Every finding on record at Urbana Health & Rehabilitation Center

Based on observations, staff and resident interviews, review of maintenance work order log, and review of the facility work order process form, the facility failed to ensure resident rooms were without holes in the drywall or torn wallpaper. This affected three (#09, #12, and #13) residents out of the four residents reviewed for homelike environment. The facility census was 47.Findings include:1.Review of the medical record for Resident #09 revealed an admission date of 08/03/23 with medical diagnoses of vascular dementia, hypertension (HTN), anxiety, and hypothyroidism. Review quarterly of the Minimum Data Set (MDS) assessment, dated 06/20/25, indicated Resident #09 had severe cognitive impairment and was dependent upon staff for toileting hygiene, transfers, and bathing and was independent with eating. 2. Review of the medical record for Resident #12 revealed an admission date of 09/22/22 with medical diagnoses of congestive heart failure, HTN, diabetes mellitus (DM), and anxiety.Review of a quarterly MDS assessment, dated 06/12/25, indicated Resident #12 was cognitively intact and was dependent upon staff for bathing, toilet hygiene, transfers, and bed mobility.3. Review of the medical record for Resident #13 revealed an admission date of 07/12/22 with medical diagnoses of HTN, DM, hyperlipidemia, and history of cerebral infarction.Review of a quarterly MDS assessment, dated 08/03/25, indicated Resident #13 was cognitively intact and was dependent upon staff for toileting hygiene, required substantial/maximum staff assistance for bathing and bed mobility. The MDS indicated Resident #13 had not transferred during review period. Observation with interview on 08/29/25 at 8:11 A.M. of Resident #13's room revealed two large holes in the wall on the right side of Resident #13's bed. The observation also revealed the wallpaper on the wall on the right side of Resident #13's bed was torn. Interview with Resident #13 confirmed the two large holes in her walls near her bed and stated the holes had been there for a long time.Interview on 08/29/25 at 8:15 A.M. with Licensed Practical Nurse (LPN) #111 confirmed there were two large holes and torn wallpaper on the wall on right side of Resident #13's bed. Observation with interview on 08/29/25 at 9:51 A.M. of Resident #12's room revealed a large hole in the wall behind the bed. The observation also revealed torn wallpaper on the wall behind Resident #12's bed. Interview with Resident #12 confirmed the hole in the wall and the torn wallpaper behind her bed but stated she was not sure how long the wall had been like that. Interview on 08/29/25 at 9:53 A.M. with LPN #111 confirmed Resident #12 had a hole in her wall behind her bed and the wallpaper was torn. Observation with interview on 08/29/25 at 9:58 A.M. with Resident #09's room revealed a hole in the wall behind her bed and torn wallpaper. Interview with Resident #09 stated she was not aware of the hole in the wall or the torn wallpaper.Interview on 08/29/25 at 10:04 A.M. with State Tested Nursing Assistant (STNA) #102 confirmed there was a hole in the wall behind Resident #09's bed and the wallpaper was torn. Review of the facility maintenance log from 06/11/25 to 08/28/25 revealed no documentation to support the facility had identified the holes in the walls in Resident #09's, #12's, and #13's room. Review of the facility work order process instructions, dated 03/06/25, stated staff are to identify maintenance/work needed and to enter into a log/binder in the Maintenance office. This deficiency represents non-compliance investigated under Complaint Number 2568278

Based on observations, record review, staff interviews and facility policy review, the facility failed to prepared palatable food. This affected 29 residents, (#20, #39, #35, #5, #28, #2, #34, #12, #33, #198, #38, #8, #17, #27, #43, #29, #3, #13, #32, #198, #22, #10, #26, #31, #25, #24, #7, #23, and #37) who were served regular consistency textured diets. The facility census was 46. Findings Include: Review of medical records revealed the following residents had a physician order for a regular consistency textured diet, Resident #20, #39, #35, #5, #28, #2, #34, #12, #33, #198, #38, #8, #17, #27, #43, #29, #3, #13, #32, #198, #22, #10, #26, #31, #25, #24, #7, #23, and #37. Observation on 06/02/25 at 11:46 A.M. revealed Residents #11, #2, and #24 received popcorn shrimp at the lunch meal in the dining room. The shrimp had a white coating and was not browned. The residents appeared to have difficulty chewing the exterior coating. Observation on 06/02/25 at 12:06 P.M. Resident #29 received her lunch meal tray in her room. The plate contained popcorn shrimp. The shrimp had a white coating and appeared hard. Resident took bites of the shrimp and took it out of her mouth. Interview on 06/02/25 at 11:47 A. M. with Residents #11, #2 and #24 revealed the shrimp was unappetizing, difficult to chew and they could not eat the shrimp. Interview on 06/02/25 at 12:06 P.M. with Resident #29 revealed she could not chew or soften the shrimp coating to swallow it. Interview on 06/04/25 at 11:17 A.M. the Registered Dietitian #400 verified the shrimp served on 06/02/25 at lunch was not an oven ready product. It should have had a golden brown appearance and a coating that was easily chewed. Interview on 06/04/25 at 12:43 P.M. with [NAME] #250 it was verified on 06/02/25 she prepared the popcorn shrimp in the oven and stated the shrimp should have been prepared in a deep fryer. [NAME] #250 stated the facility did not have a deep fryer. [NAME] #250 verified the shrimp remained white and the coating became harder in the oven. Review of facility policy, Food Production and Safety , dated 01/05/23 revealed foods are prepared by methods to maintain, develop and enhance flavor.

Based on review of the Resident Council Minutes, staff and resident interview, and policy review, the facility failed to ensure resident concerns were addressed in a timely manner or resolved. This affected three (#24, #35, #29) of three residents who attended a surveyor led Resident Council Meeting during the annual survey. The facility identified there were 13 residents who regularly attend resident council meetings. This had the potential to affect all of the residents who reside in the facility. The census was 46. Findings included: Review of the Resident Council Minutes from 01/28/25 through 05/13/25 revealed the following concerns were documented on the Resident/Family Council Agenda/Minutes form: 01/28/25 call lights not answered in a timely manner. 02/11/25 residents would like a smoke time added daily at 7:00 P.M. and showers are cold on the A-wing 03/02/25 call lights still not being answered in a timely manner and would like administration to enforce the rules for the staff. 03/11/25 staff speaking rudely to residents, asking administration to start addressing complaints. 04/08/25 staff speaking rudely to residents 04/22/25 call lights not answered timely 05/13/25 call lights not answered timely Interview with Resident's #24 (President), #35 (Vice President) and #29 during a surveyor led Resident Council Meeting on 06/04/25 at 11:01 A.M. revealed they didn't feel like complaints were getting addressed in a timely manner by the administration. They revealed the request for an additional smoking break has been going on for months with no resolution. The call lights are not being answered in a timely manner which has been going on for months with no resolution. The shower room on the A-wing is still cold. They further complained about staff being rude to the residents which they have not seen any resolution for. They complained they have wanted to meet without staff present and for a resident to take the minutes of the meeting instead of the staff, but that has not been accommodated either. Interview with Activities Director (AD) #236 on 06/04/25 at 1:50 P.M. confirmed these areas of concern in resident council meetings are not being resolved in a timely manner because the residents are still complaining about them. She confirmed she knew the residents wanted to meet without staff, but a resident had to be trained to record the minutes and she had not been able to complete the resident training. Interview with the Administrator on 06/05/25 at 9:46 A.M. revealed she looked over the Resident/Family Council Agenda/Minutes after each meeting and confirmed the call lights were not resolved even though there were audits completed that proved otherwise. She revealed the staff and the residents who complained about the rudeness from the staff were interviewed and educated on how to treat the residents in a Town Hall Meeting, but there wasn't a concern form to be given to the surveyor. She confirmed the extra smoking time had not been resolved and neither had temperature in the shower in A-wing to the resident's satisfaction. She confirmed the Resident Council was a problem. Review of the policy entitled Resident Council dated 07/01/20 revealed the facility recognizes the residents' right to form and participate In group meetings while residing in the facility. The Resident Council Is a resident-oriented group designed for the residents to discuss nursing home standards, offer suggestions for practice guidelines affecting their care and treatment, quality of life, and review of resident rights. The life Enrichment Director or designee may attend the Resident Council Meeting to act as a liaison between the group and the facility if requested by the Council. Any additional facility personnel will attend the meeting upon request of the residents. The Activity Director will attempt to accommodate the resident recommendations to the extent practicable and provide follow-up to the Resident Council. Resident issues or concerns will be documented on the Resident/Family Concern Form and forwarded to the facility Administrator for the appropriate follow-up. Once the respective department has addressed the Resident/Family Concern and document the outcome the form is returned to the Life Enrichment Director to file with the Resident council Meeting Minutes.

Based on observation, record review, staff interview, and facility policy review, the facility failed to have a medication error rate less than five percent. This affected two residents (#15 and #43) of three residents observed for medication administration. The facility census was 46. Findings Included: Observation on 06/04/25 of medication pass revealed 30 opportunities were observed with two errors for a medication error rate of 6.67%. 1. Review of medical records for Resident #43 revealed an admission date 07/18/24. Diagnoses included chronic obstructive pulmonary disease, osteoporosis, pneumonia, paroxysmal atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #43 had Brief Interview of Mental Status (BIMS) score of 15 that indicated he was cognitively intact. Review of the plan of care dated 11/25/23 revealed that Resident #43 had problems with elimination and bowel constipation related to use of pain medications. Interventions included encourage fluids, administration medication as ordered, and diet as ordered. Review of physician order dated 12/20/24 revealed Resident #43 had an order for Sennoside 8.6 milligram (mg) give two tablets for constipation twice a day. Observation on 06/04/25 at 7:37 A.M. of medication pass with Licensed Pratical (LPN) #257 who prepared medication for Resident #43. LPN #257 prepared and administered Senna Plus 8.6-50 mg two tablets to Resident #43 with his morning medication. Interview on 06/04/25 at 1:00 P.M. with LPN #257 it was verified that she did give Resident #43 the wrong medication of Senna Plus 8.6-50 mg instead of Sennoside 8.6 mg the resident had ordered. 2. Review of medical record for Resident #15 revealed an admission date 08/21/24. Diagnoses included chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension. Review of quarterly MDS dated [DATE] revealed a BIMS score of one indicating the resident was severely cognitively impaired. Review of physician order dated 09/22/24 revealed Resident #15 had an order for Potassium Chloride extended release (ER) (electrolyte supplement) 20 milliequivalent (MEQ) one tablet once a day. Observation on 06/04/25 at 8:00 A.M. with Registered Nurse (RN) #204 who was preparing medication for next Resident #15 revealed the RN prepared and administered Amiodarone 200 mg, Calciumn (supplement) 600 mg with Vitamin D 3, Citalopram (antidepressant) 20 mg, Depakote Sodium (anticonvulsant used for mood stabalization) 125 mg, Eliquis (blood thinner)5 mg, Lasix (diuretic) 40 mg, Gabapentin (anticonvulsant) 200 mg, Lansoprazole (proton pump inhibitor) 30 mg, Metoprolol (used to treat high blood pressure) 25 mg, Senna-Plus (laxative) 8.6-50 mg, and Potassium 20 Milliequivalent and crushed all medication. RN #204 placed all medication powder into applesauce. RN #204 headed to Resident #15 room, then verified she crushed all of Resident #15 medication. RN #204 gave Resident #15 her crushed medication including Potassium Chloride 20 ER MEQ. Interview on 06/04/25 at 1:19 P.M. with RN #204 who verified that Resident #15 who had Potassium Chloride ER 20 MEQ crushed and placed in applesauce and administered to the resident. Review of the facility policy titled General Dose Preparation and Medication Administration date 11/15/24 revealed prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy. The facility should not leave medications or chemicals unattended. Facility staff should avoid touching the medications with bare hands when opening a bottle or unit dose package. Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to prepare food in a sanitary manner. This affected 45 residents who received food from the kitchen. The facility census was 46. Findings Include: 1. Observation on 06/02/25 at 10:05 A.M. of Diet Manger, (DM) #208 revealed white flakes of skin surrounded with bright reddened ring of skin on bilateral underside of forearms, measuring approximately four inches by two inches. When DM #208 touched the skin areas, flaky skin was removed. Interview on 06/02/25 at 10:05 A.M. with DM #208 verified the skin areas were diagnosed as a noncommunicable skin condition. DM #208 verified the skin areas should be covered due to the flaky skin. DM #208 verified her job duties include food preparation, food service and dishwashing/sanitizing. Observation on 06/04/25 at 11:17 A.M. of DM #208 revealed the skin areas on her bilateral forearms were exposed with no protective covering and the staff was observed at the three compartment sink washing/sanitizing dishes. DM #208 was also observed to assist with the preparation of puree food items. Interview on 06/04/25 at 11:17 A.M. with DM #208 verified she did not have protective covering on her exposed skin areas on the bilateral forearms. She stated the kitchen was hot, but she would don a jacket to cover the skin areas. Observation on 06/04/25 at 11:39 A.M. revealed DM #208 had donned a jacket with long sleeves. DM #208 was observed to wash/sanitize dishes in the three compartment sink, however the sleeves of the jacket were pushed up and the skin areas remained exposed. Interview on 06/04/25 at 11:39 A.M. with DM #208 verified the sleeves of the jacket were pushed up and the skin areas remained exposed while she used the three compartment sink to wash/sanitize the dishes. Review of facility policy, Food and Nutrition, Personnel and Training, dated 03/28/25 revealed food employees report to work in clean/safe attire. Ohio Administrative Code 3717-1 -01 A, states food employees are to keep their hands and exposed portions of their arms clean. Workers with psoriasis should consider wearing protective coverings when handling food minimize the risk of skin flakes contaminating food. 2. Observation on 06/04/25 at 11:17 A.M., revealed [NAME] #250 was preparing the pureed foods with a food processor. [NAME] #250 was noted to rub her forehead with her bare hand and arm, partially exposing her hair from under the hairnet during the puree process. Between pureeing the meat mixture and then pureeing the tomatoes, [NAME] #250 washed the blender bowl in the three compartment sink. [NAME] #250 immediately reassembled the food processor by placing the bowl blade into the bowl with her bare hands. The bowl was observed to contain rinse water from the three compartment sink which covered the bottom of the bowl. Interview on 06/04/25 at 12:02 P.M. [NAME] #250 verified she reassemble the blender bowl blade in the bowl with her bare hands and did not ensure the water was removed from the bowl prior to processing the next food item. [NAME] #250 verified she rubbed her head with her bare hand and did not then sanitize her hands. [NAME] # 250 also confirmed when she used her bare hand to rub her face it dislodged hair from her hair net. Review of facility policy, Food and Nutrition, Sanitation and Infection Control, dated 06/01/18 revealed when handling cleaned and sanitized equipment, staff will avoid touching the parts that will come in contact with the food. Review of facility policy, Food and Nutrition, Personnel and Training, dated 03/28/25 revealed food employees wear a hair restraint which will cover all hair.

3. Observation of Resident #29's room on 06/03/25 at 11:26 A.M., revealed the toilet was dirty and had a metal piece on the back of the toilet to hold the seat in place that had built up yellowish gray substance on it. The handwashing sink was rusted, there was tape holding the light cover in place behind her bed, the floor was dirty and sticky and the corners of the floor had a build up gray substance in the corners. Interview with Resident #29 on 06/03/25 at 11:28 A.M., revealed she didn't like her floors looking the way they do and didn't like her toilet and sink with the rust and thought they were dirty. 4. Observation of Resident #39's room on 06/03/25 at 12:26 P.M., revealed the wires to her bed control were disconnected and the resident wasn't able to control the bed movement, the floor was sticky, the light above the Handwashing sink was burned out and the light cover was a dark yellow. Around the toilet and the floor in the bathroom was a dark gray substance and the caulking around the toilet was supposed to be white but it turned to a dark grayish color. 5. Observation of Resident #8's room on 06/03/25 at 3:14 P.M., revealed the sink was rusted, the light over the sink was yellowed to the point the light didn't get bright, there were gray stains on the bathroom floor tile, back of the toilet had a metal piece holding the toilet seat to the toilet revealed it had gray substance on it, and there were gouges on the doorway coming out of the bathroom. 6. Observation of Resident #3's room on 06/03/25 at 2:05 P.M., revealed the corners on the floor had a built up gray substance in them, there were gouges out of the walls next to her bed, the call light was taped at the connector, the bathroom floor had gray stains on it and around the bottom of the toilet was yellowed, furniture had gouges out of it and scraps on the dresser, she wasn't able to turn on her light from the bed because the string was too short, there is built up dirt on the lights and dusty bulbs. 7. Observation of Resident #37's room on 06/03/25 at 2:57 P.M., revealed the toilet seat and around the bottom of the toilet was yellowed. The floor was sticky. Observation and interview on 06/05/25 from 8:28 A.M. to 8:41 A.M., with the Maintenance Director (MD) #202, confirmed all of the above mentioned areas were in need of repair. He revealed he had no help and did the best he could. Based on observation, medical record review, staff interview, resident interview, resident council minutes review, maintenance work order review, and policy review, the faciity failed to provide an homelike environment. This affected nine residents (#3, #7, #8, #14, #29, #37, #38, #39, and #198) directly and affected all 26 residents on the A Unit of 46 resident rooms observed for environment. The facility census was 46. Findings included: 1. Review of record for Resident #38 revealed she was admitted on [DATE]. Diagnoses included hypertension, acute respiratory failure, chronic obstructive pulmonary disease, and oxygen dependent. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was alert and oriented. Review of the facility document work order date 05/01/25 revealed that Resident #38 had an order to fix her broken air conditioner. Interview on 06/03/25 at 3:05 P.M., with Resident #38 who stated that her room air conditioner had been out for a month. Resident #38 stated Maintenance Director (MD)#202 had informed her that he would order parts to be fixed. Resident #38 stated she has not seen MD #202 since. Resident #38 stated she was on oxygen and liked it cooler in her room. Observation on 06/03/25 at 3:05 P.M. room was warm, with a fan blowing on her to cool her. Resident #38 skin was warm to touch. Interview on 06/04/25 at 3:45 P.M., MD #202 verified that Resident #38 had not had her air conditioner fixed for two months, because there was an old air conditioner unit in Resident #38 room. Maintenance #202 stated he did not find any parts to be replaced for the old unit. 2. Review of record for Resident #198 revealed she was admitted on [DATE]. Diagnoses included acute and chronic systolic and diastolic heart failure, hypertension, and chronic obstructive respiratory failure with hypoxia. Review of Quarter MDS dated [DATE] revealed that Resident #198 was alert and oriented. Review of the facility document work order date 05/01/25 revealed that Resident #198 had an order to fix her broken air conditioner. Observation on 06/03/25 at 3:50 P.M., with Resident #198 who was sitting in her recliner. Resident #198's room was warm. Resident #198 was sitting watching television with a box fan blowing on her while on 4 liters of oxygen. Resident #198 was flushed and sweaty. Interview on 06/03/25 at 3:55 P.M., with MD #202 verified that Resident #198 also had no air conditioner in her room. Maintenance #202 stated the parts were unable to be found to repair the unit. 8. Review of Resident Council Meeting dated 01/28/25 and 03/19/25 revealed the residents reported low temperatures in the shower rooms. Resident Council Meeting minutes dated 02/11/25 and 03/19/25 revealed residents reported the A unit shower room was cold. Observation on 06/09/25 at 9:06 A.M. with Maintenance Director (MD) #202 revealed the room temperature near the entrance door to the shower room was 69 degrees Fahrenheit. The ceiling exhaust fan was on and there was a draft from under the door, across the shower area to the exhaust fan. There were four ceiling intake fans and louvers with a heavy build up of gray debris resembling dust and dirt above the resident shower and dressing areas. When turning on the switch to the wall heater, the unit did not come on. Interview on 06/09/25 at 9:06 A.M., MD #202 verified the shower room temperature should be 71 to 81 degrees Fahrenheit, and /or what residents feel is comfortable. He stated the fans and louvers needed cleaned and verified the wall heater did not work. He verified a draft from the floor to the ceiling in the shower area. He verified the residents had reported the A unit shower room was cold. 9. Review of the Resident Council Meeting minutes dated 05/13/25 revealed residents reported the rooms were not getting cleaned. Observation of A unit door entry floors to all resident rooms, (Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) had a blacked build up at the threshold strip juncture with the hallway. There was a blackened buildup at the doorway and corners in the rooms. Interview on 06/05/25 at 7:30 A.M., the MD #202 verified the blacked area at every room on the A unit floor at the entry way and in rooms corners. The MD #202 stated the A unit had not been renovated and there was no written planned program for the completion of the floor replacement or cleaning. 10. Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #14 include dementia, anxiety disorder, dysphagia, repeated falls, malnutrition, anemia, muscle weakness, and osteoporosis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for all Activities of Daily Living skills. Observation on 06/02/25 at 9:50 A.M., revealed Resident #14's bed up against the wall on the right side. There was a strip of wallpaper approximately 45 inches wide and six feet long missing from the wall, exposing a rough surface. Interview on 06/05/25 at 7:30 A.M., the MD # 202 verified Resident #14 had missing wallpaper with a rough surface. He verified Resident #14 laid up near the wall. MD #202 stated he was not notified of the missing wallpaper. 11. Record review of Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnosis for Resident # 37 included dementia, insomnia, and cognitive communication deficit. The resident wore a monitor device for elopement monitoring. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and ambulated without assistance devices. Review of the Resident Council Meeting minutes dated 03/11/25 revealed residents reported the chairs needed repaired. Observation on 06/03/25 at 11:12 A.M., of the dining room chairs revealed one chair of ten in the main dining room, had the left arm not adhered to the chair. The arm of the chair could easily be removed from the connecting joint when pulled up. Ten of the ten chairs had worn wooded arms with the water sealing finished removed, leaving a penetrable surface in the wood grain. Interview on 06/02/25 of Certified Nursing Assistant (CNA) #206 verified the dining chair was broken and set it along the wall in the dining room. He verified the wooden arms of all the dining chairs were worn and had the protective surfaces removed. Observation on 06/04/25 at 10:002 A.M., the identified dining room chair remained in use in the dining room by Resident #37. Interview on 06/05/25 at 7:30 A.M., the MD #202 verified the identified dining room chair remaining in the dining room and the arm of the chair was broken. MD #202 verified a resident sitting in the chair could easily pull the arm up and the chair be destabilized. MD #202 verified all the dining room chairs had exposed wooden penetrable surfaces on the chair arms. MD #202 stated the broken chair was not reported to him and taken out of service. He stated setting the chair aside in the dining room was not putting the chair out of service. Review of facility policy, Routine Environmental Cleaning, dated 06/28/24, revealed proper cleaning of environmental surfaces is necessary to break the chain of infection. This deficiency represents non-compliance investigated under Complaint Numbers OH00163527 and OH00162529.

Based on observation, medical record review, staff interview, and facility policy review the facility failed to ensure facility staff performed hand hygiene. This affected one resident (#15) observed during medication pass and additionally affected three residents (#98, #5, and #99) who had their meal trays delivered by staff without hand hygiene being performed. The census was 46. Findings included: 1. Review of Resident #15's medical record revealed an admission date 08/21/24. Diagnoses included chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored a one on the Brief Interview of Mental Status indicating the resident had severe cognitive impairment. Review of physician orders revealed the resident had the following medication orders: Lasix (diuretic) 40 milligrams (mg) take one tablet twice a day dated 08/21/24, Senna plus (laxative) 8.6-50 mg take two tablets twice a day dated 08/24/24, and Eliquis (anticoagulant) 5 mg one tablet take twice a day dated 01/09/25. Observation of medication pass for Resident #15 on 06/04/25 at 8:00 A.M. with Registered Nurse (RN) #204 revealed as the medications were prepared RN # 204 dropped the Lasix, Eliquis and the Senna plus on the top of the medication cart, and used her bare, ungloved hand to pick up the medication and put the medication in the medication cup with the rest of the morning medication for Resident #15. RN #204 proceeded to crush all of Resident #15's medications, place them in applesauce and administer the medications to the resident. Interview on 06/04/25 at 8:15 A.M. with RN #204 it was verified she had dropped the Lasix 40 mg, Eliquis 5 mg, and Senna plus 8.6-50 mg on top of her medication cart that was not clean and used her bare, ungloved fingers to pick up the medications and put the medication in the cup, crushed the medication and administered the medications to Resident #15. 2. Observation on 06/04/25 at 12:29 P.M. Dietary Manger, (DM) #208 was observed to pass lunch meal trays to three residents in three separate residents (#98, #5, and #99). DM #208 did not perform hand hygiene between resident tray passes. DM #208 was observed to enter each room, remove the food lid on the tray, set the lid down in the room, touching items on the tray and the food delivery cart. DM #208 then exited the individual resident room walking past a hand sanitizer dispenser which is mounted on the wall in each resident room. DM #208 was observed to pass the three trays to Resident #98, #5, and #99 without performing hand hygiene. Interview on 06/04/25 at 12:29 P.M. DM #208 verified she did not wash her hands or use hand sanitizer between each resident meal tray delivery. She stated she knew better and should have used hand sanitizer between each meal tray delivery. She stated she did not often deliver trays to the residents. Review of facility policy, Hand Hygiene, dated 02/28/25 revealed employees are to use alcohol based rub or hand wash after touching a patient's environment

Based on medical record review, staff and resident interview, resident council meeting, and facility policy review, the facility failed to ensure an investigation was initiated for a allegation of abuse. This affected one (#24) of three residents reviewed for abuse. The census was 46. Findings included: Review of the medical record for Resident #24 revealed an admission date of 11/10/22. Medical diagnoses included coronary artery disease, heart failure, diabetes, cerebrovascular accident (CVA) and Non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. He was independent for eating, toileting, bed mobility, and transfers. He was always continent of bowel and bladder. Review of a morning meeting form dated 01/14/25 revealed Resident #24 was upset about a resident and wanted him moved to another room and was being inappropriate and screaming at Certified Nursing Aide (CNA) #240 about the new resident. The note revealed the CNA #240 was trying to redirect Resident #24 back to his room. During a resident council meeting on 06/04/25 at 11:01 A.M. Resident #24, who was the President of the council, revealed Certified Nursing Aide (CNA) #240 called him an ass and he reported it to the Director of Nursing (DON) and she tried to smooth it over because the CNA is dating her son who also works in the facility. A subsequent interview with Resident #24 on 06/04/25 at 3:51 P.M. revealed there was a resident who moved across the hall from him and for two nights the resident would moan and groan loudly and Resident #24 wasn't able to get any sleep. He told CNA #240 she needed to get the resident moved to another room and the aide told him to quit being an ass. The resident stated he kicked CNA #240 out of his room. He stated the aide is rude to the residents and had several complaints on her from the residents. He stated the Director of Nursing (DON) talked to him and tried to cover up the incident and said maybe the aide didn't mean anything by the comment she made and he told the DON to not cover for the aide. He revealed he was angry about the CNA calling him a name and he didn't pay money at the facility to be called names and felt it was abusive. He further revealed no one had asked him for a statement. Interview with CNA #240 on 06/04/25 at 2:31 P.M. revealed Resident #24 was being rude to her and she told the resident you don't have to be rude to me and admitted to she called him an ass and changed the statement and said you don't need to be an ass. She reported she apologized to the resident about the statement and thought it was disrespectful to the resident. She reported it was a mistake on her part for the name she called him. Interview with the Administrator and DON on 06/04/25 at 2:58 P.M. revealed the Administrator didn't know anything about this incident and did not initiate an investigation. The DON said she was in the facility at the time of the incident and the resident was in the hall and he was being inappropriate with the CNA and the aide said to the resident don't talk to me that way and the resident continued and the CNA said something about treating people like an ass to the resident. The DON reported she took both of them aside and talked with them and they made amends. She reported the resident was inappropriate with staff and continues to have those behaviors. She reported she wanted to make sure her staff stays safe. She didn't have any interviews from staff or residents regarding the incident and didn't take a statement from the CNA or the resident. Review of the policy entitled Abuse, Neglect and Exploitation dated 07/11/24 revealed it was the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source.

Based on observation and resident interview, family member interview, and staff interview, the facility failed to ensure a resident was provided a pest free environment. This affected one (#11) of 46 resident rooms observed for pest. The facility census was 46. Findings include: Record review of Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnosis for Resident #11 include cerebral infarction, muscle weakness, dysphagia, and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was dependent on staff for dressing and transfers. Observation on 06/02/25 at 10:05 A.M., revealed the Resident #11 in room B 23. On 06/03/25, Resident #11 was moved into room B 21. Observation on 06/03/25 at 8:30 A.M. revealed 10 to 20 quarter length black insects with wings on the floor in Resident #11 previous room, room B23. There were no insects observed in the B 23 room on 06/02/25. Interview on 06/03/25 at 8:30 A.M., Resident #11 revealed she had a swarm of flying ants coming out of the ceiling near her window six feet from her bed, in the past day. She stated she was afraid the ants would get in her mouth when she slept. Interview on 06/03/25 at 8:35 A.M. , with Certified Nursing Assistant, (CNA) #22 verified the winged insects on the floor in B 23 and verified Resident #11 had been moved on 06/02/25 evening shift due to the flying insects. Interview on 06/04/25 at 7:10 A.M., with Resident #11 family representative stated when she visited a week ago, she had seen her mother with the bugs on her. She had to remove the insects off of Resident #11. Resident #11 family representative stated the resident had weakness to one side, and was unable to get them off herself. Resident #11 family representative stated she was upset because the facility did not manage pests in her mother's room. Interview on 06/05/25 at 7:30 A.M., with the Maintenance Director (MD) #202 verified Resident #11 had flying insects in her room on 06/02/25 and was moved due to the resident's request. He stated he was aware of the insects on 06/02/25 and contacted the pest control, which had not arrived to exterminate as of 06/05/025.

Based on record review, observation, staff interview, and facility policy review, the facility failed to ensure medications were not expired and the facility failed to provide safe storage and delivery of medication for one resident (#28). The facility census was 46. Findings Included: Observation on [DATE] at 8:40 A.M. of the overstock medication room, revealed there were seven bottles of Folic Acid 400 micrograms (mcg) with an expiration date was 02/2025. Interview on [DATE] at 8:40 A.M. with Registered Nurse (RN) #204 it was verified the seven bottles of Folic Acid 400 mcg expired 02/2025. Each bottle was unopened and contained 250 tablets. Review of the facility document titled In House Stock dated unknown revealed that the facility did have Folic Acid 400 micrograms (mcg) over the counter for stock. Review of the facility policy titled Storage and Expiration Dating of Medications and Biological's dated [DATE] revealed the facility should ensure medications and biological's are stored in an orderly manner in cabinets, drawers, carts, refrigerators, and freezers of sufficient size to prevent crowding. The facility should destroy or return all discontinued, outdated or expired, or deteriorated medications or biological's in accordance with pharmacy return/destruction guidelines and other applicable laws, and in accordance with the policy. 2. Record review for Resident #28 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #28 include diabetes, cerebral infarction, edema, symbolic dysfunctions, and hypertension. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was independent in Activities of Daily Livings (ADL) skills. The resident had physician orders for oral Hydralazine (used to treat high blood pressure)50 milligrams three times a day at 3:00 A.M. - 5:00 A.M., 1:00 P.M.- 4:00 P.M. , and 7:00 P.M. - 11:00 P.M. for hypertension . Review of the [DATE] Medication Administration Record, (MAR) revealed Resident #28 received Hydralazine 50 milligrams signed by Registered Nurse, (RN) #241. Observation on [DATE] at 9:45 A.M. of Resident #28's room revealed the resident was not in the room and there was pink/orange pill inside the pill cup on the bedside table of Resident #28. Interview on [DATE] at 9:46 A.M. with RN #204 verified there was a pill cup with a pink/orange pill on the bedside stand of Resident #28. RN #204 identified the pill as Hydralazine and verified the medication should have been given on [DATE] at 3:00 A.M. -5:00 A.M. of by the night shift nurse. Review of the June MAR with RN #204 verified the dose was documented as administered by the night shift nurse. RN #204 verified when administering medications the nurse must observe the resident taking the medication and not to leave the medication at the bedside. Interview on [DATE] at 10:30 A.M. Resident #28 revealed she is not always watched by the evening nurse when she takes her medications as sometimes she is sleepy and the medication is left on the bedside table by the nurse. Resident #28 verified the pill was in the pill cup this morning when she woke up.

Based on medical record review, staff and resident interview and facility policy review, the facility failed to ensure a follow-up appointment was made for a resident who had a tooth that was broke off at the gum line. This affected one (#29) of four residents reviewed for dental services during the annual survey. The census was 46. Findings included: Medical record review for Resident #29 revealed an admission date of 11/04/18. Medical diagnoses included a stroke, coronary artery disease, heart failure, hypertension, and diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact. She was independent for eating, toileting, bed mobility and she required a Hoyer lift for transfers. She was always incontinent for bowel and bladder. Review of the resident's dental appointment dated 09/09/24 revealed the dentist tried to extract her tooth and the root was under the gum line and it wouldn't come out. He spoke to Social Services Designee (SSD) and Director of Nursing (DON) about the appointment and the new treatment plan. There was an extraction needed for this tooth to remove the root and a referral was inserted into the chart. Review of an oral surgical referral dated 09/12/24 revealed Resident #29 had residual root tips that needed to be removed. Review of the notes for Resident #29 dated 09/20/24 revealed she had an infection of the left lateral lower retained tooth post prior partial removal. Amoxicillin was ordered for ten days and administered. The resident was to follow-up with dentistry. Interview with Resident #29 on 06/03/25 at 11:31 A.M. revealed she had an appointment last year sometime to get a tooth pulled and was supposed to have another appointment to get the root pulled out and hasn't heard back from the staff about the appointment. She stated she uses oragel if needed if the tooth bothers her. She denied she was in pain with the tooth. Interview with the Appointment Scheduler (AS) #200 on 06/09/25 at 9:44 A.M. revealed she called the surgical dentist clinic to schedule an appointment for the resident, but left a message because the recording says if they choose you to get your tooth fixed, they will call you and if not you won't hear back from the clinic. She reported the resident was on Medicaid and the surgery clinic was the only clinic that will take Medicaid residents. Review of the policy entitled Dental Services dated 04/02/24 revealed the facility will assist residents in obtaining routine and 24-hour emergency dental care/services to meet the needs of each resident.

Based on record, observation, interview, pharmacy interview, policy, the facility failed to provide safe delivery of medication by crushing potassium 20 Milliequivalent for one resident (#15) out of residents reviewed on annual. The facility census was 46. Findings Included: Review of record revealed that Resident #15 had admission date 08/21/24. Diagnoses included chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension. Review of Quarter MDS dated [DATE] revealed that BIMS was 1 that indicated she was severely cognitively impaired. Review of plan of care dated 08/21/24 revealed that Resident #15 had a risk for cardiac that had arteriosclerotic heart disease. Intervention was to provide small meals or frequent rather than three large meals, encourage activity level, and administer medications as ordered. Review of physician order dated 08/21/24 revealed that Resident #15 had an order to crush medications unless contraindicated. Review of physician order dated 09/22/24 revealed that Resident #15 had an order for Potassium Chloride extended release 20 milliequivalent one tablet once a day. Observation on 06/04/25 at 8:00 A.M. with Registered Nurse (RN) #204 who was preparing medication for next Resident #15. RN #204 took all medication including Amiodarone 200 mg, Calcium 600 mg with Vitamin D 3, Citalopram 20 mg, Depakote Sodium 125 mg, Eliquis 5 mg, Lasix 40 mg, Gabapentin 200 mg, Lansoprazole 30 mg, Metoprolol 25 mg, Senna-Plus 8.6-50 mg, and Potassium 20 Milliequivalent (MEQ) and crushed all medication. Interview on 06/04/25 at 1:19 P.M. with RN #204 who verified that Resident #15 who had Potassium extended release 20 Milliequivalent (MEQ) and placed in applesauce and gave her. Interview on 06/04/25 at 2:31 P.M. with Pharmacist #399 who stated that you are never to crush potassium chloride 20 MEQ with a pill form that was extended release. Review of the facility document titled Common Oral Dosage Forms That Should Not Be Crushed dated year 2023 revealed that Potassium K tablet extended release was not to be crushed. Review of the facility policy titled General Dose Preparation and Medication Administration date 11/15/24 revealed that the prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy. The facility should not leave medications or chemicals unattended. Facility staff should avoid touching the medications with bare hands when opening a bottle or unit dose package.

Based on observation, medical record review, staff and resident interview, the facility failed to ensure a restricted liquid diet was honored. This affected one (#39) of two reviewed for hydration during the annual survey. The census was 46. Findings include: Medical record review for Resident #39 revealed an admission date of 10/26/23. Medical diagnoses included heart failure, coronary artery disease, peripheral vascular disease, and renal insufficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact. Her functional status was independent for eating, toileting, bed mobility, and setup or clean-up assistance for transfers. She was always continent for bowel and bladder. Review of the physician's order dated 04/30/25 revealed Resident #39 was on a fluid restriction to give 1200 cubic centimeters (cc) for a 24-hour period. Dietary to give 840 cc's total, for breakfast 360 cc's, for lunch 240 cc's, and dinner 240 cc's. Observation of Resident #39's lunch tray on 06/03/25 at 12:00 P.M. revealed she had 240 cc's of water and 240 cc's of iced tea for a total of 480 cc's. Further observation of a breakfast tray on 06/05/25 revealed she had 240 cc's of milk, 240 cc's of coffee and 120 cc's of orange juice for a total of 600 cc's. Interview with Resident #39 on 06/03/25 at 12:12 P.M. revealed she was on a fluid restriction and sometimes the meals have too many fluids on them for consumption. Interview with the Dietary [NAME] (DC) #250 on 06/05/25 at 7:33 A.M. confirmed Resident #39 was on a fluid restriction and she confirmed she placed 600 cc's of fluids on her breakfast tray and should have only put 360 cc's on the tray for consumption. Interview with Registered Nurse (RN) #204 on 06/09/25 at 10:45 A.M. revealed there are times Resident #39 gets too much to drink on her meal trays.

2. Medical record review for Resident #29 revealed an admission date of 11/04/18. Her medical diagnoses included a stroke, coronary artery disease, heart failure, hypertension, and diabetes. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #29 was cognitively intact. She was independent for eating, toileting, bed mobility and required a Hoyer lift for transfers. Resident #29 was always incontinent for bowel and bladder. Review of the facility provided designated smoke times revealed the residents are allowed to smoke at: 9:00 A.M., 11:00 A.M., 1:00 P.M., 4:00 P.M. and 9:00 P.M. daily. Review of Resident/family Council Agenda/Minutes dated 02/11/25 revealed the council wanted the facility to add another smoke break to the smoke between the times of 4:00 P.M. and 9:00 P.M. Review of Resident/Family Council Agenda/Minutes from 03/02/25, 03/11/25, 03/19/25, 04/08/25, 04/22/25, and 05/13/25 revealed there was no documentation included in the old business section of the minutes to address the request of the additional smoke break time from meeting held on 02/11/25, and there was no other concern documented regarding the times of resident smoke breaks on the minutes reviewed. Review of current smoking times for the supervised smokers revealed there wasn't any smoke break time between 4:00 P.M. and 9:00 P.M. Interview with Resident #29 on 06/04/25 at 11:01 A.M. revealed the council had asked for an additional smoking break during the February council meeting and it has not been set up yet. Interview with Activities Director (AD) #236 on 06/04/25 at 1:50 P.M. revealed there wasn't enough staff (even though the smoking times were divided up between other members of staff throughout the facility) to be able to provide another smoking break for the supervised smokers at 7:00 P.M. She revealed she had a new staff member starting on 06/04/25 and she would be trained to take out the supervised smokers at 7:00 P.M. 3. Medical record review for Resident #35 revealed an admission date of 11/09/22. Medical diagnoses included peripheral vascular disease, hypertension, and diabetes. Review of the quarterly MDS dated [DATE] revealed Resident #35 was cognitively intact. Her functional status was independent for eating, dependent for toileting, substantial/maximal assistance for bed mobility and she was a Hoyer lift for transfers. She was always incontinent for bowel and bladder. Review of the facility provided designated smoke times revealed the residents are allowed to smoke at: 9:00 A.M., 11:00 A.M., 1:00 P.M., 4:00 P.M. and 9:00 P.M. daily. Review of Resident/Family Council Agenda/Minutes from 03/02/25, 03/11/25, 03/19/25, 04/08/25, 04/22/25, and 05/13/25 revealed there was no documentation included in the old business section of the minutes to address the request of the additional smoke break time from meeting held on 02/11/25, and there was no other concern documented regarding the times of resident smoke breaks on the minutes reviewed. Review of resident council minutes dated 02/11/25 revealed the council wanted to add another smoke break to the schedule of smoking times between 4:00 P.M. and 9:00 P.M. Review of current smoking times for the supervised smokers revealed there wasn't any between 4:00 P.M. and 9:00 P.M. Interview with Resident #35 on 06/04/25 at 11:01 A.M. revealed the council had asked for an additional smoking break back in February council meeting and it has not been set up yet. Interview with Activities Director (AD) #236 on 06/04/25 at 1:50 P.M. revealed there wasn't enough staff (even though the smoking times were divided up between other members of staff throughout the facility) to be able to provide another smoking break for the supervised smokers at 7:00 P.M. She revealed she had a new staff member starting on 06/04/25 and she would be trained to take out the supervised smokers at 7:00 P.M. Review of the policy entitled Residents Rights not dated revealed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Based medical record review, observation, staff and resident interview and the facility policy review, the facility failed to honor one resident's (#22) request for a smoking break of one resident reviewed for supervised smoking. The facility identified seven residents who required supervised smoking. In addition the facility failed to timely address and ensure the request for an additional smoke break was resolved for two (#29 and #35) of two residents reviewed for resident rights. The facility census was 46. Findings Included: Review of record for Resident #22 revealed admission date of 07/03/24. Diagnoses included neuromuscular dysfunction of bladder, depression, and nicotine dependence using cigarettes. Review of plan of care dated 08/12/24 revealed Resident #22 had a safe smoking environment by not having smoking violations through next review. Interventions included staff to keep smoking products, completing smoking assessment, orient and review with resident the smoking policy times, observe clothing and skin for burns, and notify staff immediately if resident was suspected in violating smoking policy. Review of the facility smoking assessment dated [DATE] revealed Resident #22 required a supervision during smoke breaks. Interview on 06/05/25 at 8:30 A.M. with Resident #22 revealed who stated that she had never got her smoke break on 06/04/25 which requested from the Social Services (SS) #333 yesterday. Resident #22 stated that she waited on the side of the bed for a half hour, and no staff came to transfer her into a wheelchair and take her to the smoke break. Interview on 06/05/25 at 8:40 A.M. with SS #333 revealed she did not tell any staff to take Resident #22 out for her smoke break. SS #333 stated she had sent a group text out to management with the information. SS #33 stated the resident should have had a smoke break yesterday after she spoke to the resident around 4:15 P.M. and let management staff be aware the resident wanted a smoke break. Interview on 06/05/25 at 8:45 A.M. with Administrator who revealed she was aware that Resident #22 wanted a smoke break on 06/04/25, the Administrator stated she was handling another situation, and thought the smoking need with Resident #22 was resolved. Review of the facility policy titled Resident Smoking Policy dated 06/20/22 revealed the facility had established resident smoking processes that took into account both smoking and non-smoking residents and that comply with applicable federal, state, and local laws and regulation regarding smoking.

Based medical record review, staff and resident interviews, and facility policy review, the facility failed to ensure staff provided dignity and respect to two residents (#22 and #21) of two residents reviewed for dignity and respect. The facility census was 46. Findings Included: Review of record for Resident #22 revealed admission dated 07/03/24. Diagnoses included neuromuscular dysfunction of bladder, depression, and nicotine dependence using cigarettes. Review of plan of care dated 08/01/24 revealed Resident #22 had risk for altered mood related to depression. Interventions included assisting residents in identify strengths, positive coping skills, anger management, approach in a calm relaxed manner, and collaborative care. Interview on 06/04/25 at 3:30 P.M. Resident #22 stated that Certified Nursing Assistant (CNA) #240 had a conversation during care, and CNA #240 was inappropriate to her. Resident #22 stated CNA #240 had lifted her own breasts with her hands outside her shirt. Resident #22 stated CNA #240 was trying to be funny, but Resident #22 stated she did not take it as funny. Resident #22 stated this happened a month ago. Interview on 06/04/25 at 3:42 P.M. with CNA #240 who stated she did make a gesture to Resident #22 one time by lifting her breasts with her two hands over her shirt in front of Resident #22 while providing care for her. CNA #240 stated she was trying to be funny and was talking about her breast. Interview on 06/04/25 at 4:10 P.M. with Administrator revealed she would give education to CNA #240 who needed more education, the CNA was written up, and was sent home. Administrator stated it was inappropriate to act this way to a resident at the facility. 2. Medical record review for Resident #21 revealed an admission date of 06/25/21. Medical diagnoses included non-traumatic brain dysfunction. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was severely cognitively impaired with memory problems. Her functional status was dependent for eating, toilet use, bed mobility and she required a Hoyer lift for transfers. The resident was always incontinent for bowel and bladder. Observation on 06/03/25 at 11:00 A.M. revealed Resident #21 was sitting in the dining room in a wheelchair. Certified Nursing Aide (CNA) #222 placed a clothing protector onto the resident and didn't ask or have an interaction with the resident while placing the protector onto the resident. Also during the observation CNA #206 said out loud Resident #21 was the only true feed in the dining room. Interview with CNA #206 on 06/03/25 at 11:05 A.M. confirmed he called Resident #21 the only true feed and could have put it differently. He reported the term feed wasn't respectful. Interview with CNA #22 on 06/03/25 at 11:18 A.M. confirmed she should have asked about the clothing protector for Resident #21 and had some kind of interaction with her. Review of the policy entitled Residents Rights date unknown revealed that the residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.

Based on observation, medical record review, and staff interview, the facility failed to ensure a safe homelike environment was free on unsecured potential poisonous chemicals. This affected one (#37) of 46 residents observed in the facility for potential hazards. The facility census was 46. Findings included: Observations on 06/02/25 through 06/04/25 from 9:45 A.M. to 3:30 P.M., revealed the following environmental issues. The shower room closet located in the short A unit hallway had a closure which was easily unlocked and had a bottle labeled disincentive chemical cleaner. The warning label stated to keep out of the reach of children. In the unlocked B hall unit shower room, there was a gallon size container, with a nozzle sprayer and tubing attached, on the floor. It contained a clear liquid. There was no label on the container to identify the liquid. Observations from 06/09/25 from 9:45 A.M through 3:30 P.M. revealed Resident #37 wandering in hallways, rooms and common areas, including the A and B units hallways. Record review of Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnosis for Resident # 37 included dementia, insomnia, and cognitive communication deficit. The resident wore a monitor device for elopement monitoring. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and ambulated without assistance devices. Interview on 06/05/25 at 7:30 A.M., the Maintenance Director, (MD) # 202 verified the unlocked closet with chemical and unlabeled gallon sprayer in the unlocked unit B shower room. He stated all chemicals should be stored with a locks a resident could not open. He stated he could not identify the clear liquid as it was unlabeled, and all containers must be labeled.

Based on medical record review, staff and resident interview, resident council meeting, and facility policy review, the facility failed to ensure the residents were safe from abuse. This affected one (#24) of three residents reviewed for abuse. The census was 46. Findings included: Review of the medical record for Resident #24 revealed an admission date of 11/10/22. Medical diagnoses included coronary artery disease, heart failure, diabetes, cerebrovascular accident (CVA) and Non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. He was independent assistance for eating, toileting, bed mobility, and transfers. He was always continent of bowel and bladder. Review of a morning meeting form dated 01/14/25 revealed Resident #24 was upset about a resident and wanted him moved to another room and was being inappropriate and screaming at Certified Nursing Aide (CNA) #240 about the new resident. The note revealed CNA #240 was trying to redirect Resident #24 back to his room. During a resident council meeting Resident #24 who was the President of the council on 06/04/25 at 11:01 A.M. revealed a Certified Nursing Aide (CNA) #240 called him an ass and he reported it to the Director of Nursing (DON) and she tried to smooth it over because the aide is dating her son who also works in the facility. A subsequent interview with Resident #24 on 06/04/25 at 3:51 P.M. revealed there was a resident who moved across the hall from him and for two nights the resident would moan and groan loudly and Resident #24 wasn't able to get any sleep. He told the CNA #240 she needed to get the resident moved to another room and the aide told him to quit being an ass. The resident stated he kicked CNA #240 out of his room. He stated the aide is rude to the residents and had several complaints on her from the residents. He stated the DON talked to him and tried to cover up the incident and said maybe the aide didn't mean anything by the comment she made and he told the DON to not cover for the aide. He revealed he was angry about the CNA calling him a name and he didn't pay money at the facility to be called names and felt it was abusive. He further revealed no one had asked him for a statement. Interview with CNA #240 on 06/04/25 at 2:31 P.M. revealed Resident #24 was being rude to her and she told the resident you don't have to be rude to me and admitted she called him an ass and changed the statement and said you don't need to be an ass. She reported she apologized to the resident about the statement and thought it was disrespectful to the resident. She reported it was a mistake on her part for the name she called him. Interview with the Administrator and DON on 06/04/25 at 2:58 P.M. revealed the Administrator didn't know anything about this incident. The DON said she was in the facility at the time of the incident and the resident was in the hall and he was being inappropriate with the CNA and the aide said to the resident don't talk to me that way and the resident continued and the CNA said something about treating people like an ass to the resident. The DON reported she took both of them aside and talked with them and they made amends. She reported the resident was inappropriate with staff and continued to have those behaviors. She reported she wanted to make sure her staff stays safe. Review of the policy entitled Abuse, Neglect and Exploitation dated 07/11/24 revealed the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Verbal abuse-is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability.

Based on medical record review, staff and resident interview, review of the care conferences and facility policy review, the facility failed to ensure residents received routine care conferences. This affected two (#29 and #39) of three residents reviewed for care conferences. The census was 46. Findings included: 1. Medical record review for Resident #29 revealed an admission date of 11/04/18. Medical diagnoses included coronary artery disease, heart failure, hypertension, and diabetes. Review of the care conferences for Resident #29 revealed there were documented care conferences on 10/10/24 and on 02/27/25. Review of the quarterly MDS dated [DATE] revealed Resident #29 was cognitively intact. Interview with the Resident #29 on 06/03/25 at 11:25 A.M. revealed she had not had a care conference every three months. Interview with Social Services Designee (SWD) #214 on 06/05/25 at 10:01 A.M. revealed she was supposed to complete care conferences every three months and she was running behind. 2. Medical record review for Resident #39 revealed an admission date of 10/26/23. Medical diagnoses included heart failure, coronary artery disease, peripheral vascular disease, and renal insufficiency. Review of the care conferences revealed Resident #39's last care conference was on 10/17/24. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact. Interview with Resident #39 on 06/03/25 at 12:03 P.M. reported she didn't remember having a care conference every three months. Interview with Social Services Designee (SSD) #214 on 06/04/25 at 10:01 A.M. confirmed she was supposed to complete care conferences every three months and she was behind. Review of the policy entitled Comprehensive Care Planning Policy dated 03/20/25 revealed the care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. At a minimum, this will occur with each comprehensive and quarterly assessment in accordance with Resident Assessment Instrument (RAI) requirements.

Based on medical record review, staff and resident interview, Resident Council meeting, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the state agency. This affected one (#24) of three residents reviewed for abuse. The census was 46. Findings included: Review of the medical record for Resident #24 revealed an admission date of 11/10/22. Medical diagnoses included coronary artery disease, heart failure, diabetes, cerebrovascular accident (CVA) and Non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. He was independent assistance for eating, toileting, bed mobility, and transfers. He was always continent for bowel and bladder. Review of a morning meeting form dated 01/14/25 revealed Resident #24 was upset about a resident and wanted him moved to another room and was being inappropriate and screaming at Certified Nursing Aide (CNA) #240 about the new resident. The note revealed the CNA #240 was trying to redirect Resident #24 back to his room. During a resident council meeting Resident #24 who was the President of the council on 06/04/25 at 11:01 A.M. revealed a Certified Nursing Aide (CNA) #240 called him an ass and he reported it to the Director of Nursing (DON) and she tried to smooth it over because the aide is dating her son who also works in the facility. A subsequent interview with Resident #24 on 06/04/25 at 3:51 P.M. revealed there was a resident who moved across the hall from him and for two nights the resident would moan and groan loudly and Resident #24 wasn't able to get any sleep. He told the CNA #240 she needed to get the resident moved to another room and the aide told him to quit being an ass. The resident stated he kicked the CNA #240 out of his room. He stated the aide is rude to the residents and had several complaints on her from the residents. He stated the DON talked to him and tried to cover up the incident and said maybe the aide didn't mean anything by the comment she made and he told the DON to not cover for the aide. He revealed he was angry about the CNA calling him a name and he didn't pay money at the facility to be called names and felt it was abusive. He further revealed no one had asked him for a statement. Interview with CNA #240 on 06/04/25 at 2:31 P.M. revealed Resident #24 was being rude to her and she told the resident you don't have to be rude to me and admitted to she called him an ass and changed the statement and said you don't need to be an ass. She reported she apologized to the resident about the statement and thought it was disrespectful to the resident. She reported it was a mistake on her part for the name she called him. Interview with the Administrator and DON on 06/04/25 at 2:58 P.M. revealed the Administrator didn't know anything about this incident and it couldn't be reported to the state agency. The DON said she was in the facility at the time of the incident and the resident was in the hall and he was being inappropriate with the CNA and the aide said to the resident don't talk to me that way and the resident continued and the CNA said something about treating people like an ass to the resident. The DON reported she took both of them aside and talked with them and they made amends. She reported the resident was inappropriate with staff and continues to have those behaviors. She reported she wanted to make sure her staff stays safe. Review of the policy entitled Abuse, Neglect and Exploitation dated 07/11/24 revealed facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy.

Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for residents who had hospice services. This affected two residents, (Residents #3 and #14) of two residents reviewed for hospice services. The facility census was 46. Findings Include: 1. Record review of Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 include dementia, anxiety, stage four kidney disease, heart disease, and shortness of breath. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was dependent on staff for transfers and mobility. The resident received hospice services starting on 11/23/24. Review of Preadmission Screening and Resident Review (PASRR) records for Resident #3 revealed no PASRR was completed when hospice services were initiated for the resident. 2. Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #14 include dementia, anxiety disorder, dysphagia, repeated falls, malnutrition, anemia, muscle weakness, and osteoporosis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for all Activities of Daily Living skills, except the resident required assistance with feeding. Resident #14 had orders for hospice services beginning on 12/17/24. Review of Preadmission Screening and Resident Review (PASRR) records for Resident #3 revealed no PASRR was completed when hospice services were initiated for the resident. Interview on 06/09/25 at 10:52 A.M. with Social Service Designee, (SSD) # 333 verified there were no additional PASRR records for Resident #3 or Resident #14, and neither resident had a PASRR completed when the resident had a significant change was was admitted to hospice services.

Based on medical record review, observation, interviews with staff and the Medical Director, review of the facility's policy, review of the manufacturer instructions for use of the glucometer, and review of the Centers for Disease Control and Prevention (CDC) guidance on infection control during blood glucose monitoring and on [MEDICAL CONDITION], the facility failed to implement an infection control protocol to prevent the potential indirect transmission of a bloodborne pathogen, [MEDICAL CONDITION], to residents who had finger stick blood sugar testing performed utilizing a shared glucose monitoring device (glucometer). The glucometer was not properly cleaned and disinfected between residents and the nurse did not perform proper hand hygiene practices between residents. The facility's failure to properly clean and disinfect glucometers between residents and perform proper hand hygiene placed five residents (#21, #22, #27, #33, and #35) who receive blood sugar monitoring and/or assistance with medication administration in Immediate Jeopardy at potential risk of serious life-threatening harm and/or negative health outcomes related to contracting the [MEDICAL CONDITION] virus. The facility identified Resident #36 with a [DIAGNOSES REDACTED].#22, #27, #33 and #35. Additionally, Resident #21 was affected when the nurse did not properly perform hand hygiene after direct contact with Resident #36's soiled blood glucose testing strip and then prepared and administered medications to Resident #21. The facility census was 42. On 03/03/21 at 2:00 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services #903 were notified that Immediate Jeopardy began on 02/24/21 at 5:11 A.M., when Licensed Practical Nurse (LPN) #301 failed to disinfect a glucometer after performing a routine finger-stick blood sugar test on Resident #36 who resided on Memory Care Unit B. This same glucometer was used to obtain blood sugar levels for the other four residents (Residents #22, #27, #33, and #35) who also have orders for blood sugar monitoring. Additionally, LPN #301 failed to wash her hands after direct contact with the soiled blood glucose testing strip when removing it from the glucometer after testing another resident's blood sugar and prior to administering medications for three residents (#21, #33, and #36). The Immediate Jeopardy was removed on 03/04/21 when the facility implemented the following corrective actions: · On 02/25/21, the DON and/or designee completed respiratory screens for Resident #21, #22, #27, #33, #35 and #36 daily for 72 hours. All residents remained at their baseline. · On 02/25/21, the DON educated 52 out of 54 current staff regarding performance of and indications of hand hygiene. The two staff members pending education were removed from the schedule until the education has been completed. · On 02/25/21, the DON completed education to 11 out of 12 current licensed nursing staff regarding glucometer disinfection. The one nurse was a new hire and education will be completed on their work start date. · On 03/03/21, new hires will be educated by the DON upon hire. Agency nurses will receive education through the center's Agency Orientation Binder. · On 03/03/21, the facility notified the nursing agency that LPN #301 was permanently removed from the facility's schedule. · On 03/03/21, Regional Director of Clinical Services #93 reviewed the current 42 residents to identify those with communicable disease. No other residents were identified. · On 03/03/21, the facility's Medical Director (#700) ordered a [MEDICAL CONDITIONS] panel for Residents #21, #22, #25, #27, and #33. The laboratory draw was completed on 03/04/21 and the residents tested negative for [MEDICAL CONDITION]. · On 03/03/21, all 17 residents requiring blood glucose monitoring were provided an individual glucometer. · On 03/03/21, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was completed with the interdisciplinary team which included the Activity Director, Social Services Director and Maintenance Director as well as the Medical Director and the Regional Director of Clinical Services. · On 03/03/21 from 11:02 A.M. through 11:26 A.M., interviews with Registered Nurse (RN) #901 and LPN #304 revealed they were knowledgeable regarding the in-service conducted on 02/25/21 about how to complete and indications of hand hygiene and glucometer disinfection. · On 03/03/21 from 11:02 A.M. through 11:26 A.M, observations of RN #901 and LPN #301 revealed they properly disinfected the glucometer after obtaining a finger stick blood sugar on Resident #22 and #36 respectively. They performed proper hand hygiene during this observation. · On 03/03/21 at 11:26 A.M., Resident #36 was observed to have her own glucometer, stored in a case with her medications. · Beginning on 03/04/21, the DON will complete observations of five staff for hand hygiene to ensure staff have implemented effective and recommended infection control practices to decrease the spread of infection. This will occur weekly for four weeks, then monthly for two months. The results of the audits will be forwarded to the facility's QAPI committee for further review and recommendations. · Beginning on 03/04/21, the DON will complete observations of five nurses for appropriate glucometer disinfecting to ensure staff have implemented effective and recommended infection control practices to decrease the spread of infection. This will occur weekly for four weeks, then monthly for two months. The results of the audits will be forwarded to the facility's QAPI committee for further review and recommendations. Although the Immediate Jeopardy was removed on 03/04/21, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Medical record review for Resident #36 revealed the resident was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the physician orders, dated 04/19/20, revealed to administer insulin [MEDICATION NAME] R Solution 100 units per milliliter per sliding scale subcutaneously before meals and at bedtime. This indicated the resident's blood sugar should be checked four times per day. Review of the facility's list of residents who share the glucometer with Resident #36 revealed Residents #22, #27, #33 and #35 all utilize the same glucometer as Resident #36. During an observation of medication administration on 02/24/21 from 5:11 A.M. through 5:26 A.M., revealed LPN #301 donned gloves and obtained a blood glucose reading on Resident #36. The LPN was not observed to wash her hands prior to donning gloves or prior to obtaining the blood glucose on the resident. The LPN removed her gloves and washed her hands before leaving the resident's room. The LPN then returned to the medication cart in the hallway and removed the blood glucose testing strip from the glucometer with her bare hands and tossed it into the sharps container. The LPN did not wash her hands or disinfect the glucometer. The LPN proceeded to prepare a medication for Resident #21. The LPN entered the room of Resident #21 and administered the medication to Resident #21 and did not wash her hands before administering the medication to the resident. The LPN washed her hands following administering the medication and before leaving Resident #21's room. LPN #301 returned to the medication cart and prepared medications, and prepared to obtain a blood glucose reading for Resident #33. The LPN did not disinfect the glucometer used for Resident #36 and used the same glucometer for Resident #33. The LPN entered Resident #33's room and donned gloves without washing her hands. The LPN then obtained a blood glucose reading, administered medication to the resident, removed her gloves and washed her hands. The LPN then returned to the medication cart, removed the used blood glucose testing strip from the glucometer with her bare hands and tossed it into the sharps container. LPN #301 did not wash her hands and then began to prepare medications for another resident. The LPN did not disinfect the glucometer during the entire observation. During an interview with LPN #301 on 02/24/21 at 5:27 A.M., LPN #301 verified she did not disinfect the shared glucometer in between glucometer use between Resident #36 and Resident #33 and did not disinfect it after use with Resident #33. The LPN verified she used her bare hands to remove the blood glucose testing strip from the glucometer after testing Resident #36's and #33's blood sugar. The LPN verified she did not wash her hands after touching the blood glucose testing strip and did not wash her hands upon entrance to Resident 21's room to administer medications. The LPN stated she only washed her hands after the administration and blood sugar check. During an interview with the facility's Medical Director (MD) #700 on 03/03/21 at 9:50 A.M., the MD confirmed the shared use of a glucometer on multiple residents, including use on a resident positive for [MEDICAL CONDITION], could potentially spread [MEDICAL CONDITION]. The MD stated Resident #36 should have her own glucometer. The MD further revealed the plan was to order laboratory tests to check for [MEDICAL CONDITION] on all the affected residents. Review of the facility's policy titled Glucometer/Point of Care Blood Testing and Disinfection, revised 10/27/20, revealed blood testing meters are to be disinfected between patient uses (before use) according to manufacturer's instructions and infection prevention guidelines. Hand hygiene should be performed before donning clean gloves and obtaining specimen. Following sample collection, the soiled testing strip should be removed with gloved hands and then hand hygiene should be performed again. Review of the facility's undated glucometer instruction manual revealed the meter should by cleaned and disinfected after use on each patient. The blood glucose monitoring system may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. The instructions state any disinfectant with the same Environmental Protection Agency (EPA) number as listed products may be used following the specific contact time recommendations. The instructions for cleaning the meter read as follows: 1. Wear gloves. 2. Remove one towelette from container. 3. Wipe the entire surface of the meter three times horizontally and three times vertically using one towelette. 4. Dispose the used towelette into a trash bin. No drying time is required prior to disinfecting. 5. Pull out a new towelette and wipe the entire surface of the meter three times horizontally and three times vertically. 6. Dispose of used towelette. 7. Allow exteriors to remain wet for the corresponding contact time for each disinfectant. 8. After disinfection, the user's gloves should be thrown away and hands washed before proceeding to the next patient. Review of the CDC's guidance titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration, dated 03/02/11, revealed CDC has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. CDC is alerting all persons who assist with blood glucose monitoring of the following infection control requirements, which included: whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. An underappreciated risk of blood glucose testing is the opportunity for exposure to [MEDICAL CONDITION] (HBV, [MEDICAL CONDITION] virus [MEDICAL CONDITION].through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g. blood glucose meters, fingerstick devices) are shared. Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include: using fingerstick devices for more than one person, using a blood glucose meter for more than one person without cleaning and disinfecting it between uses, and failing to change gloves and perform hand hygiene between fingerstick procedures. In addition, in healthcare settings, the recommendation for hand hygiene was to wear gloves during blood glucose monitoring and during any other procedures that involves potential exposure to blood or body fluids and perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other persons. Review of the CDC guidance on [MEDICAL CONDITION], dated 07/28/20, revealed [MEDICAL CONDITION] is a liver infection caused by the [MEDICAL CONDITION] virus (HCV). HCV is spread through the contact with blood from an infected person. Today, most people become infected with the [MEDICAL CONDITION] virus by sharing needles or other equipment used to prepare and inject drugs. For some people, [MEDICAL CONDITION] is a short-term illness, but for more than half of people who become infected with the [MEDICAL CONDITION] virus, it becomes a long-term, chronic infection. Chronic [MEDICAL CONDITION] can result in serious, even life-threatening health problems like [MEDICAL CONDITION] and [MEDICAL CONDITION]. The best way to prevent [MEDICAL CONDITION] is by avoiding behaviors that can spread the disease, especially injecting drugs. This deficiency substantiates Complaint Number OH 045.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, review of the facility's Transmission-Based Precautions policy, review of the facility's COVID-19 Focused Infection Control Survey Outbreak Timeline and COVID-19 cases, observations and interviews with staff, the medical director and the local health department, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy on [DATE] when the facility improperly discontinued quarantine precautions for the residents residing on the B-Wing after they were exposed to COVID-19 by a licensed nurse. This resulted in 13 (Residents #22, #29, #30, #31, #32, #34, #35, #36, #38, #39, #41, #42 and #44) of the 24 residents residing on the B-wing testing positive for COVID-19. Additionally, the lack of effective infection control practices related to COVID-19 placed all 38 (Residents #01, #02, #03, #05, #06, #07, #09, #11, #12, #13, #14, #15, #16, #17, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42) residents, currently residing in the facility, in Immediate Jeopardy and the potential risk for serious life-threatening harm, negative health complications and/or death related to the facility's failed practices of infection control. The facility census was 38. On [DATE] at 11:24 A.M., the Administrator, Director of Nursing (DON), Regional Vice President of Operations #805, Regional Director of Clinical Services #806, and Divisional Clinical Specialist #807 were notified that Immediate Jeopardy began on [DATE] when the facility discontinued the residents on B-wing from quarantine after five days of being exposed to COVID-19 by a licensed nurse on [DATE]. Licensed Practical Nurse (LPN) #300 tested positive for COVID-19 on [DATE]. LPN #300 worked on the B-wing on [DATE] and exposed all 24 residents residing on this wing. The residents residing on B-wing were quarantined for four days starting on [DATE]. The facility stated the residents on the B-wing were removed from quarantine on [DATE] because the residents had tested negative for COVID-19 twice during these four days of quarantine. On [DATE], two residents (Resident #30 and #31) on the B-wing began to exhibit signs and symptoms of COVID-19. All residents in the facility were tested for COVID-19 resulting in 13 residents (Residents #22, #29, #30, #31, #32, #34, #35, #36, #38, #39, #41, #42 and #44) testing positive for COVID-19 on [DATE]. The 13 residents who were positive resided on the B-wing. The facility's failure to effectively implement infection control practices likely contributed to the COVID-19 outbreak that spread throughout the facility infecting 41 residents with COVID-19, three (Residents #43, #44, and #45) of which expired and had a [DIAGNOSES REDACTED]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Residents #22, #29, #30, #31, #32, #34, #35, #36, #38, #39, #41, #42 and #44 were placed into isolation when they tested positive for COVID-19. Resident #44 expired on [DATE]. Resident #34 was hospitalized on [DATE] and remained in the hospital at the time of the survey. · On [DATE] at 7:00 P.M., Regional Director of Clinical Services (RDCS) #301 educated the DON and Assistant Director of Nursing (ADON) #303 on the facility's policy entitled Transmission-Based Precautions Policy which included the 14-day quarantine for those exposed to COVID-19. · On [DATE] at 9:00 A.M., RDCS #301 educated the Administrator on the facility's policy entitled Transmission-Based Precautions Policy. · On [DATE], the DON and ADON #303 completed education on the facility's policy entitled Transmission-Based Precautions Policy to 50 of the 51 staff members. There was one dietary aide who was off on medical leave and will be educated upon return to the facility. · On [DATE], RDCS #301 physically assessed and reviewed the medical records for Residents #07, #11 and #15, who were the three remaining residents residing in the facility that were negative for COVID-19. The three residents were without any signs or symptoms of COVID-19. · All newly hired staff will be educated in orientation by the DON or designee on the facility's Transmission-Based Precautions Policy, including the 14-day quarantine for direct exposure to COVID-19. · All agency staff will be educated at the start of their shifts by the DON or designee on the facility's Transmission-Based Precautions Policy, including the 14-day quarantine for direct exposure to COVID-19. · The DON and/or Administrator will conduct audits five times a week for four weeks, and then monthly for two months, to ensure the Transmission Based Precautions were implemented correctly. Results of the audits will be forwarded to the facility's Quality Assurance and Performance Improvement (QAPI) committee for review and recommendations. · Observation on [DATE] between 9:30 A.M. and 5:00 P.M. revealed all staff were observed wearing the appropriate personal protective equipment including N95 respirator masks, eye protection, isolation gowns and gloves when entering resident rooms. All the residents were placed under isolation with droplet precautions. · Interview with Licensed Practical Nurse (LPN) #903 on [DATE] at 5:24 P.M., Assistant Director of Nursing (ADON) #303 on [DATE] at 5:28 P.M., State tested Nurse Aide (STNA) #902 on [DATE] at 5:32 P.M., and STNA #903 on [DATE] at 5:37 P.M., revealed all were knowledgeable regarding the in-service conducted on [DATE] about the facility's Transmission-Based Precautions Policy. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). Review of the facility's undated timeline titled COVID-19 Focused Infection Control Survey Outbreak Timeline revealed on [DATE], the facility was notified of LPN #300 testing positive for COVID-19 during routine testing from her other job. LPN #300 worked in the facility on [DATE] on the B-wing. All the residents on the B-wing were exposed and they were placed in quarantine on [DATE]. On [DATE] and [DATE], all the residents residing in the facility were tested for COVID-19 and all the residents tested negative. On [DATE], the facility discontinued quarantine for all the residents residing on B-wing. On [DATE], two residents (Resident #30 and #31) on B-wing began exhibiting symptoms of COVID-19, were tested for COVID-19, and both were found to be positive for COVID-19. The facility completed testing on all residents residing in the facility on [DATE] and [DATE]. A total of 13 residents residing on the B-wing (Resident #22, #29, #30, #31, #32, #34, #35, #36, #38, #39, #41, #42 and #44) were found to be positive for COVID-19 on [DATE] and [DATE]. There were no residents on the other unit of the facility (A-wing) testing positive for COVID-19 at this time. Additionally, all staff were tested on [DATE]. Four staff members were found to be positive for COVID-19 between [DATE] and [DATE] and all four staff members who were found to be positive for COVID-19 worked on the B-wing. Review of the facility's list of positive COVID-19 cases revealed as of [DATE], a total of 41 residents had tested positive for COVID-19 while at the facility. A total of six residents (Resident #04, #08, #18, #21, #34 and #40) have been hospitalized while positive for COVID-19. Additionally, a total of three residents (Resident #43, #44, and #45) passed away and were positive for COVID-19 at the time of death. Interview with the DON on [DATE] at 11:13 A.M. revealed she was the facility's infection preventionist. She stated all the residents in the facility tested positive for COVID-19 except for Residents #07, #11 and #15. Resident #07, #11 and #15 resided on the A-wing. Subsequent interview with the DON on [DATE] at 3:50 P.M. revealed the residents residing on B-wing, who were exposed to COVID-19 by LPN #300 on [DATE], were tested on [DATE] and [DATE]. There were no residents found to be positive when the resident testing was completed on [DATE] and [DATE]. The residents residing on the B-wing were placed under droplet precautions on [DATE] when the facility found out LPN #300 tested positive for COVID-19. The DON stated the exposed residents on B-wing were removed from droplet precautions and out of quarantine status on [DATE] after they all tested negative for COVID-19 for a second time. She stated between [DATE] and [DATE], the staff did not wear an isolation gown or gloves when providing care for the exposed residents residing on B-wing. Interview with Communicable Disease Nurse (CDN) #400 from the local health department on [DATE] at 4:45 P.M. revealed she has been in frequent contact with the facility regarding their COVID-19 outbreak. CDN #400 denied advising the facility to discontinue quarantine with droplet precautions on [DATE] for the residents residing on the B-wing who were exposed to COVID-19 on [DATE]. The residents on B-wing who were exposed on [DATE] should have remained under quarantine with droplet precautions for 14 days despite testing negative for COVID-19 on [DATE] and [DATE]. Interview with Medical Director #500 on [DATE] at 12:20 P.M. revealed he could not recall if he was notified of the facilities plan to discontinue droplet precautions on [DATE] for the residents residing on B-wing who were exposed to COVID-19 on [DATE]. In his opinion, the residents residing on B-wing who were exposed to COVID-19 on [DATE] should have remained under droplet precautions for 14 days from the date of exposure. Interview with LPN #300 on [DATE] at 10:27 A.M. revealed she worked at the facility on the B-wing on [DATE] and [DATE]. LPN #300 stated she covered both the locked unit of the B-wing as well as the portion of the B-wing outside of the locked unit. She was notified on [DATE] by her other employer that she tested positive and she immediately notified the facility on [DATE] of her positive COVID-19 test result. LPN #300 stated she did not develop symptoms of COVID-19 prior to or after testing positive for COVID-19. Review of the facility's policy titled Transmission-Based Precautions Policy, last revised [DATE], revealed transmission-based precautions will remain in effect for a limited time period while the risk of transmission of the infectious agent persists or for the duration of the illness (See appendix A). Review of the facility's 'Appendix A', last reviewed [DATE], revealed readers should refer to the CDC background text for a detailed discussion on emerging pathogens. Review of the CDC guidance titled Responding to Coronavirus (COVID-19) in Nursing Homes, last updated [DATE], revealed long term care facilities should determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED].

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, observation, staff interview, review of radiology report, review of fall investigation, review of facility policies and procedures, and review of the facility's corrective action the facility failed to ensure appropriate care and services were provided to a resident during a transfer using a sit to stand lift mechanical device. This resulted in actual harm when Resident #02 fell from the sit to stand lift mechanical device and subsequently sustained a fracture to the right intertrochanteric (hip). This affected one (Resident #02) of one resident reviewed for falls. The facility census was 50. Findings include: Review of the medical record for Resident #02 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #02 had moderate cognitive impairments. She was assessed as requiring extensive assistance with two person physical assist for transfers and total assistance with two person assist with toileting. She was also assessed as always incontinent of bowel and bladder. The MDS lacked any documentation of falls since her admission to the facility. Review of the quarterly MDS assessment dated [DATE] documented Resident #02 was cognitively intact without any impairments. Review of the comprehensive care plans revealed Resident #02 did not have any care plan in place to provide her assistance as needed for activities of daily living (ADL) from 04/28/19 through 10/16/19. Review of a physician's orders [REDACTED].#02 was ordered to be a two person transfer with the sit to stand lift. Review of the nursing note date 10/14/19 at 11:35 [NAME]M. documented State tested Nursing Assistant (STNA) #144 reported she was transferring Resident #02 with the sit to stand lift and the residents arm slipped out of the lift pad. The resident began to fall from the lift and STNA#144 reported lowering the resident to the ground slowly so the resident would not obtain an injury. STNA #144 then put on the resident's call light for assistance to transfer the resident back in the recliner, so she could be transferred to her wheelchair for lunch. The resident was assessed by the nurse to have no injuries, no neurological deficits and was alert and oriented times three. The family and physician were notified of the fall occurrence. At 6:30 P.M. Resident #02 started to have complaints of right leg pain and bruising was noted to her right lower leg. At 7:37 P.M. an order was obtained for an X-ray of the right hip and leg. Further review lacked any documentation of the resident needing neurological checks related to the fall which was witnessed, and Resident #02 did not hit her head. Review of a physician order [REDACTED].#02's right hip and thigh. Further review lacked any order for neurological checks. Review of the radiology report dated 10/14/19 revealed Resident #02 had an acute right intertrochanteric fracture with modest displacement. The joint showed no dislocation. Review of nursing note dated 10/15/19 at 12:05 [NAME]M. revealed the X-ray result came back showing an acute fracture to the right hip. The physician and the daughter were notified, and an ambulance was called to transport Resident #02 to the emergency room (ER) for evaluation. At 5:15 [NAME]M., Resident #02's daughter notified the facility the resident was being admitted to the hospital to have surgery to her right hip. Review of physician order [REDACTED].#02 to the emergency room for positive right hip X-ray. Review of the facility fall investigation dated 10/14/19 through 10/16/19 revealed the facility completed a thorough investigation surrounding the circumstances involving Resident #02's fall. Through the investigation it was determined through STNA #144's written statement she did not use two nursing staff members to assist with the sit to stand lift as ordered and required per the facility policy while transferring Resident #02. On 10/15/19 the family provided a video of Resident #02's fall for the facility's investigation. STNA #144 was immediately suspended and then terminated based on previously receiving verbal education on 10/12/19 by the Director of Nursing (DON) to use two people for any mechanical lift. Also the video provided by the family revealed STNA #144 did not ensure the residents safety when she failed to use two staff members for the sit to stand lift which resulted in the resident having a right [MEDICAL CONDITION]. Review of nursing notes dated 10/17/19 at 4:40 P.M. revealed Resident #02 was readmitted to the facility from the hospital after right hip surgery. On 11/03/19 at 3:38 P.M. interview with Administrator verified Resident #02's family had verbalized care concerns with an improper transfer by STNA #144. The family shared a video of the improper transfer. The Administrator verified STNA #144 did not transfer Resident #02 appropriately or safely with the sit to stand mechanical lift. On 11/03/19 at 3:42 P.M. interview with the DON verified STNA #144 did not use the sit to stand lift appropriately when transferring Resident #02. She verified STNA #144 attempted to transfer Resident #02 with only one person assist. The DON indicated, after watching the video, she concluded STNA #144 did not ensure the resident was positioned correctly in the sit to stand mechanical lift to ensure a safe transfer which resulted in Resident #02 falling and sustaining a [MEDICAL CONDITION]. The DON also verified after watching the video of the incident, provided by the family, STNA #144 was terminated due to her previous verbal education to always use two STNA's for mechanical lift transfers. On 11/04/19 at 12:57 P.M. interview with Resident #02 revealed she did sustain a fall recently when she slipped out of the lift. The resident indicated the fall scared her. On 11/04/19 at 1:21 P.M. interview with STNA #158 verified she was working the day of 10/14/19 when Resident #02 fell . She further verified there were two STNAs (herself and STNA #144) and Licensed Practical Nurse (LPN) #132 working on the secured unit. She revealed STNA #144 never requested assistance to transfer Resident #02. The resident sustained [REDACTED]. STNA #158 verified when using any lift there should be two staff to assist to ensure the resident's safety. She also revealed she would have been available to help with Resident #02's transfer if STNA #144 had requested assistance. She verified later in the day, Resident #02 had complaints of pain only with movement. She stated she notified LPN #132 and an X-ray was ordered. She denied Resident #02 had constant complaints of pain or any visible bruising to her right hip until later in the evening after the fall occurred. On 11/04/19 at 2:00 P.M. interview with LPN #132 revealed STNA #144 did not ask anyone for assistance to help transfer Resident #02. LPN #132 stated she verbally educated STNA #144 immediately after the incident occurred about using two staff members to transfer Resident #02. LPN #132 revealed after the fall Resident #02 was sitting on the floor with her back against the recliner with her right leg over one of the sit to stand lift leg bases. Initially the resident did not complain of any pain, but later in the evening she started to complain of pain with movement and had visible bruising which was not present on her initial fall assessment. The physician was notified of the pain and an order was received to obtain an X-ray. LPN #132 verified Resident #02 was sent out to the ER after her shift due to the X-ray being positive for a right [MEDICAL CONDITION]. On 11/05/19 at 2:26 P.M. and 2:37 P.M. an attempt was made to contact STNA #144 who was providing care to Resident #02 when her fall with fracture occurred. STNA #144 was no longer an employee at the facility and contact was not able to be made. Review of facility policy and procedure for fall prevention and fall management dated (MONTH) 2010 documented a program will identify [MEDICATION NAME] and extrinsic risk factors related to the resident who is at risk for falls. The residents assessment helps to determine the resident's degree of mobility and physical impairment to determine if the resident requires one or two assists for mechanical transfer devices is needed for safe transfer. Review of policy and procedure for comprehensive care planning revised 07/19/19 documented the facility must develop a comprehensive care plan for each of the residents to meet all their needs. The facility had seven days after a comprehensive MDS assessment was complete to initiate or update the care plan as needed. The comprehensive care plan will be reviewed and updated as needed at least every 90 days. Review of the facility's mechanical lift policy revised (MONTH) 2019 documented two-person assist is required for total body lifts and sit to stand lifts. As a result of the incident the facility took the following actions to correct the deficient practice by 10/24/19: · On 10/14/19, the DON initiated an investigation into the incident. STNA #144 was interviewed and confirmed she had transferred Resident #02 by herself. She also received disciplinary action for not following the appropriate procedure and creating an unsafe environment for the resident. · On 10/15/19, Resident #02's family member provided the facility with video footage of the incident. STNA #144 was placed on suspension pending fall investigation outcome due to new evidence. · All nursing staff were educated beginning 10/15/19 and ending 10/18/19 regarding ensuring resident care plans identified the need for two persons transfer and proper transfer techniques. The content directed staff to make sure to read and follow each resident's plan of care, and that any resident that required the use of assistive devices such as a mechanical lift or stand-up lift always required the assistance of two staff. Competency evaluation and training regarding staff demonstration of proper use of the stand-up lift for resident transfers was completed for all licensed nurses and STNA's. · On 10/18/19, STNA #144 was terminated due to the improper use of the lift. After review of the video footage the facility felt STNA #144 could have possibly caused more harm by the events that occurred in the video then they initially thought from her statement. · Performance monitoring was initiated on 10/24/19 to maintain ongoing compliance. The facility will audit five residents medical charts every week for four weeks, then five residents medical charts monthly for three months. Results will be reviewed monthly in Quality Assurance Program Improvement (QAPI) meetings. Performance monitoring was completed on 10/24/19 and on 10/31/19 with 100 percent compliance identified. · On 11/03/19, Resident #02 was observed being properly transferred using a Hoyer by two STNAs. · On 11/05/19, Resident #22 was observed being properly transferred with the sit to stand lift. · On 11/05/19, STNA #154 and STNA #158 were interviewed to determine if they had been recently educated regarding the proper use of mechanical lifts and sit to stand lifts. The STNA's were knowledgeable and reported they had been educated on the proper use of sit to stand lifts. Both STNAs reported that they were to always have two nursing staff when transferring residents using a sit to stand lift or any mechanical lift. This deficiency substantiates Complaint Number OH 781.

Based on medical record review, observation, interviews with staff, a resident, a family member, and a community citizen, review of written statements by staff, review of a police report and review of a facility policy titled Elopement Policy, the facility failed to provide adequate supervision to prevent elopement of a resident who was assessed as being at risk for elopement. This resulted in Immediate Jeopardy when one resident (#02) was placed at risk for potential serious harm and injury when the resident eloped from the facility, without staff knowledge, and was missing for approximately 55 minutes. The resident was found in the street in her motorized wheelchair by the owner of a local hardware store one half mile from the facility. The resident was near the curb of a state route with a 35 mile per hour speed limit, four lanes of moving traffic, and a turn lane. This affected one (#02) of three residents reviewed for risk of elopement. The facility identified four residents at high risk for elopement. The facility census was 49. On 08/14/19 at 2:50 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Director of Clinical Services (RDCS) #25 were notified Immediate Jeopardy began on 07/01/19 at approximately 8:50 P.M. when Resident #02 was placed in her motorized wheelchair, not provided adequate supervision, and subsequently eloped from the facility unknown to staff. At approximately 9:20 P.M. to 9:30 P.M., a citizen in the community (#53) saw traffic going around someone at the curb on the state route. Citizen #53 walked to the street and discovered Resident #02 in her motorized wheelchair 12 to 18 inches from the curb and three feet into the street. Citizen #53 tried to move the resident's wheelchair, but it was locked up. After ten minutes of trying to move the resident, Citizen #53 was finally able to get the wheelchair into neutral and get the resident out of the street. During this time, he was trying to flag traffic around the resident, who was sitting in the street. Resident #02 was only wearing a bra, shirt and incontinence brief; however, was covered from her ankles to lap with a blanket. Citizen #53 obtained a family members phone number from Resident #02 and contacted the family and then the facility. The family member contacted the local police. The Immediate Jeopardy was removed on 08/14/19 when the facility implemented the following corrective actions: · On 07/01/19 at 10:15 P.M., a head-to-toe assessment was completed for Resident #02 and the resident was placed on one-to-one supervision. · On 07/01/19 at 10:20 P.M., a new Wanderguard was placed on the resident's wheelchair. · On 07/02/19 at 6:00 [NAME]M., the one-to-one supervision was discontinued and Resident #02 was placed on 15-minute checks for 24 hours. · On 07/02/19 at 3:52 P.M., the ADON educated the family about removing the Wanderguard from Resident #02's wheelchair. · On 08/14/19, the physician examined the resident and determined the resident should be supervised during leaves of absence due to her physical state. · On 08/14/19, all residents were assessed for elopement risk. · On 08/14/19 at 3:55 P.M., education on elopement for all staff was initiated regarding the facility's Elopement Policy. · On 08/14/19 at 3:58 P.M., an elopement drill was conducted. · On 08/14/19 at 4:00 P.M., a request was made for therapy to screen Resident #02 for wheelchair safety. · On 08/14/19 at 6:15 P.M., a Quality Assurance Performance Improvement (QAPI) for the elopement was completed. The facility will perform elopement drills every shift times two, weekly for four weeks, then monthly. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #02's medical record revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 was alert and oriented. She required extensive assistance of two staff for bed mobility and transfers and the assistance of one staff with eating and toileting. Resident #02 was independently mobile in a motorized wheelchair. Review of Resident #02's elopement assessments dated 04/17/18 and 04/17/19 documented she was not an elopement risk. Review of Resident #02's progress notes dated 05/16/19 revealed at 3:45 P.M. the resident was seen going out the front doors by staff in her motorized wheelchair and attempted to go toward the street. The resident was always in sight of the staff. When the resident was re-directed back to the building with an attempt to educate her on safety, the resident continued to show poor judgement and stated she didn't care. There was a new Wanderguard placed to the wheelchair for safety. The note further documented to monitor behaviors and educate the resident as needed. The elopement assessment completed on 05/16/19 indicated the resident was an elopement risk. Review of Resident #02's care plan, initiated on 05/16/19, revealed she was at risk for elopement due to taking herself outside toward the street with no regard for safety. Interventions included the following: complete elopement risk review upon admission, quarterly and as needed; psychiatric referral if needed; staff to follow procedures for elopements, if applicable, to ensure safe return; utilize distractions to help decrease wandering for example crafts, puzzles, music, and activities; utilize Wanderguard for safety, apply Wanderguard to wheelchair at left front leg, check placement, function and expiration every shift. Review of the police report dated 07/01/19 at 10:02 P.M. revealed they were dispatched to the hardware store in reference to Resident #02 escaping from the facility and was with Citizen #53, LPN #50, STNA #02, and a family member. The officer arrived and was informed Resident #02 was okay. The officer revealed the resident was in a motorized wheelchair and was unable to communicate verbally. LPN #50 and STNA #02 stated they had not noticed the resident was gone until the family called the facility. The officer stood by until the resident was transported back to the facility. The family informed the officer this was the second time the resident had eloped and was concerned about the facility having the proper staffing. Review of a progress note dated 07/01/19 at 10:05 P.M. revealed the resident was on her way to the hospital for a stomach ache and pain in her back and she wanted to get checked out by a physician at the hospital (local hospital is approximately a mile from the facility). The resident stated she was her own person and could take herself out of the facility. The resident stated she was okay the entire time she was out of the facility. The facility offered to send her to the hospital, but she declined. Review of the written statement from STNA #53 revealed on 07/01/19 at 8:50 P.M., she was giving care to someone else and when she walked out into the hallway, another resident's family member approached and said Resident #02 was lying on the floor. She went into see the resident and placed her in a wheelchair and left to take care of another resident. Review of the written statement dated 07/01/19 from LPN #50 revealed the nurse received a phone call from a community citizen (#53) at 9:55 P.M. stating Resident #02 was in her motorized wheelchair riding down the sidewalk and went off the curb in front of the hardware store. Community Citizen #53 stated the resident was safe and in the hardware store parking lot. The resident was last seen at 8:50 P.M. sitting in the activities room. LPN #50 and STNA #02 went to the hardware store and found Resident #02 sitting in the parking lot safely with community Citizen #53 and one of her family members. The police were notified by the resident's family and facility for report. The resident was transferred by facility vehicle back to the facility. A skin examination was completed, and the resident was placed on one-to-one supervision until 6:00 [NAME]M. Review of the written statement from LPN #02, dated 07/01/19, documented a few minutes to 10:00 P.M., the nurse stepped out and said there was an outside citizen on the phone and had Resident #02 at the hardware store. She told the citizen the facility would be there to get the resident shortly. Review of the progress note dated 07/02/19 revealed on 07/01/19 at 9:55 P.M., community Citizen #53 called the facility, stating Resident #02 was in an electric wheelchair riding down the sidewalk and went off the curb in front of the local hardware store. Community Citizen #53 said the resident was safe and with family in the parking lot. The resident was last seen by LPN #50 at approximately 8:50 P.M. in the activities room. LPN #50 and STNA #02 went to the hardware store and found the resident safely in the parking lot with community Citizen #53 and one of her family members. The police were notified by the resident's family. The resident was transferred back to the facility by a facility vehicle. Skin assessment was completed, and no injuries were noted. The resident was placed on one-to-one care until 6:00 [NAME]M., then 15-minute checks. Interview with Resident #02's family member on 08/14/19 at 9:50 [NAME]M. revealed Resident #02 had eloped a few weeks ago and she was found down on a state route around the corner from the facility. She stated it was about three weeks ago and the facility placed a lock (Wanderguard) on Resident #02's wheelchair and she admitted she cut it off so she wouldn't be confined to the facility. Interview with LPN #50 on 08/14/19 at 11:50 [NAME]M. revealed she was passing medications when she got the phone call that Resident #02 was down the street at the local hardware store. She stated she and STNA #02 went to get her and it took them five to six minutes to get to the store but didn't remember what time it was. She stated the police had been called by the family member and the resident said she was going to the hospital and was laughing about it but didn't give a reason why she was going to the hospital. She revealed she didn't know the resident had left the facility and she hadn't seen her that evening yet. She stated the resident had exit seeking behaviors. Observation on 08/14/19 at 12:50 P.M. revealed the route (path of travel) Resident #02 took was driven and measured one half mile from the facility. Route 36 was observed as a five lane, main road with four lanes of traffic and a turn lane in the middle. Route 36 was a major thoroughfare through town. Interview with STNA #53 on 08/19/19 at 6:01 [NAME]M. revealed she checked on Resident #02 on 07/01/19 at 8:40 P.M. to 8:45 P.M. and she was lying on the floor, which she was care planned for. She stated Resident #02 wanted to get up off the floor and into her motorized wheelchair and that was completed. She said she last saw her on 07/01/19 at 8:50 P.M. Interview with STNA #02 on 08/19/19 at 6:08 [NAME]M. revealed she clocked in about 10:00 P.M. She stated as she was going around the nursing station, LPN #50 told her there was a man on the phone who wanted to speak to her, so she got on the phone. He told her he had Resident #02 at the hardware store around the corner, her electric wheelchair wasn't working, and he had to help her get out of the street by pushing her wheelchair as he flagged the traffic. She and LPN #50 took off and found Resident #02 in her wheelchair in the parking lot at the hardware store with a family member and community Citizen #53. She said Resident #02 told her she was going to the hospital. The resident was laughing, giggling and denied she was in pain. The facility van picked her up and took her back to the facility and she was put to bed and slept well the rest of the night. She was placed on one to one staff observation for the rest of the night. Interview with Resident #02 on 08/14/19 at 12:10 P.M. revealed she left the facility to go to the hospital because she had a stomach ache and pain in her kidneys. She couldn't remember the time or the date. Interview with community Citizen #53 on 08/14/19 at 1:04 P.M. revealed on 07/01/19 at approximately 9:20 P.M. to 9:30 P.M., he saw traffic was going around someone at the curb on the state route. He walked to the street and discovered Resident #02 was in her motorized wheelchair. He said she was 12-18 inches from the curb and three feet into the street. He tried to move the resident's wheelchair, but it was locked up. After ten minutes of trying, he finally was able to get the wheelchair in neutral and get the resident out of the street. During this time, he was trying to flag traffic around the resident, who was sitting in the street. He stated the resident was only wearing a bra, shirt and incontinence brief. She was covered from her ankles to lap with a blanket. He asked her for someone to call and she wrote down her name and a family member to call. He called the family member and then called the facility. He stated the family member called the police. He stated the family arrived and then LPN #50 and STNA #2. Interview with the Administrator, RCDS #25, Regional Vice President of Operations (RVPO), and the DON on 08/15/19 at 10:02 [NAME]M. revealed on 07/01/19, the resident ' s family came in and got the resident all riled up. The resident became upset and she went out the doors of the facility to go to the hospital. Staff stated she was supposed to have a Wanderguard on her wheelchair, but a family member had cut it off the day before. They stated they didn't know the Wanderguard had been cut off until after the resident got out of the facility. They didn't know the owner of the hardware store had found the resident, who called the family and then the facility to report she had been found initially on the curb in her wheelchair. They further revealed the resident had anger issues and impulsive behavior and had no safety awareness. Review of the facility policy titled Elopement Policy, revised on 04/02/18, revealed the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures immediately to locate the resident in a timely manner. This is an incidental deficiency discovered during the investigation of Complaint Number OH 167.

Based on review of the facility's self reported incidents, closed record review, review of employee personnel files and staff interview, the facility failed to ensure a physician ordered fall intervention was in place for a resident with a history of falls. Failure to provide this intervention resulted in an avoidable fall which resulted in a hip fracture for one (#51) of four sampled residents. Findings include: Review of the face sheet in the closed medical record of Resident #51 revealed the resident was admitted to the facility on [DATE] and expired on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively impaired, required limited assistance of one person with activities of daily living (ADL) including transfers, walking and locomotion and required extensive assistance with ADL's including dressing, toileting and personal hygiene. The MDS further revealed the resident's balance was unsteady, she was only able to stabilize with human assistance when moving from seated to standing position, when walking (with assistive device), when turning around and during surface to surface transfers. The MDS indicated Resident #51 used a walker for mobility. Review of the resident's physician order [REDACTED]. Review of a facility self reported incident report dated [DATE] revealed on [DATE] the resident was seated in the dining room/television room watching television with other residents. Two state tested nurse aides (STNA) were passing snacks and making frequent checks on the four residents watching television. The report stated STNA #15 assisted Resident #51 to the toilet around 6:45 P.M. and returned her to the dining room/television room. Around 7:00 P.M., Resident #51 got up from the table and walked approximately five to six feet and then fell . The fall was not witnessed by staff. The resident was assisted by staff after the fall and noted to have vomited and have an outer rotation of her left lower extremity and swelling and bruising of her right hand and fingers. The resident was sent to the emergency room and found to have left hip fracture. Review of the personnel file of STNA #15 revealed she was given a written warning for failing to comply with all health and safety rules. The warning notice stated the STNA placed a resident in the dining room after toileting her but failed to place the resident's chair alarm in her chair and that improper placement of the intervention occurred on [DATE] and resulted in the resident having a fall with significant injury. Further review of the employee's file revealed she had received an employee coaching form on [DATE] for transferring a resident that required hands on without using a gait belt. Further review of the resident's closed record revealed a significant change MDS dated [DATE] that stated the resident had a decline in her functional status and required extensive assistance for ADL's including bed mobility, transfers, locomotion, eating, toilet use, personal hygiene and bathing. During interview on [DATE], the Director of Nursing (DON) confirmed Resident #51 had a physician's orders [REDACTED]. During interview on [DATE] at 3:10 P.M. STNA #15 stated she was not aware the resident had a physician's orders [REDACTED]. STNA #15 stated the facility did not usually use an alarm for the resident in the dining room and that it was only used in the resident's room. At the time of the complaint investigation the facility was unable to provide documentation of monitoring of compliance with residents' assistive device per request of the surveyor. This certification deficiency substantiates Complaint Control Number OH 054.