wearing a gown and gloves when providing direct care and tracheostomy care, monitoring and documenting respiratory status per orders, and specific instructions in the event of an unplanned decannulation (trach tube out/dislodged). There were no interventions specified for routine trach care or maintenance. Review of the current physician orders revealed an order dated 07/17/25 for Resident #4 to have trach care rendered every shift and as needed (PRN). Review of the previous trach care orders revealed an order dated from 01/10/25 through 07/17/25 for trach care daily and PRN. Additional tracheostomy-related orders for Resident #4 included: Change the trach tube every month starting on 01/10/25 and continuing monthly on the 10th each month and as needed (dated 01/10/25). Change the trach ties weekly every Monday on day shift and as needed (dated 01/10/25). Suction the trach every shift as needed (dated 01/10/25). Change the inner cannula daily with trach care and as needed (dated 01/27/25).Review of the treatment administration record (TAR) for July 2025 revealed documentation that trach care was performed once daily from 07/01/25 through 07/16/25 and then every shift starting with the night shift on 07/17/25. PRN trach-related documentation included trach tie changes on 07/17/25 and on 07/21/25 and triple antibiotic ointment application to the trach as needed for redness on 07/17/25 at 6:19 A.M. There was no documentation that additional trach care was performed on an as-needed basis from 07/01/25 through 07/31/25. Review of the nurses' notes dated 07/17/25 at 6:15 A.M. revealed Resident #4 had the trach ties changed with a note indicating the site was cleansed with normal saline, dried with gauze, triple antibiotic ointment was applied to the trach site, and the area was left open to air. The note revealed no description of the trach stoma or surrounding area or reason for the additional trach tie change. Review of a follow-up note dated 07/17/25 at 8:00 A.M. revealed Physician #395 was at the facility and was notified of excoriation underneath the trach ties and an order was given for mupirocin lidocaine 2-2% ointment to be applied four times a day for 14 days and that the resident representative for Resident #4 was notified of the new order. Review of all progress notes from 06/07/25 through 08/07/25 revealed no mention of the presence of maggots around the trach ties or trach stoma or of any unusual substance noted around the trach and surrounding area. Review of the assessments titled Respiratory Assessment/Vent Check completed on 07/17/25 at 7:26 A.M., 9:00 A.M., 10:36 A.M., and 2:15 P.M. revealed no mention of any unusual assessment criteria or occurrences related to Resident #4's trach or surrounding area. Interview on 08/07/25 at 10:22 A.M. with Registered Nurse (RN) #396 confirmed viewing video footage of maggots crawling around the neck, the trach, and under the trach ties on both sides of the neck of Resident #4 during the night shift on 07/16/25. RN #396 further stated the video was recorded by Licensed Practical Nurse (LPN) #325 and forwarded to the previous Director of Nursing (DON) #399 and the Licensed Nursing Home Administrator (LNHA). RN #396 revealed during the interview that the maggots were able to be removed by staff on duty, new trach ties were applied after cleaning Resident #4, and the physician was notified that maggots were found around the trach and neck of Resident #4. Telephone interview on 08/07/25 at 12:59 P.M. with the Ombudsman confirmed allegations were received from two separate sources on 07/24/25 of improper care of a resident's tracheostomy (trach). The first source was anonymous and did not provide the name of the resident but included three photos which appeared to be maggots around a trach collar. The second source revealed they had been sent or shown pictures of Resident #4 with maggots around his trach ties. The Ombudsman further revealed an in-person visit was made to the facility on [DATE] where it was confirmed the facility had been informed of maggots being noted near Resident #4's trach between the night of 07/16/25 and the morning of 07/17/25 (a Wednesday night to Thursday morning shift). During the on-site visit, the Ombudsman further found that the window to Resident #4's room had no screen at the time of the incident, and staff had reported a wasp had previously been observed entering that window. Interview on 08/07/25 at 2:11 P.M. with the LNHA confirmed being alerted by the previous DON #399 on the morning of 07/17/25 that there were some maggots noted on Resident #4 but that she had not seen them and did not see the picture of the maggots until shown by the Ombudsman on 07/24/25. At the time of this interview, the LNHA confirmed the trach care orders changed for Resident #4 once discovery of the maggots was made to prevent it from happening again. Interview on 08/07/25 at 4:22 P.M. with Certified Nursing Assistant (CNA) #326 confirmed LPN #325 reported to staff during the nightshift on 07/16/25 that some small white things were seen moving around near Resident #4's neck and trach tube and had requested assistance from staff in identifying and addressing the concern. CNA #326 further confirmed observing maggots were localized around the trach and completely around Resident #4's neck. During the interview, CNA #326 stated Resident #4 was given a complete bed bath, the neck was washed thoroughly while the aide and two nurses removed the maggots, trach care was provided by LPN #325, and all the bedding and clothing was changed. Interview on 08/07/25 at 4:49 P.M. with RN #337 confirmed the presence of maggots around the trach collar of Resident #4 during nightshift on 07/16/25 and assisting LPN #325 and the aide with cleaning and removing the maggots. During the interview, RN #337 stated most of the trach care in the facility was performed by the Respiratory Therapist (RT) and night nurses typically just suctioned the trach and changed trach ties if needed. RN #337 further confirmed Resident #4 tended to drool a lot, causing the trach ties to get moist and on that night (night shift scheduled 07/16/25 to 07/17/25), Resident #4's trach ties were very moist. Observation on 08/11/25 at 8:55 A.M. revealed CNA #315 entered Resident #4's room and informed RT #385 that Resident #4 was going to be showered. During the observation, RT #385 stated she would return and do trach care after Resident #4 was out of the shower adding trach care had also been completed earlier that morning. Observation on 08/11/25 from 10:10 A.M to 10:20 A.M. of trach care for Resident #4 performed by RT #385 revealed the old trach ties were wet from the shower earlier that morning and the skin beneath was moist. During the observation, the new trach ties were applied and secured to hold the trach in place without the moist skin beneath the trach ties first being dried. Skin beneath the new trach ties appeared shiny and slightly moist. Trach care continued once the new ties were replaced with no additional concerns with the procedure. Interview with RT #385 after completion of the trach care confirmed the new trach ties were applied directly after removing the wet ones without drying the area in between steps. While in Resident #4's room for trach care, a note was observed posted next to the window requesting nobody open the window because there was no screen and a wasp had previously flown in through the window. A closer observation of the window revealed there was a screen in place on this date. At this time, RT #385 confirmed the presence and content/verbiage of the sign. A follow-up interview on 08/11/25 at 10:28 A.M. with RT #385 confirmed trach care frequency was typically conflicting as to whether it was performed one or two times a day. Per RT #385, changing of trach pads would be done as needed but opening the whole pack for trach care was usually only done once a day. During the interview, RT #385 confirmed Resident #4's order changed to twice daily after the maggots were noted because he drooled a lot and the order change was also to reiterate to the nurses that care was getting done. RT #385 also confirmed Resident #23, the other resident with a trach, still had orders for trach care once a day and as needed and his orders had not changed. Further interview confirmed trach ties were changed once weekly and as needed and the RT would often need to change the trach ties when in the facility on Mondays and Fridays due to the increased secretions or drainage around Resident #4's neck. Interview on 08/11/25 at 2:02 P.M. with CNA #340 confirmed that Resident #4 had no screen, staff sometimes opened that window, and a wasp was observed flying into the room. CNA #340 further stated she verbalized concerns that Resident #4 was unable to speak for himself or make sure insects did not land on him, so a sign was placed instructing that nobody open the window. CNA #340 also confirmed assisting to identify and help remove maggots from around the trach of Resident #4 during the night shift on 07/16/25. Interview on 08/11/25 at 3:02 P.M. with LPN #325 confirmed that the night of 07/16/25 to 07/17/25 Resident #4 was receiving oral care when it was noted the trach dressing was saturated. Upon closer inspection when preparing to change the gauze dressing, hundreds of tiny white things she had never seen before were noted moving around under the gauze, around the trach stoma, and around the neck under the trach ties. Further interview with LPN #325 confirmed she requested other facility staff to help identify the white moving items and help clean Resident #4. During the interview, LPN #325 stated the initial attempts to reach the Nurse Practitioner on-call and the DON were unsuccessful so video was taken to show the DON what the concern was so Resident #4 could get cleaned up and appropriate orders could be obtained. Interview on 08/11/25 at 4:10 P.M. with CNA #324 confirmed Resident #4 did not have a screen in the window and CNA #324 had observed the window being left open with no screen. Telephone interview on 08/11/25 at 5:06 P.M. with LPN #366 confirmed the investigative role involved talking with RT #385 and nurses, assisting with nursing re-education, and policy reviews. According to LPN #366, nursing in-services that were marked as reviewed over the phone included nurses being provided copies of the policies when they returned to the facility for their shifts and did not include a return demonstration of trach care and suctioning. Interview on 08/11/25 at 5:59 P.M. with CNA #302 confirmed she visualized the maggots around Resident #4's trach the night of 07/16/25 to 07/17/25. CNA #302 further confirmed Resident #4's trach pad (she described as the gauze around the stoma) and trach ties typically got easily saturated and nurses would change the gauze when notified of it being soiled but had not personally observed trach ties being changed during the night shifts. During the interview, CNA #302 confirmed Resident #4 did not have a screen in the window for several months and that there were occasions it was cracked open and had to be shut upon CNA #302s arrival. Interview on 08/12/25 at 10:10 A.M. with Maintenance #362 confirmed the facility installed new windows in March 2025 and Resident #4 did not have a screen prior to the incident with the maggots around his trach on 07/17/25. Interview on 08/12/25 at 10:24 A.M. with the DON confirmed Resident #4 had orders changed to increase the frequency of trach care to twice a day after an incident involving maggot around his trach. During the interview, the trach care policy was reviewed and the DON confirmed that the facility policy was to provide trach care at least two times a day. The DON further confirmed that when wet or moist trach ties were removed, the skin was to be thoroughly dried prior to placing and securing new trach ties. Review of the policy titled Tracheostomy Care, dated 03/01/25, revealed trach care should be performed at least twice daily, and trach ties were to be changed whenever soiled or wet. This deficiency represents noncompliance investigated under Incident Number 2579881 and Complaint Number 2579936.

Based on record review, observation, interview, review of nursing schedules for 07/15/25 through 07/21/25, review of the purchase order and receipt from facility maintenance, review of facility policies, and review of the facility investigation of self-reported incident (SRI) number 263186, the facility failed to ensure a thorough investigation and documentation was completed related to allegations of inadequate care of Resident #4 who had a tracheostomy. This affected one (Resident #4) of two residents reviewed for tracheostomy care and had the potential to affect two (Residents #4 and #23) identified by the facility with tracheostomies. The facility census was 46. Findings include:Review of the medical record for the Resident #4 revealed an admission date of 01/10/25 with diagnoses including acute respiratory failure with hypoxia, cerebral infarction, type two diabetes mellitus, atrial fibrillation, paranoid schizophrenia, post-traumatic subdural hemorrhage, lymphangioma, sepsis, encephalopathy, gastrostomy status, and encounter for attention to tracheostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/10/25 revealed Resident #4 had severely impaired cognition and was dependent for all activities of daily living (ADL), including, bathing, dressing, personal hygiene, oral hygiene, bed mobility, and transfers. Further review of the MDS revealed Resident #4 required oxygen therapy, suctioning, and tracheostomy (trach) care. Review of all progress notes from 06/07/25 through 08/07/25 revealed no mention of the presence of maggots around the trach ties or trach stoma or of any unusual substance noted around the trach and surrounding area. Review of the assessments titled Respiratory Assessment/Vent Check completed on 07/17/25 at 7:26 A.M., 9:00 A.M., 10:36 A.M., and 2:15 P.M. revealed no mention of any unusual assessment criteria or occurrences related to Resident #4's trach or surrounding area from the previous shift (night shift on 07/16/25). There was no respiratory therapist on duty on night shifts to record assessments on the Respiratory Assessment/Vent Check form. Telephone interview on 08/07/25 at 12:59 P.M. with the Ombudsman confirmed allegations were received from two separate sources on 07/24/25 of improper care of a resident's tracheostomy (trach). The first source was anonymous and did not provide the name of the resident but included three photos which appeared to be maggots around a trach collar. The second source revealed they had been sent or shown pictures of Resident #4 with maggots around his trach ties. The Ombudsman further revealed an in-person visit was made to the facility on [DATE] where it was confirmed the facility had been informed of maggots being noted near Resident #4's trach between the night of 07/16/25 and the morning of 07/17/25 (a Wednesday night to Thursday morning shift) and the facility had not filed a SRI with the Ohio Department of Health. During the on-site visit, the Ombudsman further found that the window to Resident #4's room had no screen at the time of the incident, and staff reported a wasp had previously been observed entering that window. Review of the facility incident log from 06/01/25 through 08/07/25 revealed no incidents or unusual occurrences were logged regarding trach care for Resident #4. Interview on 08/07/25 at 2:11 P.M. with the Licensed Nursing Home Administrator (LNHA) confirmed being alerted by the previous Director of Nursing (DON) #399 on the morning of 07/17/25 that there were some maggots noted on Resident #4 but that she had not seen them and did not see the picture of the maggots until shown by the Ombudsman on 07/24/25. During the interview, the LNHA confirmed the facility had not filed a SRI until after the Ombudsman was at the facility on 07/24/25. The LNHA confirmed a witness statement was never obtained from the nurse who initially discovered and reported the maggots, Licensed Practical Nurse (LPN) #325, and that previous DON #399 failed to do a proper investigation before employment ended at the facility. Review of the nursing scheduled from 07/15/25 through 07/17/25 confirmed LPN #325 worked the 7:00 P.M. to 7:00 A.M. shift on 07/15/25, 07/16/25, 07/19/25, and 07/20/25. Further review of the nursing schedules revealed a total of two nurses, Registered Nurse (RN) #337 and LPN#325) and six Certified Nurse Aides (CNAs #302, #326, #340, #375, #379, and #383) worked nightshift on 07/16/25. Review of the SRI investigation revealed only three witness statements, including an undated statement from LPN #366 who was not on duty the night of the alleged incident but noted an unsuccessful attempt to contact LPN #325, a statement from respiratory Therapist (RT) #385, who was not on duty on 07/16/25 or 07/17/25 and had not observed or include knowledge of any maggots, and a third statement, also written by LPN #366, detailing an interview conducted with LPN #321, who was on duty for day shift on 07/17/25. There was no witness statements obtained from any staff scheduled from 7:00 P.M. on 07/16/25 to 7:00 A.M. on 07/17/25 and no notes indicating attempts were made to contact any of the scheduled staff except LPN #325 (no date, time, or details were documented). The investigation included no mention of maggots and no mention of Resident #4's room missing a screen and what facility follow-up was regarding the screen. Additionally, there was no evidence Resident #23 had a comprehensive assessment or that any other resident had been interviewed or their skin was assessed for excess moisture or the presence of maggots. Telephone interview on 08/11/25 at 5:06 P.M. with LPN #366 confirmed the investigative role involved talking with RT #385 and nurses, assisting with nursing re-education, and policy reviews. LPN #366 further confirmed the current DON performed a head-to-toe assessment on Resident #4 after the facility filed the SRI. According to LPN #366, nursing in-services that were marked as reviewed over the phone included nurses being provided copies of the policies when they returned to the facility for their shifts and did not include a return demonstration of trach care and suctioning. During the interview, LPN #366 confirmed there were other interviews she conducted, other than the one nurse (LPN #321) and RT #385. Interview on 08/11/25 at 5:40 P.M. with the LNHA confirmed the information in the folder provided to the surveyor to be reviewed on site was the complete investigation conducted by the facility, including all witness statements. During the interview, the LNHA confirmed both trach residents were checked, but the LNHA verbalized uncertainty as to whether a full assessment was completed and documented of any like residents (other resident(s) with a trach) or any other resident susceptible to altered skin integrity. Interview on 08/12/25 at 10:10 A.M. with Maintenance #362 confirmed the facility installed new windows in March 2025, and Resident #4 did not have a screen prior to the incident with the maggots around his trach on 07/17/25. Review of the purchase order for Quality Glass & Mirror, Incorporated, revealed an order was placed for two window screens measuring approximately 29.5 inches by 17 5/16 inches on 07/18/25 and a receipt for the total price charged for the two screens dated 07/28/25. Review of the undated procedure titled Incidents Requiring Immediate Notification revealed facility incident reports were crucial for documenting the event and facilitating investigations. Further review of the procedure revealed all relevant details about the incident, witnesses, and actions taken were considered essential documentation. This deficiency represents noncompliance investigated under Incident Number 2579881 and Complaint Number 2579936.

Based on observation, record review and interviews, the facility failed to provide adequate supervision to prevent exit seeking behavior and elopement for Resident #40 and a fall for Resident #11. This affected two (Residents #11 and #40) of two residents reviewed for accident hazards. The facility census was 51. Findings include: 1. Review of the medical record for Resident #40 revealed an admitted [DATE] with diagnosis including late onset Alzheimer's Disease, dementia, anxiety and depression. Her medical record contained a photograph so that she was identifiable to staff. Review of the Admission Elopement assessment dated [DATE] revealed Resident #40 was mobile and had unsafe wandering prior to coming to the facility. Review of the Elopement assessment dated [DATE] revealed Resident #40 was at risk for elopement due to being cognitively impaired, making poor decisions, exit seeking and having a history of an actual elopement or unsafe wandering. Review of the physician's orders dated 03/04/24 revealed Resident #40 had a wander guard (a device that an at-risk resident wears which alerts caregivers when the resident has wandered from the protected and secured zone) to her right ankle. The staff were to check placement and function every shift. Review of the Treatment Administration Record (TAR) for March 2024 and April 2024 for Resident #40 revealed staff were checking placement of her wander guard and it was in place on her right ankle. Review of Resident #40's care plan dated 03/04/24 revealed she was an elopement risk and wanderer related to dementia, being disoriented to place, history of attempts to leave the facility unattended and impaired safety awareness. The care plan stated she wandered aimlessly. Interventions included checking the wander guard placement every shift, identifying patterns of wandering and intervene as appropriate. Review of the nursing progress note dated 03/04/24 at 4:09 P.M. revealed while Resident #40 was at home, her family had become aware that she had symptoms of dementia as she had gotten out of her home and fell and broke her wrist. It was noted on 03/06/24, 03/23/24, 03/24/24 and 03/25/24 that Resident #40 was exit seeking and wandering, however, the facility staff were able to redirect her and keep her from exiting the building. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #40 had impaired cognition. She had wandered one to three days on this assessment and had delusions. Review of the nursing progress note on 03/26/24 at 2:52 P.M. revealed that approximately 1:30 P.M. Resident #40 pushed another resident out the front door of the facility. An STNA noted the residents outside the front door and both residents were brought back into the facility. An additional nursing progress note on 04/14/24 at 6:05 P.M. revealed Resident #40 had her wander guard on and alarmed the front door of the facility attempting to exit the building. However, a nurse had intervened before she was able to leave. She was observed to be pacing in the hallways and pushing on the doors to leave the facility. Review of the facility elopement investigation for 03/26/24 at 1:30 P.M. for Resident #40 revealed she had escorted another resident outside by pushing her in her wheelchair. State tested Nurse Aide (STNA) #209's witness statement dated 03/26/24 revealed at 1:30 P.M. she was going to her car to get her lunch when she saw two residents (Residents #11 and #40) outside the facility doors. She stated one resident (Resident #11) was out of her wheelchair and on her knees. She stated she got assistance from another nurse and was able to bring both residents back in the building. Resident #40 was placed on 15 minutes checks from 03/26/24 through 03/28/24. Review of the facility elopement investigation for Resident #40 on 04/09/24 revealed she had gone to the front of the facility and was attempting to push open the doors to leave. Resident #40 then went to the back of the facility to the door where the generator was located. She pushed on the door, and it alarmed and opened after 15 seconds. The facility staff heard the alarm, called a code [NAME] (elopement code) and went to the door that alarmed as well as around the front of the building where Resident #40 was located in the parking lot. Resident #40 was redirected and brought back into the building. She was placed on 1:1 supervision at that time until 04/10/24 and then 15 minutes checks were initiated. Interview on 04/15/24 at 7:23 A.M. with Resident #40 revealed she was confused and was unable to understand the questions this surveyor asked. She was observed to have a wander guard to her right ankle. Interview on 04/15/24 at 10:27 A.M. with Licensed Practical Nurse (LPN) #204 revealed Resident #40 had been ambulating independently on 04/09/24 and seen by an aide who thought the resident was going to her room. She stated one minute later, the generator door alarm sounded, and the aide called a code brown and then went to the generator door. LPN #204 stated staff went to the parking lot where Resident #40 was located and redirected her inside. She stated Resident #40 exited on 04/09/24 at 3:52 P.M. and the staff were able to redirect her though it did take seven minutes due to the resident not wishing to return to the building. Interview on 04/15/24 at 10:40 A.M. with the Maintenance Director #207 revealed on 04/09/24 he had heard the code brown and he went out the front of the facility and observed Resident #40 in the parking lot. He stated she was only in the parking lot 30 seconds before he reached her. Interview on 04/15/24 at 11:16 A.M. with the Director of Nursing (DON) revealed on 03/26/24 Receptionist #206 was at the front desk, had put the code in and opened the door for Resident #11 and Resident #40 for them to leave the facility. The DON stated Receptionist #206 did not know that Resident #40 was a resident at the facility and was an elopement risk. He stated she was educated and 15-minute checks on Resident #40 were initiated. Interview on 04/15/24 at 11:29 A.M. with STNA #209 revealed she was going to lunch on 03/26/24 at 1:30 P.M. when she observed Residents #11 and #40 outside of the facility. She stated both residents were outside by the facility doors. She updated the nurse and went to assist both residents. STNA #209 stated she was also working on 04/09/24 when Resident #40 went out the generator door and staff called a code brown and went immediately to both the generator door and front doors where Resident #40 was located in the parking lot. Interview on 04/15/24 at 11:40 A.M. with Receptionist #206 revealed she had been at the front entrance on 03/26/24 and saw Resident #40 pushing Resident #11 in her wheelchair and believed that Resident #40 was a family member and not a resident. She stated Resident #40 was new to the facility and she did not recognize her. She stated she placed the code in so that the doors would unlock and both residents would be able to exit the building. Receptionist #206 stated an STNA came to the front to leave for lunch and noted both residents outside. She stated the aide was able to redirect them back into the building. Interview and observation on 04/15/24 at 12:05 P.M. with the Maintenance Director #207 revealed a video on his phone dated 03/26/24 at 1:32 P.M. of Resident #40 pushing Resident #11 in her wheelchair. Receptionist #206 placed the door code and allowed both residents to exit the facility. Receptionist #206 then was observed walking away from the front doors at 1:33 P.M. At 1:34 P.M. STNA #205 was seen to be walking in the common area and over to the main doors when she witnessed both residents outside the door. She then called for assistance and went outside with the residents. He was unable to provide a copy of the video file. Interview on 04/16/24 at 8:33 A.M. with the Administrator revealed Resident #40 attempted to exit the building for a third time on 04/14/24 at 5:59 P.M. but the nurse on duty intervened and was able to redirect her. Interview and observation on 04/16/24 at 9:18 A.M. with Maintenance Director #207 revealed Resident #40 was seen on 04/14/24 at 5:58 P.M. pushing on the main entrance doors waiting for the 15 seconds for the door to open. At 5:59 the door open and Resident #40 was seen exiting through the first set of doors, however, the nurse on duty was seen running to the resident before the second set of doors were opened. He was unable to provide a copy of the video file. Review of the facility policy titled, Elopements and Wandering Residents, last reviewed/revised on 02/02/21, revealed the facility would ensure residents who exhibit wandering behavior or are a risk for elopement receive adequate supervision. 2. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including Huntington's Disease (disorder that causes nerve cells in parts of the brain to gradually break down and die), schizoaffective disorder, dementia and depression. Review of the elopement assessment dated [DATE] for Resident #11 revealed resident was at risk for elopement. She was cognitively impaired with poor decision-making skills. Resident #11 had a history of elopement or unsafe wandering. Resident #11 had no other elopement assessments in her chart from 06/06/22 until 04/10/24. Review of Resident #11's physician's orders revealed an order dated 12/27/23 for a wander guard to be on the left ankle. Staff were to check placement and function every shift. Review of the TAR for March 2023 and April 2023 for Resident #11 revealed staff ensured the wander guard was on her left ankle and functioning. Review of the care plan dated 03/04/24 and last updated on 04/10/24 revealed Resident #11 was an elopement risk related to dementia, disoriented to place, history of attempts to leave the facility unattended and impaired safety awareness. It was noted that she wandered aimlessly. Interventions included checking for wander guard placement each shift, to identify pattern of wandering and to intervene as appropriate. Review of the nursing progress note dated 03/26/24 at 1:45 P.M. revealed Resident #11 was pushed outside the door in her wheelchair by another resident. Review of the facility elopement investigation for 03/26/24 for Residents #11 and #40 at 1:30 P.M. revealed Resident #40 escorted Resident #11 outside by pushing her in her wheelchair. STNA #209's witness statement dated 03/26/24 revealed at 1:30 P.M. she was going to her car to get her lunch when she saw two residents (Residents #11 and #40) outside the facility doors. She stated one resident (Resident #11) was out of her wheelchair and on her knees. She stated she got assistance from another nurse and was able to bring both residents back into the building. Interview on 04/15/24 at 11:16 A.M. with the DON revealed on 03/26/24 Receptionist #206 was at the front desk, had put the code in and opened the door for Resident #11 and Resident #40 for them to leave the facility. The DON stated Receptionist #206 did not know that Resident #40 was a resident at the facility and believed she was a family member of Resident #11. Interview on 04/15/24 at 11:29 A.M. with STNA #209 revealed she was going to lunch on 03/26/24 at 1:30 P.M. when she observed Residents #11 and #40 outside of the facility. She stated both residents were outside by the facility doors. She updated the nurse and went to assist both residents. Interview on 04/15/24 at 11:40 A.M. with Receptionist #206 revealed she had been at the front entrance on 03/26/24 and saw Resident #40 pushing Resident #11 in her wheelchair and believed that Resident #40 was a family member and not a resident. She stated Resident #40 was new to the facility and she did not recognize her. She stated she placed the code in so that the doors would unlock and both residents were able to exit the building. Receptionist #206 stated an STNA came to the front to leave for lunch and noted both residents outside. She stated the aide was able to redirect them back into the building. Interview and observation on 04/15/24 at 12:05 P.M. with the Maintenance Director #207 revealed a video on his phone dated 03/26/24 at 1:32 P.M. of Resident #40 pushing Resident #11 in her wheelchair. Receptionist #206 placed the door code and allowed both residents to exit the facility. Receptionist #206 then was observed walking away from the front doors at 1:33 P.M. At 1:34 P.M. STNA #205 was seen to be walking in the common area and over to the main doors when she witnessed both residents outside the door. She then called for assistance and went outside with the residents. He was unable to provide a copy of the video file. Review of the facility policy titled, Elopements and Wandering Residents, last reviewed/revised on 02/02/21, revealed the facility would ensure residents who exhibit wandering behavior or are a risk for elopement receive adequate supervision. This deficiency represents non-compliance investigated under Complaint Number OH00152322.

Based on observation, medical record review, review of a Self-Reported Incident (SRI), review of witness statements, resident interviews, staff interviews, review of the police report, review of facility fall incident reports, and review of the facility polices for Behavioral Health Services, Unmanageable Residents and Behavioral, Assessment, Intervention and Monitoring, the facility failed to ensure Resident #203, who had a history of behaviors, was provided an effective and individualized plan of care to address how staff would provide care and treatment safely and/or interventions to address behaviors when the resident was displaying behaviors. This resulted in Actual Harm on 07/01/23 at approximately 9:00 P.M., when Resident #203 sustained an acute, nondisplaced humeral fracture during care by State tested Nursing Assistant (STNA) #515. While STNA #515 was providing personal care, Resident #203 exhibited signs of agitation, aggression, and combative behaviors, however the STNA failed to address the behaviors, failed to stop providing care and reproach and/or provide care in a safe and non-threatening manner. As the STNA continued to provide care, Resident #203 was yelling out expletive words and stop that hurts. The STNA failed to stop until care was completed. This affected one Resident (#203) of three residents reviewed. The facility census was 54. Findings include: Review of the medical record for Resident #203 revealed an admitted [DATE]. Diagnoses included infection and inflammatory reaction due to internal left knee prosthesis, type II diabetes mellitus with stage III chronic kidney disease, methicillin resistant staphylococcus aureus, catatonic schizophrenia, and schizoaffective disorder. Review of Resident #203's care plan initiated on 01/13/23 revealed she required one to two staff for care due to frequent behaviors such as yelling out, swearing, swatting at staff, kicks at staff, kicks at bed and wall. The plan of care did not provide parameters for which situations required two staff for care. Resident #203's care plan did not identify all targeted behaviors when the resident became combative with care, there were no person-centered interventions to provide safeguards for the resident when displaying combative behaviors or to identify interventions for staff to utilize to ensure resident and staff safety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #203 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) section of the MDS revealed the resident required extensive assist of two staff for bed mobility, dressing total dependence of two staff for transfer, toileting, personal hygiene, bathing, total dependence of one staff for locomotion on unit, and supervision of one for eating. Resident #203 was noted to be incontinent of bladder and frequently incontinent of bowel. Resident #203 was assessed to be short tempered and easily annoyed almost daily and exhibited physical and verbal behaviors one to three days of the review period. Review of Behavior Symptom monitoring from 06/08/23 to 07/07/23 for Resident #203 revealed she was being monitored for behaviors daily. Resident #203 was noted to exhibit daily behaviors including yelling, kicking/hitting, grabbing, biting, abusive language, threatening behavior, and rejection of care. Review of the nurse progress note dated 07/01/23 at 9:24 P.M., revealed Registered Nurse (RN) #549 was outside of Resident #203's room when she heard the resident yelling. RN #549 approached Resident #203 and asked what wrong and Resident #203 stated her left arm was hurting. RN #549 asked for clarification on where exactly her arm was hurting. Resident #203 stated, the whole arm, and then clarified it was the elbow. No redness, swelling, bruising or obvious deformity noted at time of assessment. Medical Doctor (MD) #570 was notified of new onset of pain. An as needed (PRN) analgesic was administered, and guardian was notified. Review of radiology report dated 07/02/23, performed at 12:26 P.M. and reported at 12:50 P.M., for Resident #203 revealed an acute, transverse, nondisplaced epicondylar fracture of the distal humerus. The proximal radius and ulna appeared intake. No significant joint effusion. Mild soft tissue swelling. Severe atherosclerosis. Review of the facility SRI dated 07/02/23 and timed 5:04 P.M., revealed the facility noted an injury of unknown injury related to resident complaining of pain, which was not normal for Resident #203. Resident #203's x-ray results revealed a to a distal humerus fracture. The facility unsubstantiated any evidence of abuse. Review of the witness statement provided by Assistant Director of Nursing (ADON) #573 revealed she called LPN #574, and she was in Resident #203's room at the time. ADON #573 requested to speak with Resident #203 and LPN #574 held the phone for Resident #203. ADON #573 asked Resident #203 if she was able to tell her what happened to her arm. Resident #203 stated, it hurt. ADON #573 proceeded to ask her when it began hurting and Resident #203 stated late last night and further stated STNA #515 (identified by name) pulled on it. ADON #573 asked Resident #203 what STNA #515 was doing and Resident #203 stated, she was changing me. ADON #573 asked Resident #203 if another staff was present and Resident #203 stated, she was alone. Review of witness statement dated 07/02/23 from STNA #515 revealed while she was changing Resident #203, she began reaching back and hitting her. STNA #515 stated she asked Resident #203 to stop, and it got worse and when STNA #515 pulled Resident #203 towards her to untuck her brief from the other side, Resident #203 grabbed her right arm and scratched her. Resident #203 continued to kick and swing and hit STNA #515 as she pulled her up in the bed. As STNA #515 was leaving the room, Resident #203 was telling her to (expletive word) off, (expletive word)! and called her (expletive word)! STNA #515 stated she knew nothing about Resident #203's arm or her having pain until STNA #536 asked her what happened because RN #549 has asked STNA #536 about what happened. STNA #515 stated RN #549 did not ask her what happened. Review of police report #22307007 dated 07/02/23 timed at 7:43 P.M., for Resident #203 revealed Police Officer (PO) #571 was dispatched to the local hospital due to RN #571 reporting Resident #203 stated STNA #515 pulled her arm out of place while she was changing her at Regency Care of [NAME] (which is now called Tranquility of [NAME]). There was no mention of Resident #203 having stated she had a fall. Based on the police investigation, nothing criminal was identified. The alleged perpetrator reported having to hold Resident #203 down to finish care, but no further description was described. Interview on 07/05/23 at 2:40 P.M., with RN #549 revealed on 07/01/23 at around 9:00 P.M., State tested Nurse Aide (STNA) #515 went into Resident #203's room to provide care. Resident #203 yelled out, Stop you (expletive word)!. RN #549 stated she was passing medications and since Resident #203 yells out frequently during care she did not think it necessarily unusual. RN #549 continued to pass medications and then heard Resident #203 yell out in pain again, It hurts you, (expletive word). RN #549 stated she went in to investigate since Resident #203 does not usually yell out in pain. Resident #203 stated her entire left arm hurt. RN #549 lightly touched different points on Resident #203's arm but did not see any visible bruising or obvious deformity. Resident #203 stated her left elbow hurt and agreed to take pain medication. RN #549 contacted MD #570 and obtained an order for a STAT x-ray. RN #549 confirmed she was not aware of any other staff in the room with Resident #203 other than STNA #515. RN #549 stated Resident #203 was a two-person transfer and one to two staff for care due to the resident's history of combativeness. RN #549 confirmed she did not ask Resident #203 what happened and did not ask staff for witness statements. Interview on 07/05/23 at 3:29 P.M., with STNA #530 revealed on 07/02/23 around 7:10 A.M. she entered Resident # 203's room with STNA #531 to provide care for both Resident #203 and #204. While STNA #530 was washing Resident #203's face, she moved the pillow by Resident #203's left arm and she immediately screamed out that her left arm hurt. STNA #530 stated she noticed a small bruise just above the left elbow. STNA #530 asked Resident #203 what happened and Resident #203 screamed the name, STNA #515 (identified by name). STNA #530 asked Resident #203 about what happened, Resident #203 stated, STNA #515 (identified by name) yanked on my arm. STNA #530 went to go get Licensed Practical Nurse (LPN) #574. LPN #574 stated she was aware of the order for the x-ray and proceeded to evaluate her and stated she was waiting for the x-ray to be completed. STNA #530 stated she and STNA #531 finished changing the resident and kept her in bed and did not move her. STNA #530 stated she asked Resident #203's roommate (Resident #204) about what happened and Resident #204 stated staff had been aggressive with Resident #203 but she was not able to see because the curtain was pulled. After lunch the x-ray revealed a fracture and LPN #574 notified the Director of Nursing (DON). Interview on 07/05/23 at 4:40 P.M., with STNA #531 revealed on 07/02/23 around 7:00 A.M. she was in changing Resident #204 while STNA #530 was assisting Resident #203. When STNA #530 removed the pillow from underneath her left arm, Resident #203 cried out in pain. STNA #530 asked for assistance from STNA #531 and when they rolled Resident #203 over to change her, she again cried out in pain. After STNA #530 and #531 finished cleaning her up, they asked her what happened and Resident #203 replied, STNA #515 (identified by name). When STNA #530 and #531 asked Resident #203 about what happened she stated, she yanked my left arm. Resident #203's roommate (Resident #204) stated she heard night shift being rough with Resident #203. Initially, Resident #204 stated it was just STNA #515 in the room but then later stated, them but was unsure if another staff member was in the room since the curtain was pulled. Resident #204 stated she heard Resident #203 tell staff, Stop! You are hurting me! STNA #530 and #531 told LPN #574 and she proceeded to assess the resident. A telephone interview on 07/05/23 at 5:05 P.M., with STNA #515 revealed she went in to assist Resident #204 (Resident #203's roommate) to get her up to smoke around 9:00 P.M. on 07/01/23. RN #549 was in the room passing medications to Resident #203 and RN #549 told STNA #515 Resident #203 had removed her brief. After STNA #515 finished with Resident #204, she proceeded to assist Resident #203. STNA #515 stated she got supplies to clean Resident #203 up and proceeded to roll Resident #203 onto her right arm towards the wall to clean her up. Resident #203 began swinging at her. STNA #515 stated Resident #203 hit her (STNA #515) in the face and scratched her right arm. STNA #515 stated she finished changing Resident #203 and left the room. STNA #515 stated RN #549 did not ask her what happened, but asked STNA #536 about what happened with Resident #203. Around 11:00 P.M., STNA #515 stated she was sitting at the nurses' station with STNA #536, and STNA #537 and saw an order for an x-ray for Resident #203. STNA #537 asked RN #549 why Resident #203 needed an x-ray and RN #549 stated Resident #203 was complaining of pain to her left arm, but was not accusing STNA #515 of foul play and just wanted to be safe. STNA #515 stated she received a call from Police Officer (PO) #571 on 07/02/23, who informed her of Resident #203's left elbow fracture. STNA #515 stated PO #571 told her Resident #203 stated she fell out of bed and that was how she injured her arm. STNA #515 stated Resident #203 did not fall out of bed while she was working with her on 07/01/23 and had not mentioned a fall to her during her shift. Interview on 07/05/23 at 5:29 P.M., with Resident #204, the roommate of Resident #203, revealed she was in the room when STNA #515 was providing care to Resident #203. The curtain was pulled, and she heard Resident #203 scream loudly, which was sometimes normal, but this time was very different. Resident #204 stated it sounded like extreme pain. Resident #203 stated to STNA #515, You are hurting me, you (expletive words)! and said it multiple times. Resident #204 stated STNA #515 continued to provide care. Resident #204 stated STNA #515 said, Shut up, we're not hurting you. When asked if there was another staff member in the room, Resident #204 stated she was unsure because the curtain was pulled. Interview on 07/06/23 at 6:35 A.M., with STNA #519 revealed she asked Resident #203 what happened during the night shift of 07/01/23. Resident #203 stated she didn't want to say. Resident #204 (Resident #203's roommate) stated she was asleep and woke up to them fighting. She stated STNA #515 was arguing with Resident #203 and was holding Resident #203's arms and Resident #203 began screaming loudly. Resident #203 stated Resident #203 yelled out in pain. Resident #204 stated she could see STNA #515 from her bed because of the mirror on the opposite of the room across from her bed even though the curtain was pulled. Interview on 07/06/23 at 9:25 A.M., with the Director of Nursing (DON) revealed he became aware of this incident on 07/02/23 at around 2:00 A.M., when he read a text from RN #549 which stated Resident #203 was having pain and had been combative while care was being provided by STNA #515. The DON revealed Resident #203 was combative with care at times but does not cry out in pain frequently. On 07/02/23, an x-ray for Resident #203 was obtained and based on those results, she was sent out to the hospital for further evaluations. The DON stated around 5:00 P.M. on 07/02/23, the facility opened a self-reported incident (SRI), and they obtained witness statements from the staff. The DON stated he was not aware of any previous concerns related to STNA #515 and did not believe abuse had occurred. The DON stated STNA #515 told him Resident #203 had fallen a few days earlier, but he was not aware of any fall incidents prior to the injury noted on 07/01/23. The DON confirmed there was not a fall incident listed on the facility incident report around the time of the incident nor over the past month involving Resident #204. Review of the facility fall incident reports revealed Resident #203 had not had a documented fall in the past 30 days. Interview on 07/06/23 at 11:03 A.M., with Resident #203 revealed on 07/01/23 during the evening shift, STNA #515 was changing her brief and pulled on her arm and it hurt. Resident #203 confirmed this had not happened before. Resident #203 declined to speak further about the incident. Observation at the time of the interview revealed Resident #203 had a flat affect and her was voice was monotone while answering. Follow up interview on 07/06/23 at 1:05 P.M., with Resident #203 revealed falling out of bed was not how she was injured, and she did not want to speak about it further. Observation at the time of the interview with Resident #203 revealed she had a flat affect and she spoke with a monotone voice. Follow up interview on 07/06/23 at 2:25 P.M., with STNA #515 revealed around 9:00 P.M. on 07/01/23 she responded to the call light for Resident #204 to get up to go smoke. RN #549 was already in the room giving Resident #203 her medications and proceeded to tell STNA #515 Resident #203 had removed her brief. After finishing with Resident #204 she proceeded to assist Resident #203. STNA #515 gathered water and a soapy cloth to clean Resident #203 up before putting on her brief. STNA #515 rolled Resident #203 onto her right side towards the wall to clean her bottom. Resident #203 began flailing and hitting her. Resident #203 attempted to hit STNA #515, and she attempted to block her with her own arm and Resident #203 scratched her right arm. Resident #203 then rolled back onto her back. STNA #515 stated she already had the brief underneath her tucked in and was able to pull the tab for the brief out of the other side to fasten the brief. While STNA #515 was fastening the brief, Resident #203 was holding STNA #515's right arm and scratched it. When asked about clarification about the statement given to the police officer, STNA #515 stated she did not tell the police officer she had to hold Resident #203 down to finish her care. STNA #515 stated she raised the foot of Resident #203's bed and used the pad underneath her to pull her up. STNA #203 stated she did not have her hands on Resident #203 when pulling her up and stated she was trying to do it herself. When asked if she should have continued to provide care when Resident #203 became combative, STNA #515 stated What was I supposed to do, leave the resident half-changed? STNA #515 stated she did not know where her partner (the other STNA) or the nurse was. STNA #515 confirmed if a resident becomes combative with care, she was supposed to request other staff to assist, and confirmed she did not yell out for help or text for assistance. STNA #515 stated she looked out in the hallway but did not see anyone, so she proceeded to finish. Phone interview on 07/06/23 at 5:50 P.M., with STNA #536 revealed she did not become aware of the incident with Resident #203 until around 10:00 P.M. when RN #549 asked about why Resident #203 was yelling out. Following being asked, STNA #536 proceeded to enter Resident #203's room and found Resident #203 sleeping with her arms behind her head and left the room. Around 12:30 A.M., STNA #515 came to get STNA #536 to assist with changing Resident #203 because her lower half was hanging off the bed. STNA #536 entered the room after STNA #515, and they proceeded to use the sheets from the bed to hoist Resident #203 back into bed. Once Resident #203 was back in bed, they proceeded to change Resident #203 with no complaints of pain. STNA #536 confirmed Resident #203 was not combative when they changed her. STNA #515 told STNA #536 that Resident #203 had been combative with her around 9:00 P.M. and had scratched her arm. STNA #536 confirmed she did not ask Resident #203 what happened to her left arm and Resident #203 never made comments as to what had occurred. Follow up interview on 07/07/23 at 5:40 A.M., with RN #549 revealed she asked Resident #203 where her arm hurt but did not recall asking her how it happened. RN #549 stated she figured since Resident #203 was sometimes combative with care, she may have gotten hurt while being changed, possibly she had hyper-extended it, if she tried to swing at the aide. After talking with MD #570, he gave an order for a STAT x-ray to be completed. RN #549 stated she requested the x-ray just to be safe but did not think it was potentially abuse and did not start an investigation. RN #549 attempted to place the STAT order for the -x-ray for Resident #203, but her sign in for the x-ray company did not work. RN #549 stated she called Assistant Director of Nursing (ADON) #573 at 9:15 P.M. and the DON at 9:20 P.M. and informed them Resident #203 had complained of pain and MD #570 had requested a STAT x-ray and she was unable to place the order. ADON #573 asked RN #549 to call LPN #576 to place the order, but she was also unable to complete the order for the x-ray, so she called ADON #573 again around 10:00 P.M. RN #549 finished her med pass around 11:30 P.M.-12:00 A.M. and had still not heard back from ADON #573 or the DON, so she called the mobile x-ray company, and they were able to place the order for Resident #203. The x-ray company had not come when she left at 7:15 A.M. on 07/02/23. RN #549 stated she was told she did not have to write a witness statement because she had already written the nursing progress note. RN #549 confirmed STNA #515 finished her shift as scheduled on 07/01/23. RN #549 stated if she suspected potential abuse, she would separate the employee from the resident and ask the employee to leave immediately, report the incident to the DON, start an investigation immediately and obtain witness statements from all the employees involved and residents, since there is only two hours to report it to the state. Interview on 07/07/23 at 10:09 A.M., with LPN #574 revealed around 12:55 P.M. she checked Resident #203's arm and lifted it and Resident #203 stated, Ow!. Observation at the time, revealed Resident #203's arm to be more swollen and bluish in color, oblong in shape about two inches by one and a half inches left of the antecubital. While LPN #574 was in Resident #203's room she got a call from ADON #573 who requested to speak with Resident #203. LPN #574 held the phone up to Resident #203's ear and ADON #573 asked what happened to which Resident #203 responded that it happened while being turned in bed while she was being changed. LPN #574 stated no additional questions were asked and no additional information was given by Resident #203. When the x-ray results came back, LPN #574 notified ADON #573 who made the arrangements for the ambulance transfer. Interview on 07/07/23 at 10:42 A.M. with ADON #573 revealed while she was on the phone with Resident #203 on 07/02/23 around 1:00 P.M., Resident #203 responded that she was injured while being turned and stated STNA #515 was helping her. Based on that conversation, ADON #573 stated the facility opened a self-reported incident (for an injury of unknown origin) and began requesting witness statements of anything that may have been out of the ordinary for Resident #203. Phone interview on 07/07/23 at 12:36 P.M., with MD #570 revealed he was informed Resident #203 had probably slammed her elbow into something and thought it from trauma and suspected Resident #203 had osteopenia. Since it was a clean break and not a spiral fracture, he did not suspect abuse. Interview on 07/07/23 at 2:46 P.M., with the Administrator and ADON #573 revealed they were not aware of any disciplinary actions related to STNA #515. The Administrator stated they were not informed by the hospital of any suspected abuse. The police officer showed up at the facility on 07/07/23 at 9:06 P.M. and was referred to the DON. Interview on 07/07/23 at 3:37 P.M., with the DON revealed he spoke on the phone with Police Officer #571 who stated he did not suspect anything related to abuse and stated the nurses at the hospital had stated they did not feel the injury was a result of physical abuse, but stated it was customary to report to the police for investigation. The facility had started the SRI investigation after receiving the x-ray results for Resident #203 and proceeded under injury of unknown origin. Based on the investigation and witness statements, they did not feel there was definitive proof of the cause of Resident #203's fracture. Review of the policy titled Behavioral, Assessment, Intervention and Monitoring revised 2016, revealed interventions and approaches would be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for behavior, targeted and individualized interventions for the behavioral and psychosocial symptoms, rational for the interventions, specific an measurable goals for behaviors and how the staff would monitor for effectiveness of the interventions. Review of the policy titled, Unmanageable Residents dated revised April 2010, revealed should a resident's behavior become abusive, hostile, assaultive, or unmanageable that would jeopardize his or her safety or the safety of other, the Nurse Supervisor/Charge nurse must immediately provide for the safety of all concerns, notify the resident physician, notify the DON, and notify the representative. Review of the policy titled, Behavioral Health Services dated October 01, 2010, revealed non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being. The facility would ensure that necessary behavioral health care services were person-centered and reflect the resident's goal for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Facility staff would implement person-centered care approaches designed to meet the individual goals and needs of each resident which includes non-pharmacological interventions. This deficiency represents non-compliance investigated under Complaint Number OH00144212.

Based on interview, record review, and policy review, the facility failed to timely vaccinate residents for COVID-19 after consents were signed to receive the vaccine. This affected four residents (Resident #19, Resident #29, Resident #33, and Resident #48) out of five unvaccinated residents reviewed for vaccinations. Findings include: 1. Review of Resident #19's medical record revealed an admitted [DATE]. Review of Resident #19's COVID=19 immunization form revealed a consent was signed on 04/29/22 verifying the resident wanted to receive the COVID-19 vaccine. Review of the Resident #19's nursing notes revealed the resident tested positive for COVID-19 on 09/26/22 and was unvaccinated against COVID-19. Interview on 10/06/22 at 10:52 A.M. with Director of Nursing (DON) confirmed Resident #19 did not timely receive COVID-19 vaccinations after consenting to receive the vaccinations. 2. Review of Resident #29's medical record revealed an admitted [DATE]. Review of Resident #29's COVID-19 immunization form revealed a consent was signed on 08/19/22 verifying the resident wanted to receive the COVID-19 vaccine. Review of Resident #29's medical record revealed she never received a COVID-19 vaccination. Interview on 10/06/22 at 10:52 A.M. with DON confirmed Resident #29 did not timely receive COVID-19 vaccinations after consenting to receive the vaccinations. 3. Review of Resident #33's medical record revealed an admitted [DATE]. Review of Resident #33's COVID-19 immunization form revealed a consent was signed on 06/08/22 verifying the resident wanted to receive the COVID-19 vaccine. Review of Resident #33's medical record revealed she received her first COVID-19 vaccine on 06/17/22 but did not receive her second vaccination. Review of Resident #33's nursing notes revealed she tested positive for COVID-19 on 09/26/22 and was not fully vaccinated. Interview on 10/06/22 at 10:52 A.M. with DON confirmed Resident #33 did not timely receive COVID-19 vaccinations after consenting to receive the vaccinations. 4. Review of Resident #48's medical record revealed an admitted [DATE]. Review of Resident #48's COVID-19 immunization form revealed a consent was signed on 02/16/22 verifying the resident wanted to receive the COVID-19 vaccine. Review of the Resident #48's medical record revealed the resident did not receive the first dose of her COVID-19 vaccine until 06/17/22 and did not receive her second vaccination. Interview on 10/06/22 at 10:52 A.M. with DON confirmed Resident #48 did not receive timely COVID-19 vaccinations after consenting to receive the vaccinations. Reviewed of the facility's COVID-19 Vaccination Policy, dated 09/28/22, revealed the interval between the first and second dose should be three to eight weeks. The facility may administer the vaccine directly or through an arrangement with a pharmacy partner or local health department.

Based on observation, interview, medical record review, and policy review, the facility failed to ensure proper infection control was maintained throughout the facility related to COVID-19 and catheter care. This affected 41 of 49 residents residing in the facility as eight residents were identified as COVID-19 positive (Resident #1, #33, #40, #19, #150, #5, #45, #16). Findings include: 1. Review of Resident #150 medical record revealed an admitted [DATE]. Review of Resident #150's October 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/03/22 at 11:54 A.M. revealed State tested Nursing Aide (STNA) #566 walk into Resident #150's room without eye protection, collected trash, removed her gown and gloves, exited the room, and walked down the hall. Upon exiting the room she did not put on a clean N-95 Mask. Interview on 10/03/22 at 11:55 A.M. with STNA #566 confirmed that she did not have eye protection on when entering Resident #150's room, saying that she forgot her goggles up front. She also confirmed she did not put a clean N-95 mask on upon exiting the COVID positive room. Review of the undated facility policy, Transmission-Based (Isolation) Precaution, revealed the category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. Signage that included instructions for use specific PPE will be placed in a conspicuous location outside of the residents room. Regarding Droplet precautions the policy states, based on the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves, a gown as well as goggles or a face shield should be worn. 2. Observation on 10/03/22 until 10/04/22 revealed Resident #150, Resident #19, Resident #1, Resident #33 all had signs outside of their rooms indicating the residents were on contact isolation. The signage stated to clean hands before and after leaving, put gloves on before room entry, discard at exit, and use disposable equipment. Interview on 10/04/22 at 10:05 A.M. with Director of Nursing confirmed Resident #150, Resident #19, Resident #1, Resident #33 were all COVID-19 positive and on droplet isolation. He continued that the wrong signs were in front of their rooms, and verified that the signage does not indicate that mask and eye protection should be worn while taking care of the residents. Review of the undated facility policy, Transmission-Based (Isolation) Precaution, revealed the category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. Signage that included instructions for use specific PPE will be placed in a conspicuous location outside of the residents room. Regarding Droplet precautions the policy states, based on the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves a gown as well as goggles or a face shield should be worn. 3. Observation on 10/03/22 at 2:57 P.M. of the facility laundry room with Maintenance Director # 545 and Laundry Aide #535 revealed the facility did not have gowns available for the laundry staff to wear while doing the facility isolation laundry. Maintenance Director #545 confirmed the gowns were not in the laundry room and he stated he would replace them right away. Interview on 10/03/22 at 3:03 P.M. with Laundry Aide #535 revealed the facility does not always have gowns available to wear while doing isolation laundry. She continued she at times she has to just wear gloves and was careful not to let the isolation laundry touch her as she was placing it in the washing machine. Interview on 10/04/22 at 10:05 A.M. with the Director of Nursing confirmed the facility has had COVID-19 positive residents in the facility since 09/26/22. Review of the facility's policy, Laundry, dated 10/01/22, revealed the facility's laundry area would provide hand washing facilities and products as well as PPE. 4. Review of Resident #39 medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's October 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/05/22 at 8:48 A.M. revealed Resident #39 lying in bed. The resident's catheter and catheter tubing was laying directly on the floor. Observation on 10/05/22 at 11:48 A.M. revealed the residents catheter and tubing was still laying directly on the floor. Interview on 10/05/22 at 11:48 A.M. with the Director of Nursing confirmed Resident #39 catheter and catheter tubing was laying directly on the floor.

Based on interview and observation, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner. This had the potential to affect 47 of the 49 residents, excluding Resident #18 and Resident #39, who received nothing by mouth. Findings included: Observation of the kitchen on 10/03/22 at from 9:30 A.M. to 10:15 A.M. revealed the following: - Dietary Aide #522 was standing inside kitchen by the entrance door with no hairnet on. - The hood above the stove had brown drip spots on the outside of it - The wall behind the stove had numerous amount of brown drip stains on it. - Brown colored stains were noted on the outside of the upper steamer. - In the walk in cooler, there was a plastic canister with strawberry glaze in it that was not dated - There was paper, dirt and debris noted under the main freezer - The counter across from the stove that had a shelve below it was noted to have large bowls, and metal baking sheets and the shelve was noted to have a white colored shelve paper on it that had brown stains, and food crumbs on it. - Observation of the large kitchen mixer showed dried stuck on debris on the inside of the mixing bowel. -There was noted paper, food crumbs, dirt and grease noted on the floor of the kitchen and some areas of the floor were sticky. Interview on 10/03/22 at 9:30 A.M. with Dietary Aide #522 revealed she did take her hairnet off because it was too hot in the kitchen Interview on 10/03/22 at 10:00 A.M. with the Dietary Manager #525 verified the above findings of uncleanliness. He stated he had just got back from vacation and usually these areas were kept clean,

Based on observation, interview, medical record review, and policy review, the facility failed to thorough assess Resident #33's pressure ulcer, notify the physician of the pressure ulcer, and timely initiate wound treatment. This affected one resident (Resident #33) out of two residents reviewed for pressure ulcers. Findings include: Review of Resident #33 medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's Nursing Note, dated 6/30/2022, revealed the nurse was notified of open areas to the residents buttocks. The resident's left buttock area measured 1.6 centimeter (cm) by 1.6 cm and an open area on right buttock measured 0.5 cm x 2.0 cm. The areas were cleaned and cream applied. The note did not indicate the physician or family were notified. Review of Resident #33's June and July 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders included to cleanse the area pat dry, apply zinc, and apply border gauze daily and as needed for wound treatment. Review of Resident #33's first document Wound Assessment sheet, dated 07/06/22, revealed the resident had a stage three pressure ulcer to the resident's coccyx that was acquired on 06/30/22. They were described as being 40 percent (%) granulation and 60% skin. The area measured 4.3 cm (length) by 7.5 cm (width), no depth. The note stated the resident had a recurrent stage three pressure ulcer noted to the resident's bilateral buttocks/coccyx with intervening skin. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment, dated 08/17/22, revealed the resident had impaired cognition and required extensive assistance of two people for bed mobility. Interview on 10/06/22 at 12:40 P.M. with Licensed Practical Nurse #539, who identified herself as the wound nurse, revealed Resident #33 developed a pressure area on 06/30/22. She confirmed the facility did not notify the physician and begin treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated it is facility policy to assess the areas and notify the physician right away to start timely treatment. Review of the facility's undated policy, Pressure Injury Prevention and Management, revealed the attending physician would be notified of the presence of a new a new pressure injury upon identification.

Based on record review, observation, and interview, the facility failed to ensure Resident #18's head was elevated per the physician's order while receiving continuous tube feeding. This affected one resident (Resident #18) of one resident reviewed for enteral feedings. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order dated 03/13/22 revealed she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18 also had a physician's order dated 08/05/22 for the head of the bed to be elevated 30 to 45 degrees when not providing care to prevent aspiration from tube feeding. Review of her care plan dated 03/14/18 revealed Resident #18 required a tube feeding via peg tube related to [CONDITION(S)] and inability to swallow effectively. Interventions included to have the head of the bed elevated 45 degrees during and thirty minutes after tube feeding. Observation on 10/04/22 at 12:53 P.M. with Licensed Practical Nurse (LPN) #565 revealed Resident #18 to be lying flat in bed with a pillow on each side of her. Her bed was not elevated nor did she have a pillow under her head. Resident #18's tube feeding was running at 50 mL per hour (continuously). There were no other staff present in the room providing care. LPN #565 verified Resident #18 was lying flat and she should have had her head elevated between 30 to 45 degrees to prevent aspiration from the tube feeding. Review of the facility policy titled, Care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and facility policy review, the facility failed to ensure expired medications were removed from the medication cart and the medication storage room. This affected one resident (Resident #11) but had the potential to affect all residents residing in the facility. Findings include: Observation and interview on 10/04/22 at 7:46 A.M. with Licensed Practical Nurse (LPN) #536 during the medication administration for Resident #11, revealed she was unable to administer Aspirin 325 milligrams (mg) as it was not available in her medication cart on the Emerald Unit. LPN #536 went to the medication storage room where it was observed that eight of eight bottles of Aspirin 325 mg had the expiration date of August 2022. LPN #536 verified all eight bottles were expired. LPN #536 then went to the medication cart on the Sapphire Unit where LPN #565 verified the bottle of Aspirin 325 mg in her cart had the expiration date of August 2022. There were no other available bottles of Aspirin 325 mg in the facility. Facility policy review titled, Medication Storage, dated 2022, revealed the facility did not follow their policy related to disposing of expired medications.

Based on staff interview, observation, medical record review, and facility policy review, the facility failed to ensure medication error rate was less than five percent. There were 12 medication errors out of 31 opportunities, resulting in a 38.71 percent medication error rate. This affected one Resident (Resident #11) out of six residents reviewed for medication administration. Findings include: Review of the medical record for Resident #11 revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order dated 01/28/21 for Resident #11 revealed nursing was to administer his morning medications after breakfast. He also had physician's orders dated 01/05/21 for [MEDICATION(S)] 100 milligrams (mg) (medication for gout), [MEDICATION(S)] 10 mg (medication for hypertension), [MEDICATION(S)] 2000 units (Vitamin D supplement), [MEDICATION(S)] 50 mg (medication for [CONDITION(S)]), [MEDICATION(S)] Sodium 100 mg (medication for constipation), [MEDICATION(S)] 50,000 units (Vitamin D supplement), [MEDICATION(S)] 40 mg (medication for [CONDITION(S)]), [MEDICATION(S)] Tatrate 25 mg (medication for hypertension), multivitamin, Potassium Chloride extended release 10 milliequivalents (meq) and [MEDICATION(S)] Sodium 40 mg (medication for high cholesterol), all of which were scheduled for 8:00 A.M. Resident #18 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Observation on 10/04/22 at 8:05 A.M. with Licensed Practical Nurse (LPN) #536 of the medication administration to Resident #11 revealed he was in the dining room waiting on breakfast to be served. LPN #536 administered Resident #11's medications including [MEDICATION(S)] mg, [MEDICATION(S)] 100 mg, Vitamin D3 2000 units, [MEDICATION(S)] 50 mg, [MEDICATION(S)] Sodium 100 mg, [MEDICATION(S)] 40 mg, [MEDICATION(S)] [MEDICATION(S)] 25 mg, multi-vitamin, potassium chloride 10 meq, [MEDICATION(S)] 40 mg, Vitamin D3 50,000 units and [MEDICATION(S)] 10 mg. Interview on 10/04/22 at 8:22 A.M. with LPN #536 revealed Resident #11 still had not received breakfast and was waiting in the dining room. She verified the physician's order that Resident #11 was to have his morning medications after he had breakfast. LPN #536 verified she administered his medications prior to him receiving breakfast. Review of the facility policy titled, Medication Administration, dated 2022, revealed nursing staff should review the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review, the facility failed to ensure food was served at appropriate and palatable temperatures. This affected 54 of 56 residents receiving food from the kitchen (Resident #37 and Resident #39 did not receive food from the kitchen). Findings include: Review of the menu spreadsheet for Week 3, Monday corresponding to 03/16/20 revealed a meal of two ounces egg salad with bread, six ounces Italian wedding soup, four ounces cucumber and tomato salad and one square gelatin. Observation of the lunch meal trayline starting on 03/16/20 at 11:37 A.M. revealed Cook #210 conducting temperatures of the foods for service using a self-calibrating thermometer. These foods included egg salad, 39 degrees Fahrenheit (F); cucumber and tomato salad, 39 degrees F; pureed egg salad, 48 degrees F; pureed cucumber and tomato salad, 53 degrees F; and Italian wedding soup, 193 degrees F. Interview with Cook #210 on 03/16/20 at 11:37 A.M. revealed she looked for cold foods to be at a temperature of 40 degrees F or below for service. A test tray was requested for the second meal cart. The second cart was started at 11:56 A.M., the test tray was made at 12:10 P.M., the cart went to the unit at 12:10 P.M. and tray pass started at 12:11 P.M. The tray was sampled with Certified Dietary Manager (CDM) #206 at 12:25 P.M. using the facility's self-calibrating thermometer. Temperatures of the foods present included egg salad, 57 degrees Fahrenheit (F); tomato and cucumber salad, 58 degrees F; soup, 140 degrees F; milk, 44 degrees F and coffee, 109 degrees F. The cucumber and tomato salad tasted lukewarm and the egg salad did not taste chilled. CDM #206 verified she expected cold-held foods to have a temperature of 39 to 40 degrees F and confirmed these foods were not within range at the time of service. Review of undated facility safe food handling materials revealed the temperature danger zone, where bacteria flourished, was between 40 degrees F and 140 degrees F. A food temperature list defined cold holding temperatures for foods as having an internal temperature of 41 degrees F or less. This deficiency substantiates Complaint Number OH 430.

Based on observation, interview and menu review, the facility failed to follow planned menus as written. This affected residents on pureed diets (Residents #19, #20, #41, #55) and residents on mechanical soft diets (Residents #5, #6, #10, #38, #43, #44, #45, #46, #49, #50). Facility census was 56 residents. Findings include: Review of the menu spreadsheet for Week 3, Monday corresponding to 03/16/20 revealed residents receiving a mechanical soft diet were to receive two ounces egg salad with bread, six ounces Italian wedding soup, four ounces seasoned carrots and one square of gelatin. Residents receiving a pureed diet were to receive three ounces pureed egg salad sandwich, six ounces pureed Italian wedding soup, four ounces pureed carrots and one square pureed gelatin. Observation of the lunch meal trayline starting on 03/16/20 at 11:37 A.M. revealed Cook #210 conducting temperatures of the foods for service. These foods included egg salad, cucumber and tomato salad, pureed egg salad, pureed cucumber and tomato salad, Italian wedding soup and gelatin. No carrots or pureed carrots were noticed on the steam table. Residents receiving a mechanical soft diet were observed to not receive a vegetable item for the lunch meal, and residents receiving a pureed diet were observed to receive pudding as their dessert item. Interview on 03/16/20 at 11:44 A.M. with Cook #210 revealed residents on mechanical soft diets could not receive the cucumber and tomato salad and would just receive soup with their egg salad. Interview on 03/16/20 at 12:11 P.M. with Certified Dietary Manager (CDM) #206 verified residents on mechanical soft diets could not have raw vegetables, so they could not have the cucumber and tomato salad on the menu today and required an alternate vegetable to be prepared and served. When asked about the pureed carrots and gelatin not being available, CDM #206 stated some of the dietary staff was newer and did not know how to puree so the pudding was provided instead of the pureed gelatin. CDM #206 verified staff did not follow the menu as written in regards to residents on puree and mechanical soft diets.

Based on record review and interview, the facility failed to ensure Resident #38's medicated eye drops were promptly provided from pharmacy. This affected one of three residents reviewed for medications. Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #38 was alert and oriented and was cognitively intact. He required supervision for activities of daily living. Review of the physcian order dated 06/16/18 revealed Resident #38 was prescribed medicated eye drops, [MED] Solution 0.005%, for [MEDICAL CONDITION]. He was to receive one drop in each eye every night at bedtime. Review of the pharmacy ordering sheet dated 12/02/19 revealed the medication [MED] Solution 0.005% was re-ordered by the nurse. It was re-ordered again on 01/02/20. Review of the January 2020 Medication Administration Record [REDACTED]. The electronic MAR indicated [REDACTED]. Review of the pharmacy docutrack document dated 0[DATE] revealed Licensed Practical Nurse (LPN) #111 notified the pharmacy concerning the eye medication that was re-ordered 01/02/20 and explained that had not yet been delivered. Review of the policy and procedure titled, Guidelines For Medication Orders, dated 06/21/17, revealed chronic (long term) physician orders [REDACTED]. The pharmacy was to continue to dispense these medications as requested or per cycle dispensing schedules. Interview with the Administrator at 2:30 P.M. on 0[DATE] verified Resident #38 did not receive his physician ordered eye drops for three days as the medication was not sent over from the pharmacy. This deficiency substantiates Complaint Number OH 762.

Based on record review and interview the facility failed to provide additional supervision to Resident #33 and Resident #45 following a physical altercation between the residents to prevent an additional altercation from occurring on the same day. This affected two residents (#33 and #45) of four residents reviewed for abuse. Findings include: Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/12/19 revealed the resident's cognition was severely impaired, the resident required supervision with locomotion and walking, did not display physical or behavioral symptoms, and did wander daily. . Resident #33's incident note, dated 11/05/19 at 2:51 P.M. revealed the resident was standing next to Resident #45 and out of no where the resident pushed her body into Resident #33 and Resident #33 toppled to the floor. Resident #33 did not have any injuries or signs of discomfort. Review of a facility Self Reported Incident (SRI), submitted 11/05/19 revealed on 11/05/19 at 9:20 [NAME]M. in the common area on the facility secured behavior unit Resident #45 bumped into Resident #33. The facility investigation related to the SRI included witnesses of the incident that were unable to identify if Resident #45 intentionally pushed Resident #33 or not. Resident #33's and Resident #45's medical records contained no evidence of increased supervision or additional interventions to ensure the resident's safety immediately after the incident. Resident #33's nursing note, dated 11/05/19 revealed the resident was walking around per her usual and stopped near where Resident #45 was sitting in the common area. Resident #45 jumped up, started yelling at her to move, then immediately punched her in the stomach. There was no evidence Resident #33 sustained an injury related to the incident. Review of a facility SRI, submitted 11/05/19, revealed on 11/05/19 at 12:15 P.M. a second physical altercation occurred between Resident #33 and Resident #45. Interview on 12/09/19 at 2:02 P.M. with the Administrator and Director of Nursing (DON) revealed Resident #33 wandered, was nonverbal, had trouble seeing without her glasses and gets in residents' personal space. The DON revealed Resident #45 had development disabilities and psychiatric needs and does not understand that Resident #33 cannot recognize personal space. The Administrator explained after a resident to resident altercation, like on 11/05/19 at 9:20 [NAME]M., the facility would increase supervision of residents by completing 15 minutes checks on the residents. Interview on 12/09/19 3:49 P.M. with the DON revealed the facility did not have evidence of 15 minute checks after the incident between Resident #33 and Resident #45 on 11/05/19 at 9:20 [NAME]M. through the second incident on 11/05/19 at 12:15 P.M. Interview on 12/09/19 at 3:53 P.M. with Assistant Director of Nursing #202 revealed she kept a closer eye on Resident #33 and Resident #45 between the two altercations on 11/05/19, but she could not identify how long she supervised the residents or when she last saw the residents. This deficiency is an incidental finding to Complaint Number OH 559.

Based on observation, interview and review of pest control documentation, the facility failed to maintain a pest free environment. This affected all 58 residents in the facility. Findings include: The kitchen was observed on 10/15/19 at 8:45 [NAME]M. There were small winged flying insects near the dish washing area and around the steam table. Interview with Dietary Manager (DM) #420 on 10/15/19 at 9:00 [NAME]M. said they had a problem with gnats. She said after each meal she puts bleach down the drains and was not able to eliminate the gnats. A subsequent visit to the kitchen on 10/16/19 at 11:00 [NAME]M. revealed gnats were still flying around the kitchen. Interview with Director of Maintenance #104 on 10/16/19 at 2:50 P.M. said they have monthly pest control who treat the kitchen for gnats, and the Dietary Manager also does a bleach treatment after every meal. Review of the pest control service reports indicated the facility was treated for [REDACTED]. It noted to please remove food product to prevent attraction by pests. Standing water was identified in the kitchen. This could provide a breeding site for flies. Standing water should be eliminated. On 05/22/19, the kitchen had the same recommendations as 04/29/19. The severity was medium. The drains were treated for [REDACTED]. Please remove the debris to unblock the drain and prevent attraction by pests. Mop sink. An accumulation of food product in grout lines from damaged goods noted. Please remove food product to prevent attraction by pests. Standing water in the kitchen could provide a breeding site for flies. Eliminate standing water. On 08/29/19, they treated all floor drains, conducted a thorough inspection and made recommendations to staff. On 09/18/19, a high severity of an accumulation of food product from damaged goods was noted. Please remove food product to prevent attraction by pests. A water leak/standing water was inside the kitchen. The recommendation was to please remove water and repair the leak to prevent unsanitary conditions and attraction by pests, debris or other material in the drain was causing a blockage. Please remove debris to unblock the drain and prevent attraction by pests.

Based on staff interview, review of personnel files and the abuse policy and procedure, the facility failed to implement policies and procedures including screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. This affected four (Housekeeping Staff #60, #62 and #63 and Dietary Aide #61) of personnel files reviewed. This had the potential to affect all 58 residents in the facility resulting in substandard quality care. Findings include: Review of 12 personnel files revealed four staff were not checked against the State of Ohio Nurse Aide Registry. Review of three Housekeeping Staff (#60, #62 and #63) and Dietary Aide #61 lacked evidence they were screened against the State of Ohio Nurse Aide Registry for negative findings. State tested Nurse Aides (STNA) #64, #65 and #66, Registered Nurses (RN) #67 and #71 and Licensed Practical Nurses (LPN) #68, #69 and #70 had evidence they were screened on the State of Ohio Nurse Aide Registry and were in good standing. The identification of findings would be necessary to determine if any employee had actions identified that would validate allegations of abuse, neglect, exploitation, mistreatment of [REDACTED]. The facility provided a document that they hired 52 staff since the last annual survey dated 09/20/19. Twelve of the new hires were not nurses, aides, therapy or activity staff and had no evidence they were screened against the State of Ohio Nurse Aide Registry. Interview with the Business Office Manager (BOM) #420 on 10/16/19 at 8:50 [NAME]M. indicated only the nurses and aides had been checked. Interview with the Administrator on 10/16/19 at 9:10 [NAME]M. said the Ohio Department of Health Abuse Investigator came out and told him he had to check all staff against the State of Ohio Nurse Aide Registry. Interview with the Corporate Nurse on 10/16/19 at 10:26 [NAME]M. provided evidence the facility screened all activity, housekeeping, laundry and dietary staff today against the State of Ohio Nurse Aide Registry. Interview with BOM #420 on 10/16/19 at 10:41 [NAME]M. verified activity, housekeeping, dietary and laundry staff had not been screened against the State of Ohio Nurse Aide Registry until this morning. Review of the Ohio Resident Abuse Policy dated 03/03/17 identified screening to include not employing individuals who had a finding of abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property reported into a state nurse aide registry.

Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary kitchen. This affected all residents who take food by mouth. The facility census was 58. Findings include: The initial tour of the kitchen was conducted with the Dietary Manager (DM) #404 on 10/15/19 at 8:45 [NAME]M. The DM #404 verified the following: the walk in cooler had a container the DM #404 identified as containing coleslaw and another with vegetables that was not labeled or dated. A milk carton and dried spilled milk was on the floor in the walk in cooler. A cup was stored in a container the DM #404 identified as thickener. The large stand mixer was heavily splattered with a dried beige substance on the splash guard, turning mechanism and outside of the bowl. The whish attachment stored in the bowl also had areas of dried food debris. Two Vulcan ovens were heavily rusted on the outside. There was a moderate amount of food debris on the floor of the oven. The back covers were stained and had oily drips over the flat top. The space between the flat top and the burners had black charred food debris. The wall behind the ovens had a moderate amount of grease. Three tiered carts were observed to transport food from one area to the other and were soiled with food debris. The floor and wall in the dish washing area was heavily soiled with thick scum. Interview with DM #404 on 10/15/19 at 9:00 [NAME]M. verified the above observations. She said the dietary aides were responsible for cleaning and labeling items. Tray line temperatures were observed on 10/16/19 at 7:25 [NAME]M. by Dietary Aide (DA) #421. She took a probe thermometer out of the sheath and put it into oatmeal. She began looking around for a wipe. There were alcohol wipes on the shelf next to her. She looked over the alcohol wipes and said she does not want to use them. She got a white towel and wiped the probe of the thermometer. She tested cream of wheat, egg patty, sausage patties, puree eggs and pureed muffins and wiped off the probe with the dish towel after each food item. After the food temperatures were taken the tray line began. There was a tray of coffee in mugs with lids. There was an excess amount of spilled coffee on the tray and some on the plastic lids. Each cup that was put on a food tray splashed coffee on the meal tray and onto the clean napkins. On 10/16/19 at 11:00 [NAME]M., DA #421 was observed to puree foods. The DM #404 had to direct her to change her gloves and wash her hands prior to hand tearing food to place in the food processor. At the end of the process, after DA #421 tore food, poured milk out of a gallon jug, operated the food processor and stirred the mixture, she used her soiled gloved finger to scrape food from the rubber spatula into the steam table pan. During a test tray on 10/16/19 at 12:04 P.M., DM #404 was observed to use an alcohol swab to cleanse the probe of the thermometer. Interview with DM #404 on 10/16/19 at 12:04 P.M. verified the probe thermometer should be cleansed with an alcohol swab after each food item. Review of the undated thermometer policy and procedure indicated to clean and sanitize the thermometer before and between each product tested . The use of individually wrapped alcohol pads were acceptable; however, allow time for the alcohol to evaporate before using. 2. Observation on 10/15/19 at 11:50 AM revealed the closed metal meal cart came of out to the Emerald unit with lunch trays. The outside of the meal cart had a large amount of a white substance and a tan substance splashed all over the outside of the cart. There was a thick, black, sticky substance on the bottom ledge of the meal cart along with a large amount of food debris. The inside of the meal cart had a white substance splashed inside of it and had a large amount of food debris littering the bottom shelve. There were old, dried, noodles in the bottom corners in the inside of the meal cart. An interview at this time, State tested Nursing Assistant (STNA) #406 verified the meal cart was very dirty. She indicated the meal carts were always dirty, you always are putting your hand in something sticky, and it was gross. Observation on 10/15/19 at 12:00 P.M. the metal meal cart came out to the Sapphire unit with lunch trays. The outside of the meal cart had a white substance splashed al over the outside of it. There was a thick, black, sticky substance on the bottom ledge of the meal cart along with food debris. The inside of the meal cart had a large amount of dried food debris in the corners. An interview at this time, STNA #407 verified the meal cart was very dirty. Review of the cleaning task worksheet revealed it was the morning and evening dishwashers responsibility to clean the meal carts twice a day. An interview on 10/16/19 at 3:45 P.M. Dietary Manager #404 indicated the meal carts were to be cleaned in the morning after breakfast and in the evening after supper. She indicated the staff indicated to her the meal carts had been cleaned.

Based on observation, staff and resident interviews, review of the smoking policy, resident smoking assessments and medical record review, the facility failed to ensure six residents residing on the secure unit, assessed as needing supervision with smoking, did not smoke unsupervised in non-smoking areas and maintain smoking paraphernalia in their possession. This resulted in Immediate Jeopardy when six residents (Residents #14, #15, #16, #39, #82 and #87) were discovered smoking in their rooms between 06/01/17 and 06/05/17. This unsupervised smoking posed a fire risk and the threat of serious harm to residents if a fire occurred. In addition, the facility failed to assess the independent smoking ability of two residents (Residents #6 and #99) and failed to care plan the smoking safety of eight residents (Residents #6, #7, #11, #22, #33, #39, #82 and #99). On 06/14/17 at 4:10 P.M., the administrator, Assistant Director of Nursing (ADON) #4, Corporate Registered Nurse #5, Registered Nurse (RN) #6, Dietitian #7 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 06/01/17 when Resident #14 was discovered smoking a cigarette in her room. The Immediate Jeopardy continued through 06/14/17 as five additional residents were discovered smoking in their rooms between those dates. The Immediate Jeopardy was removed on 06/15/17 and the deficient practice continued at a lower scope and severity, level two, with the potential for more than minimal harm that is not immediate jeopardy, until it was corrected on 06/26/17 at 9:30 A.M. when the facility implemented the following corrective actions: * On 06/14/17 at 6:01 P.M., Social Service Designee (SSD) #21 reviewed and updated smoking assessments for residents residing on the secured unit (Residents #4, #6, #7, #11, #12, #14, #15, #16, #19, #22 #33, #39, #42, #55, #65, #82, #87, #90, #92 and #99). Random audits to be completed by the administrator and the DON weekly for four weeks to ensure all new residents were assessed for their smoking safety. * On 06/14/17 at 7:00 P.M., RN #6 reviewed and updated smoking care plans for residents in the secured unit including Residents #4, #6, #7, #11, #12, #14, #15, #16, #19, #22, #33, #39, #42, #55, #65, #82, #87, #90, #92 and #99. Random audits to be completed by RN #6 weekly for four weeks to ensure care plans updated as appropriate. * On 06/14/17 at 5:30 P.M. and 06/15/17 at 7:00 P.M., Maintenance Staff #26 completed an audit of the smoking area/grounds on the secured unit for safety including observing for any cigarette butts that had not been placed in the appropriate receptacle. Audits of smoking area/grounds for safety to be completed twice daily for four weeks by Maintenance Staff #26. * On 06/14/17 at 5:45 P.M. and 06/14/17 at 6:45 P.M., Maintenance Staff #26 completed audits of the smoking area/grounds on the general population side of the facility for safety including observing for any cigarette butts that had not been placed in the appropriate receptacle. Audits of smoking area/grounds for safety to be completed twice daily for four weeks by Maintenance Staff #26. * On 06/14/17 at 7:00 P.M., Dietitian #7, Maintenance Staff #26 and the administrator inspected resident rooms on the secured unit for cigarettes or lighters and none were found. Random room searches to be completed by Maintenance Staff #26 once per week for four weeks. * On 06/14/17 at 7:00 P.M., the DON reviewed the smoking policy with Residents #4, #6, #11, #12, #14, #15, #16, #19, #22, #33, #39, #42, #55, #65, #82, #87, #92 and #99. Each resident signed the policy and procedure indicating they understood and agreed to follow the policy. Residents #7 and #90 were currently in the hospital and education would be implemented upon return to the facility. * On 06/15/17 at 6:54 A.M., SSD #21 reviewed and updated smoking assessments for residents in the general population (Residents #3, #9, #34, #35, #36, #43 and #93). * Interviews on 06/15/17 from 8:05 A.M. to 8:50 A.M. with State tested Nursing Assistant (STNA) #10, Licensed Practical Nurse (LPN) #17, RN #15, LPN #18, STNA #19, LPN #20, STNA #22, LPN #23 and Activity Director (AD) #12 indicated the staff were aware of the current smoking policy and interventions to be implemented for safety during resident smoking. * On 06/15/17 at 9:00 A.M., Business office manager (BOM) #28 provided Residents #3, #9, #34, #35, #36, #43 and #93 education on posted smoking times for residents in the general population. * On 06/15/17 at 9:00 A.M., SSD #21 reviewed the smoking policy and provided education for residents in the general population (Residents #3, #9, #34, #35, #36, #43 and #93). Each resident signed the policy and procedure indicating they understood and agreed to follow the policy. * On 06/15/17 at 9:00 A.M., RN #6 updated smoking care plans for the general population (Residents #3, #9, #34, #35, #36, #43 and #93). * On 06/15/17 at 10:00 A.M., the DON, ADON #4 and the administrator educated staff to ensure that all cigarette butts were disposed of and extinguished in the provided containers and the smoking policy was reviewed which included two staff members to supervise residents while smoking during the assigned times. Staff must ensure that residents did not enter the facility with any extinguished butts and the smoking population would be divided as evenly as possible into two groups to ensure accurate monitoring. Education was provided to six housekeeping/laundry staff, twenty-seven STNAs, six RNs, seventeen LPNs, seven office personnel, nine dietary staff and one maintenance staff. Random supervised smoke break audits to be completed by administrator and DON weekly for four weeks. * On 06/15/17 at 10:00 A.M., BOM #28 inspected resident rooms in the general population for cigarettes or lighters and none were found. * On 06/15/17 at 1:00 P.M., Corporate RN #5 provided the master list of staff who were educated on safe smoking. At this time it was verified all staff had received education on safe smoking policies and procedures. * On 06/20/17 Resident #90 was readmitted and received education on and signed the smoking policy and procedure, was assessed for smoking abilities and a care plan was initiated based on the assessed findings. * On 06/26/17 at 5:50 A.M., observation revealed smoking times were posted at the nurse's desk in the main common area on the secure unit. * On 06/26/16 at 5:56 A.M., 5:57 A.M. and 6:05 A.M. interviews with LPN #13, STNA #31 and STNA #32 confirmed they were knowledgeable regarding the facility policy and procedures related to safe smoking. * On 06/26/17 at 6:10 A.M., observation revealed supervised smoking was completed according to facility policy and procedure and all residents were observed extinguishing and disposing cigarette butts into an approved fire resistant receptacle prior to re-entering the facility. No new cigarette butts were observed on the ground in the smoking area. * On 06/26/17 at 9:30 A.M., interview with the administrator revealed there had been no smoking inside the facility since 06/14/17. The facility admitted on e new admission and the resident was a non-smoker. * On 06/26/17 at 9:30 A.M., review of facility audit tools dated 06/14/17 through 06/22/17 revealed audits were completed as planned and no concerns were noted. Findings include: 1. The facility identified six residents (Residents #14, #15, #16, #39, #82 and #87) as residing on the secured unit who were observed by facility staff from 06/01/17 to 06/14/17 smoking in resident rooms. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress note dated 06/01/17 at 5:14 A.M. authored by LPN #13 noted the resident was in her room with another resident when smoke was smelled in the hallway. The nurse confronted the residents involved and the resident admitted to smoking but the other unidentified resident denied smoking. No lighter was handed over. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#15's smoking assessment dated [DATE] indicated the resident was assessed to need supervision when smoking. Review of Resident #15's progress note dated 06/02/17 at 5:09 A.M. authored by LPN #13 indicated on 06/02/17 at 5:09 A.M. smoking activity was going on in the resident's room with another unidentified resident. Resident #15 denied taking part. No cigarettes or lighters were confiscated. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#16's smoking assessment dated [DATE] indicated the resident was a supervised smoker. Review of Resident #16's progress note dated 06/01/17 at 5:03 A.M. authored by LPN #13 indicated the resident was in her room with another unidentified resident smoking. LPN #13 requested the lighter and any cigarettes. The resident denied smoking but the smell of smoke was obvious. Review of Resident #16's progress note dated 06/02/17 at 5:06 A.M. authored by LPN #13 indicated the resident was in another resident's room and the staff could smell smoke from the hallway. The resident denied any smoking activity again. No cigarettes or lighters were obtained from the residents. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Nurses notes dated 06/01/17 at 5:10 P.M. stated the resident was in another resident's room, the room and hallway smelled of smoke. LPN #13 confronted the residents involved and Resident#39 admitted to smoking in the room, but no one would admit to having a lighter. The resident did not have a care plan for smoking. Review of Resident #82's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#82's smoking assessment dated [DATE] indicated the resident required supervision when smoking. Review of Resident #82's progress note dated 06/05/17 at 11:10 P.M. revealed LPN #16 indicated the resident and a roommate were found smoking in the room. The residents were asked to turn in any cigarettes and lighters. Resident #82 and the roommate denied a lighter and indicated the cigarette was still lit from outside during the smoke break. Review of Resident #87's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#87's smoking assessment dated [DATE] indicated the resident required supervision while smoking. Review of Resident #87's progress note dated 06/05/17 at 11:12 P.M. authored by LPN #16 indicated the resident was caught in the resident's room smoking with a roommate. Resident #87 and the roommate denied having a lighter and revealed the cigarette was still lit from outside during the smoke break. Observation of supervised smoking on 06/12/17 at 9:39 A.M. revealed two STNAs providing supervision for seven to eight residents. Approximately 76 cigarette butts were observed on the ground in the smoking area. The smoking receptacle lid was slightly off base and not locked. STNA #30 said she told the nurses about the cigarette butts many times. Interview with Human Resource Staff #29 and SSD #21 on 06/14/17 at 5:15 P.M. revealed the facility did not have a policy or procedure to provide guidance/directions to staff regarding what supervision of smokers involved. There was no formal education related to providing smoking supervision, new hires were verbally instructed on safe smoking. Human Resource Staff #29 and SSD #21, who completed the training, could not elaborate on what the new hires were specifically told. Interview on 06/26/17 at 5:56 A.M. with LPN #13 revealed Resident #16 and Resident #39 were found smoking in Resident 16's room. LPN #13 indicated Resident #39 confirmed she was smoking and indicated she lit the cigarette with a match. LPN #13 said although it was facility policy to complete a room search immediately upon finding residents smoking in their rooms, a room search was not completed until the next shift after she went home. Interview on 06/26/17 at 5:57 A.M. with STNA #31 confirmed residents had been found smoking in their rooms. STNA #31 was not sure of the exact dates but it was sometime in June. STNA #31 explained during one incident Resident #87 and Resident #82 were found smoking in their room. It was determined Resident #87 left the smoking area during a smoke break cupping a lit cigarette in her hand which she then carried to her room where Resident #87 and Resident #82 were later found smoking. The room was searched as well as everyone in the immediate area then the search was expanded to all rooms. Personal belongings, drawers and pockets were searched. Cigarette butts were found in the toilet and on the floor of Resident #87 and 82's room. Cigarette butts were also found in the pockets of Resident #87's clothing. No lighter or matches were found. The second incident involved Resident #11 and Resident #39 smoking in their room. This incident did involve use of a lighter which was not confiscated. The room and residents were searched but no lighter was obtained. Interview on 06/26/17 at 6:05 A.M. with STNA #32 confirmed residents had been caught smoking in their rooms on night shift during the first two weeks of June but she could not be sure of the exact dates. STNA #1 explained she was completing rounds at approximately 4:30 A.M. a couple weeks ago when she smelled smoke. She followed the odor to Resident #87's room. When she entered the room Resident #87 immediately extinguished a cigarette on her bedside stand. Resident #87 said she got a lighter from her roommate, Resident #82. Resident #82 denied smoking or having a lighter. STNA #32 immediately notified the nurse (could not identify the nurse). The nurse got rid of the cigarette butt by flushing it down the toilet. STNA #32 indicated Resident #82 had been found with cigarettes in the past, she cupped cigarettes in her hands or slid them up her jacket sleeves during smoke breaks. STNA #32 felt Resident #87 may have gotten a lighter from Resident #11 who had been caught smoking in the facility multiple times but Resident #11 denied providing a lighter to anyone. Resident #87's room including drawers and bedding were searched and Resident #87 was patted down but nothing was found. They were both placed on every 15 minute checks for two days. On another unknown date and time another STNA caught Resident #11 and Resident #15 smoking. The residents admitted they were smoking and they indicated the lighter and cigarettes belonged to Resident #11. The lighter was confiscated. STNA #32 said it was felt Resident #11 who went out on LOAs returned with the smoking paraphernalia. Interview on 06/26/17 at 6:25 A.M. with Resident #39 revealed she was found smoking in her room but could not remember the date and could not remember where she obtained the cigarette or if a room search was completed when she was found smoking in the room. Interview on 06/26/17 at 6:31 A.M. with Resident #82 indicated she obtained a cigarette from the smoking receptacle in the smoking courtyard, lit it outside and brought it inside the facility and into her room. Resident #82 was unable to identify the exact date that it happened or if the staff searched her room following the incident. Interview on 06/26/17 at 6:35 A.M. with Resident #16 indicated she picked up a cigarette butt off the ground in the smoking courtyard on the secured unit to smoke at a later time. Resident #16 revealed she lit the cigarette butt in her room using a lighter another resident had given her. Resident #16 also indicated she gave the lighter to the nurses when the nursing staff observed the resident smoking in the resident's room. Resident #16 denied having a lighter or cigarettes in her room at the present time. Interview on 06/26/17 at 6:39 A.M. with Resident #14 indicated Resident #82, Resident #15 and Resident #16 were smoking in her room but she was unable to recall the exact date or time or where they obtained the lighter. Resident #14 denied that she had also been smoking in her room. Interview on 06/26/17 at 6:40 A.M. with Resident #15 indicated the staff told her at an unknown date that they smelled smoke but she was not smoking in her room and she could not identify who else could have been smoking in her room. Interview on 06/26/17 at 8:55 A.M. with Resident #87 confirmed she had been found smoking in her room but she was unable to identify the exact date. Resident #87 revealed the cigarette was disposed of in the toilet. Interview with the administrator on 06/26/16 at 11:30 A.M. revealed Resident #11's family was no longer visiting or taking the resident on LOAs. Resident #11's smoking paraphernalia was maintained in a locked area and was provided to the resident only during supervised smoke breaks. 2. The facility identified twenty residents (Residents #4, #6, #7, #11, #12, #14, #15, #16, #19, #22, #33, #39, #42, #55, #65, #82 #87, #90, #92 and #99) residing on the secured unit who smoked and required supervision to smoke. Review of the secured unit resident records on 06/14/17 revealed two residents were not assessed for safe smoking including Residents #6 and #99, however no unsafe incidents were noted. Further review of resident records revealed eight residents (Residents #6, #7, #11, #22, #33, #39, #82 and #99) did not have care plans developed and interventions identified to ensure resident safety during smoke breaks. Review of the Smoking Policy revised 11/23/11 indicated all residents were to be supervised while smoking and staff would light all smoking products and provide other assistance and protective devices as needed. Smoking was only allowed in areas of the facility that were designated smoking areas. Smoke times would be posted and all smoking materials would be kept in a secured area and distributed by facility staff. Review of the facility Behavior Unit Admission Process policy dated December 2003 indicated the behavioral unit was for residents who needed stabilization and on-going treatment.

Based on observation, resident interview, staff interview, medical record review, and review of the facility 's contingency box policy, the facility failed to provide two doses of the regularly scheduled narcotic medication [MEDICATION NAME] to one resident (Resident #63) of three residents observed for medication administration of 64 residents receiving medication in the facility. Harm occurred when the facility missed two doses of [MEDICATION NAME] for Resident #63 who was observed on 04/21/16 at 8:43 A.M. to be rubbing the left side of her face near her ear, rocking back and forth in her chair, grimacing, and complaining of unbearable pain to her left ear. Resident #63 complained about not receiving the [MEDICATION NAME] the night before and the pain in her left ear was unbearable. Licensed Practical Nurse (LPN) #10 confirmed that the [MEDICATION NAME] was still unavailable. Findings Include: Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual comprehensive assessment completed on 02/17/16 revealed the resident was cognitively intact. On 04/21/16 at 8:29 A.M. LPN #10 was observed to access 18 out of 20 of the prescribed medications for Resident #63. LPN #10 was observed to access the narcotic storage box in the medication cart but was unable to find any [MEDICATION NAME] tablets for Resident #63. She was also unable to find the ordered [MEDICATION NAME] 250 milligram (mg) supplement used to treat high cholesterol levels. LPN #10 indicated she would have to find out what to do for the [MEDICATION NAME]. LPN #10 was observed to enter Resident #63's room at 8:43 A.M. Resident #63 was observed to be rocking back and forth in her chair moaning, leaning slightly to the left, grimacing, and rubbing her hand on her left cheek by her ear. Resident #63 said her left ear was hurting so bad she could not stand it. Resident #63 indicated that she had not received her [MEDICATION NAME] from the previous evening due to none being available. LPN #10 informed the resident her medication was on order but had not yet been received and proceeded to administer the other routine morning medications. The resident continued to display evidence of pain while the LPN was administrating the medications. LPN #10 did not offer any other interventions to Resident #63 to help alleviate the pain. An interview was conducted with the director of nursing (DON) on 04/21/16 at 8:50 A.M. regarding [MEDICATION NAME] being unavailable for a resident with chronic pai[DIAGNOSES REDACTED]. The DON said whenever the facility has an issue with medications she contacts the facility's pharmacist (RPh) #20 and discusses the issue with him. The DON said they have [MEDICATION NAME] in their contingency box provided by pharmacy. Staff need to complete an authorization form in order to pull the medication. The staff also need to fax the pharmacy the authorization form for permission and indicate how many pills were dispensed. The DON said she would complete one for Resident #63 and she should be able to have her medication within the hour. On 04/21/16 at 9:30 A.M. the DON provided a copy of the medications contained in the contingency box as well as a policy on use of the contingency box. The DON confirmed the nurses should be removing unavailable medications for the residents from the contingency box and the [MEDICATION NAME], marked as unavailable for Resident #63, was indeed available in the box. Narcotics were available in the contingency box and can be accessed by all shifts after completing the authorization to pull form. A phone interview was conducted with RPh #20 on 04/21/16 at 9:30 A.M. regarding the unavailability of [MEDICATION NAME] for Resident #63. RPh #20 said it was a bit more difficult to obtain narcotics as the facility must complete the authorization to pull form, fax it to the pharmacy, and then wait for pharmacy approval on how many narcotics could be removed from the contingency box. As for non-narcotic medications, RPh #20 said he could customize the contingency box to whatever the facility needs as well as increase the number of medications provided. An interview was conducted with LPN #11 on 04/21/16 at 3:00 P.M. who confirmed she worked night shift at the facility. LPN #11 confirmed the night shift nurses were able to obtain narcotics from the contingency box at night just as they could during the day. LPN #11 said she completed the authorization to pull form and then fax it to the pharmacy. The pharmacy had a pharmacist on duty 24 hours a day. The pharmacist then faxed the request back to the facility providing them with how many narcotics could be dispensed. LPN #11 said she and a second nurse would then go to the contingency box and confirm the four plastic tags on the box were the correct numbers on the tags. They would then remove the tags, count all the medications in the box to confirm the count sheet matched what was in the box. They would then remove the medication authorized, re-count the medications and record the findings. The pharmacy exchanged the contingency box every Friday and provides the facility with a new box of medications. An interview was conducted with the Administrator on 04/21/16 at 3:10 P.M. regarding Resident #63. The Administrator indicated the resident was very quiet and rarely complained about anything. The Administrator was made aware of the observations made of Resident #63 at 8:43 A.M. She confirmed that the reaction of Resident #63 was definitely uncharacteristic of the resident. Review of the facility's policy 6.6 Emergency Medication Supplies , revised on 01/01/13, indicated a Request for Removal of Controlled Medication From Contingency Supply form needed to be completed and faxed to the pharmacy for any Schedule II Controlled substances of which [MEDICATION NAME] was considered. Once the facility received the faxed authorization from the pharmacy they may then remove the controlled substance from the contingency box. Once the authorized medication was removed the facility must then count and confirm the number of medications in the box matches the amount that should be in the box. Any discrepancies must be reported immediately to the pharmacy. Review of the available medications in the facility's contingency box revealed the box contains 30 tablets of [MEDICATION NAME] 5/325 mg which was the generic version of [MEDICATION NAME]. Review of Resident #63's Request for Removal of Controlled Medication From Contingency Supply indicated on 04/21/16 at 8:49 A.M. the facility faxed to pharmacy a request for removing [MEDICATION NAME] from the contingency box. The pharmacy faxed back the authorization to remove three [MEDICATION NAME] tablets from the contingency box at 9:08 A.M. At 10:00 A.M. an illegible nurse signature removed the three authorized [MEDICATION NAME] from the contingency box. Review of Resident #63's nursing notes revealed no documentation regarding the observation of the resident's grimacing, rocking back and forth in her chair, rubbing the left ear and face, leaning to the left, or her complaint of being unable to stand the pain. No assessment was completed and no interventions were found regarding the facility's failure to alleviate Resident #63's complaints or provide interventions.