Every finding on record at St Luke Lutheran Community-Portage Lakes

Based on observations of staff, staff interview, review of the Payroll Based Journal (PBJ) report, review of staff schedules for the residential care facility (RCF) and skilled nursing facility (SNF), the facility failed to have a distinct dedicated staff to provide care and services to the SNF residents and failed to ensure they reported accurate information for PBJ report. This had the potential to affect all 49 residents residing in the SNF. The facility census was 49. Findings include:1. Review of the schedules for SNF and RCF, also commonly referred to as Assisted Living (AL), revealed they were written on the same page. It had four to five assignments with specified units or rooms on SNF and then an AL assignment.Interview on 08/10/26 at 1:58 P.M. with Certified Nursing Assistant (CNA) #222 on the SNF revealed she was working on AL that day but came over to help SNF. When asked if she worked SNF and AL on the same date and schedule, she responded definitely!. Interview on 08/11/26 at 3:37 P.M. with Administrator revealed there were five CNA assignments on first shift (7:00 A.M. to 3:00 P.M.) and second shift (3:00 P.M. to 11:00 P.M.) and four CNA assignments on third shift (11:00 P.M. to 7:00 A.M.). The fourth/fifth CNA assignment was designated for AL only. The nurses had two assignments per shift on SNF. Nurse One had [NAME] and North. Nurse Two had South, East and AL. She stated Nurse Two would start shift on SNF then go to AL to administer medications around meal times and bed time. Administrator stated Nurse One would cover the cart on SNF while Nurse Two was on AL. The schedule was not set times and would vary based on resident needs. She did not know a specific timeframe the nurse spent on AL as it could change based on needs. Administrator, with the help of the Director of Nursing (DON), estimated the SNF nurse spent one and a half hours total on the AL for the day. Administrator verified she was not aware they could not share staff as this was her first time managing an AL. Subsequent interview with Administrator on 08/12/26 at 10:15 A.M. revealed moving forward, we are putting a nurse over there (AL). Interview on 08/12/26 at 10:00 A.M. with CNA #257 revealed she has left AL at times to help with a mechanical lift on SNF but stated it was rare.Interview on 08/12/26 at 10:13 A.M. with CNA #248 revealed Nurse Two may tell her when she was leaving SNF to go to AL but not always.Observation on 08/12/26 at 2:06 P.M. indicated no staff on AL.Observation on 08/12/26 at 2:17 P.M. revealed CNA #257 returned to AL with water pitchers.Interview 08/12/26 at 2:17 P.M. with CNA #257 revealed she was off AL to get ice water, and no staff were on AL. She stated she had to go to kitchen to get trays for each meal. She also stated she would come to skilled hall to assist with transfers as needed. She stated she had a beeper that would alert if a resident needed something.Review of staffing tool revealed the direct care daily average was above 3.48 for week of 08/03/26 through 08/09/26 after deducting one and a half hours of nursing hours for first and second shifts.2. Review of the PBJ report revealed one-star staffing for quarter 3 2026.Interview on 08/10/26 at 9:00 A.M. with Administrator revealed the facility discovered they were not submitting Administrator hours for the PBJ which she stated was the cause of the one-star staff rating.Review of samples of PBJ reporting and interview on 08/12/26 at 3:40 P.M. with Director of Nursing revealed they did not report Administrator hours 11/30/25 through 12/06/25 and 08/16/26 through 08/22/26 revealed Administrator hours as zero. The DON stated these were just examples she pulled of when Administrator hours were not entered. No other information was provided.This deficiency represents non-compliance investigated under Master Complaint Number 3095361, Complaint Number 3012133, Complaint Number 2966187, Complaint Number 2796124 and Complaint Number 2718329.

Based on observation, staff interviews, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This had the potential to affect 93 out of 94 residents residing in the facility. Resident #10 was identified by the facility as eating nothing by mouth. The facility census was 94.Findings include:A tour of the kitchen on 08/10/26 at 8:08 A.M. with Dietary Aide (DA) #402 revealed near the tray line was a reach-in refrigerator that had a torn gasket with mold on the gasket and food residue on the bottom. There was a fan running in the kitchen that had grease and dust on the blades. The reach-in freezer had grease on the front of the freezer door and on the handle, and dust over the vents to the compressor. The shelf over the stove had grease, dirt and grime on it. The exhaust hood had greasy filters. In the storeroom, there was colored pasta, elbow noodles that were open but not labeled or dated, along with a thickener and a container of breadcrumbs that were also open and not covered, without a label or date. In the walk-in refrigerator there was a food item that DA #402 identified as chicken casserole that did not have a label or date. DA #402 verified all of the above findings. Interview on 08/11/26 at 12:25 P.M. with Registered Dietitian (RD) #300 revealed that she audits the kitchen every month and sanitation was a concern.Review of the facility policy dated 11/22 titled, Sanitation, revealed that the food service area is maintained in a clean and sanitary manner.This deficiency represents non-compliance investigated under Complaint Number 2796124.

Review of the Payroll Based Journal (PBJ) report revealed that the facility failed to accurately report the required staffing information for PBJ report. This had the potential to affect all 49 residents. The facility census was 49. Findings include:Review of the PBJ report revealed one-star staffing for Quarter 3 2026.Interview on 08/10/26 at 9:00 A.M. with Administrator revealed the facility discovered they were not submitting Administrator hours for the PBJ which she stated was the cause of the one-star staff rating.Review of samples of PBJ reporting and interview on 08/12/26 at 3:40 P.M. with Director of Nursing (DON) revealed they did not report Administrator hours 11/30/25 through 12/06/25 and 08/16/26 through 08/22/26. The DON stated these were just examples she pulled showing zero hours for the Administrator, as the hours were not entered.

Based on observation and staff interviews the facility failed to maintain a clean, sanitary and safe environment. The facility also failed to ensure there was enough linens to care for residents. This had the potential to affect all 49 residents residing in the facility. The facility census 49.Findings include:1. Observation on 08/11/26 at 5:45 A.M. revealed that the front door of the facility was opened wide. Activities Director (AD) #700 verified that the door was wide open at 5:50 A.M.Interview on 08/11/26 at 5:47 A.M. with Director of Nursing (DON) revealed that the front door of the facility should have been closed and locked. The DON had a head count of residents, and all residents were accounted for that resided in the facility.2. Observation on 08/11/26 at 5:55 A.M. with Certified Nursing Assistant (CNA) #249 revealed that the linen cart had two bath towels and seven washcloths for 49 residents. Interview with CNA #249 at the time of the observation revealed the facility was always short linen.3. Observation and interview on 08/11/26 at 6:03 A.M. with Housekeeping Supervisor (HS) #302 revealed that there were no clean wash clothes or towels located in the laundry department. In the linen closet where emergency supplies are kept, there were extra sheets, pillowcases, and blankets. HS #302 stated that he ordered linen four months ago and only received one case of wash clothes. HS #302 shared he had not placed any other orders for linen lately.Interview on 08/11/26 at 6:14 A.M. with CNA #209 revealed the facility was always short linen.Interview on 08/11/26 at 6:23 A.M. with CNA #251 revealed the facility was always short linen.Interview on 08/11/26 at 6:45 A.M. with Administrator and Director of Nursing revealed that there should be enough linen for morning care because an aid is supposed to wash linens at night. Interview on 08/11/26 at 6:56 A.M. with CNA #255 revealed the facility was always short linen.4. A tour of the facility on 08/12/2026 from 2:15 P.M. to 3:00 P.M. with Maintenance Director (MD) #301 revealed the following:-In Resident #9's room, there were two bulbs out in the bathroom.-In Resident #57's room, the sink was coming off the wall.-In Resident #2's room, the privacy curtain was dirty.-In Resident #22's room, the blinds were broken, there were several holes in the walls, and privacy curtain was dirty.-In Resident #16's room, there was a broken tile on the floor.-In Resident #29's room, the sink is not working. MD #301 stated that the water was turned off because it leaked.Interview on 08/12/26 at 3:00 P.M. with MD #301 revealed that work orders get put into the system by the Administrator but most of the time, staff just tell him what needs to be fixed.This deficiency represents non-compliance investigated under Complaint Number 3048348, Complaint Number 3012133, Complaint Number 3007850, Complaint Number 2966187, Complaint Number 2969676, Complaint Number 2806618 and Complaint Number 2796124.

Based on the review of personnel files and staff interviews the facility failed to provide evidence that Certified Nursing Assistants (CNA) completed 12 hours of annual training. This affected two (#200 and #260) of two CNAs whose personnel files were reviewed. The census was 49.Findings include:1. Review of the personnel file of CNA #200 revealed a hire date of 12/02/24. There was no evidence of any training.2. Review of the personnel file of CNA #260 revealed a hire date of 04/01/25. Review of list of training revealed 9.1 hours of training was completed annually.Interview on 08/13/26 at 4:43 P.M. with the Corporate Administrator (CA) #602 revealed he could not provide evidence for the required 12 hours annual training for either CNA #200 or CNA #260.This deficiency represents non-compliance investigated under Complaint Number 2966187.

Based on observation, interview, and record review the facility failed to administer medications as ordered resulting in an error rate of 10%. This affected four (#5, #14, #20, #38) of five residents observed for medication administration. The facility census was 49.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 07/11/26. Diagnoses included acute combined systolic and diastolic heart failure, acute pulmonary edema, and chronic obstructive pulmonary disease.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had mild cognitive impairment. Resident #5 required partial to moderate assistance for all activities of daily living.Review of the care plan dated 07/14/26 revealed Resident #5 was at risk for potential nutritional problem. Interventions included to administer medications as ordered and to explain the importance of following the prescribed diet orders.Review of the physician's order dated 07/12/26 revealed an order to administer Resident #5 folic acid 1 milligram (mg) every morning related to diastolic heart failure.2. Review of the medical record for Resident #14 revealed an admission date of 07/14/26. Diagnoses included displaced oblique fracture of shaft of left tibia, burn of unspecified degree of the left ankle, hypertension, and cerebral infarction.Review of the admission MDS dated [DATE] revealed Resident #14 had intact cognition. Resident #14 required minimal assistance for all activities of daily living.Review of the care plan dated 07/17/26 revealed Resident #14 had hypertension. Interventions included to administer hypertensive medications as ordered and monitor blood pressure as ordered.Review of the physician's order dated 07/15/26 for Resident #14 revealed an order to administer lisinopril 5mg daily related to a diagnosis of hypertension.3. Review of the medical record for Resident #20 revealed an admission date of 03/10/26. Diagnoses included chronic kidney disease, atrial fibrillation, and atherosclerotic heart disease.Review of the quarterly MDS dated [DATE] revealed Resident #20 had intact cognition. Resident #20 required substantial/maximal assistance for all activities of daily living.Review of the care plan dated 08/12/26 revealed Resident #20 has cardiac problems. Interventions included to administer medications as ordered and assess for signs of decreased cardiac output.Review of the physician's order dated 03/11/26 revealed an order to administer Resident #20 calcium 600mg every shift.4. Review of the medical record for Resident #38 revealed an admission date of 11/06/25. Diagnoses included type two diabetes mellitus, hypertension, and chronic obstructive pulmonary disease.Review of the quarterly MDS dated [DATE] revealed Resident #38 had intact cognition. Resident #38 required minimal to moderate assistance for all activities of daily living.Review of the care plan dated 07/28/26 revealed Resident #38 was at risk for malnutrition. Interventions included administer medications as ordered and administer diet as ordered.Review of the physician's order dated 11/24/26 revealed an order to administer folic acid 1 mg daily for Resident #38.Observation and interview on 08/12/26 at 8:38 A.M. revealed Licensed Practical Nurse (LPN) #218 when administering medications to Resident #38 no folic acid was available for administration. Resident #14 had no lisinopril 5mg available. Resident #20 had no calcium 600 mg available. Resident #5 had no folic acid available. LPN #218 checked all medication carts and the medication storage room for the medications, but they were not available. LPN #218 did notify the pharmacy, physician, and Director of Nursing of the medications not being administered as they were unavailable. The complete observation of medication administration with LPN #218 involved 40 medication administration opportunities with four errors resulting in an error rate of 10%.Review of the facility policy administering medications, revised April 2019, revealed medications are administered in a safe and timely manner, and as prescribed.This deficiency represents non-compliance investigated under Master Complaint Number 3095361, Complaint Number 2796124 and Complaint Number 2797332.

Based on observation, record review, and interview, the facility failed to ensure privacy was maintained during incontinence care. This affected one (#28) of three residents reviewed for incontinence care. The census was 49.Findings include:Review of the medical record for Resident #28 revealed an admission date of 12/20/25. Diagnoses include but are not limited to heart failure, dementia, and acute respiratory failure with hypoxia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/01/26, revealed the resident had severely impaired cognition. Further review of the MDS revealed Resident #28 was dependent for activities of daily living (ADLs).Observation on 08/10/26 at 10:52 A.M. from the hallway in front of Resident #28's room revealed that the door was open and the privacy curtain was not drawn to protect privacy, Resident #28 was turned on his side and was receiving peri-care by Certified Nursing Assistant (CNA) #248 This observation was verified at time by CNA #222 followed by CNA #222 pulling the door closed.Review of the facility policy dated 10/25 titled, Dignity, revealed that residents are to be always treated with dignity and respect.This deficiency represents non-compliance investigated under Master Complaint Number 3095361, Complaint Number 2797332 and Complaint Number 2727597.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure fall interventions were in place for Resident #27. This affected one (#27) of one resident reviewed for falls. The census was 49.Findings include:Review of the medical record for Resident #7 revealed an admission date of 10/01/25 and re-admission date of 11/29/25. Diagnoses included cellulitis, aphasia, dysphagia, cognitive communication deficit and abnormality of gait.Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired, and the resident was dependent for activities of daily living.Review of the care plan dated 10/13/25 for Resident #7 revealed multiple goals with interventions related to falls. The fall care plan dated 11/23/25 revealed interventions to reduce fall risk and included ensuring the call light and frequently used items were within reach and to do frequent rounding. The fall care plan updated 03/01/26 revealed interventions to minimize fall risk including to keep the call light within reach and place resident in common area in his wheelchair and to turn on a television show on the resident likes.Review of fall investigation of a fall that occurred on 03/01/26 at 12:20 A.M. revealed Resident #7 rolled himself out of bed and obtained two skin tears to his back. The fall investigation stated the resident got frustrated and irritated but was unable to communicate why. The new intervention implemented was to place Resident #7 in common/supervised area when in chair.Review of fall investigation dated 06/03/26 at 8:00 A.M. revealed Resident #7 was found on the floor next to bed. Witness statements revealed the camera in the room showed that the resident became agitated and rolled himself out of bed. A new intervention implemented was to add a floor mat next to bed.Observation on 08/10/26 at 1:58 P.M. during the annual screening revealed Resident #7 was up in his wheelchair in the common area and television was off. Resident #7 was unable to respond to questions when asked.Observation on 08/12/26 at 2:35 P.M. with Maintenance Director (MD) #301 revealed Resident #7 was sitting in his wheelchair in his room. Resident #7's call light was on the floor near the nightstand, outside of the resident's reach and his fall mat was behind him. MD #301 verified the call light was on the floor not within the reach of the resident and the fall mat was on the floor behind Resident #7 at time of observation.Interview on 08/13/26 at 1:33 P.M. with Director of Nursing (DON) verified Resident #7's fall interventions were to be up in chair in common area with the television tuned into a show the resident likes and to have call light within reach when in room.Review of the facility policy titled Fall and Fall Risk, Managing, dated March 2018, revealed the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff will monitor and document each resident's response to interventions and will continue interventions or reconsider whether these measures are still needed.This deficiency represents non-compliance investigated under Complaint Number 2727597.

Based on interview, record review, and facility policy review the facility failed develop a comprehensive care plan for wounds and wound care for Resident #1. This affected one resident (Resident #1) out of three residents reviewed for wound care. The facility census was 40. Findings include: Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses included dementia, cerebral infarction, ataxia, diabetes mellitus, anxiety disorder, seizures, drug induced subacute dyskinesia, muscle wasting and atrophy. Review of Resident #1's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #1 required supervision or touching assistance for eating, substantial to maximal assistance for bed mobility, and was dependent on staff for oral hygiene, toileting, showers, dressing, and personal hygiene. Review of the facility document titled Provider Consultation, dated 12/05/24 and authored by WCNP #807 revealed the WCNP #807 had been consulted for a new wound to the coccyx for evaluation and treatment for Resident #1. A treatment for Santyl for enzymatic debriding, alginate, bordered foam dressing everyday and as needed was the treatment ordered and signed on 12/09/24 by the WCNP #807. Review of Resident #1's care plan revealed there was not a care plan triggered for Resident #1's coccyx wound nor the wound treatment intervention ordered by WCNP #807 on 12/09/24. Interview on 01/28/25 at 12:39 P.M. with the Director of Nursing and the Assistant Director of Nursing (ADON) verified a wound care plan had not been developed for Resident #1. Review of the facility policy titled Baseline Care Plan, last reviewed August 2024 revealed it stated The facility will develop and implement a care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This deficiency represents noncompliance identified during investigation of Complaint Number OH00160998.

Based on record review and interview the facility failed to ensure wound care treatments were completed timely and per physician orders for Resident #41. This affected one resident (Resident #41) out of three residents reviewed for wound care. The faciltiy census was 40. Findings include: Review of Resident #41's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnosis included cellulitis of right lower extremity, sepsis, fracture of right tibia, type two diabetes, atrial fibrillation, rash, head laceration, wedge compression fracture of T4, ulcerative colitis, age related osteoporosis, nicotine dependency, and gastroesophageal reflux disease. Review of Resident #41's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had intact cognition. They required supervision or touching assistance for eating, set up or clean up assistance for bed mobility, and partial to moderate assistance for oral hygiene, toileting, showers, dressing and personal hygiene. Review of Resident #41's care plan revealed there was a care plan initiated related to Resident #41 was at risk for skin breakdown due to impaired balance, fractured right lower extremity, head laceration, and multiple medical conditions. Interventions including supervision for showering, barrier cream after each incontinence episode and as needed, float heels when in bed if the resident allows, turn and reposition every two hours and as needed, pressure reduction mattress, and anticipate the residents needs. There was a care plan initiated on 12/17/24 related to venous stasis ulcers to lower extremities related to CHF with no interventions or goals listed. Review of Resident #41's physician orders dated 12/17/24 revealed orders to clean the right foot venous wounds with normal saline, apply mesalt and cover with boarder foam dressing every day and as needed, and a physician order dated 12/19/24 to cleanse right leg venous wounds with normal saline, apply Dakins moistened gauze to wounds, cover with ABD pad and wrap with kerlix every day. Review of Resident #41's Treatment Administration Record (TAR) dated December 2024 revealed the residents treatments were not completed on 12/17/24, 12/18/24 and 12/21/24. Interview on 01/28/25 at 10:35 A.M. with Licensed Practical Nurse (LPN) #803 revealed there were issues with LPN #805 completing Resident #41's treatments as ordered and was ultimately fired for not doing them. Interview on 01/28/25 at 12:39 P.M. with the Director of Nursing and the Assistant Director of Nursing (ADON) revealed LPN #805 was educated and disciplined multiple times for not completing Resident #41's treatments as ordered and was terminated on 12/22/24 for insubordination related to not completing the treatments for Resident #41 as ordered and instructed to by the DON. The DON and the ADON both confirmed treatments were not completed by LPN #805 on 12/17/24, 12/18/24 and 12/21/24. Review of LPN #805's employee file revealed she was terminated on 12/22/24 due to insubordination and for not completing treatments for Resident #41 as instructed to do by the DON. This deficiency represents noncompliance identified during investigation of Complaint Number OH00160998.

Based on interview and record review the facility failed to ensure the residents medical record was complete and reflected treatment orders put in place for wound care. This affected one resident (Resident #1) of three residents reviewed for wound care. The facility census was 40. Findings Include: Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses included dementia, cerebral infarction, ataxia, diabetes mellitus, anxiety disorder, seizures, drug induced subacute dyskinesia, muscle wasting and atrophy. Review of Resident #1's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #1 required supervision or touching assistance for eating, substantial to maximal assistance for bed mobility, and was dependent on staff for oral hygiene, toileting, showers, dressing, and personal hygiene. Review of the facility document titled Provider Consultation, dated 12/05/24 and authored by WCNP #807 revealed the WCNP #807 had been consulted for a new wound to the coccyx for evaluation and treatment for Resident #1. A treatment for Santyl for enzymatic debriding, alginate, bordered foam dressing everyday and as needed was the treatment ordered and signed on 12/09/24 by the WCNP #807. Review of Resident #1's care plan revealed there was no care plan triggered to address the wound to the coccyx and the recommended treatment by the WCNP. Review of Resident #1's physician orders dated for December 2024 and January 2025 revealed the orders put in place by WCNP #807 were not transcribed into the Electronic Medical Record (EMR) physician orders. Review of Resident #1's Treatment Administration Record (TAR) dated December 2024 and January 2025 revealed there was no order or documentation of treatment for the wound to the residents coccyx. Review of Resident #1's nurse progress notes dated from 12/09/24 through 01/28/25 revealed nursing staff were monitoring and completing the treatment to Resident #1's coccyx as recommended by WCNP #807. Review of Resident #1's facility weekly wound care assessments for December 2024 and January 2025 revealed the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) monitored, assessed and measured the residents wound weekly. Observation made on 01/28/25 at 10:20 A.M. of wound care for Resident #1 by Licensed Practical Nurse (LPN) #803 with help from Certified Nursing Assistant (CNA) #804 revealed all infection control measures were followed, and the treatment recommended by the WCNP was being followed. Interview on 01/28/25 at 10:35 A.M. with LPN #803 revealed she completed wound care for Resident #1 per orders put in place by WCNP #807. When asked to show the survey where the wound care orders were in the EMR physician orders, LPN #803 confirmed the orders were never transcribed from WCNP #807's weekly assessments. Interview on 01/28/25 at 12:39 P.M. with the DON and the ADON revealed they confirmed treatments for Resident #1 were being completed as noted in the progress notes however the physician orders and the TAR did not reflect the orders put in place by WCNP #807 on 12/09/24. They confirmed the orders were never transcribed into the EMR. They stated they had completed all weekly wound care assessments and monitored, assessed and measured the residents wounds and communicated with WCNP #807 if needed. Interview on 01/29/25 at 11:15 A.M. with the WCNP #807 regarding Resident #1 revealed she put all her orders on her assessments which were provided to the facility so it would be up to the facility to ensure her orders were entered into the physician orders in the EMR. She stated if there were changes to the orders she communicated them to the nursing staff. Interview on 01/29/25 at 11:30 A.M. with Registered Nurse (RN) #808 revealed they completed wound care for Resident #1 when assigned to the resident and would enter what care was provided into a nurse progress note. This deficiency represents noncompliance identified during investigation of Complaint Number OH00160998.

Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interview, the facility failed to provide the correct Quality Improvement Organization (QIO) information to residents who were completing therapy. This affected three (Resident #145, Resident #146 and Resident #147) of three reviewed for liability notices. The census was 37. Findings include: 1. Review of Resident #145's medical record revealed they were readmitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 09/26/24. The letter did not provide the correct QIO information. Interview on 11/27/24 at 11:45 A.M. with the Administrator and Social Service Designee #240 verified the letters to the residents did not provide the correct QIO information. 2. Review of Resident #146's medical record revealed they were admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 08/31/24. The letter did not provide the correct QIO information. Interview on 11/27/24 at 11:45 A.M. with the Administrator and Social Service Designee #240 verified the letters to the residents did not provide the correct QIO information. 3. Review of Resident #147's medical record revealed they were admitted to the facility on [DATE]. A Notice of Medicare Non-Coverage letter revealed services were ended on 02/20/24. The letter did not provide the correct QIO information. Interview on 11/27/24 at 11:45 A.M. with the Administrator and Social Service Designee #240 verified the letters to the residents did not provide the correct QIO information.

Based on record reviews, review of shower documentation and interviews the facility failed to ensure residents received adqueate assistance with activities of daily living to completed showers as scheduled. This affected three residents (Resident #15, Resident #25 and Resident #29) of three residents reviewed for showers. The census was 37. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included complete lesion at T-7 through T-10 level of thoracic spinal cord, neuromuscular dysfunction of bladder and hypotension. The resident was cognitively intact. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was dependent for showers. Review of the shower sheets for the last 60 days revealed showers were offered or given on 09/09/24, 09/11/24, 11/07/24 and 11/25/24. Interview on 11/25/24 at 10:06 A.M. with Resident #15 revealed he did not getting showers as scheduled. Interview on 11/26/24 at 6:30 P.M. with the Director of Nursing verified there was a lack of evidence showers were given twice a week as scheduled for Resident #15. 2. Review of the medical record for Resident #25 revealed an admitted [DATE]. Diagnoses included Down Syndrome, difficulty walking and anxiety disorder. The resident was cognitively impaired. Review of the quarterly MDS assessment dated [DATE] revealed she was dependent for showers. Review of the shower sheets revealed showers were offered or given on 10/07/24, 10/29/24, 11/01/24, 11/15/24, 11/19/24, 11/20/24, 11/22/24. Interview on 11/26/24 at 6:30 P.M. with the Director of Nursing verified there was a lack of evidence showers were given twice a week as scheduled for Resident #25. 3. Review of the closed medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included radiculopathy lumbar region, type 2 diabetes mellitus and hyperlipidemia. The resident was cognitively intact. Review of the 5-day MDS assessment dated [DATE] revealed he was dependent for showers. Review of the shower sheets since admission revealed a shower was given on 11/05/24. Interview on 11/25/24 at 11:37 A.M. with Resident #29 revealed he did not get showers as scheduled. Interview on 11/26/24 at 6:30 P.M. with the Director of Nursing verified there was a lack of evidence showers were given twice a week as scheduled for Resident #29. This deficiency represents non-compliance investigated under Complaint Number OH00159785.

Based on record review and interviews the facility failed to ensure Resident #29 received meals as scheduled to meet their dietary needs. This affected one resident (Resident #29) of three residents reviewed for meal service. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included radiculopathy of lumbar region, type 2 diabetes mellitus and hyperlipidemia. He was on a regular diet with thin liquids. Review of the 5-day Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Interview on 11/25/24 at 11:37 A.M. with Resident #29 revealed he was not served breakfast one day and lunch another day but couldn't recall the dates. Interview on 11/26/24 at 4:00 P.M. with the Food Service Director #213 revealed she was off the day Resident #29 was admitted and therefore there was no diet card created for him. She stated she believed he missed at least two meals from the kitchen. Interview on 11/26/24 at 6:30 P.M. with the Director of Nursing revealed Resident #29 missed breakfast and missed a dinner but could not identify the dates. Review of the concern log revealed Resident #29 had a concern on 11/04/24 that a dinner tray was not served timely. The resolution was the facility was called and the facility retrieved him food from an outside source. This deficiency represents non-compliance investigated under Complaint Number OH00159785.

Based on medical record review, interviews, review of facility policy, and review of a facility self-reported incident (SRI) investigation, the facility failed to ensure Resident #7 was free from staff to resident physical abuse. This affected one resident (#7) of three residents reviewed for abuse. The facility census was 38. Actual harm occurred on 09/09/24 when Resident #7 was physically abused by a State tested Nursing Assistant (STNA) during care resulting in large areas of bruising to both of the resident's arms. Bruising to the left upper arm measured 4.5 centimeters (cm) in length by 3.0 cm width and was described as purple to dark red in color. Bruising to the right upper arm measured 15.0 cm in length by 6.0 cm with and was described as deep purple and dark red with intact skin. A facility SRI dated 09/09/24 indicated Resident #7 reported pain as a result of in incident, however the type or level of pain was not described. An interview with Resident #7 by the Director of Nursing (DON) on 09/09/24 about the nature of his injuries revealed the resident reported the STNA had been rough with him. An interview with Resident #7's daughter revealed this bruising was not the first time Resident #7 had sustained bruising from staff as a result of rough care. In addition to the actual physical harm/pain caused to the resident, by using the reasonable person concept, Resident #7 would have experienced psychosocial harm as a result of the physical abuse since there was an expectation the resident would not be harmed by staff providing his care. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including hypertensive heart disease without heart failure, asthma with status asthmaticus, dementia with agitation, depression, type two diabetes mellitus, pulmonary fibrosis, left eye cataract, dizziness, and insomnia. Review of the care plan dated 07/29/24 revealed Resident #7 had a self-care deficit related to multiple medical conditions. The care plan was updated on 09/09/24 to reflect Resident #7 had bilateral arm bruising with an added intervention to monitor the bilateral arm bruising and report any other type of skin abnormality. Further review of Resident #7's care plan revealed an update dated 09/13/24 which noted Resident #7 demonstrated anxiety and resistance with transfers. Interventions included breaking tasks into manageable subtasks, providing cuing and prompting as needed, allowing for frequent rest periods, and monitoring for signs of fatigue, frustration, being overwhelmed, or intolerance to care. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 08/02/24 revealed Resident #7 had intact cognition. Resident #7 was always continent of urine but required substantial assistance for toileting hygiene, bathing, personal hygiene, chair to bed transfers, and toilet transfers. The MDS did not indicate the use of anticoagulants. Review of a nurse's note dated 09/09/24 timed at 3:15 P.M. revealed Certified Nurse Practitioner (CNP) #300 and the resident's family were notified Resident #7 sustained bruises to both of his arms. Review of the Skin and Wound assessment dated [DATE] revealed in-house acquired bruising to Resident #7's left upper arm measuring 4.5 centimeters (cm) by 3.0 cm by 0.0 cm, described as purple to dark red in color with no pain. Review of a second Skin and Wound Assessment completed on 09/09/24 revealed in-house acquired bruising to Resident #7's right upper arm measuring 15.0 cm by 6.0 cm by 0.0 cm, described as deep purple and dark red with intact skin and no pain. Review of the progress notes dated 09/10/24 timed at 10:47 A.M., authored by CNP #300, revealed an assessment of bilateral arm contusions with additional similar discolorations over the antecubital region of both arms. At the time of this assessment, Resident #7 was noted to have full range of motion of both arms and no indicators of pain. Review of the nursing progress note dated 09/10/24 timed at 1:50 P.M. revealed an x-ray was taken of the right humerus with no acute osseous abnormality noted. Review of a facility SRI submitted to the Ohio Department of Health (ODH) Enhanced Information Dissemination & Collection (EIDC) on-line system on 09/09/24 revealed Hospice Nurse #329 reported to the facility Administrator that Resident #7 sustained bruising on his right upper arm after the assigned STNA from the prior night shift was too rough with him. The SRI initial report revealed Resident #7 did report pain and the Nurse Manager reported Resident #7 sustained bruising on both the right and left upper arms. Resident #7 was interviewed by the DON on 09/09/24 about the nature of his injuries and reported the STNA had been rough with him. Review of the findings for the incident investigation competed on 09/13/24 revealed the facility did not substantiate abuse had occurred due to the nurse on duty at the time, Licensed Practical Nurse (LPN) #323, reported the alleged perpetrator, STNA #332, was not rough with Resident #7 when she requested STNA #332 to stay with him while he was in the bathroom. Review of LPN #323's undated witness statement revealed no indication she was present at the time of Resident #7's injuries but did indicate STNA #332 was witnessed entering Resident #7's room later that shift. Review of a witness statements from Hospice Nurse #329 dated 09/09/24 (untimed), STNA #333 (undated and untimed), and STNA #334 dated 09/09/24 timed 11:19 A.M. revealed none had witnessed the cause of Resident #7's bilateral arm bruises. Review of the witness statement from STNA #332 forwarded from the staffing agency to the facility on [DATE] at 3:47 P.M. revealed no knowledge of abuse and no confirmation she provided care to Resident #7 on the night shift scheduled from 11:00 P.M. on 09/08/24 to 09/09/24 at 7:00 A.M. Interview on 09/24/24 at 10:07 A.M. with Resident #7 confirmed he remembered a couple of girls being too rough with him and hurting his arms, but he could not recall any additional details. During the interview, Resident #7 used hand gestures to demonstrate his arms being grabbed. Observation at that time revealed a medium purplish to yellow healing bruise on his right forearm, a yellow healing bruise to his right upper arm, and a faint yellowish bruise to his left upper arm. Interview on 09/24/24 at 10:10 A.M. with the daughter of Resident #7 (Daughter #1) confirmed the resident had sustained bruises to both of his arms on 09/09/24 and a few weeks prior. She further stated the previous DON was informed of the first incident and the STNAs involved were not allowed back in the facility and the family was shocked when the resident was injured again in the same manner. Interview on 09/24/24 at 11:28 A.M. with the power of attorney (POA) for Resident #7's healthcare (Daughter #2) confirmed Resident #7 sustained bruises on his arms on two separate occasions by staff handling him too roughly during night shifts. The POA further revealed both incidents were first assessed and reported by the Hospice nurses and the previous DON was involved in investigating and terminating facility privileges to the perpetrators after the first incident, which she was unable to confirm the date of. Daughter #2 further indicated the current DON had informed the family the staff responsible for Resident #7's injuries reported on 09/09/24 were not allowed back to the facility. The POA had no knowledge of who the named alleged perpetrators were for either incident. Telephone interview on 09/24/24 with Hospice Nursing Supervisor #327 at 11:39 A.M. confirmed Resident #7 sustained two separate negative events leading to bruising of his arms, one reported by Hospice Nurse #329 on 09/09/24 and one reported by Hospice Nurse #328 on 08/28/24. Telephone interview on 09/24/24 at 12:47 P.M. with Hospice Nurse #328 confirmed she visited Resident #7 on 08/28/24 for a (hospice) recertification visit and noted bruises on his arms in various stages, some new around both upper arms. Hospice Nurse #328 further stated Resident #7 reported an STNA, described as a short, heavy-set black lady, threw him onto the bed like he was a rag doll (Hospice Nurse #328 said those were his exact words). Hospice Nurse #328 stated she was informed by the previous DON the girl Resident #7 reported was agency staff and was placed on the do not return list as a result of the incident. Hospice Nurse #328 was unaware of any additional follow-up. Interview on 09/24/24 at 4:05 P.M. with STNA #325 confirmed Resident #7 informed her he had been handled too roughly and was injured by another staff member. During the interview, STNA #325 confirmed she reported it to the nurse who informed her the facility was aware and involved staff would not be allowed to return to the facility. Telephone interview on 09/24/24 at 5:32 P.M. with LPN #323 revealed she was the only nurse on duty on the night shift beginning 09/08/24 until 09/09/24 and that STNA #332 from a staffing agency was the STNA assigned to the hall where Resident #7 resided. LPN #323 further confirmed she was not present in Resident #7's room for any chair, bed, or toilet transfers but had found Resident #7 on the toilet by himself and instructed STNA #332 to stay with Resident #7 and not leave him unattended while in the bathroom because he was a fall risk. LPN #323 stated there was no bruising to Resident #7's arms when she left him with STNA #332, and she had not seen his arms or been present during any other care by STNA #332 after that encounter. The next night, LPN #323 noticed the bruising on Resident #7's right arm and stated it looked suspicious of a fracture. According to LPN #323, Resident #7 stated the aide from the previous night had to show him who was the boss, so she threw him near the couch in the room. LPN #323 revealed she immediately reported this information to the DON via telephone and was informed the facility was aware and investigating and the aide involved would not be allowed back in the facility. LPN #323 confirmed an x-ray was ordered. The x-ray showed there was no fracture. Telephone interview on 09/25/24 at 7:06 A.M. with STNA #309 confirmed knowledge of bilateral arm bruises on Resident #7, stating there was no reason for that sort of bruising if he was handled properly, as he described large bright red bruises on both arms, including from the forearm all the way to his upper arm. During the interview, STNA #309 revealed Resident #7 informed STNA #309 the night aides were too rough with him during a previous incident as well and gave no indicators that would cause facility staff not to believe Resident #7. STNA #309 further stated when the conversation with Resident #7 was reported to the previous DON, the STNA was informed the facility was aware and that two female STNAs were not allowed back to work in the facility as a result of the incidents. STNA #309 denied receiving any in-service or training related to abuse after the reported injuries sustained by Resident #7. Telephone interview on 09/25/24 at 8:56 A.M. with STNA #306 confirmed she had knowledge Resident #7 had bright red bruises on both arms. During the interview, STNA #306 was unable to recall the date she first noted bilateral arm bruising, but stated she reported the bruises to the nurse on duty who informed her the incident was under investigation. STNA #306 stated when Resident #7 was asked about the origin of the bruises, he responded that the aide from the previous night had to show me who's boss. Interview on 09/25/24 at 10:35 A.M. with Hospice Nurse #329 confirmed that on 09/09/24 she noted large bright red bruises on both of Resident #7's arms. She further confirmed Resident #7 would occasionally get small, scattered marks on his skin, but stated this was different, they looked like two hand grasps and were new skin concern areas. During the interview, Hospice Nurse #329 confirmed Resident #7 had occasional short-term memory issues, but was alert and oriented to person, place, time, and situation and could see no reason to doubt his recall of events. Hospice Nurse #329 also stated that the facility seemed to believe Resident #7 right away. She also confirmed that when she reported the incident to her supervisor, she was informed that Hospice Nurse #328 had reported an incident of bruising that occurred previously after being handled too rough by facility staff. Interview on 09/25/24 at 1:31 P.M. with STNA #326 confirmed awareness that Resident #7 sustained bruises on his arms somewhere around the end of August 2024 or the beginning of September 2024 then heard there was a second similar incident not long after. STNA #326 was not certain of the date(s) of injury. During the interview, STNA #326 stated some of the other aides may not have the patience required for Resident #7's night-time confusion and this was reported to the previous DON. STNA #326 was not aware of the outcome after reporting to the previous DON. Interview with the current DON on 09/25/24 between 2:30 P.M. and 2:50 P.M. confirmed she placed two agency STNAs (STNAs #332 and #334) on the do not return list because she felt they were both being dishonest and could not confirm with 100 percent certainty which one of them may have been providing care to Resident #7 the night he sustained bilateral arm bruising and accused staff of being too rough with him. During the interview, the DON confirmed she had no reason not to believe Resident #7's report of how he sustained the bruises, but added he did have a tendency to display some confusion and agitation in the late afternoon or evenings and thought the injuries could possibly have been incidentally caused during a difficult transfer. The DON also confirmed after learning on 09/24/24 that the Hospice staff, Resident #7, and Resident #7's two daughters reported there was a previous incident involving staff causing bruises by handling too roughly, she went to the room and spoke with the daughter who was Resident #7's POA for care. Resident #7's POA confirmed there was an incident in August 2024 where Hospice Nurse #328 reported bilateral arm bruising Resident #7 told her happened when the aide was too rough with him. According to the DON, the POA stated this was reported to the previous DON who immediately placed that staff member on the facility's do not return list, though she did not know who the alleged perpetrator was determined to be. Interview on 09/25/24 at 3:00 P.M. with the Administrator confirmed there had been no thorough/comprehensive investigation completed regarding the bruises reported by the Hospice Nurse to the previous DON on 08/28/24 and that he was waiting for Hospice to provide additional information at which time he planned to move forward with an investigation. He reported this was all new information to him and was awaiting additional information before moving forward. Review of the policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property dated 11/28/16 revealed the facility was to take steps to identify and prevent resident harm, including injury caused by rough handling during resident care. The definition of abuse included the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Mistreatment was defined as inappropriate treatment or exploitation of resident. The policy indicated willful meant the individual must have acted deliberately, not that the individual must have attended to inflict injury or harm. This deficiency represents non-compliance investigated under Complaint Number OH00157332.

Based on observation, interview, review of call light audits, and review of facility policy, the facility failed to maintain a resident call system that adequately communicated resident calls directly to a staff member or to a centralized location to alert staff to a resident in need. This had the potential to affect all residents in the facility. The facility census was 38. Findings include: Observation of the call lights from the centralized common area (between all four halls) on 09/24/24 from 9:36 A.M. to 10:00 A.M. revealed the following: room [ROOM NUMBER]: At 9:36 A.M. the call light was on. It was not observed what time room [ROOM NUMBER]'s light was triggered. This light was answered at 9:46 A.M. for a total of 10 minutes. room [ROOM NUMBER]: At 9:38 A.M., room [ROOM NUMBER]'s light was noted to be lit above the room door. Staff responded to the call light at 9:55 A.M. for a total of 17 minutes observed. room [ROOM NUMBER]: At 9:38 A.M. the light at the end of the North hallway was on, indicating the suite around the corner triggered the light. Staff responded to the light at 9:48 A.M. for a total of 10 minutes observed. At 9:52 A.M., the call light in room [ROOM NUMBER] was activated, State tested Nurse Aide (STNA) responded at 9:56 A.M. During observation of the call lights, no audible sound was noted. There was no light panel near the nurses' station indicating call lights were triggered. During the 24-minute observation, Licensed Practice Nurse (LPN) #321 was observed sitting at the nurses' station and for approximately 10 to 15 minutes of this observation a second nurse, LPN #335, also sat at the nurse's station. While the lights remained lit in the hallway, one STNA was in the bathing room, one STNA was assisting a resident in room [ROOM NUMBER] and then room [ROOM NUMBER], and one STNA was observed entering a resident's room in the [NAME] Hall. Additionally, two staff from the therapy department and one office staff member walked by rooms [ROOM NUMBERS]. Interview on 09/23/24 at 4:43 P.M. with Resident #23 revealed it took quite some time for staff to answer call lights. No specifics were provided during the interview. Interview on 09/24/24 at 10:22 A.M. with Resident #10 revealed she was concerned with call light response times. When asked how long she must wait, she exclaimed that they sometimes never came but was unable to provide details. During the interview, Resident #10's daughter stated the call light was put on around 10:00 A.M. over the weekend and at 2:00 P.M. Resident #10 called her daughter for help because staff did not respond to her call light. Interview on 09/24/24 at 10:43 A.M. with LPN #321 confirmed call lights did not emit an audible sound, but lit up outside the resident's door and the signal went to a pager that the STNAs were supposed to carry. When asked how the nurses knew if the lights were activated when they were sitting at the nurse's station, LPN #321 stated there was no centralized panel at the nurses' station and nurses were also supposed to be alerted through a pager. LPN #321 confirmed she had no pager. Observation at this time revealed three pagers in a basket at the nurses station with no batteries. Interview on 09/24/24 at 10:48 A.M. with LPN #335 confirmed she was unaware the call lights in rooms [ROOM NUMBER] were on between 9:40 A.M. and 10:00 A.M. when she was at the nurses' station and further confirmed she did not know about a pager for call light alerts. Interview on 09/24/24 at 3:50 P.M. with STNA #324 confirmed the pagers for the call lights had no batteries so she had not been carrying one. STNA #324 further confirmed the only way to know if a resident activated a call light was to watch the lights in the hall and whoever saw the light should be the first responder to the resident call. Interview on 09/24/24 at 4:05 P.M. with STNA #325 confirmed call lights should be answered immediately or as soon as possible, but the only way to know if one was activated was to be up and moving around the assigned halls. STNA #325 further confirmed she would not know a call light was going off in her assigned area if she was not in the hall watching because the pagers for the alerts were not in use. STNA #325 was unable to specify exactly how long staff had been without the pagers, but stated it has been a while and stated they needed batteries and set-up to work correctly. Interview on 09/24/24 at 4:25 P.M. with STNA #322 confirmed it was her belief only one pager in the facility was working and it was being used in the Assisted Living section of the facility. STNA #322 stated the STNAs must constantly be looking at the lights above the doors as the only method of call light notification. Interview on 09/24/24 at 4:40 P.M. with the Director of Nursing (DON) revealed it was the responsibility of all staff to respond timely to call lights. There was not a set time frame, but lights should be answered immediately or as soon as able by whoever saw the light first. Interview on 09/25/24 at 12:16 P.M. with Resident #13 revealed call lights took a while to get answered, stating it had taken up to one to two hours at times to get staff to answer her light. Interview on 09/25/24 at 1:31 P.M. with STNA #326 revealed staff were educated on the call system requiring the use of pagers for alerts, but nobody had been using them, except on the assisted living unit. STNA #326 further confirmed the only way to determine if a call light was going off was to be watching above all the doors and not to be at the nurses' station. Review of a 24-hour look-back audit for call light response times for room [ROOM NUMBER] between 09/23/24 and 09/24/24 revealed the following response times greater than 20 minutes: 09/23/24 from 11:14 P.M. to 12:10 A.M., 55 minutes and 52 seconds 09/24/24 from 5:54 A.M. to 6:17 A.M., 23 minutes and 38 seconds 09/2424 from 9:19 A.M. to 9:46 A.M., 27 minutes and 30 seconds Review of a 24-hour look-back audit for call light response times for Rooms 111 between 09/23/24 and 09/24/24 revealed the following response times greater than 20 minutes: 09/23/24 from 7:12 A.M. to 7:32 A.M., 20 minutes and 51 seconds 09/23/24 from 10:42 A.M. to 11:06 A.M., 24 minutes and 12 seconds 09/24/24 from 9:14 A.M. to 9:48 A.M., 34 minutes and 48 seconds Review of a 24-hour look-back audit for call light response times for room [ROOM NUMBER] between 09/23/24 and 09/24/24 revealed the following response times greater than 20 minutes: 09/23/24 from 7:21 A.M. to 7:46 A.M., 24 minutes and 57 seconds 09/23/24 from 8:31 A.M. to 8:57 A.M. 26 minutes and 22 seconds 09/23/24 from 9:08 A.M. to 9:59 A.M., 51 minutes and 14 seconds 09/23/24 from 2:34 A.M. to 3:11 A.M., 37 minutes and 13 seconds 09/23/24 from 4:25 A.M. to 4:55 A.M., 30 minutes and 27 seconds 09/23/24 from 6:43 A.M. to 7:07 A.M., 23 minutes and 49 seconds 09/23/24 from 8:04 A.M. to 8:33 A.M., 28 minutes and 37 seconds 09/24/24 from 8:22 A.M. to 9:15 A.M., 52 minutes and 37 seconds 09/24/24 from 9:15 A.M. to 9:37 A.M., 21 minutes and 14 seconds Review of the facility policy Call Lights: Accessibility and Timely Response dated September 2023 revealed the facility was to ensure call lights went to the staff members directly or that the calls went to a centralized staff work area. The policy further revealed staff members who saw or heard the activated call light were responsible for responding. This deficiency represents non-compliance investigated under Complaint Number OH00157294.

Based on medical record review, interviews, review of facility policy, and review of facility self-reported incident (SRI) investigation, the facility failed to ensure allegations of potential abuse were thoroughly investigated, thereby preventing further similar instances of abuse involving the same resident. This affected one resident (Resident #7) of three residents reviewed for abuse. The facility census was 38. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including hypertensive heart disease without heart failure, asthma with status asthmaticus, dementia with agitation, depression, type two diabetes mellitus, pulmonary fibrosis, left eye cataract, dizziness, and insomnia. Review if the admission Minimum Data Set (MDS) 3.0 assessment completed on 08/02/24 revealed Resident #7 had intact cognition. Resident #7 was always continent of urine but required substantial assistance for toileting hygiene, bathing, personal hygiene, chair to bed transfers, and toilet transfers. The MDS did not indicate the use of anticoagulants. Review of the care plan dated 07/29/24 revealed Resident #7 had a self-care deficit related to multiple medical conditions. Further review of the care plan revealed on 09/09/24 Resident #7 was noted to have bilateral arm bruising with an added intervention to monitor the bilateral arm bruising and report any other type of skin abnormality. On 09/13/24, the care plan noted Resident #7 demonstrated anxiety and resistance with transfers. Interventions included breaking tasks into manageable subtasks, providing cuing and prompting as needed, allowing for frequent rest periods, and monitoring for signs of fatigue, frustration, being overwhelmed, or intolerance to care. Review of the nurses note dated 09/09/24 timed at 3:15 P.M. revealed Certified Nurse Practitioner (CNP) #300 and the resident's family were notified that Resident #7 sustained bruises to both of his arms. Review of the progress note dated 09/10/24 timed at 10:47 A.M. entered by CNP #300 revealed an assessment of bilateral arm contusions with additional similar discolorations over the antecubital region of both arms. At the time of this assessment, Resident #7 was noted to have full range of motion of both arms and no indicators of pain. Review of the nursing progress note dated 09/10/24 timed at 1:50 P.M. revealed an x-ray was taken of the right humorous with no acute osseous abnormality noted. Review of the assessments revealed Resident #7 had no weekly skin assessments completed since the date of admission to present. There was no skin or wound assessment completed on 08/28/24. Review of the Skin and Wound assessment dated [DATE] revealed in-house acquired bruising to Resident #7's left upper arm measuring 4.5 centimeters (cm) by 3.0 cm by 0.0 cm, described as purple to dark red in color with no pain. Review of a second Skin and Wound Assessment completed on 09/09/24 revealed in-house acquired bruising to Resident #7's right upper arm measuring 15.0 cm by 6.0 cm by 0.0 cm, described as deep purple and dark red with intact skin and no pain. Review of the facility SRI submitted to the Ohio Department of Health (ODH) Enhanced Information Dissemination & Collection (EIDC) on-line system on 09/09/24 revealed Hospice Nurse #329 reported to the facility Administrator that Resident #7 sustained bruising on his right upper arm after the assigned State tested Nurse Aide (STNA) from the prior night shift was too rough with him. The SRI initial report revealed Resident #7 did report pain and the Nurse Manager reported Resident #7 sustained bruising on both the right and left upper arms. Resident #7 was interviewed by the Director of Nursing (DON) on 09/09/24 about the nature of his injuries and reported the STNA had been rough with him. Review of the facility SRI submitted to the ODH EIDC on-line system on 09/25/24 revealed the facility opened an investigation into allegations made by Resident #7 to Hospice Nurse (#328) on 08/28/24. The preliminary incident detail did not include Resident #7's power of attorney (POA) corroboration of this being a separate occurrence from the incident reported 09/09/24. Review of the incident investigation findings for the incident reported on 09/09/24 revealed the facility did not substantiate abuse had occurred due to the nurse on duty at the time, Licensed Practical Nurse (LPN) #323, reported the alleged perpetrator, STNA #332, was not rough with Resident #7 when she requested STNA #332 to stay with him while he was in the bathroom. Review of LPN #323's witness statement (dated?) revealed no indication she was present at the time of Resident #7's injuries but did indicate STNA #332 was witnessed entering Resident #7's room later that shift. Further review of the investigation documentation revealed written witness statements were collected but there was no documentation of witness or alleged perpetrator interviews. The written witness statements were collected through email or in writing from Hospice Nurse #329, LPN #323 (as noted above), STNA #332, STNA #333, and STNA#334. Review of the in-service sign-in sheet dated 09/11/24 on abuse, neglect, and misappropriation revealed a total of nine signatures, including the DON. Interview on 09/24/24 at 10:07 A.M. with Resident #7 confirmed he remembered a couple of girls being too rough with him and hurting his arms, but he could not recall any additional details. During the interview, Resident #7 used hand gestures to demonstrate his arms being grabbed. Observation at that time revealed a medium purplish to yellow healing bruise on his right forearm, a yellow healing bruise to his right upper arm, and a faint yellowish bruise to his left upper arm. Interview on 09/24/24 at 10:10 A.M. with the daughter of Resident #7 (Daughter #1) confirmed he sustained bruises to both of his arms on 09/09/24 and a few weeks prior. She further stated the previous DON was informed of the first incident and the STNAs involved were not allowed back in the facility and they were shocked when he was injured again in the same manner. During the interview, Resident #7's daughter did verbalize she was pleased with the swift outcome of restricting the alleged perpetrators from returning to the facility. Interview on 09/24/24 at 11:28 A.M. with the power of attorney (POA) for Resident #7's healthcare (Daughter #2) confirmed Resident #7 sustained bruises on his arms on two separate occasions by staff handling him too roughly during night shifts. The POA further confirmed both incidents were first assessed and reported by the Hospice nurses and the previous DON was involved in investigating and terminating facility privileges to the perpetrators after the first incident, which she was unable to confirm the date. She further confirmed the current DON had informed the family the staff responsible for Resident #7's injuries reported on 09/09/24 were not allowed back to the facility. The POA had no knowledge of who the named alleged perpetrators were for either incident. Telephone interview on 09/24/24 with Hospice Nursing Supervisor #327 at 11:39 A.M. confirmed Resident #7 sustained two separate negative events leading to bruising of his arms, one reported by Hospice Nurse #329 on 09/09/24 and one reported by Hospice Nurse #328 on 08/28/24. Hospice Supervisor #327 further confirmed the facility followed up after both incidents and reported the involved staff were no longer allowed in the facility. Telephone interview on 09/24/24 at 12:47 P.M. with Hospice Nurse #328 confirmed she visited Resident #7 on 08/28/24 for a recertification visit and noted bruises on his arms in various stages, some new around both upper arms. Hospice Nurse #328 stated Resident #7 reported an STNA, described as a short, heavy-set black lady, threw him onto the bed like he was a rag doll (Hospice Nurse #328 said those were his exact words). Hospice Nurse #328 stated she was informed by the previous DON the girl Resident #7 reported was agency staff and was placed on the do not return list. She was unaware of any additional follow-up. Interview on 04/24/24 at 4:45 P.M. with the Administrator regarding the determination of the investigation for the incident reported on 09/09/24 confirmed the facility concluded the allegation was unsubstantiated because he thought LPN #323's witness statement pointed to the LPN being present during the toilet transfer, which was when he thought Resident #7 sustained the bruising, and LPN #323 indicated in the witness statement that she did not witness any rough care at that time. Telephone interview on 09/24/24 at 5:32 P.M. with LPN #323 revealed she was the only nurse on duty on the night shift 09/08/24 - 09/09/24 and that STNA #332 from the staffing agency was the STNA assigned to the [NAME] Hall room [ROOM NUMBER], where Resident #7 resided. LPN #323 further confirmed she was not present in Resident #7's room for any chair, bed, or toilet transfers but had found Resident #7 on the toilet by himself and instructed STNA #332 to stay with Resident #7 and not leave him unattended while in the bathroom because he was a fall risk. LPN #323 confirmed that there was no bruising to Resident #7's arms when she left him with STNA #332, and she had not seen his arms or been present during any other care rendered by STNA #332 after that encounter. The next night, LPN #323 noticed the bruising on Resident #7's right arm looked suspicious of a fracture. According to LPN #323, Resident #7 stated the aide from the previous night had to show him who was the boss, so she threw him near the couch in the room. LPN #323 also confirmed she immediately reported this information to the DON via telephone and was informed the facility was aware and investigating and the aide involved would not be allowed back in the facility. Interview on 09/25/24 at 10:35 A.M. with Hospice Nurse #329 confirmed that on 09/09/24 she noted large bright red bruises on both of Resident #7's arms. She further confirmed Resident #7 would occasionally get small, scattered marks on his skin, but stated this was different, they looked like two hand grasps and were new skin concern areas. During the interview, Hospice Nurse #329 revealed Resident #7 had occasional short-term memory issues, but was alert and oriented to person, place, time, and situation and could see no reason to doubt his recall of events. Hospice Nurse #329 also stated that the facility seemed to believe Resident #7 right away. She also confirmed that when she reported the incident to her supervisor, she was informed that Hospice Nurse #328 had reported an incident of bruising that occurred previously after being handled too rough by facility staff. Interview with the current DON on 09/25/24 between 2:30 P.M. and 2:50 P.M. revealed she placed two agency STNAs (STNAs #332 and #334) on the do not return list because she felt they were both being dishonest and could not confirm with 100% certainty which one of them may have been providing care to Resident #7 the night he sustained bilateral arm bruising and accused staff of being too rough with him. During the interview, the DON confirmed she had no reason not to believe Resident #7's report of how he sustained the bruises, but added he did have a tendency to display some confusion and agitation in the late afternoon or evenings and thought the injuries could possibly have been incidentally caused during a difficult transfer. The DON also confirmed after learning on 09/24/24 that the Hospice staff, Resident #7, and Resident #7's two daughters reported there was a previous incident involving staff causing bruises by handling too roughly, she went to the room and spoke with the daughter who was Resident #7's POA for healthcare. The DON stated Resident #7's POA confirmed there was an incident in August 2024 where Hospice Nurse #328 reported bilateral arm bruising Resident #7 told her happened when the aide was too rough with him. According to the DON, the POA stated this was reported to the previous DON who immediately placed that staff member on the facility's do not return list, though she did not know who the alleged perpetrator was determined to be. She confirmed there was no facility record of this previously reported incident. A follow-up interview with the Administrator on 09/25/24 at 3:00 P.M. confirmed he was unaware two staff were placed on the do not return list after the reported incident on 09/09/24 and he could not determine the cause of the bruises on Resident #7's arms because he was not clinical. The Administrator stated the information found by the DON on 09/24/24 after interviewing Resident #7's POA and the information gained from the surveyor regarding LPN #323 not being a witness to Resident #7's injuries was all new news to him and he would have to interview LPN #323 prior to determining whether to reopen and continue to investigate the allegation of abuse on 09/09/24 and he would have to investigate the allegation of abuse alleged to have been reported to the previous DON on 08/28/24. Review of the policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property dated 11/28/16 revealed the facility was to take steps to identify and prevent resident harm, including injury caused by rough handling during resident care. The policy further revealed all alleged incidents involving suspected abuse or injuries of unknown origin were to be reported to the Administrator and the Ohio Department of Health and investigated. Information gathered during the investigation was to be thoroughly analyzed to determine whether the allegation could be substantiated. This deficiency represents non-compliance investigated under Complaint Number OH00157332.

Based on medical record review, interview, and review of facility policy, the facility failed to review and revise the comprehensive care plan as resident needs and required interventions changed. This affected one resident (Resident #10) of three residents whose care plans were reviewed for timely and appropriate interventions. The facility census was 38. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including senile degeneration of the brain, dysphagia, hemiplegia or hemiparesis of the left dominant side following a cerebrovascular accident, major depressive disorder, anxiety disorder, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 09/03/24 revealed Resident #10 had severely impaired cognition, impaired range of motion on one side and was dependent for eating. The MDS also revealed Resident #10 was not on any mechanically altered or therapeutic diet. Review of the physician orders revealed the following meal related orders: An order dated 02/29/24 for staff to assist with meals. An order date 03/06/24 directing that Resident #10 needed to be asked to go to the dining room for all meals to be fed and if she refused, please feed Resident #10 in her room. Orders dated 06/28/24 for Resident #10 to have a regular diet with regular texture and thin liquids, as well as a pleasure diet as tolerated. An order dated 08/10/24 to verify meal intake was documented in the orange folder in Resident #10's room. Review of the care plan initiated 03/01/24 revealed Resident #10 had self-care deficits requiring staff assistance with activities of daily living (ADLs). There were no interventions related to level of assistance needed for eating. Further review of the care plan revealed that Resident #10 was at risk for altered nutrition or hydration related to needing meal assistance, depression, difficulty chewing or swallowing, increased confusion in the evenings, and a mechanically altered diet. Interventions included honoring preferences, providing a mechanical soft, chopped diet, and encouraging completion of meals. There were no care plan interventions that spoke to Resident #10's abilities or level of feeding assistance requirements, encouraging to eat in the dining room, logging the amount eaten in the orange folder, resident food preferences, resident history of meal refusals, or that the diet had been upgraded to a regular texture diet and pleasure diet as tolerated on 06/28/24. Review of the progress notes and assessments from 05/01/24 through 09/25/24 revealed no information regarding interdisciplinary care planning meetings or outcomes. Review of the Dietary/Nutrition assessment dated [DATE] revealed Resident #10 was upgraded to a regular diet on 06/28/24 and was allowed a pleasure diet as tolerated. Resident #10 was to receive staff assistance with every meal and she had a tendency to sundown late afternoons or evenings which sometimes caused variability with her appetite. Resident #10 was to be asked if she wanted to eat in the dining room for all meals and may be fed in her room upon refusal. Interview on 09/24/24 at 10:22 A.M. with Resident #10 revealed sometimes staff assisted her with meals and sometimes they did not. She also stated the level of assistance varied, from feeding her to cutting things up and letting her eat while watching. Observation at this time revealed there was no orange folder in Resident #10's room on which to log meal intake. At this time, Resident #10's daughter stated it had been missing for a few days. Resident #10 revealed it was removed from the room on 09/21/24. Interview on 09/24/24 at 10:48 A.M. with Licensed Practical Nurse (LPN) #335 revealed she was informed there was a binder the aides were required to document on after they fed Resident #10. LPN #335 stated the folder was at the nurses' station (she pointed out its location), was not sure why it was there, and could not speak to why the logs had some missing information, as well as some dates written in out of sequence. Review of the meal intake logs from 08/10/24 to 09/24/24 revealed inconsistency with date sequences and how the logs were being filled out. Most dates were accounted for but appeared to contain some overlap with different details. For example, 09/13/24 was on top of one page and noted Resident 10 refused breakfast but was noted at the bottom of a different page noting she ate 75% of her breakfast, while the top of the page noted Resident #10 ate a hotdog and was fed by her daughter on 09/13/24 but the bottom of the previous page noted she ate 25% of her breakfast. Another example included each meal entry dated 09/23/24 was blank; however, the line below it marked 09/24 appeared to have a light mark over the four that looked like a three, and indicated breakfast was refused but Resident #10 had coffee cake and yogurt and ate 50% of her lunch, which had not yet been served on 09/24/24 at the time this form was being reviewed. There was no entry for dinner for 09/23/24 in either row. Interview on 09/24/24 at 3:30 P.M. with State tested Nurse Aide (STNA) #324 revealed she was aware staff were supposed to provide feeding assistance but was unclear on how much, since Resident #10 demonstrated the ability to hold her own cup and eat finger foods independently. STNA #324 also confirmed Resident #10 had a history of meal refusals and would often tell staff her boyfriend would be bringing her food and would become agitated at times if staff kept offering her tray. STNA #324 was uncertain if the resident's care plan mentioned staff were to log meal intakes in the orange folder, but stated the previous Director of Nursing (DON) told them to do so and pass it on to other staff in report. Interview on 09/24/24 at 4:05 P.M. with STNA #325 revealed Resident #10 refused meal trays and preferred to wait until her daughter or boyfriend brought in food from home or take-out. STNA #325 was not aware of any paper log on which staff were to document meal intake. Interview on 09/25/24 with STNA #326 confirmed the care plan did not say what level of assistance was required to feed Resident #10. She further stated she was initially told she needed some assistance and supervision with finger foods, but then was told she was a total feed, despite Resident #10's ability to have some independence when offered finger foods. STNA #326 revealed the previous and the current DON educated aides on documenting on the log and further confirmed the log was not in Resident #10's room on 09/24/24. Interview on 09/25/24 with the DON from 2:30 P.M. to 2:50 P.M. revealed interdisciplinary team (IDT) meetings were held quarterly and with changes in condition and each resident's care plan should be reviewed and updated as necessary at that time, based on the assessments and the meeting outcomes. The DON used to document IDT meetings on a specific form, but those forms stopped being utilized at some point with the previous DON. The DON said there were multiple care conferences regarding Resident #10, and she was not in attendance for the last meetings, so she was unaware the care plan had not been updated. The DON confirmed Resident #10's care plan did not accurately reflect her current diet orders, level of assistance required with meals, history of refusals, encouraging meals in the dining room, or logging meal intake. During a follow-up interview with the DON on 09/25/24 at 3:44 P.M., she confirmed there was no record of any care conference meetings, including dates, attendees, progress toward goals, or meeting outcomes/need for new interventions. Review of the policy titled Comprehensive Care Plans, undated (but from a 2024 compliance manual) revealed the facility was to develop and implement a comprehensive person-centered care plan based on an assessment of each resident's needs and strengths which incorporated the residents personal and cultural preferences, as well as the care and services required to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. The policy further revealed all care assessment areas (CAA's) from the MDS assessment were to be considered during the development of the care plan. This deficiency represents non-compliance investigated under Complaint Number OH00157294.

Based on observation, medical record review, policy review and interview, the facility failed to accommodate Resident #13's preference in regard to transferring out of bed. This affected one (Resident #13) of three residents revealed for mechanical lift transfers. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses of cerebral infarction, hemiplegia affecting left non-dominant side, alcoholic fatty liver, morbid obesity, diabetes, restlessness and agitation, and depression. Review of the of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #13 was moderately cognitively impaired, required substantial/maximal assistance with rolling left and right in bed, was totally dependent on staff for transferring from the bed to the chair and used a wheelchair for mobility. Review of the self-care deficit care plan updated 09/26/23 revealed Resident #13 had a self-care deficit related to status post cerebral vascular accident (CVA) with left-sided weakness, impaired balance, and medical condition. Interventions included Hoyer (mechanical lift) assist and used a motorized wheelchair. An initial observation on 07/30/24 at 4:20 P.M. revealed Resident #13 was sitting in his electric wheelchair while propelling around the units. Interview, during the observation, with Resident #13 revealed the staff did not always get him out of bed when he wanted. Resident #13 stated he needed a mechanical lift to transfer out and into bed and he preferred to get out bed in the morning after he finished eating breakfast. Observation on 08/05/24 at 7:40 A.M. revealed Resident #13 was lying in his bed, asleep and his electric wheelchair was plugged in, charging outside his room. At 8:10 A.M., Resident #13 was awake, looking at his cellphone. At 8:36 A.M., the meal cart was delivered to the units and staff were passing breakfast trays. At 10:35 A.M., Resident #13 continued to lay in bed, looking at his cellphone. Interview, during the observation, with Resident #13 revealed he asked a state tested nurse aide (unknown name) to get out of bed however the state tested nurse aide (STNA) told him to wait until after he had a bowel movement. Resident #13 stated, I hate when they do that. Interview on 08/05/24 at 10:38 A.M. with STNA #3 verified she was Resident #13's STNA that day. STNA #3 verified that Resident #13 asked to get out of bed that morning and STNA #3 stated that she would get him out of bed after he had a bowel movement and after she finished her showers [for other residents]. Observation on 08/05/24 at 11:15 A.M. revealed Resident #13's electric wheelchair continued to sit outside his room. At 11:25 A.M., Agency STNA #3 was observed sitting at the nursing station chatting with Agency STNA #6. At 11:55 A.M., Resident #13 continued to lay in bed, and he was asleep. At 12:05 P.M., the Director of Nursing served Resident #13 his lunch while the resident was still in bed and his electric wheelchair was outside his room. Interview on 08/05/24 at 12:30 P.M. with the interim Administrator and Director of Nursing (DON) verified Resident #13 should have been assisted out of bed when he requested to get out of bed. Review of the facility's AM Care policy dated September 2013 revealed nursing personnel would perform AM care on all residents who needed assistance. Non-ambulatory residents: transfer to wheelchair. This deficiency represents non-compliance investigated under Complaint Number OH00155952.

Based on record review, interview and policy review the facility failed to ensure narcotic medication were reconciled each shift for medication carts two and three. This affected 10 residents (Resident #3, #5, #8, #23, #24, #25, #29, #30, #31, #33) who received narcotic medication from medication cart two and three. The facility census was 31. Findings included: Review of the narcotic reconciliation sheet for medication cart two revealed no documentation the shift to shift narcotic reconciliation was completed on 10/11/23, 10/16/23, 10/17/23 and 10/18/23. Review of the narcotic reconciliation sheet for medication cart three revealed no documentation of the shift-to-shift narcotic reconciliation was completed on 10/13/23, 10/17/23 and 10/18/23. On 10/18/23 at 9:20 A.M. an interview with Registered Nurse #100 revealed she had completed the narcotic count with the night shift nurse but the night shift nurse was in a hurry and never documented narcotic reconciliation had occurred. On 10/19/23 at 9:00 A.M. an interview with the Director of Nursing verified the narcotic count/reconciliation sheets did not indicate narcotic count was completed on the dates identified. She stated the nurses were to count and document the narcotic count was completed at every shift change. Review of the facility policy titled, Narcotic Accountability, dated 03/17 revealed all drugs with abuse potential were stored and monitored properly and accurate record keeping maintained. All controlled substances were to be counted each shift or whenever there was an exchange of keys between off-going and on-coming licensed nurses. This deficiency represents non-compliance investigated under Complaint Number OH00146827.

Based on observation, interview and record review the facility failed to supervise and implement individualized safety measures to ensure Resident #1, who was assessed as an elopement risk with a history of wandering, did not leave the facility unsupervised. Resident #1 was wearing a functioning wander guard bracelet that signaled staff when he left the building. All facility staff, signaled by the wander guard of Resident #1's leaving the building, failed to respond. This resulted in Immediate Jeopardy when Resident #1, who required supervision to leave the building, left unattended and was later found a mile from the facility which placed the resident at risk for the likelihood of serious injury, impairment or death. This had the potential to affect the nine residents (Resident #1, #2, #3, #4, #5, #6, #7, #8 and #9) identified as being at risk for elopement On 01/26/17 at 3:06 P.M., the administrator, director of nursing (DON) and Director of Administrative Services (DAS) #51 were informed Immediate Jeopardy began on 01/15/17 at 10:33 A.M. when Resident #1 left the facility unsupervised. No staff responded to the alarm generated when the wander guard bracelet activated a signal that Resident #1 had exited through the front door. Resident #1 was found wearing a coat and hat, walking with a walker in the street in a wooded neighborhood, with no sidewalks. Resident #1 was returned to the facility at 12:05 P.M. The temperature that day was 37 degrees Fahrenheit (F) according to Accuweather.com. The Immediate Jeopardy was removed on 01/23/17 when the facility implemented the following measures: · On 01/15/17 Registered Nurse (RN) #49 checked the function of all the direct care staff pagers and all wander guards to ensure proper function. · On 01/15/17 RN #17 was on call and came into the facility to obtain witness statements and started an investigation. RN #17 educated working staff on the use of the pager and response to wander guard activation. · On 01/16/17 SecuriTech Technician #52 checked the security system and it was found to be functioning correctly. · On 01/16/17 the Minimum Data Set (MDS) nurse, RN #30, reviewed all elopement assessments and care plans, for the nine residents identified at risk for elopement, and updated them as necessary to ensure correctness. · On 01/16/17 the DON initiated daily audits to ensure proper function of the wander guard bracelets and timely staff response to the pager alerts. The daily audits will continue until 01/31/17 followed by weekly audits from 02/01/17 to 02/28/17 and then twice monthly audits from 03/01/17 to 04/30/17. · On 01/19/17 Manager of Information Services (MIS) #53 made changes to the wander guard security system. Changes included allowing the pagers to be audible and blocking the staff's ability to put the pagers on vibrate. An additional sound was added to all exit doors to activate whenever a wander guard bracelet was near. The activation sound was only able to be de-activated by a nurse. · On 01/20/17 the DON began education for all direct care staff related to elopement, the wander guard security system including changes and responsibility and updates to policies and procedures. · On 01/26/17 at 11:30 A.M. the surveyor and MIS #53 activated the wander guard alarm to observe staff response. State tested Nurse Aide (STNAs) #9, #28 and #43, RNs #48 and #37 and Licensed Practical Nurse (LPN) #24 responded to the activation of the alarm in a timely manner. An alert to the individual pagers was verified. · On 01/26/17 between 11:35 A.M. and 11:50 A.M., and between 5:30 P.M. and 5:40 P.M., interview with STNAs #9, #25, #36, RN #48 and RN #21 verified they received education to ensure immediate response to all pager alerts sounded by a wanderguard when a resident left the building unattended. The staff verified the education included ensuring the resident was visibly safe and remained in the facility. · On 02/07/17 between 9:10 A.M. and 9:25 A.M., observation of all nine residents identified by the facility as being at risk for elopement were observed in the facility with the wanderguard bracelets in place. No residents were exit seeking. · On 02/07/17 between 9:30 A.M. and 10:10 A.M., interviews with RN #49, LPNs #24, and #50 and STNAs #35, #18, #9 and #6 verified their knowledge of response to a resident attempting to exit the facility unattended with a wanderguard in place. · On 02/07/17 review of all nine residents elopement risk assessments and plans of care revealed all were reviewed and updated as needed. · Review of the in-service log revealed all staff, including non- direct care staff, had been educated 02/01/17 on monitoring elopement risk residents loitering at exit doors. · Review of the January and February, 2017 daily audits to ensure proper function of the wander guard bracelets and pager response checks revealed the audits were completed as planned. Although the Immediate Jeopardy was removed the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of conducting audits to verify the corrective action was effective. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 11/30/16 revealed Resident #1 had severe cognitive impairment and required supervision with one person and his walker for locomotion due to an unsteady gait. Review of Resident #1's plan of care initiated 01/21/15 revealed there was no plan specific for elopement. Further review of the fall and behavior plan of care revealed the resident had a wanderguard bracelet to alert all staff of unassisted attempts to exit the facility. Interventions included to check function of the wanderguard according to policy, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. Review of the STNA care assignment sheet revealed Resident #1 wandered the unit and had a wanderguard in place to alert staff of unassisted attempts to exit the facility. The assignment sheet indicated Resident #1 ambulated with assistance of staff and the use of a walker. Review of physician's orders [REDACTED].#1 had a wanderguard to his wheelchair and walker to alert staff of unassisted attempts to leave the facility. Review of the comprehensive wandering assessment dated [DATE] revealed Resident #1 was unaccepting of living at the facility, exhibited behaviors indicating a desire to leave and was exit seeking in the last 60 days. The assessment revealed Resident #1, at times, wished to leave the facility because he did not live there. Many times he sat by the exit doors waiting for someone to pick him up. The assessment indicated a plan of care should be developed with associated interventions to address the exit seeking behavior. Review of the quarterly wandering assessment dated [DATE] revealed Resident #1 was unaccepting of living at the facility, exhibited behaviors indicating a desire to leave and was exit seeking in the last 60 days. The wanderguard continued to be in place to alert staff of unassisted attempts to leave facility. The assessment indicated to develop a plan of care with associated interventions to address the exit seeking behavior. Review of a nursing note dated 01/15/17 at 12:40 P.M., by LPN #7 indicated Resident #1 had exited the building. The resident's son was notified immediately. The resident was back in the building at that time. On 01/26/17 at 9:10 A.M., interview with the DON verified the facility did not have any documented evidence of monitoring the process and response to the wanderguard system prior to 01/15/17 when Resident #1 eloped from the facility. The DON verified each wanderguard was coded with the resident's name and the wanderguard was able to identify the specific door the resident was approaching. The DON explained when a resident with a wanderguard approached an exit door, the door locked. If the resident remained near the door for three minutes, all direct care staff and management's pagers and cell phones were alerted of the resident's location at the specific door. If the resident remained in the area for two more minutes another alert was sent out to all staff. The expectation was all staff should respond to the alert. If the door was open when the resident approached the door, the pagers would indicate which resident had exited the building and from what specific door. The DON verified on 01/15/17 at 10:33 A.M. a visitor was leaving the building and Resident #1 followed the unknown visitor out of the building. The DON verified the wanderguard system functioned properly on 01/15/17, alerted staff, including herself, that the resident was exiting the main front door but no staff responded to the alarm. The staff assumed the resident's son was taking the resident out of the facility. The DON verified it was a Sunday and she received the alert at home but also assumed the resident's son took him out of the building. No one knew the resident left the building unattended until the local police called and asked LPN #7 if Resident #1 was missing. The police informed LPN #7 Resident #1 was found walking down the road with his walker about one mile away from the facility which was located in a wooded area surrounded by a lake. The DON verified LPN #7 notified the on call nurse, RN #17, who did not come into the facility or notify the DON. The DON called into the facility for an unrelated concern at 3:00 P.M. when she was informed by LPN #7 that Resident #1 had eloped from the facility but was brought back by emergency medical services (EMS) unharmed. The DON verified she then contacted RN #17 and instructed her to go to the facility and obtain statements from the staff. It was determined the wanderguard system was functioning as designed and the failure was the staff did not respond to the alert. The DON verified on 01/16/17 the wanderguard technician came into the facility and verified the system was functioning properly. On 01/17/17 MIS #53 adjusted the security system by adding sound activation at each of the exit doors when approached by a wanderguard, that could only be deactivated by a nurse from a computer. On 01/26/17 at 10:35 A.M., phone interview with SecuriTec Technician #52 verified he was at the facility on 01/16/17 and acknowledged the wanderguard alarm system was functioning as designed. On 01/26/17 at 11:11 A.M., interview with MIS #53 verified on 01/15/17 he was called to check the computer to ensure the security system was functioning properly. On 01/16/17 MIS #53 had SecuriTec Company Technician #52 check the system which was found to be in working order. On 01/17/17 MIS #53 made adjustments to the security system to include all pagers would have an audible alert that could not be silenced. Previously staff were able to set the pager to sleep or vibrate. In addition a sound activation was installed at all of the exit doors that could only be turned off by a nurse from the computer. All changes were tested and functioned as designed. On 01/26/17 at 11:30 A.M. the surveyor and MIS #53 tested the wanderguard system at the front door. When approaching the front door it locked and after three minutes the surveyor observed all staff pagers sounding and the pagers read loitering at the front door. On 01/26/17 at 12:00 P.M., interview with RN #17 revealed she was not in the facility on 01/15/17 but was on call. She received the alert on her cell phone stating Resident #1 exited the alarmed front main door at 10:33 A.M. RN #17 stated because it was a Sunday, I assumed his son probably took him out of the building. RN #17 stated LPN #7 called and told her the police had called the facility and said Resident #1 had been found wandering approximately one mile from the facility. RN #17 stated Resident #1 was returned to the facility around 12:15 P.M. RN #17 stated that evening about 3:45 P.M., the DON had her come into the facility to get statements from the staff to start the investigation. RN #17 verified the resident's wanderguard was attached to his walker and it was left on when the resident left the building. RN #17 verified LPN #7 and RN #49 were the nurses working at the time Resident #1 left the building. RN #17 verified LPN #7 wrote a statement but she had to call RN #49 to get his statement. RN #17 verified the staff usually delete the alert on the pager after an alert was sent. RN #17 verified the nurse should have assured the resident was safe either by responding to the alert themselves or verifying an STNA observed the resident was safe. On 01/26/17 at 12:55 P.M., Resident #1 was observed in the dining room at a table by himself with his walker at his side. The walker had the wanderguard attached to the bar. The surveyor attempted to interview the resident but he was pleasantly confused and not interviewable. On 01/26/17 at 3:40 P.M., Resident #1 was sitting in the dining room with his walker nearby. A group of women were in an activity at another table. Resident #1 was interviewed and did not want to be involved with the activity. He said he was waiting to eat. Two of the female residents stated Resident #1 would not join the activity. They stated he won't come with us, he misses his family and always looks for them and wants to leave. On 01/26/17 at 4:10 P.M., the area around the facility was observed. A lake was observed on the right side with a long driveway through the woods which led into a neighborhood without sidewalks. The route Resident #1 took, as documented by the police, was 0.9 miles from the facility and ended at an intersection. On 01/26/17 at 5:25 P.M., RN #30 verified Resident #1 wandered frequently and wanted his family. She stated he did not usually wear his coat and hat while wandering the facility but he did sit at the front door frequently looking for his son. On 01/26/17 at 5:30 P.M., interview with STNA #36 verified the pager alerted when residents with wanderguards were by the doors. STNA #36 stated when the resident had exited the facility all staff should have tried to respond. She indicated no system was in place to verify if a resident was found or if any staff had responded to the alert. She stated Resident #1 paced a lot and he hardly slept. He was always talking about wanting to go home and sat at the main front door looking for his son. He was very difficult to re-direct. On 01/26/17 at 5:35 P.M., interview with STNA #25 verified the pager alerted when residents with wander guards where loitering at an exit door and when the resident had exited the facility. She stated all staff should try to respond but no system was in place to verify if a resident was found. STNA #25 stated Resident #1 was very restless and always on the move or sitting at the main front door looking for his son. On 01/26/17 at 5:40 P.M., interview with RN #21 verified the pager alerted when residents with wanderguards were loitering at an exit door. She stated all staff were expected to respond. If she was not able to respond immediately, as soon as she could, she would look for the resident to ensure the resident was in the building and safe. She stated Resident #1 was always walking around the facility. On 01/27/17 at 8:40 A.M., phone interview with Resident #1's physician, Physician #54, verified he could not remember if he was informed of the resident eloping from the facility or if the resident was not hurt. He stated he would let the facility handle the situation. On 01/27/17 at 9:06 A.M., phone interview with the local Assistant Fire Chief indicated on 01/15/17 the firemen were getting fuel when an individual stopped and asked if they would check on an elderly male walking down the road with a walker. The firemen approached the elderly male, called the police department, and determined the elderly male was a resident at the facility. The firemen returned the resident to the facility via the EMS squad. The Assistant Fire Chief verified if there were any injuries to the resident they would have completed an incident report. There was no incident report filed so he assumed the resident was unharmed when taken back to the facility. On 01/27/17 at 11:55 A.M., phone interview with RN #49 verified he, LPN #7 and LPN #50 were working day shift on 01/15/17. RN #49 verified he observed Resident #1 around 10:00 A.M. with his coat and hat on, using his walker and walking toward the main front exit. He stated it was unusual for him to be wearing his coat and hat but he did not think too much about it. He verified the son always told the nurse when he was taking Resident #1 out of the facility and they were supposed to document in the nurse's notes when the resident left and when the resident returned. RN #49 verified a little after 12:00 P.M. he was informed by LPN #7 the police found Resident #1 about a mile away and were bringing him back. RN #49 verified his pager alerted him Resident #1 was exiting the front main door at 10:33 A.M. but he did not respond to the alert. He did not verify if anyone responded to the alert. RN #49 stated after Resident #1 was returned he checked all the wander guards and pagers and everything was functioning. RN #49 stated the facility had a few residents that wandered and attempted to exit the building but was not able to give any details regarding residents, incident or dates. On 01/27/17 at 12:30 P.M., interview with LPN #50, who was working days on 01/15/17, verified Resident #1 did not usually wear a hat and coat when walking throughout the facility. He was always wandering the facility going to doors especially the front door looking for his son, who usually came on Sundays. She verified she had her pager on the medication cart and was in a room caring for another resident. When she came out, she observed the alert that Resident #1 had exited the building and revealed she did not follow up to see if the resident actually left the building unattended. She verified whoever was available was supposed to respond to the alert of a wander guard for a resident exiting the building but it was no one person's responsibility. LPN #50 stated when she came back from lunch after 11:30 A.M. she went into a resident's room for a while and when she came out of the room LPN #7 said the police called, found Resident #1 walking the streets, and they were bringing him back. She was not aware of any of the staff communicating about the alert because he usually goes out with his son on Sundays. She stated the son signs Resident #1 out in the book and they were to document in the nursing notes when he leaves and when he returns. On 01/27/17 at 2:10 P.M., phone interview with LPN #7 revealed Resident #1 was acting his usual on 01/15/17 doing laps around the facility. He had his coat and hat on but she did not think it was unusual because his son usually took him out on Sundays. LPN #7 verified her pager was on the medication cart and she was in a resident's room. She stated she did not get the alert on her pager. She verified the resident's son always came and told the nurses when he was taking the resident out of the facility. The family was supposed to document in the leave of absence (LOA) book when they take a resident out of the facility. The nurses were to document in the nursing notes when the residents left and returned to the facility. Review of the wanderguard alarms resident safety policy dated 05/10/10 revealed the facility would ensure the safety of residents who had a history of [REDACTED]. Nursing would complete the wandering elopement risk assessment. Nursing would attempt to intervene and re-direct the resident to a safe area. The problem would be addressed on the resident's individual plan of care. Nursing would initiate the safety assistive device flow sheet and place in the proper section of the STNA books. Review of the SecuriTec EV2 pager system policy dated 05/08/13 revealed an electronic paging system with pagers was used for STNAs, nurses and cell phone notification for the DON, RN coordinator, on-call RN, and administrator to be able to respond to the activation of a call light. The policy did not address the use of wander guards.

Based on observation, interview and record review, the facility failed to ensure Resident #1, who fell resulting in a fractured right leg, received treatment including medication for pain to keep the resident comfortable. This resulted in actual harm when Resident #1's pain, rated a nine on a scale of one to 10, was not addressed resulting in ongoing pain and [MEDICAL CONDITION]. This affected one of one resident reviewed for falls and pain managment. Findings include: Resident #1 was admitted to the facility on [DATE] from an assisted living facility because she needed more assistance with activities of daily living (ADL's). [DIAGNOSES REDACTED]. Review of the physicians orders, dated 12/05/16, revealed orders for [MEDICATION NAME] 1000 milligrams (mg) at bedtime for pain and 500 mg three times a day for chronic pain. [MEDICATION NAME] 400 mg every four hours was also ordered as needed for pain. Review of the admission Minimum Data Set (MDS) 3.0, dated 12/12/16, revealed a brief interview for mental status indicated the resident's memory was intact. Review of the pain assessment dated [DATE] revealed the resident had chronic pain but no current pain and was receiving [MEDICATION NAME] as ordered. There were no further pain assessments to review. Review of a nursing note revealed on 12/18/16 at 11:58 P.M., the resident was found on the floor by State tested Nursing Assistant (STNA) #210 with no injury noted. There was no evidence of any further assessments, monitoring or indication of the nurse checking on the resident after the fall until 12/19/16 at 8:16 A.M. Review of a nursing note dated 12/19/16 at 8:16 A.M. revealed the resident complained of right ankle pain rated a nine on a scale of zero to 10 (10 being the worst) with numbness and tingling. At 8:20 A.M., the physician was notified and an x-ray was ordered. At 8:51 A.M., the resident's ankle was elevated with ice applied to the affected area. At 12:53 P.M., the technician arrived for the x-ray and the resident complained of a pain score of four. Review of the x-ray dated 12/19/16 at 1:43 P.M., revealed an acute [MEDICAL CONDITION] distal fibula with pain and swelling. Review of the nursing note dated 12/19/16 at 5:55 P.M., revealed the resident was sent to the hospital and returned at 10:24 P.M. with a splinted right ankle fracture and a prescription for a narcotic pain medication. Review of the physicians order revealed on 12/19/16 at 9:46 P.M., [MEDICATION NAME]-[MEDICATION NAME] five mg-325 mg three times a day as needed was prescribed for a total of 15 tablets. Review of the nursing notes revealed no evidence of assessments of pain from the time of the discovery of the fall on 12/18/16 at 11:58 P.M., until 12/19/16 at 8:16 A.M. when the resident rated the pain a nine out of 10. Review of the medication administrator record (MAR) for December 2016 revealed the as needed [MEDICATION NAME] was never given for pain and, the as needed [MEDICATION NAME]-[MEDICATION NAME] was only given on 12/21/16 at 8:51 A.M. despite the resident having expressed concerns with pain. Review of the fall investigation for the 12/18/16 fall revealed LPN #201's witness statement verified the resident complained of pain immediately after the fall to the right ankle; she looked up her as needed pain medication but nothing was given. Witness statement from Resident #1 verified she informed the nurses right after the fall her ankle hurt and she stated she did not sleep that night because she was uncomfortable and her ankle hurt. A witness statement from STNA #202 revealed she was in the room after the resident fell and the resident reported pain in her right ankle and continued to complain of pain throughout the night. STNA #202 indicated she was in her room every 30-45 minutes answering her call bell because she was in pain. STNA #202 verified the resident told LPN #208 she was having pain. STNA #202 stated Resident #1's ankle, was huge, when we got her off the floor and into bed it was visibly swollen, easily twice the normal size. Review of a witness statement from LPN #207 who worked day turn on 12/19/16 verified LPN #201 indicated she faxed the doctor about the resident's fall when she gave report. LPN #207 stated when she went to give the resident her morning medications the resident told her the right ankle was hurting. On 12/21/16 at 10:04 A.M., Resident #1 was observed in the wheelchair with her right lower leg in a white cast, not elevated but on the leg rest on a pillow about three inches from the floor. On 12/21/16 at 10:05 A.M., interview with Resident #1 revealed she broke her leg two days ago because she had to use the restroom. Staff was not responding to her request for assistance so she attempted to toilet herself. The resident stated she had immediate pain in the right ankle with numbness, burning and throbbing, continuing even now. Resident #1 stated she kept asking for pain medication the last two nights but the nurse said she would have to wait until morning shift. The resident stated she knew she had an order for [REDACTED]. She then asked if it was supposed to be given on a regular basis and asked for it to be checked on. On 12//21/16 at 3:40 P.M., interview with the director of nursing (DON) verified the above concerns including lack of any pain assessments, evidence of the resident complaining of pain, and no evidence the pain was addressed. The DON stated no one called her after the resident fell on [DATE]. The DON said the investigation revealed the facility was aware of the immediate pain in the resident's right ankle directly after the fall and no interventions were attempted until 12/19/16 at 8:51 A.M. when ice was applied. The DON verified the resident continued to complain of pain on 12/19/16, 12/20/16, and 12/21/16 and there was no documented evidence the as needed pain medications were offered to the resident except for one time on 12//21/16 at 8:51 A.M. The DON verified Resident #1 went for at least 33 hours without relief of her right ankle pain, swelling, numbness, throbbing and tingling. Review of the pain management policy revised 01/01/05 revealed staff would respond in a timely manner when pain was reported, and provide effective pain management. Every shift daily the nurse would monitor and assess for pain, provide pain management as needed and document accordingly, and notify the physician if pain was not relieved with medication. This deficiency was an incidental finding discovered during this complaint investigation.

Based on observation, record review and interview the facility failed to ensure a skin assessment of the right leg was completed with the brace off upon the resident's return from the hospital on [DATE] until 07/11/13. The lack of assessment of the right foot skin integrity resulted in actual harm as evidenced by unstageable pressure ulcers that developed on the right heel and the side of the right great toe. This affected one resident (Resident #85) of one resident reviewed for pressure ulcers. The census was 55 residents. Findings include: Resident #85 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. The assessment indicated the resident had no pressure ulcers. The resident required extensive assistance of one to two people for activities of daily living. The skin risk assessment revealed the resident was at high risk for developing pressure ulcers. The resident admission assessment dated [DATE] revealed the resident had scabbed areas to 2nd and 4th right toes. The assessment did not indicate any other areas or any pressure ulcers. Review of the readmission MDS dated [DATE] revealed the resident was cognitively intact. The assessment revealed the resident had two Stage I (A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) pressure ulcers and two unstageable (covered with eschar/necrotic tissue and the wound bed was not visible) pressure ulcers. The assessment revealed the resident required extensive assistance of one to two people for activities of daily living. The weekly skin grid or change in skin condition document dated 07/11/13 revealed a change in skin condition, an open blister on the right heel that measured 1.4 centimeters (cm) long, 1.6 cm wide and 0.1 cm deep. The side of the right great toe had a blister that measured 1.3 cm long and 1.2 cm wide. The right heel wound had a bright red center without any drainage noted. The right great toe had an intact blister with redness seen through the blister. Hydrogel with [MEDICATION NAME] was the ordered treatment for [REDACTED]. The weekly skin grid or change in skin condition dated 07/28/13 revealed a right bunion-type blister that measured 1.3 cm long and 1.4 cm wide, a right heel ulcer that measured 3.0 cm long and 3.2 cm wide, right lateral foot redness and left heel redness. The wound nurse assessment dated [DATE] revealed a right heel pressure ulcer that measured 3.2 cm long and 3.0 cm wide that was a suspected deep tissue injury and a right bunion pressure ulcer that measured 1.6 cm long and 1.4 cm wide. All wounds were 100% necrotic, intact with no drainage, bright red periwound to the bunion and bright red mushy soft tissue surrounding the right heel ulcer. The resident was observed on 07/29/13 at 11:10 A.M. in therapy in a wheelchair with a right leg brace that extended from the upper leg to a plastic foot piece. The resident was observed on 07/29/13 at 11:50 A.M. and on 07/30/13 at 1:55 P.M. in the wheelchair with the right leg brace on. The resident was observed on 07/31/13 at 10:00 A.M. in his room in bed and the right leg brace in place. The resident was observed in bed with the right leg brace on 07/31/13 at 2:30 P.M. as LPN #50 prepared to change the pressure ulcer dressings. The resident's left heel was flush against the mattress. The LPN washed her hands and gloved after bringing the wound supplies into the room and placing them on the radiator. The LPN removed the right leg brace and leg sleeve. The LPN removed the right heel dressing and the dressing to the right side of the great toe with the same gloves. The right heel wound had black eschar covering the wound bed surrounded by beet red tissue and a moderate amount of tan drainage. The heel presented as an unstageable pressure ulcer. The side of the right great toe had black eschar covering the wound bed surrounded by beet red tissue with a moderate amount of tan drainage. The side of the right great toe presented as an unstageable pressure ulcer. The LPN changed gloves, but did not wash or cleanse her hands. She applied wound cleanser to the right heel and the side of the right great toe with the same gloves. She changed gloves without cleansing her hands, sprayed [MEDICATION NAME] on the gloves and applied the [MEDICATION NAME] onto the heel and great toe wounds with the same gloves. She changed gloves and applied skin prep to the reddened area on the lateral side of the right foot. The right heel was resting on the bed. The left heel was red and non-blancheable. The LPN stated the left heel reddened area was recently discovered and there was no treatment ordered. The LPN changed gloves without cleansing her hands and applied 4 x 4 gauze to the right heel and right great toe wounds. The LPN changed gloves without washing and applied [MEDICATION NAME] lotion to the resident's right leg. The LPN placed the tape on the bed then onto the radiator where the cleanser, [MEDICATION NAME] and [MEDICATION NAME] lotion had been placed. The LPN changed gloves without cleansing her hands and applied the leg sleeve and leg/foot brace. A thin piece of sheepskin was placed in the plastic foot area of the brace. The LPN washed her hands and gloved. She cleansed the cleanser, [MEDICATION NAME] and [MEDICATION NAME] containers with bleach wipes and replaced them on the radiator. She placed the tape in her pocket. She disposed of the refuse, returned the supplies to the cart and cleansed her hands. An interview with LPN #50 on 07/31/13 at 2:50 P.M. verified the resident's left heel that had a reddened area was flush against the mattress. She verified that she did not wash or cleanse her hands during the dressing change. She verified the right heel ulcer was on the bed after she had cleansed the area and applied the [MEDICATION NAME]. She verified she placed the lotion, cleanser and [MEDICATION NAME] containers on the radiator without a barrier after cleaning them. She verified she placed the tape in her pocket. She verified the right heel and the side of the right great toe were pressure ulcers. She verified the pressure ulcers were covered with black eschar and had tan drainage. She verified the areas on the lateral side of the right foot and the left heel had non-blancheable reddened areas. An interview on 08/01/13 at 8:55 A.M. with the wound nurse, LPN #51, revealed the wound assessment dated [DATE] was completed by another nurse. LPN #51 verified she documented the information regarding the pressure ulcers on 07/12/13 and 07/30/13. LPN #51 verified the heel, right great toe and redness on the lateral side of the right foot were pressure ulcers from the brace. She verified the documentation indicated there were no pressure areas when the resident was readmitted to the facility on [DATE] and the pressure areas to the right heel and right great toe were discovered on 07/11/13 at a significant size and severity. She verified the resident had a leg brace to the right leg that had a plastic part under and on the side of the right foot. She stated the plastic piece of the brace was the cause of the pressure areas. She stated the brace was to be removed when assessing skin integrity. She verified the documentation of 07/28/13 indicated the resident had a red, non-blancheable area on the left heel. She verified there was no further documentation regarding the reddened area on the left heel. She stated she measured and documented on wounds about once a week if possible. She stated the nursing staff informed her when wounds were discovered, she would assess the wounds, document and get orders from the physician. She verified she was unaware that Resident #85's right heel ulcer and right great toe ulcer were draining tan drainage. She stated she would need to inform the physician and get further orders.

Based on interview and record review, the facility failed to provide appropriate positioning of a resident during delivery of personal care. This resulted in actual harm for Resident #17 who sustained a fall with a fracture. This affected one of three residents reviewed for falls. The facility also failed to ensure the safe transfer of a portable oxygen tank for Resident #41. This had the potential to affect the 10 residents residing in the corridor and residents in Rooms 100-104. The facility census was 55. Findings include: 1. Record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plans dated 01/14/13 and updated through 10/01/13 revealed Resident #17 had cognitive impairment related to dementia. The care plans indicated that the resident was at risk for falls due to impaired balance, medications, and non-compliance with mobility aids. Review of the nursing notes dated 06/07/13 timed 4:28 A.M. revealed Resident #17 sustained a fall from her bed. An alarm was sounding and the resident stated that she was trying to turn the sound off. The resident did not sustain any injuries with this fall. Interventions included a fall matt to the window side of the bed and the bed was to kept in the low position. Review of the nursing notes dated 07/11/13 timed 3:00 A.M. revealed Resident #17 had fallen out of her bed while an STNA was turning her and doing personal care. The resident was found by the nurse on the floor with her head on the base of the dresser. The bed was found in the high position. The note indicated that " copious amounts of red drainage was noted " from a laceration on the left occipital side of her head. The resident was sent to the hospital emergency room and returned on 07/11/13 at 7:25 A.M. Review of nurse's notes indicated after return to the facility Resident #17 complained of pain to her left leg. Resident #17 was sent back to the hospital on [DATE] at 5:19 P.M. and was admitted to the hospital with [REDACTED]. Interview with Registered Nurse (RN) #43 on 07/30/13 at 4:35 P.M. revealed that the investigation of the incident revealed the STNA was holding the resident's hip when the resident pushed away from her. The resident stated she was going to fall and then fell out of the opposite side of the bed onto the floor. Interview with the director of nursing (DON) on 07/31/13 at 11:00 A.M. revealed that she had interviewed the STNA involved and had her demonstrate how the incident occurred. The DON stated that it was determined that the aide had not pulled Resident #17 close enough to her when care was being provided and the resident was able to push herself away from the STNA and fall out the opposite side to the floor from the bed as it was in the high position. The involved STNA was unavailable for interview. Fall interventions following the incident included fall mats to the floor on both sides of the bed, bilateral half side rails and maintain the bed in the low position. Observation of Resident #17 on 08/01/13 at 2:45 P.M. revealed her bed with bilateral half siderails up. However, the bed was not in the low position and floor mats were not in place on both sides of the bed. This was verified at the time of the observation with another surveyor. On 08/01/13 at 1:30 P.M. Resident #17 was observed in her bed with bilateral side rails in the up position. A floor mat was in place between the two beds in the room, but a mat was not on the side by the window. Resident #17's bed was not in the low position. Verification was made with Licensed Practical Nurse (LPN) #45 at the time of the observation. The DON verified on 08/02/13 at 9:00 A.M. that Resident #17 sustained a fall resulting in a fracture when she was not positioned properly during care. 2. Observation was made of Licensed Practical Nurse (LPN) #50 removing an oxygen portable E tank from Resident #41's wheelchair. She walked into the hall by Rooms 100-104 and placed the tank next to the medication cart without securing it in a container. LPN #50 verified there was still a small amount of oxygen in the tank at the time of the observation. An interview with the LPN #50 on 07/31/13 at 11:25 A.M. verified she carried the portable oxygen tank into the hall and placed it on the floor next to the medication cart in the hall without having it in a secure container. This deficiency substantiated allegations contained in complaint #OH 27.