Every finding on record at Singleton Health Care Center

Based on medical record review, financial record review, staff interview, and facility policy review, the facility failed to ensure financial records were timely update. This affected 14 (Residents #50, #7, #8, #51, #13, #16, #21, #22, #52, #31, #35, #36, #46, and #53) of 14 resident financial records reviewed. The census was 49.Findings Include:Resident #50 was admitted to the facility on [DATE]. His diagnoses were hypertension, sepsis, and paranoid schizophrenia. Review of Resident #50's minimum data set (MDS) assessment revealed his cognitive status had not been completed.Review of Resident #50's resident trust account information, dated 02/27/26, revealed he had a negative balance in his account of -$970.99.Resident #7 was admitted to the facility on [DATE]. Her diagnoses were major depressive disorder, dementia, dysphagia, allergic rhinitis, osteoporosis, valgus deformity, slow transit constipation, disorder of thyroid, alcohol dependence, hyperlipidemia, and anemia. Review of her MDS assessment, dated 01/01/26, revealed she had a mild cognitive impairment.Review of Resident #7's resident trust account information, dated 02/27/26, revealed she had a negative balance in her account of -$31.45.Resident #8 was admitted to the facility on [DATE]. His diagnoses were hemiplegia, major depressive disorder, hydrocephalus, spondylosis, rheumatic tricuspid insufficiency, alcohol abuse, hypokalemia, hypo-osmolality and hyponatremia, hypertension, vitamin D deficiency, and lack of coordination. Review of his MDS assessment, dated 01/27/26, revealed he had a mild cognitive impairment.Review of Resident #8's resident trust account information, dated 02/27/26, revealed he had a negative balance in his account of -$59.09.Resident #51 was admitted to the facility on [DATE]. His diagnoses were hypertension, benign prostatic hyperplasia, and anemia. Review of his MDS assessment found his cognitive status has not been reviewed.Review of Resident #51's resident trust account information, dated 02/27/26, revealed he had a negative balance in his account of -$77.14.Resident #13 was admitted to the facility on [DATE]. His diagnoses were anxiety disorder, major depressive disorder, malignant neoplasm of larynx, dysphonia, dementia, vitamin D deficiency, nicotine dependence, and insomnia. Review of his MDS assessment, dated 12/08/25, revealed he had a severe cognitive impairment.Review of Resident #13's resident trust account information, dated 02/27/26, revealed he had a negative balance in his account of -$110.97.Resident #16 was admitted to the facility on [DATE]. His diagnoses were flat foot, pain, cataracts, insomnia, chronic hepatitis, osteoarthritis, schizoaffective disorder, hypertension, dementia, and malignant neoplasm of prostate. Review of his MDS assessment, dated 12/23/25, revealed he was cognitively intact.Review of Resident #16's resident trust account information, dated 02/27/26, revealed he had a negative balance in his account of -$31.57.Resident #21 was admitted to the facility on [DATE]. Her diagnoses were restlessness and agitation, hyperlipidemia, cognitive communication deficit, dementia, peripheral vascular disease, and schizophrenia. Review of her MDS assessment, dated 12/23/25, revealed she was cognitively intact.Review of Resident #21's resident trust account information, dated 02/27/26, revealed she had a negative balance in his account of -$56.96.Resident #22 was admitted to the facility 10/08/21. Her diagnoses were centrilobular emphysema, dementia, schizophrenia, mood disorder, hyperlipidemia, nicotine dependence, hypertension, insomnia, glaucoma, cannabis dependence, alcohol abuse, anxiety disorder, and osteoarthritis. Review of her MDS assessment, dated 02/12/26, revealed she was cognitively intact.Review of Resident #22's resident trust account information, dated 02/27/26, revealed she had a negative balance in his account of -$44.47.Resident #52 was admitted to the facility on [DATE]. Her diagnoses were schizophrenia, anxiety disorder, and vitamin D deficiency. Review of her MDS assessment found her cognitive status had not been evaluated.Review of Resident #52's resident trust account information, dated 02/27/26, revealed she had a negative balance in his account of -$4.73.Resident #31 was admitted to the facility on [DATE]. His diagnoses were edema, other obesity due to excess calorie, cognitive communication deficit, hypertension, anemia, paranoid schizophrenia, chronic obstructive pulmonary disease, and anxiety disorder. Review of his MDS assessment, dated 01/07/26, revealed he was cognitively intact.Review of Resident #31's resident trust account information, dated 02/27/26, revealed he had a negative balance in his account of -$18.97.Resident #35 was admitted to the facility on [DATE]. Her diagnoses were osteoporosis, hyperlipidemia, neuromuscular dysfunction of bladder, dementia, hypertension, pulmonary embolism, osteoarthritis, dysphagia, type II diabetes, hemiplegia and hemiparesis, and chronic obstructive pulmonary disease. Review of her MDS assessment, dated 01/01/26, revealed she was cognitively intact.Review of Resident #35's resident trust account information, dated 02/27/26, revealed she had a negative balance in his account of -$64.57.Resident #36 was admitted to the facility on [DATE]. His diagnoses were hypertension, tachycardia, obsessive compulsive disorder, thrombocytopenia, anemia, hyperlipidemia, moderate intellectual disabilities, vitamin D deficiency, type II diabetes, impulse disorder, and disorganized schizophrenia. Review of her MDS assessment, dated 01/22/26, revealed he was cognitively intact.Review of Resident #36's resident trust account information, dated 02/27/26, revealed he had a negative balance in his account of -$39.72.Resident #46 was admitted to the facility on [DATE]. His diagnoses were type II diabetes, hydrocephalus, spondylosis, cognitive communication deficit, vitamin D deficiency, insomnia, vascular dementia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, alcohol abuse, atherosclerotic heart disease, alcohol abuse, and chronic kidney disease. Review of his MDS assessment, dated 01/15/26, revealed he had a severe cognitive impairment. Review of Resident #46's resident trust account information, dated 02/27/26, revealed he had a negative balance in his account of -$1,819.10.Resident #53 was admitted to the facility on [DATE]. Her diagnoses were hypertension, paranoid schizophrenia, vitamin D deficiency, drug induced subacute dyskinesia, and tobacco use. Review of her MDs assessment revealed her cognitive status had not been evaluated.Review of Resident #53's resident trust account information, dated 02/27/26, revealed she had a negative balance in his account of -$36.71.Interview with Business Office Manager (BOM) #200 on 02/27/26 at 11:15 A.M. confirmed there are many resident financial records that are not currently up to date, which is reflected by a negative balance. She stated she gets financial information from Executive Director (ED) #150, who is responsible for cashing resident checks and paying cost of care costs; she will get that information from ED #150 whenever he has it. She confirmed she is dependent on ED #150 information to update the resident's financial statements.Interview with Administrator on 02/27/26 at 11:20 A.M. confirmed they are behind in paperwork and book keeping for resident financial records. She confirmed that there are resident financial records reflecting they have negative balances that really don't have a negative balance. She confirmed they need to find a new way of keeping the financial records to make sure they are up to date more timely. She confirmed if a resident has a negative balance at the end of the year, and the reason for the negative balance is because the facility allowed them to spend more than they had, the facility will take responsibility for the overages and balance the resident's account. Interview with ED #150 on 02/27/26 at 1:50 P.M. confirmed he can get behind on documenting the expenses and revenues for resident financials, but he does try to have them up to date by the end of the quarter when they send out the financial statements to the residents and/or representatives. He confirmed that most of the residents who currently have a negative balance, don't really have a negative balance; they haven't updated the financial records yet.Review of facility Resident Rights and Dignity policy, undated, revealed the resident is permitted to manage one's personal funds or if funds are managed by the home, to receive upon request, quarterly statements showing all deposits and how the money was spent.Review of facility Personal Allowance guidelines, dated 2022, revealed upon written authorization, the facility will open an account in the resident's name to manage your personal allowance funds. An amount less than $50.00 can be kept in a non-interest bearing checking account or petty cash account for easy withdrawal. Any amount more than $50.00 will be kept in an interest bearing cash fund account. Both the checking account and cash fund account are accounts strictly separate from the facility accounts. The resident or responsible party can find the balance of the accounts by contacting the business office during regular business hours. Upon request, the resident can also get a written breakdown of your resident fund activity. Interest from the cash fund is figured regularly and added into the account. This account bears a surety bond to ensure that any money placed in the account is secure and guaranteed. Withdrawals and deposits to the allowance fund can be made through the business office during regular business hours. Signed requests or validated receipts for merchandise are required to release funds for the account. This deficiency represented non-compliance investigated regarding complaint number 2655352.

Based on medical record review and staff interview, the facility failed to ensure resident records were complete and accurate. This affected one (Resident #46) of three resident records reviewed. The census was 49.Findings Include:Resident #46 was admitted to the facility on [DATE]. His diagnoses were type II diabetes, hydrocephalus, spondylosis, cognitive communication deficit, vitamin D deficiency, insomnia, vascular dementia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, alcohol abuse, atherosclerotic heart disease, alcohol abuse, and chronic kidney disease. Review of his minimum data set (MDS) assessment, dated 01/15/26, revealed he had a severe cognitive impairment. Review of Resident #46 progress notes found no evidence of any psychiatric evaluations or notes regarding meetings they have had in the last 12 months. There was no documentation to support his Veteran's Administration (VA) psychiatric physician was consulted or was made aware of any pharmacy recommendations regarding his ordered medications. Finally, there was no documentation to support the VA psychiatric physician was consulted about any medications that were ordered by the facility physician, including psychotropic medications.Interview with Director of Nursing (DON) on 02/27/26 at 1:45 P.M. confirmed they have no documentation to support psychiatric appointments or meetings with Resident #46 VA physician. She confirmed they have evidence that telehealth meetings between Resident #46, his wife, the facility, and the VA physician occurred on 02/13/25, 11/05/25, and 02/13/26, but they have no documentation about these meetings, what was discussed, and if there were any recommendations made for the resident's health.This deficiency represented non-compliance investigated regarding complaint number 2655352.

Based on resident record review, resident interview, staff interview and facility policy review, the facility failed to ensure Resident #42 was treated with respect and dignity. This affected one resident (#42) of two residents reviewed for respect and dignity. The facility census was 48. Findings include: Review of the medical record for Resident #42 revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, schizophrenia, and schizoaffective disorder. Review of the care plan dated 02/14/22, revealed Resident #42 behaved in a problematic manner characterized by ineffective coping with paranoia and suspicious behaviors related to psychiatric illness. Interventions included reassuring safety and talking in a low pitch, calm voice to decrease and/or eliminate undesired behaviors and provide diversional activities. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of three, indicating she had severe cognitive impairment. She was independent with some setup assistance with activities of daily living (ADL). Review of the MDS assessment revealed Resident #42 had a history of delusional thoughts. Observation on 11/13/24 at 3:44 P.M. revealed Resident #42 approached the locked secured door adjacent to the receptionist's desk and began knocking. Medical Secretary (MS) #562 got up from the seated position, opened the door in a forceful manner, and approached Resident #42 stating in a rude, blunt tone What do you want? Why are you knocking on the door that hard? Resident #42 was observed taking a step back from the door and asked MS #562 a question that was unclear. MS #562 revealed she did not know the answer to Resident #42's question, and Resident #42 turned and walked away. Interview on 11/13/24 at 3:45 P.M. with MS #562, while turning her eyes upward, revealed she did not always speak to residents in that manner, but Resident #42 was knocking on the door really hard. MS #562 confirmed and verified the interaction with Resident #42. Interview on 11/13/24 at 3:46 P.M. was attempted with Resident #42, but she declined to speak. Interview on 11/14/24 at 8:55 A.M. with Resident #42 revealed she was sometimes treated with respect and dignity. Resident #42 revealed MS #562 was sometimes mean and rude when she approached her. Review of the facility document titled Resident Rights and Dignity Policy, revised 2024, revealed the facility had a policy in place that residents would always be treated with courtesy and respect.

Based on record review, interview and facility policy review, the facility failed to ensure Resident #200's baseline care plan was completed timely. This affected one resident (#200) of two residents reviewed for baseline care plans. The facility census was 48. Findings include: Review of the medical record for Resident #200 revealed an admitted [DATE] with diagnoses including diabetes mellitus and malignant neoplasm of pancreas (cancer). Resident #200 was discharged to the hospital on 10/10/24 and did not return to the facility. Review of the baseline care plan in the electronic health record dated 10/07/24 revealed it was blank and had not been completed. Interview on 11/14/24 at 9:48 A.M. with Licensed Practical Nurse (LPN) #569 revealed she assisted in completing the baseline care plans. She stated Resident #200 was admitted on [DATE] and was discharged on [DATE]. She stated she had initiated the baseline care plan, printed it out, and then began filling in the information by hand on the form with information provided through staff interviews and observations. She verified she had not completed the baseline care plan within 48 hours or entered it into the computer so nursing staff had it available. LPN #569 verified the baseline care plan should have been in the computer completed by 48 hours and reviewed with the resident and family. Review of the facility policy titled, Baseline Care Plan, dated 11/28/17, revealed the baseline care plan should be started on admission and completed within 48 consecutive hours of admission.

Based on record review, interviews and facility policy review, the facility failed to ensure fall prevention interventions were documented on the Kardex, failed to ensure an accurate falls risk assessment, and failed to do post fall assessments for 72 hours according to the facility policy for Resident #34. In addition, the facility failed to ensure safety of Resident #200 during care. This affected two residents (#34 and #200) of two residents reviewed for accidents. The facility census was 48. Findings include: 1. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including epilepsy, hypertension, bradycardia, conversion disorder with seizures, cognitive communication deficit, dementia with behaviors, schizophrenia, cardiomyopathy, congestive heart failure, and vitamin B12 deficiency. Review of Resident #34's medication orders for July 2024 through September 2024 revealed orders for Norvasc, Losartan Potassium, Metoprolol Succinate ER (antihypertensives), Torsemide, hydralazine HCL, Furosemide, spironolactone (diuretics) and Depakote ER and Keppra (anti-seizure medications). Review of the fall incident description dated 09/29/24 at 6:07 P.M. revealed Resident #34 was in his room with a Certified Nurse Aide (CNA) present, and he tripped over a book bag that was kept underneath his bed. Resident #34 was observed on floor on all fours and was assessed by the nurse and had no injuries. He was educated to educated to keep the walkway free of clutter. Review of medical record dated 09/29/24 to 10/01/24 revealed the facility failed to assess Resident #34 every shift post fall for 72 hours according to their policy. Review of the Medication Administration Record (MAR) for September 2024 revealed Resident #34 had been receiving the antihypertensives, antiseizure and diuretic medications as ordered. Review of the fall risk assessment dated [DATE] for Resident #34 revealed under section G. Medications, the resident took only one to two of the following medications in the last seven days: anesthetics, antihistamines, antiseizure, antihypertensives, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychoactives, sedatives/hypnotics. Further review revealed under section H. Predisposing diseases included CVA, Parkinson's disease, seizures, arthritis, loss of limb, arthritis, osteoporosis, fractures, multiple sclerosis, vertigo and hypotension, and the assessment indicated Resident #34 had none of the predisposing diseases. Review of the plan of care, dated 10/07/24, revealed Resident #34 had a risk for falls related to seizure disorder. An intervention included to ensure the floor was free of clutter. Review of Resident #34's current Kardex revealed the intervention dated 10/07/24 to ensure the resident's floor remained free of clutter had not been added. Interview with the Director of Nursing (DON) on 11/13/24 at 1:35 P.M. confirmed the new fall intervention dated 10/07/24 ensure floor remain free of clutter was not on the Kardex. Interview with CNA #524 on 11/14/24 at 9:28 A.M. revealed that she refers to the Kardex or will ask the nurse regarding any changes or updates to a resident's care. Interview with Minimum Data Set 3.0 (MDS) Licensed Practical Nurse (LPN) #569 on 11/13/24 at 1:42 P.M. confirmed incorrect documentation was identified on the falls risk assessment dated [DATE] based on the record review pertaining to the medications and predisposing diseases. Interview with the Director of Nursing (DON) on 11/13/24 at 2:53 P.M. confirmed that nursing documentation was not completed on every shift for 72 hours per [NAME] Health Care Post Fall Protocol, dated 12/01/2016. Review of the facility policy titled, [NAME] Health Care Post Fall Protocol, dated 12/01/16, revealed the MDS Coordinator would complete a fall risk assessment after the fall and add new interventions to the resident's fall risk care plan. 43063 2. Review of the medical record for Resident #200 revealed an admitted [DATE] with diagnoses including diabetes mellitus and malignant neoplasm of pancreas (cancer). Resident #200 was discharged to the hospital on 10/10/24 and did not return to the facility. Review of the nursing admission observation dated 10/05/24 revealed Resident #200 needed a mechanical Hoyer lift for transfers. He was dependent on staff for personal hygiene, including bed baths. Review of the fall risk assessment dated [DATE] stated Resident #200 was at risk for falls as he was disoriented and had decreased muscle coordination with jerking movements. It was noted that Resident #200 did not have any falls in the past three months. Review of the baseline care plan in the electronic health record dated 10/07/24 revealed it was blank and had not been completed. Review of the nursing progress note dated 10/07/24 at 6:32 A.M. for Resident #200 revealed he fell at approximately 5:45 A.M. during care. Resident #200 was rolled on his side by the aide during bathing and the resident fell out of bed. The resident had no injuries from the fall. Review of the fall investigation dated 10/07/24 stated Resident #200 fell out of bed when Certified Nursing Assistant (CNA) #523 rolled him onto his side during care. Resident #200 rolled off the bed and onto the floor. The statement from CNA #523 verified he had rolled the resident onto his side, and the resident had rolled off the bed onto the floor. Review of the verbal warning by the DON to CNA #523 dated 10/09/24 revealed he was disciplined and educated for giving care to a bed bound resident and leaving him in an unsafe position resulting in a fall. Interview on 11/14/24 at 9:41 A.M. with the DON verified CNA #523 was providing care to Resident #200 on the morning of 10/07/24 and rolled him onto his side, and the resident rolled out of bed onto the floor in between the wall and the bed. She stated CNA #523 was educated and provided a verbal warning because he did not ensure the positioning of the bed against the wall and did not have two staff members while providing care. She verified she was unsure if Resident #200 needed the assistance of two staff members during bed mobility or bathing due to the baseline care plan not being completed timely. Interview on 11/14/24 at 9:48 A.M. with LPN #569 revealed she assisted in completing the baseline care plan for Resident #200. She stated Resident #200 was admitted on [DATE] and was discharged on [DATE]. She stated she had initiated the baseline care plan, printed it out, and then began filling in the information through staff interviews and observations. She verified she had not completed the baseline care plan within 48 hours or placed it in the computer so that nursing staff had it available. LPN #569 verified the baseline care plan should have been completed and entered into the computer within 48 hours of admission and reviewed with the resident and family. She also verified there were no interventions to assist in preventing falls for Resident #200. Attempted interviews on 11/14/24 at 10:59 A.M. and 2:15 P.M. with CNA #523 were unsuccessful. Voicemail messages were left and were not returned. Review of the facility policy titled, Baseline Care Plan, dated 11/28/17, revealed the baseline care plan should be started on admission and completed within 48 consecutive hours of admission.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were followed up on for Resident #1. This affected one resident (Residents #1) of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including arthritis, schizophrenia and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact. She required set up assistance for eating and oral hygiene and substantial or maximum assistance for dressing, toileting, showering and personal hygiene. Review of the Medication Administration Record (MAR) for July 2024 revealed an order for Haldol (an antipsychotic medication) 0.5 milligrams (mg) intramuscularly (IM) every six hours as needed (prn). The order began on 07/22/24 and was discontinued on 08/29/24. Review of the document titled Note to Attending Physician/Prescriber dated 07/18/24 revealed pharmacist #570 requested Medical Director (MD) #571 to consider adding an end date of 08/05/24 to Haldol IM 0.5 mg. There was no evidence MD #572 addressed the recommendation. Interview on 11/14/24 at 10:36 A.M. with the Director of Nursing confirmed the recommendation by Pharmacist #570 for Resident #1 dated 07/18/24 was not addressed by MD #572 regarding the end date of 08/05/24 for the Haldol. Review of the facility policy titled Medication Monitoring dated 06/21/17 revealed residents who received psychotropic medications would receive gradual dose reductions unless clinically contraindicated.

Based on interview and record review, the facility failed to ensure fall risk assessments were documented accurately for Resident #34 who was at risk of falls. This affected one resident (Resident #34) of three residents reviewed for falls. The facility census was 48. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including epilepsy, hypertension, bradycardia, conversion disorder with seizures, cognitive communication deficit, dementia with behaviors, schizophrenia, cardiomyopathy, congestive heart failure, and vitamin B12 deficiency. Review of Resident #34's medication orders for July 2024 through September 2024 revealed orders for Norvasc, Losartan Potassium, Metoprolol Succinate ER (antihypertensives), Torsemide, hydralazine HCL, Furosemide, spironolactone (diuretics) and Depakote ER and Keppra (anti-seizure medications). Review of the fall risk assessments dated 07/05/24 and 10/02/24 for Resident #34 revealed under section G. Medications, the resident took only one to two of the following medications in the last seven days: anesthetics, antihistamines, antiseizure, antihypertensives, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychoactives, sedatives/hypnotics. Review of the Medication Administration Record (MAR) for September 2024 revealed Resident #34 had been receiving the antihypertensives, antiseizure and diuretic medications as ordered. Further review of the fall risk assessments dated 07/05/24 and 10/02/24 revealed under section H. Predisposing diseases included CVA, Parkinson's disease, seizures, arthritis, loss of limb, arthritis, osteoporosis, fractures, multiple sclerosis, vertigo and hypotension, and the assessment indicated Resident #34 had none of the predisposing diseases. Interview with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #569 on 11/13/24 at 1:42 P.M. confirmed that incorrect documentation was identified on the falls risk assessments dated 10/2/24 and 07/05/24. LPN #569 confirmed that each of the assessments had identical documentation that was incorrect based on the record review pertaining to the medications and predisposing diseases.

Based on record review, facility policy and procedure review and interview the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This had the potential to affect all 49 residents residing in the facility. Findings include: Review of the personnel file for Registered Nurse (RN) #260 revealed a hire date of 05/02/22. There was no printed evidence of RN #260 being checked against the NAR. Review of the personnel file for Housekeeper #262 revealed a hire date of 02/02/22. There was no evidence of Housekeeper #262 being checked against the NAR. Review of the personnel file for Licensed Practical Nurse (LPN) #218 revealed a hire date of 04/21/22. There was no printed evidence of LPN #218 being checked against the NAR. Review of the personnel file for State tested Nursing Assistant (STNA) #202 revealed a hire date of 04/21/22. The printed evidence of STNA #202 being checked against the NAR was not completed until 04/27/22. Interview on 05/24/22 at 3:47 P.M. with Business Office #217 confirmed screening/checking employees through the Ohio Nurse Aide Registry for abuse, neglect, exploitation, and misappropriation was not completed for RN #260, Housekeeper #262, LPN #218 or STNA #202 prior to or on the first date of hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy, Abuse Prevention Policy, revised 05/15/19, revealed through the employee screening process, no individual who was convicted of abusing, neglecting, or mistreating individuals would be employed by the facility.

Based on record review, observations, and interviews the facility administration failed to ensure its resources were effectively and efficiently managed to attain and maintain the highest practicable physical, mental, and psychosocial well-being of all 48 residents residing in the facility. The facility census was 49. Findings include: The following concerns were identified during the annual survey: 1. Review of the medical records of Residents #26 and #31 revealed documentation Resident #24 was witnessed hitting Resident #31. Interview on 05/25/22 at 11:53 A.M. with the Administrator revealed the Director of Nursing (DON) reported the physical altercation to the Administrator on 03/26/22 by phone who received the report from Licensed Practical Nurse (LPN) #252 on 03/25/22 after the incident occurred. The Administrator confirmed not reporting the allegation of physical abuse to the State agency or conducting a thorough investigation as required. There were no witness statements obtained from the perpetrator, victim, or witnesses. 2. Review of facility personnel files revealed Registered Nurse (RN) #260, Housekeeper #262, Licensed Practical Nurse (LPN) #218, and State tested Nursing Assistant (STNA) #202 were not checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 05/26/22 at 2:57 P.M. with the Administrator revealed she was aware of the need to check the NAR for all employees but did not make sure it was being done. 3. Review of resident personal fund accounts revealed on 05/23/22 the total of all active resident funds was $60,518.11. The facility only secured a surety bond with a value of $20,000.00. Interview on 05/25/22 at 10:30 A.M. with the Administrator confirmed the surety bond was not the appropriate amount on 05/23/22 as required. The Administrator indicated when the survey process began on 05/23/22, she realized the surety bond was not the correct value and increased the surety bond value on 05/24/22 to $75,000.00.

Based on observation, interview, record review, facility policy review, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to maintain infection control practices to prevent the spread of infectious diseases by failing to ensure the appropriate storage of clean linen and handling of soiled linen. This had the potential to affect all 49 residents who resided in the facility. Findings include: 1. Observation on 05/23/22 at 12:23 P.M. revealed a clean linen cart with three shelves located next to room [ROOM NUMBER]. Each shelf was stocked with bed linens, incontinence pads, gowns, washcloths, and briefs. There was one sheet applied to the highest shelf which left the lower two shelves with clean linen exposed. Interview at the time of the observation with the Director of Nursing (DON) verified the clean linen cart located next to room [ROOM NUMBER] was not covered as required. Observation on 05/23/22 at 12:25 P.M. revealed a clean linen cart with three shelves located next to room [ROOM NUMBER]. Each shelf was stocked with bed linens, incontinence pads, towels, washcloths, and pillow cases. There was one sheet applied to the highest shelf which left the lower two shelves with clean linen exposed. Interview at the time of the observation with DON verified the clean linen cart located next to room [ROOM NUMBER] was not covered as required. Observation on 05/23/22 at 12:27 P.M. revealed a clean linen cart with three shelves located next to room [ROOM NUMBER]. Each shelf was stocked with bed linens, incontinence pads, briefs, and gowns. There was one sheet applied to the highest shelf which left the lower two shelves with clean linen exposed. Interview at the time of the observation with the DON verified the clean linen cart located next to room [ROOM NUMBER] was not covered as required. Observation on 05/23/22 at 12:29 P.M. revealed a clean linen cart with three shelves located between room [ROOM NUMBER] and room [ROOM NUMBER]. Each shelf was stocked with bed linens, incontinence pads, towels, and washcloths. There was one sheet applied to the highest shelf which left the lower two shelves with clean linen exposed. Interview at the time of the observation with the DON verified the clean linen cart located between Rom 120 and room [ROOM NUMBER] was not covered as required. Review of facility policy, Clean Linen Storage, effective 10/20/21, revealed State tested Nursing Assistants were to keep clean linen cart covered at all times, and to ensure linen was handled and stored in a manner to keep it free from contamination. Review of Best Practices for Management of Clean Linen, last reviewed on 03/27/20, from the Centers for Disease Control and Prevention's Healthcare-Associated Infections (HAIs) Appendix D: Linen and Laundry Management, located at https://www.cdc.gov/hai/prevent/resource-limited/laundry.html#anchor_ 204 revealed to store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items. 2. On 05/25/22 at 9:01 A.M. observation of urinary catheter care performed by State tested Nursing Assistant (STNA) #229 for Resident #43 revealed STNA #229 carrying soiled linens with dirty gloves approximately fifteen feet into the hallway to discard the soiled linen in the soiled linen cart and dirty gloves into the trash can; both located in the hallway outside of room [ROOM NUMBER]. On 05/25/22 at 9:14 A.M. interview with STNA #229 verified she walked into the hallway carrying soiled linen with dirty gloves. STNA #229 stated she normally would bag the soiled linens after use in the resident's room, discard her dirty gloves, perform hand hygiene, and discard of the bagged soiled linen in the appropriate soiled linen cart. Review of the facility's policy, Linen Management, dated 03/25/20, revealed soiled linen would be placed into designated bags or other appropriate containers at the point of use.

Based on record review, interview and facility policy review, the facility failed to report to the State agency an alleged violation involving physical abuse between Residents #24 and #31. This affected two residents (#24 and #31) of five residents (#24, #26, #31, #48 and #148) reviewed for abuse, neglect, exploitation, and misappropriation. The facility census was 49. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note dated 03/26/22 at 2:35 P.M. by Registered Nurse (RN) #212 revealed Resident #24 was going into the B side television room at 11:00 P.M. when he was witnessed hitting another resident. Resident #24 stated he was defending himself because another resident was the aggressor. Interview on 05/24/22 at 11:24 A.M. with the Administrator verified Resident #24 had a physical altercation with Resident #31 on 03/25/22. The Administrator confirmed there was no self-reported incident (SRI) filed to the State agency or an investigation completed through the abuse, neglect, exploitation, and misappropriation process. Review of a one page investigation form dated 03/28/22 provided by the Administrator revealed an incident occurred on 03/25/22 which was reported by a nurse (unnamed) as a physical altercation between Residents #24 and #31. The Administrator viewed camera footage and saw Resident #31 walk quickly toward Resident #24 and grab a wet floor sign on the ground next to Resident #24 then Resident #24 hit Resident #31. Review of the medical record for Resident #31 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note dated 03/26/22 at 2:29 P.M. created by RN #212 revealed Resident #31 was in the B side television room when he was hit by another resident. When questioned Resident #31 stated hit me and there were no bruises noted. Review of the nursing progress note dated 03/26/22 at 3:32 P.M. created by Licensed Practical Nurse (LPN) #266 revealed after the resident to resident altercation, Resident #31 was quiet during the shift with no behaviors. Interview on 05/25/22 at 11:53 A.M. with the Administrator verified the Director of Nursing (DON) reported the incident to the Administrator on 03/26/22 by phone who received the report from LPN #252 on 03/25/22. Interview on 05/25/22 at 3:02 P.M. with RN #212 confirmed on 03/25/22 at 11:00 P.M. Residents #24 and #31 had an altercation which RN #212 did not see but heard. RN #212 indicated LPN #252 witnessed the incident and saw the hitting between Residents #24 and #31. RN #212 verified contacting the DON and the nurse practitioner after the incident occurred. Interview on 05/25/22 at 3:16 P.M. with LPN #252 verified on 03/25/22 at 11:00 P.M. Resident #24 hit Resident #31, and stated they were both attempting to hit each other. LPN #252 confirmed RN #212 reported the incident to the DON at the time it occurred. Interview on 05/25/22 at 11:53 A.M. with the Administrator verified the one page investigation form dated 03/28/22 was the only documentation available regarding the incident between Residents #24 and #31. The Administrator stated the incident happened over the weekend so on the following Monday, 03/28/22, she looked at the camera footage of the incident. The Administrator indicated believing since there were no injuries it was okay to wait until Monday to look at the camera footage and stated since it was not a big event it was recorded in a soft file, not as an allegation of physical abuse or SRI to the State agency. The Administrator confirmed LPN #252 witnessed the incident and since there were no negative outcomes or an actual injury it was decided not to report it through the abuse process. The Administrator further stated there were two criteria used to decide whether to file a SRI to the State agency after receiving an allegation of abuse which was whether there was a negative outcome such as a bruise or an actual injury or how public it was such as if there was a family member upset or a witness from the outside; otherwise, I could report five or six things a day. The Administrator verified for all alleged abuse incidents she completed a brief investigation to determine if a physical or emotional outcome occurred, and if not then it was not reported but soft files were kept of her actions. The Administrator stated there were times an SRI was filed with bad outcomes such as incidents with a lot of drama. Interview on 05/25/22 at 1:59 P.M. with the DON verified LPN #252 contacted her by telephone on 03/25/22 after the incident occurred and reported Residents #26 and #31 were arguing and swinging at each other. LPN #252 believed Resident #26 may have hit Resident #31 and reported one or two other residents also saw it happen. Interview on 05/26/22 at 9:32 A.M. with the DON confirmed the alleged physical altercation between Residents #26 and #31 occurred on 03/25/22 in the evening, and RN #212 contacted her by telephone after the incident occurred. The DON verified reporting the incident to the Administrator by telephone on 03/26/22 the next morning. Review of facility policy, Abuse Prevention Policy, revised 05/15/19 revealed all allegations of abuse must be reported to the Administrator and DON immediately, and the Administrator will initiate an investigation and submit a report to the State agency online reporting system immediately and complete the investigation no later than five days after the event. Examples of abuse include either reacting inappropriately to a situation such as pushing, poking, or slapping a resident or intentionally doing bodily harm.

Based on record review, interview and facility policy review, the facility failed to complete a thorough investigation involving an alleged violation of physical abuse between Residents #24 and #31. This affected two residents (#24 and #31) of five residents (#24, #26, #31, #48 and #148) reviewed for abuse, neglect, exploitation, and misappropriation. The facility census was 49. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note dated 03/26/22 at 2:35 P.M. by Registered Nurse (RN) #212 revealed Resident #24 was going into the B side television room at 11:00 P.M. when he was witnessed hitting another resident. Resident #24 stated he was defending himself because another resident was the aggressor. Interview on 05/24/22 at 11:24 A.M. with the Administrator verified Resident #24 had a physical altercation with Resident #31 on 03/25/22. The Administrator confirmed there was no self-reported incident (SRI) filed to the State agency or an investigation completed through the abuse, neglect, exploitation, and misappropriation process. Review of a one page investigation form dated 03/28/22 provided by the Administrator revealed an incident occurred on 03/25/22 which was reported by a nurse (unnamed) as a physical altercation between Residents #24 and #31. The Administrator viewed camera footage and saw Resident #31 walk quickly toward Resident #24 and grab a wet floor sign on the ground next to Resident #24 then Resident #24 hit Resident #31. Review of the medical record for Resident #31 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note dated 03/26/22 at 2:29 P.M. created by RN #212 revealed Resident #31 was in the B side television room when he was hit by another resident. When questioned Resident #31 stated hit me and there were no bruises noted. Review of the nursing progress note dated 03/26/22 at 3:32 P.M. created by Licensed Practical Nurse (LPN) #266 revealed after the resident to resident altercation, Resident #31 was quiet during the shift with no behaviors. Interview on 05/25/22 at 11:53 A.M. with the Administrator verified the Director of Nursing (DON) reported the incident to the Administrator on 03/26/22 by phone who received the report from LPN #252 on 03/25/22. Interview on 05/25/22 at 3:02 P.M. with RN #212 confirmed on 03/25/22 at 11:00 P.M. Residents #24 and #31 had an altercation which RN #212 did not see but heard. RN #212 indicated LPN #252 witnessed the incident and saw the hitting between Residents #24 and #31. RN #212 verified contacting the DON and the nurse practitioner after the incident occurred. RN #212 stated a facility incident report was completed. Interview on 05/25/22 at 3:16 P.M. with LPN #252 verified on 03/25/22 at 11:00 P.M. Resident #24 hit Resident #31, and stated they were both attempting to hit each other. LPN #252 confirmed RN #212 reported the incident to the DON at the time it occurred and a facility incident report was completed. Interview on 05/25/22 at 11:53 A.M. with the Administrator verified the one page investigation form dated 03/28/22 was the only documentation available regarding the incident between Residents #24 and #31. The Administrator stated the incident happened over the weekend so on the following Monday, 03/28/22, she looked at the camera footage of the incident. The Administrator indicated believing since there were no injuries it was okay to wait until Monday to look at the camera footage and stated since it was not a big event it was recorded in a soft file, not as an allegation of physical abuse or SRI to the State agency. The Administrator confirmed LPN #252 witnessed the incident and since there were no negative outcomes or an actual injury it was decided not to report it or investigate through the abuse process. The Administrator confirmed there were no witness statements obtained from the perpetrator, victim, or witnesses from the reported physical altercation between Residents #26 and #31 on 03/25/22. Interview on 05/25/22 at 1:59 P.M. with the DON verified LPN #252 contacted her by telephone on 03/25/22 after the incident occurred and reported Residents #26 and #31 were arguing and swinging at each other. LPN #252 believed Resident #26 may have hit Resident #31 and reported one or two other residents also saw it happen. Interview on 05/26/22 at 9:32 A.M. with the DON confirmed the alleged physical altercation between Residents #26 and #31 occurred on 03/25/22 in the evening, and RN #212 contacted her by telephone after the incident occurred. The DON verified reporting the incident to the Administrator by telephone on 03/26/22 the next morning. Review of facility policy, Abuse Prevention Policy, revised 05/15/19 revealed all allegations of abuse must be reported to the Administrator and Director of Nursing immediately, and the Administrator will initiate an investigation and submit a report to the State agency online reporting system immediately and complete the investigation no later than five days after the event. Examples of abuse include either reacting inappropriately to a situation such as pushing, poking, or slapping a resident or intentionally doing bodily harm.

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity. This affected one resident (Resident #14) of 48 residents living in the facility at the time of the survey. Findings include: Observation of the A-section dining room on 07/01/19 at 12:07 P.M. revealed Resident #14 wheeled up to State tested Nursing Aide (STNA) #203 and announced I don't want nothing to eat. STNA #203 walked past the resident and called over her shoulder with her back to the resident, You don't want nothing to eat? as she delivered a meal tray to a different resident. STNA #203 then turned back to Resident #14 and began walking towards him and the resident said again, I don't want nothing to eat, as STNA #203 walked past him again. STNA #203 again called over her shoulder, You don't want nothing to eat? STNA #203 continued serving food to other residents, and did not return to Resident #14's side or further acknowledge him. Resident #14 then wheeled himself out of the dining room. The above observations were confirmed with STNA #203 on 07/01/19 at 12:14 P.M. Interview with Resident #14 at 2:55 P.M. on 07/01/19 revealed he felt some people at the facility were not nice, but he did not identify any specific concerns with the staff.

Based on observation, interview, and record review, the facility failed to ensure a table was provided in a timely manner for Resident #298's suction machine. This affected one of one resident reviewed for [MEDICAL CONDITION] care. The facility census was 48. Findings include: Review of Resident #198's medical record revealed the resident was admitted to the facility 02/06/19 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #198's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was independent and required set up only for all areas of activities of daily living. Review of Resident #198's plan of care dated 06/22/19 revealed the resident had a [MEDICAL CONDITION] related to impaired breathing mechanics. Interventions included: ensure [MEDICAL CONDITION] are always secured. Monitor/document for restlessness, agitation, confusion, increased heart rate ([MEDICAL CONDITION], and slow heart rate ([MEDICAL CONDITION]). Suction as necessary. Use one humidification device each evening for [MEDICAL CONDITION]. Observation of Resident #198's room on 07/01/19 at 1:56 P.M. revealed the resident's suction machine was located on the floor and not within reach if the resident required emergency suctioning. The observations were verified with Registered Nurse (RN) #303 on 07/01/19 at 1:56 P.M. Interview with Resident #198 on 07/01/19 at 2:20 P.M. revealed she independently suctioned herself and cleaned her [MEDICAL CONDITION] stoma without supervision of staff. Resident #198 stated she had asked the facility for a table to place her suction machine. Resident #198 stated in case of an emergency she would have to pick up the suction machine off of the floor to use it if she had a mucous plug or trouble breathing. Observation of Resident #198's room on 07/02/19 at 12:22 P.M. revealed the resident's suction machine was located on the floor and not within reach if the resident required emergency suctioning. The observation was verified with RN #303 on 07/02/19 at 12:22 P.M. Interview with RN #303 on 0702/19 at 1:22 P.M. verified the resident needed a table to place the suction machine and aerosol nebulizer on. RN #303 verified the suction machine was not within reach if the resident required emergency suctioning through her [MEDICAL CONDITION]. Observation of Resident #198's room on 07/03/19 at 8:10 A.M. revealed the resident's suction machine was in direct contact with the soiled floor and uncovered. A table for the suction machine was not provided until 07/03/19 at 12:00 P.M.

Based on observation, interview, and record review, the facility failed to ensure Resident #37 was provided privacy during incontinence care. this affected one resident observed for incontinence care. The facility census was 48. Findings include: Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident required extensive assist of two persons for bed mobility and transfers. Resident #37 required and extensive assist of one person for dressing, toilet use and personal hygiene. Review of Resident #37's plan of care dated 07/02/19 revealed the resident had a behavior problem related to exposing self and urinating on the floor. Interventions included: administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Resident to keep urinal with him throughout the day. Observation of Resident #37's bowel incontinence care with State tested Nursing Assistant (STNA) # 300 revealed the resident had been incontinent of bowel. STNA #300 removed his pants and instructed the resident to sit in the wheelchair until she could obtain wash cloths and towels to complete his incontinence care. STNA #300 left the room, left resident 337's door wide open with the resident genitals exposed to any resident of visitor passing the room. Interview with Registered Nurse (RN) # 303 on 07/01/19 t 1:20 P.M. verified all staff were to provide privacy when completing incontinence care.

Based on observation, interview and record review, the facility failed to implement Resident #37's plan of care to ensure his wheelchair brakes could be locked to prevent the wheelchair from pushing backward when the resident stood up. This affected one of four residents observed for wheelchair brakes in good repair. The facility census was 48. Finding include: Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required an extensive assist of two persons for bed mobility and transfers. Resident #37 required extensive assist of one person for dressing, toilet use and personal hygiene. Resident #37's MDS 3.0 dated 05/14/19 also revealed the resident had unsteady balance when moving from a seated position to a standing position, was not steady when walking or turning around and facing the opposite side. Review of Resident #37's plan of care dated 09/06/18 revealed the resident was at risk for falls related to gait/balance problems. Interventions included: anticipate and meet needs. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. Bed Alarm. Chair Alarm. Educate resident to ensure he is sitting all the way in his wheelchair. Educate resident to lock wheelchair prior to attempting to transfer out of wheelchair. Educated resident to call for assistance when wanting to transfer out of bed. Fix wheelchair locks, and ensure wheelchair is working properly before use. Follow fall protocol. Observation of Resident #37 on 07/01/19 at 12:38 P.M. revealed State tested Nurse Aide (STNA) #300 verbally prompt Resident #37 to self-propel himself to the sink. Resident #37 was incontinent of bowel movement and needed to be washed up. Resident #37 was able to self-propel the wheelchair with the brakes locked in place. STNA #300 had the resident stand at the sink and hold onto the sink while she cleaned him up. Resident #37 was unsteady as he stood holding on to the sink. Resident #37 stated he couldn't stand much longer and was told he had to stand while he was cleaned up. Resident #37 was unsteady as STNA #300 transferred the resident from the seated position in the wheelchair to a standing position. STNA #300 did not obtain a second person to provide assistance to ensure the resident did not fall while trying to hold onto the sink. Interview with Registered Nurse (RN) #303 on 07/02/19 at 11:10 A.M. verified STNA #300 should have obtained a second staff member to help with Resident #37. RN #303 further stated night shift was to check Resident #37's brakes on a nightly basis and let maintenance know if the brakes needed tightening. RN #303 stated she could not find documented evidence maintenance had been notified of the resident's wheelchair brakes not locking properly. Interview with Maintenance Director (MD) #304 on 07/02/19 at 10:55 A.M. revealed he was unaware Resident #37's wheelchair brakes needed tightened. MD #304 stated normally staff would send him a work order and he would tighten the brakes the same day. MD #304 verified at 11:50 A.M. he did not have a work order to tighten the resident's wheelchair brakes. MD #304 verified the brakes were loose and the brakes had to be tightened to work properly.

Based on record review and interview, the facility failed to ensure residents received all required information upon their discharge. This affected one (Resident #49) of one resident reviewed for appropriate discharge. The total census was 48. Findings include: Record review of Resident #49 revealed the resident was admitted to the facility 10/17/18 and had [DIAGNOSES REDACTED]. He was discharged from the facility on 05/06/19. His discharge instructions dated 05/06/19 revealed that he was discharged to a group home, was to follow up with his primary care provider, and had medications called in to a pharmacy. No evidence could be found in the instructions or elsewhere that the resident received discharge information including a summary of his stay or status, reconciliation of the discharge medications, a post-discharge plan or care, or instructions clarifying any specifics of his care needs. Interview with Assistant Administrator #202 on 07/03/19 at 8:56 A.M. confirmed the above findings.

Based on observation, interview and record review, the facility failed to provide supervision to prevent Resident #11 from obtaining a lighter. This affected one of five residents identified as residents who smoked. The facility census was 48. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was independent and required no set up for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Review of Resident #11's plan of care dated 04/03/19 revealed the resident was a smoker. Goals included the resident would always be kept safe while smoking. Interventions included resident was not to have any lighters or matches in his or her possession. Resident to remain compliant of the smoking policy always. Staff to keep cigarettes in a designated area, giving each resident one cigarette at a time. Staff to educate and encourage resident to start a smoking cessation program. Review of Resident #11's smoking assessment dated [DATE] revealed the resident was alert and oriented to person, place and time. Resident #11 was deemed independent for skills in making daily decisions. The resident's clothing was free of burns, vision was adequate for holding a cigarette and extinguishing it properly and the resident was physically able to smoke. Resident #11 was deemed safe to independently smoke. Observation of Resident #11 on 07/01/19 at 9:10 A.M. revealed the resident was lying on his right side facing the wall. Resident #11 had a cigarette lighter in his bed, in plain sight, on top of his bed, laying near his buttocks. The observation was verified with Registered Nurse (RN) #303 on 07/01/19 at 9:11 A.M. Interview with RN #303 on 07/01/19 at 9:11 A.M. verified Resident #11 was independent in smoking, and no resident was to have a cigarette lighter in their room. RN #303 stated she had no idea how the resident would have obtained the lighter because staff were the only ones to have access to the lighter. Review of the facility's Smoking Policy revised 07/03/18 revealed for the safety of the residents and staff smoking would only be permitted indoors in the smoking room located on the first floor next to the dining room. Outdoor smoking would be permitted on the front porch off the main dining room effective from (MONTH) through (MONTH) and in the back courtyard effective (MONTH) through September. No person (staff, resident, or visitor) would be permitted to smoke in any other areas of the building. Smoking in resident rooms was strictly prohibited. No resident would be permitted to keep matches or a lighter. The facility provided a lighter in the smoke room that residents must use to light their cigarettes. In the event that the facility discovered or suspected that a resident was non compliant with the policy it was to be reported immediately to the supervisor. If the suspicion was confirmed by the supervisor, the supervisor would contact the Director of Nursing to inform her of the situation. The Director of Nursing would initiate a room sweep to ensure all smoking related materials were safely secured. The Director of Nursing would notify the administrator immediately and the administrator might initiate a 15-minute check depending on the seriousness of the offense. A 30-day discharge might be initiated depending on the seriousness of the offense. Failure by staff to report any noncompliance would result in disciplinary action.

Based on observation, interview and record review, the facility failed to ensure Resident #36's oxygen tank was handled appropriately and was not empty while in use. This affected one of three residents observed in the dining room with a portable oxygen tank in use. The facility census was 48. Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #36's 14-day Minimum Data Set assessment dated [DATE] revealed the resident required limited assistance from one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #36's plan of care dated 05/03/19 revealed the resident had [MEDICAL CONDITION] related to smoking. Interventions included check resident Pulse-oximetery every shift to ensure greater than 90%. Educate resident on the risk factors of continuing to smoke and encourage resident to quit. Give oxygen therapy as ordered by the physician. Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence. Monitor/document/report to physician as needed any signs and symptoms of respiratory infection: fever, chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing. Observation on 07/01/19 at 11:55 A.M. revealed Resident #36 seated at a table with a portable oxygen tank on back of the wheelchair with a nasal cannula hooked to it. The tank gauge was in red and on zero. The resident was not in respiratory distress. State tested Nurse Aide (STNA) #300 was observed getting the dining room ready for lunch. At 12:10 P.M. the surveyor asked STNA #300 if the tank was empty. STNA #300 stated the tank was empty, unhooked the nasal cannula and removed the oxygen tank from the wheelchair. STNA #300 took the empty oxygen tank to the B unit and returned with a new oxygen tank. STNA #300 hooked up the nasal cannula connecter to the flow meter on the tank, adjusted the flow to three liter/minute. The surveyor asked STNA #300 to obtain a nurse to check the resident's pulse oxygenation. Registered Nurse (RN) #303 came to the dining room at 12:12 P.M. and checked the resident pulse oxygenation which was 92% on three liter of oxygen per minute via a nasal cannula. Interview with the Director of Nursing (DON) on 07/02/19 at 2:34 P.M. revealed nursing staff was to ensure the tank was full and if getting low STNA's were to inform the nurse and the nurse would provide a new tank to replace the empty tank. Review of the facility's Care of Oxygen Policy and Procedure (no date) revealed there must be a physician's orders [REDACTED]. Only licensed nurses were authorized to set up oxygen administration or make changes to oxygen administration. Staff members must be instructed to notify the Unit Nurse if the oxygen canister was low or empty, the resident removed the face mask or cannula or disconnected any of the tubing. The Unit Nurse must instruct staff members that they must not disconnect any of the oxygen tubing or change the flow rate of the oxygen.

Based on observation, record review, and interview, the facility failed to ensure bed rails were only applied for residents with appropriate consent, assessment, and documentation. This affected one (Resident #43) of one resident reviewed for restraints. The total census was 48. Findings include: Observation of Resident #43 on 07/01/19 at 2:47 revealed he had two quarter-length bedrails pulled up on each side of his bed. Record review of Resident #43 revealed he was admitted to the facility on [DATE], and was identified by the facility as having severe cognitive impairment, and required supervision for bed mobility and transfers. He had [DIAGNOSES REDACTED]. The review revealed no evidence of any orders or care plan for bed rails, no signs of an assessment for risk of entrapment or restraint, no evidence of informed consent for bed rails, and no mention of their use in the progress notes. These findings were confirmed with the Director of Nursing on 07/02/19 at 11:37 A.M.

Based on observations, staff and resident interviews, review of the facility ' s smoking policy, review of 15 minute check logs and record review, the facility failed to provide adequate supervision and interventions related to smoking and failed to enforce smoking policy rules. This resulted in Immediate Jeopardy for three of six residents reviewed who were smokers, Residents #42 and #44 who smoked while using or having oxygen tanks adjacent to their person, and Resident #40 who was observed smoking in her room. There were 14 identified smokers in the facility. The census was 47. On 06/24/14 at 4:50 P.M., the administrator and director of nursing (DON)were notified that Immediate Jeopardy began on 07/12/13 at 1:37 P.M. when Resident #44 was smoking in his room while using oxygen. The Immediate Jeopardy continued when Resident #44 was found smoking in his room on 08/19/13, 10/13/13, 11/05/13, 11/12/13, 05/21/14, 05/23/14, 06/10/14 and on 06/24/14. In addition, Resident #42 was smoking with the oxygen tank on his wheelchair on 04/02/14, 04/03/14, 06/09/14, 06/16/14 and 06/24/14. Resident #40 was found smoking in her room on 01/07/14 and was observed on 06/23/14 with a lighter in her room. The Immediate Jeopardy was removed on 06/25/14 when the facility implemented the following corrective actions: ? On 06/24/14 at 5:30 P.M. the administrator designated one assigned staff person per shift to monitor the designated smoking room during assigned specified times and the monitoring system was implemented on 06/24/14 at 7:30 P.M. by the DON. ? On 06/24/14 at 5:30 P.M. the administrator and DON conducted room sweeps removing 11 lighters from resident rooms. ? On 06/24/14 at 5:40 P.M. the administrator closed access to smoking outside of the building making the interior smoke room the only designated smoking area. ? On 06/24/14 at 6:15 P.M. the administrator and DON met with the 14 residents in the nursing home who smoked and informed them of the significance of safe smoking and that not following safety rules would result in discharge from the facility. The administrator was given 2-3 more lighters by the residents at that time that were not provided during previous room sweeps. The residents had the lighters on their person. ? On 06/24/14 at 7:00 P.M. the smoking policy and procedure was revised to include the monitoring system for the designated smoke room, smoking would only be permitted in the designated smoking room on the first floor next to the dining room and noncompliance would result in a 30 day discharge notice. ? On 06/24/14 at 7:45 P.M. the administrator informed his supervisory team that no staff person would return to work without receiving education on the revised smoking policy and procedure. ? On 06/24/14 at 8:00 P.M. the DON educated 13 evening and night shift staff, of 46 total staff, on the revised smoking policy and procedure. The staff signed a receipt and they were provided a copy of the policy. ? On 06/24/14 at 8:00 P.M. the administrator educated all 14 smoking residents of the change in policy. Each resident signed receipt of the policy. ? On 06/24/14 at 10:30 P.M. the DON completed an audit of the smoking assessments of Residents #40, #42 and #44 and the 11 other residents who smoked (Residents #11, #12, #15, #16, #17, #19, #27, #31, #46, #49 and #53) and revised their care plans as needed. Although the Immediate Jeopardy was removed when the facility established systems to ensure monitoring of residents ' smoking activity, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because although the facility initiated training on the revised smoking policy and procedure on 06/24/14, all 46 staff members had not received the training. Findings include: 1. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial nursing assessment dated [DATE] indicated he was cooperative, alert, and used oxygen continuously. Review of the initial smoking assessment dated [DATE] and smoking assessments dated 09/23/13, 10/08/13, 01/24/14 and 06/06/14 indicated Resident #44 was unsafe when smoking. Resident #44 needed reminders not to bring his oxygen tank into the smoking room and reminders to smoke strictly in designated smoking areas and not in his room. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #44 was alert and oriented and able to make decisions. No behaviors were identified. Review of the care plan lacked indication he was unsafe when smoking related to using oxygen. Review of the progress note, authored by Social Services (SS) #93, identified Resident #44 was found smoking in his room on 07/12/13 at 1:37 P.M. Resident #44 was educated on the smoking areas and times. Resident #44 indicated he would not smoke in his room again. The note did not indicate if SS #93 removed a lighter from the room. Review of the progress note dated 08/19/13 at 2:38 P.M., authored by the DON, indicated Resident #44 was observed smoking in his room wearing his oxygen. The room smelled strongly of smoke. Resident #44 informed the DON he smoked because he was bored. He was made aware of the risk of smoking while oxygen was in use. The note indicated he had been made aware on several occasions not to smoke while oxygen was in use. Resident #44 was informed that this was his last warning before a 30 day notice would be issued. The physician/medical director was made aware of Resident #44 ' s noncompliance with smoking in his room. Review of the progress note dated 10/13/13 at 7:11 A.M., authored by Licensed Practical Nurse (LPN) #55, indicated she observed a large amount of cigarette ashes in the resident ' s bathroom floor. The resident was asleep at the time. Review of the progress note dated 10/28/13 at 11:00 A.M., authored by SS #93, indicated the administrator and SS #93 discussed the smoking rules with Resident #44. Resident #44 was informed if he was noncompliant with the smoking rules that the facility would take action and could discharge him from the facility. Review of the progress note dated 11/05/13 at 5:54 P.M., authored by Registered Nurse (RN) #53, indicated Resident #44 was found smoking in the bathroom. Resident #44 was informed of the danger of smoking while using oxygen. The note did not indicate RN #53 had asked the resident to turn in his lighter. Review of the progress note dated 11/12/13 at 4:28 P.M., authored by the DON, revealed Resident #44 ' s room smelled of smoke and ashes were on the toilet seat. The administrator and DON met with the resident to discuss smoking in his room. Resident #44 gave up the smoking materials. The DON noted there had been several attempts to address his smoking in his room. Review of the progress note dated 05/21/14 at 2:55 P.M., authored by RN #53, indicated Resident #44 was smoking in his room and caused the smoke alarm to go off. The note indicated Resident #44 bought a pack of cigarettes from another resident. Resident #44 finally gave his cigarettes to staff but RN #53 noted he ' d been seen going to the smoke room twice without asking for cigarettes. RN #53 documented she believed that the resident had a pack of cigarettes in his possession. The note did not indicate RN #53 asked the resident to turn in his smoking materials. Review of the progress note dated 05/23/14 at 6:25 A.M., authored by the DON, revealed Resident #44 was observed sitting on the toilet with his oxygen concentrator on via nasal cannula and smoking a cigarette. The DON asked Resident #44 to put the cigarette out and hand it over. Resident #44 refused, began to scream and closed the bathroom door. Review of the progress note dated 05/23/14 at 11:49 A.M., authored by the administrator, indicated the administrator had educated Resident #44 that it was against the rules to smoke anywhere other than the designated smoking areas. Resident #44 was informed that if there was ever an incident of smoking in his room he would be issued a 30 day discharge notice. Review of a Discharge Notice form revealed Resident #44 was given a 30 day discharge notice dated 06/10/14. The notice indicated on 05/23/14 Resident #44 had been smoking in his room, and the administrator reviewed the facility smoking policy with the resident and informed him that any further violations would result in his discharge from the facility. A 15 minute check schedule had been initiated to ensure Resident #44 stayed in compliance with the facility policy. The discharge notice indicated that on 06/10/14 at 10:30 A.M., the smoke detector was activated in Resident #44 ' s room. RN #94 responded and found a cigarette butt on the floor of the bathroom. The notice indicated that despite the facility ' s efforts Resident #44 continued to disregard the facility policy and it was determined it was in the best interest of the facility and the other residents to find alternative placement for Resident #44. Review of the progress notes revealed no entry regarding the 06/10/14 incident. On 06/23/14 at various times during the day, including 3:00 P.M. and on 06/24/14 at 8:57 A.M., multiple residents were observed entering/exiting independently out the back door on the B wing to smoke. No staff were observed monitoring the area. Interview with RN #54 on 06/24/14 at 2:10 P.M. reported Resident #44 received a 30 day discharge notice. RN #54 stated he used oxygen continuously and was caught smoking in his room last night on 06/23/14. RN #54 stated staff could not enforce the rules with the resident because he would just curse at them. She stated the policy was that residents in the attached assisted living could have lighters but long term care residents could not. RN #54 was aware residents in the long term care area had lighters. She stated they often got them from the assisted living residents or had Resident #17 purchase lighters upon request. RN #54 verified Resident #44 was noncompliant with the smoking rules. Interview with RN #53 on 06/24/14 at 2:38 P.M. revealed she was also aware of Resident #44 smoking in his room. She stated one evening (no date specified) he walked in from the outside smoking a cigarette on his way to his room. RN #53 made him put out the cigarette and provided education. RN #53 said the resident was on 15 minute checks to ensure he was not smoking in an undesignated area. She searched through a stack of papers and found a few 15 Minute Check logs with various dates in June 2014. The 15 Minute Check logs identified date, time, location and staff signatures. Review of the 15 Minute Check logs dated June 2014 revealed the logs were not complete. Review of Resident #44 ' s 15 Minute Check log for 06/24/14 at 2:40 P.M. with RN #53 revealed there were no staff signatures on the document but at 8:00 A.M., " Smoking in room " was handwritten on the log. The log was incomplete from 8:30 A.M. until 1:45 P.M. The log documented at 2:00 P.M., 2:15 P.M., and 2:30 P.M. the resident was " in room smoking " . RN #53 was not aware the resident had been found smoking in his room at those times. There was no evidence these incidents were reported to nursing or if intervention was attempted. State tested Nurse Aide (STNA) #66, who had been assigned to Resident #44 on 06/24/14, had already left for the day. Interview with RN #54 on 06/24/14 at 4:47 P.M. revealed she was unaware Resident #44 had smoked in his room on 06/24/14 until the surveyor brought it to her attention. She stated in the past when he set off the smoke alarm in his room by smoking and wearing the oxygen, she reported it to the DON. Interviews on 06/24/14 with STNA #58 at 4:50 P.M., STNA #59 at 4:55 P.M., and LPN #56 at 5:20 P.M. revealed they were all aware Resident #44 had been caught smoking in his room while using oxygen and needed to be monitored. These staff were aware of the dangers of smoking near oxygen and that the residents had their own smoking materials including lighters. Interview with STNA #66 on 06/26/14 at 8:12 A.M. verified she was assigned to Resident #44. She showed the surveyor the 15 Minute Check log revealing three notations on 06/26/14 at 7:00 A.M., 7:15 A.M. and 7:30 A.M. that indicated the resident was in his room asleep. She had not signed each entry. She verified she had seen the resident in his room asleep but she did not sign her name. She said she had been educated that she should have signed each entry. She verified that she caught Resident #44 smoking in his room four times on 06/24/14. She stated she did not witness him actually smoking but found the room thick with smoke. She stated Resident #44 denied smoking on each occasion. STNA #66 stated she reported each occurrence to the DON. 2. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the June 2014 physician orders [REDACTED]. Review of the smoking assessment dated [DATE] indicated Resident #42 required supervision while smoking cigarettes. The plan of care did not address smoking while having the portable oxygen tank attached to his wheelchair. The progress notes dated 04/02/14 at 9:45 A.M., 04/03/14 at 8:40 P.M., 06/09/14 at 4:01 P.M., 06/16/14 at 3:34 P.M., and 06/24/14 at 2:58 P.M. indicated that he continued to take off his oxygen and smoke. On 06/24/14 at 2:00 P.M. Resident #42 was observed in his wheelchair coming from outside the B wing back door. He was wheeling himself toward his room. A nasal cannula was draped over the left arm rest and a portable oxygen tank was on the back of his wheelchair. The oxygen tank was turned off. Interview with Resident #42 on 06/24/14 at 2:00 P.M. verified he ' d been smoking outside. He was aware he shouldn ' t have the oxygen on while smoking. No staff were observed monitoring the area Interview with RN #54 on 06/24/14 at 2:10 P.M. verified the resident smoked with the tank on his wheelchair but the oxygen turned off. She revealed she was aware Resident #42 went outside to smoke independently with an oxygen tank. She said she had educated him repeatedly but it was not effective. RN #54 reported Resident #42 brought his oxygen tank into the smoke room. She stated staff could tell him over and over and he would still do it. He wanted to smoke no matter what. She said Resident #42 was not the only resident who disregarded the smoking rules. 3. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the progress note dated 01/07/14 at 8:43 P.M., authored by RN #94, Resident #40 was caught smoking in her room. RN #94 educated the resident and explained she needed to smoke in the smoke room. Review of a Smoking assessment dated [DATE] for Resident #40 revealed she had been assessed to be an independent smoker. Her record contained no care plan regarding smoking. Resident #40 was interviewed on 06/23/14 at 1:27 P.M. and a lighter was observed on her overbed table. Review of the facility ' s smoking policy dated 05/23/14 indicated no resident would be permitted to keep matches or lighters. If these items were found, the facility had the right to confiscate the items. There was to be no smoking in the facility except in the designated area near the A wing dining room. Residents could smoke in the courtyard weather permitting. Residents could smoke anytime except for meal times. Interview with the following second and third shift staff verified they were all provided training on the new smoking policy and procedure dated 06/24/14 by the DON: LPN #55 on 06/25/14 at 6:25 A.M., STNA #61 on 06/25/14 at 6:55 A.M., STNA #62 on 06/25/14 at 6:20 A.M. and STNA #63 on 06/25/14 at 6:23 A.M. On 06/25/14 at 7:00 A.M. the administrator was observed providing training on the new smoking policy and procedure to the day shift attended by14 staff including STNAs, dietary and housekeeping staff. Observations on 06/25/14 at 6:20 A.M., on 06/25/14 at 1:18 P.M. and on 06/26/14 at 2:55 P.M. revealed a staff person was monitoring residents smoking in the smoking room. Observations on 06/30/14 at 3:56 P.M. and 4:47 P.M., and on 07/01/14 at 8:31 A.M., 10:10 A.M., 10:32 A.M., 11:12 A.M., 2:15 P.M. and 2:55 P.M. revealed a staff person was monitoring residents smoking in the smoking room. Observation on 07/01/14 at 10:10 A.M. revealed Resident #42 was smoking a cigarette in the smoking room. He did not have his oxygen tubing or oxygen tank with him in the room.