Every finding on record at Venetian Gardens

Based on medical record review, review of resident banking records, review of facility investigative reports, review of facility Self-Reported Incidents (SRIs), resident interview, staff interview, police interview, and review of facility policy, the facility failed to ensure residents were free from misappropriation. This affected five (Residents #4, #5, #55, #65 and #67 of five residents reviewed for misappropriation. The facility census was 93. Findings include: Review of the medical record for Resident #55 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Review of a facility SRI (261001) created on 05/29/25 for an allegation of Misappropriation discovered on 05/28/25. The corporate staff alleged multiple incidences of misappropriation by Former Business Office Manager (BOM) #10, who was terminated for attendance issues on 05/01/25. Subsequently, a temporary BOM identified accounting irregularities with the resident accounts, which triggered additional audits. On 05/28/25, the Administrator received communication from the corporate Accounts Receivable (AR) office advising that multiple resident accounts were suspected to be compromised; therefore, a comprehensive investigation was initiated to review all resident accounts. The AR team identified 50 former and/or current residents with accounting irregularities suspicious of misappropriation. The audit indicated the former BOM #10 had manipulated accounting software applications (e.g., changing payable to), then printed checks made out to Petty Cash, signed the administrator's name, and cashed. Upon interview with the administrative staff, there were no eyewitnesses to the alleged misappropriation. Interview with the residents and staff revealed no related allegations of misappropriation. The corporate Director of AR validated that none of the 50 residents identified had an interruption in treatment, services, room or board (i.e., all bills were paid) due to the alleged misappropriation. The Director of Nursing (DON) and designees reviewed all residents' quality of care, personal funds accounts, medications, care plans, billing, etc. and found no evidence of harm or unmet needs as a result of the allegation. There was reasonable evidence to substantiate the former BOM #10 misappropriated funds. The facility substantiated the allegation of misappropriation which was verified by evidence and completed the SRI on 06/04/25. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #55 had intact cognition.Review of the personnel file for former BOM #10 on 08/19/25 at 1:00 P.M. with the Regional BOM (RBOM) #905, revealed a hire date 08/29/11. The appropriate references were completed, and a Bureau of Criminal Investigation (BCI) background check was completed on 08/30/25 which returned with no criminal history. Former BOM #10 was terminated on 05/05/25 for falsification of personal documents related to a medical leave of absence, and attendance issues which dated prior to 08/26/24. Interview 08/19/25 at 1:08 P.M. with RBOM #905 who stated that former BOM #10 was hired in 2011, and the misappropriation started in October/November 2021. RBOM #905 stated former BOM #10 manually manipulated the residents RFMS Withdrawal Documents and Statements Report which then affected the facility's accounts receivable report. On 05/28/25 an audit of the facility's RFMS was initiated by the regional and corporate personnel, and it was discovered that the former BOM #10 created an excessive amount of checks made out to Petty Cash. RBOM #905 stated as an example, on 04/23/25, Resident #55 provided former BOM #10 with a check for $7,000.00 to open a RFMS account to be used for facility room and board (Medicaid spend-down) and for personal items. On 04/23/25, former BOM #10 then generated a check from RFMS written out to Petty Cash for $7,000.00, cashed the check, and kept the cash. Former BOM #10 then manually manipulated Resident #55's Resident Statement to show the check for $7,000.00 never existed. When the funds were to be transferred to pay for the resident's room and board, former BOM #10 would manually manipulate RFMS documents to have it appear that the money was transferred and paid to the facility. RBOM #905 stated Former BOM #10 was also manipulating the names of legitimate resident vendors (such as paying the resident's phone bill, online orders, funeral homes, etc.) on the checks to Petty Cash. However, in the RFMS system, the original vendor's name stayed the same in the system. RBOM #905 stated originally, former BOM #10 started all of this by misappropriating smaller amounts of money and the last amount misappropriated totaled $12,000.00. The audit determined the misappropriation started in October/November 2021 and total amount of money misappropriated totaled $219,721.21, which consisted of $93,639.21 being owed to the facility for resident care and services, and $126,082.00 was owed to the residents. RBOM #905 stated when the misappropriation was discovered on 05/28/25, the facility created an SRI, and a comprehensive investigation was initiated which included notification to the local police department. RBOM #905 stated the facility substantiated the SRI for misappropriation, and the local police department's investigation was ongoing. RBOM #905 stated the company also audited all their other facilities and found no similar concerns. RBOM #905 stated an audit of all resident accounts dating back to October/November 2021 was initiated and the residents affected by the actions of former BOM #10 were refunded the amount misappropriated. RBOM #905 stated on 08/06/25, the facility met with local police department detective assigned to the case to demonstrate how former BOM #10 manipulated the RFMS account to misappropriate the money. RBOM #905 stated once this manipulation was identified, the company worked with the creator of the RFMS software to disable capabilities for the BOMs to change names on checks, void checks, and change vendors. RBOM #905 stated those functions can now only be completed by a RBOM or corporate personnel. RBOM #905 verified there were no residents denied Medicaid services, and the audit results revealed no documented evidence that residents who requested monies were ever denied. Review of the facility's deposit record on 08/19/25 at 1:12 P.M. with RBOM #905, revealed on 06/17/25, a total of $219,272.71 was deposited into the RFMS accounts of 50 residents identified by the facility audit as having funds misappropriated by the former BOM #10. This was paid to the facility in form of check from the parent organization payable to the facility. Review of RFMS accounts for Residents #55, #65 and #67 on 08/19/25 at 1:20 P.M. with RBOM #905, revealed Resident #55's RFMS account had $7,000.00 returned on 06/27/25; Resident #65's RFMS account had $6,667 returned on 06/17/25; and Resident #67's RFMS account had $2,090.00 returned on 06/17/25. These dollar amounts correlated directly to the Deposit Record dated 06/17/25. RBOM #905 stated the three accounts were directly related to the misappropriation by former BOM #10. Interview on 08/19/25 at 1:42 P.M. with the Administrator, revealed notification was made to all residents and/or the representatives affected by the misappropriation. The Administrator revealed 50 residents were affected by this incident and verified that all 50 residents' RFMS accounts had been reimbursed for the monies identified as being misappropriated. Interviews on 08/19/25 between 3:40 P.M. and 4:00 P.M. with Residents #55, #65 and #67, revealed no knowledge of any misappropriation. Interview via phone on 08/20/25 at 4:10 P.M. with Detective #900, revealed the investigation into the misappropriation had been completed and the results were sent to the Prosecutor's office for review and that subpoena's will be issued. The Detective stated the facility provided good information in his investigation and a good explanation of how the RFMS system functioned. Review of the policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source. Additionally, the facility should immediately report all such allegations to the Administrator and to the Ohio Department of Health. In cases where a crime is suspected, staff should also report the same to local law enforcement. Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The deficient practice was corrected on 06/17/25, when the facility implemented the following corrective actions: On 05/01/25, former BOM #10 was terminated related to a progressive discipline pattern secondary to attendance issues. On 05/28/25, a temporary BOM identified accounting irregularities with numerous residents' RFMS accounts dating back to October/November 2021. An SRI was created, and a comprehensive investigation was initiated which included notification to the local police department. The facility substantiated the SRI on 06/04/25 for misappropriation, and the local police department investigation is ongoing. On 05/28/25, an audit of all resident accounts was initiated by the regional and corporate personnel and found that former BOM #10 created an excessive amount of checks made out to petty cash. The audit determined the misappropriation of 50 resident's RFMS accounts started in October/November 2021 and total amount of money misappropriated totaled $219,721.21, which consisted of $93,639.21 being owed to the facility for resident care and services, and $126,082.00 owed to the residents. The former BOM #10 manipulated the accounting software applications, made checks out to Petty Cash, signed the Administrator's name and cashed the checks. The audit revealed no residents were denied Medicaid services, and no evidence that residents who requested monies were ever denied. On 05/28/25, the company initiated additional audits for all other facility's RFMS accounts and found no similar concerns. On 05/28/25, the DON and designees initiated an audit of all residents' quality of care, personal funds accounts, medications, care plans, billing, and found no documented harm or unmet needs. On 05/28/25, all staff and residents were interviewed and no concerns regarding misappropriation were identified. On 06/04/25, An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held, to include the Medical Director, to review applicable policies, the investigation results and to create an internal comprehensive QAPI plan. On 06/04/25, The Corporate Human Resources staff provided education to the Administration on the Personal Needs Accounting Policy followed by all staff being educated on the Abuse, Neglect and Misappropriation policy and procedure. On 06/04/25, the affected residents and families were notified and noted they would be reimbursed once the final amount owed was determined. On 06/04/25, the corporate office worked with the creator of the RMFS software to disable the capabilities for the BOMs to change names on checks, void checks and change vendors. These functions now can only be completed by the RBOM or corporate personnel. On 06/04/25, the corporate audit process was changed so that every vendor transaction was audited, compared to the old process where there was a random sample of certain transactions audited. On 06/04/25, in addition to corporate audits, the facility conducted an audit of Personal Needs Accounts for four weeks and as directed by the QAPI committee. No further issues were discovered. On 06/17/25, all misappropriated money was returned to the residents' accounts. On 08/06/25, the facility met with local police department detective assigned to the case to demonstrate how former BOM #10 manipulated the RFMS to misappropriate the monies.This deficiency represents non-compliance investigated under Complaint Number OH00166340 (1364331).

Based on medical record review, staff, physician, and non-physician providers (NPP) interviews, and review of facility policy, the facility failed to ensure a resident's representative was notified when a resident had a documented change in condition which required the physician to be contacted and x-rays ordered. This affected one Resident (#10) of three residents reviewed. The facility census was 88. Findings included: Review of the medical record for the Resident #10 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severely impaired cognition, had no behaviors, did not reject care, did not wander, was two plus person assist and required extensive assistance with activities of daily livings (ADLs) and was always incontinent to bowel and bladder. Review of nurse's progress notes for Resident #10 dated 02/1/22 at 9:15 P.M. by Licensed Practical Nurse (LPN) #34 indicated the Stated tested Nurse's Aides (STNA) notified nurse while giving care to resident and she complained of left arm pain and notes indicated resident also expressed pain to LPN #34. Notes indicated an as needed [MEDICATION(S)] (narcotic pain medication) was given with effective results. Notes indicated the physician was notified and new orders for X-ray of left arm was received. Nurse's notes were silent for any indication resident's representative was notified and nurses notes revealed no documented assessment of new onset of left arm pain. Interview with LPN #34 on 03/03/22 at 2:24 P.M. indicated she worked nightshift (7:00 P.M. to 7:00 A.M.) on 02/01/22 and was tasked with caring for Resident #10. LPN #34 stated State tested Nurse's Aides (STNAs) (#42 and #43) notified her around 9:15 P.M. that resident had left arm pain after they provided a bed bath from incontinence episode. LPN #34 stated she assessed resident, administered an as needed pain medication, ordered a left elbow x-ray via phone, and sent a fax notification letter to the on-call provider. LPN #34 verified she did not notify the residents family when resident had a change in condition on 02/01/22. Interview with Director of Nursing (DON) and Regional Clinical Director #102 on 03/03/22 at 2:55 P.M. verified there was no documentation the facility notified the residents representative on 02/01/22 when resident was discovered with arm pain. Review of 10/18/02 facility policy titled Change in Condition indicated the facility shall notify the residents guardian/interested family member of all changes in resident's condition. This deficiency substantiates Complaint Number OH 274.

Based on medical record review, staff, physician, and non-physician providers (NPP) interviews, and review of facility policy, the facility failed to ensure a resident was promptly provided with appropriate care and services when facility discovered resident had a new onset of left arm pain which resulted in left arm fracture discovered three days later. This affected one Resident (#10) of the three residents reviewed. The facility census was 88. Findings included: Review of the medical record for the Resident #10, revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severely impaired cognition, had no behaviors, did not reject care, did not wander, was two plus person assist and required extensive assistance with activities of daily livings (ADLs) and was always incontinent to bowel and bladder. Review of nurse's progress notes for Resident #10 dated 02/1/22 at 9:15 P.M. by licensed Practical Nurse (LPN) #34 indicated the State tested Nurse's Aides (STNAs) notified LPN resident had new onset of left arm pain while STNAs giving care to resident. Notes indicated resident complained of left arm pain to nurse. Notes indicated an as needed [MEDICATION(S)] (narcotic pain medication) was given with effective results. Notes indicated the physician was notified and new orders for X-ray of left arm was received. Review of nurse's progress notes for Resident #10 dated 02/2/22 at 2:10 P.M. indicated resident complained of pain and left shoulder redness was noted. Review of nurse's progress notes for Resident #10 dated 02/03/22 at 12:29 A.M. indicated resident continued with pain to left bicep with redness and warmth and bruising noted. Notes indicated as needed pain medications were administered and nurse called X-ray company, and they indicated they would arrive on 02/03/22 and nurse placed an urgent order. Review of nurse's progress notes for Resident #10 dated 02/03/22 at 10:21 A.M. by LPN # 30 indicated resident continued with redness to left arm and no signs and symptoms of pain or discomfort noted at this time. Review of nurse's progress notes for Resident #10 dated 02/03/22 at 10:39 A.M. by LPN #35 indicated resident had left bicep area with dark purple bruising and area noted to be swollen. Notes indicated an X-ray would be obtained on 02/04/22 and residents arm positioned on pillow for comfort. Review of X-ray report dated 02/04/22 at 11:38 A.M. indicated resident had new onset of pain with no known injury. Notes indicated resident had grossly displaced proximal humeral shaft fracture. Notes indicated osteopenia with lateral soft tissue swelling was noted. Review of nurse's progress notes for Resident #10 dated 02/04/22 at 1:22 P.M. by LPN #30 indicated X-ray results received, and results were reviewed with Nurse Practitioner (NP) #101. Notes indicated NP #101 ordered resident to be sent to the emergency room for evaluation and treatment and family was aware. Review of nurse's progress notes for Resident #10 dated 02/04/22 at 4:31 P.M. by LPN #30 indicated resident transferred to hospital. Review of nurse's progress notes for Resident #10 dated 02/04/22 at 11:00 P.M. indicated Resident returned to facility and hospital noted resident had fracture at left humerus and soft cast with sling was ordered. Notes indicated resident was to follow up with orthopedic surgeon and new as needed pain medications were ordered. Additional review of nurse's progress notes from 02/01/22 through 02/04/22 revealed no documented evidence the physician or NP #101 was notified of the delay in X-ray being completed. Review of hospital notes for Resident #10 dated 02/04/22 indicated resident was seen for arm injury and diagnosed with close displaced oblique fracture of shaft of left humerus. Notes indicated resident was ordered new pain medications, was splinted, and returned to the facility with orders for an appointment with orthopedic surgery as soon as possible. Interview with LPN #30 on 03/03/22 at 2:09 P.M. indicated she worked on 02/03/22 and 2/04/22 from 7:00 A.M. to 7:00 P.M. LPN #30 stated she was told facility was waiting on X-ray. LPN #30 stated she questioned x-ray not being done but was told the weather delayed the X-ray company from doing the exam. LPN #30 stated she called the X-ray service on 02/03/22 and questioned the status but never followed up and assumed they had not shown up due to weather conditions. LPN #30 verified she did not notify the physician or NP #101 of the delayed X-ray exam. Interview with LPN #34 on 03/03/22 at 2:24 P.M. indicated she worked nightshift (7:00 P./M. to 7:00 A.M.) on 02/01/22 and was tasked with caring for Resident #10. LPN #34 stated the STNAs (#42 and #43) notified her around 9:00 P.M. that resident had left arm pain after they provided a bed bath. LPN #34 stated she assessed resident, administered an as needed pain medication, ordered a routine left elbow x-ray via phone and sent a fax notification letter to the on-call provider. LPN #34 stated she received a return fax document at 11:22 P.M. and the physician ordered a humerus X-ray, so she called and changed the order from left elbow to left humerus and updated the orders. LPN #34 stated she was off for two days and when she came back to work on 02/04/22 at 7:00 P.M. she learned Resident #10 had a fractured arm. Interview with Director of Nursing (DON) and Regional Clinical Director #102 on 03/03/22 at 2:55 indicated there was a snowstorm on 02/02/22 and the X-ray company did not show up. DON stated the facility called the X-ray company a few times and when they arrived in facility on 02/04/22, X-ray resulted with fracture of left humerus due to osteopenia and [CONDITION(S)]. DON stated resident was sent to the hospital. DON verified there was no documentation the facility notified the physician or NP #101 with delay in getting an X-ray for Resident #10. Interview with Physician #100 on 03/15/22 at 2:13 P.M. indicated she was alerted on 03/05/22 when she arrived to do rounds that resident had a non-displaced oblique fracture. Physician #100 initially stated she was not aware of resident with increased arm pain and was not aware of the x-ray order placed on 02/01/22. Physician #100 stated the staff must have called her on call Nurse Practitioner (NP #101). During review of the of the facility document at same time titled Return Fax dated 02/01/22 and received by facility at 11:22 P.M. indicated the physicians response noted OK, left humerus. Physician initially stated she did not sign and/or communicate the X-ray order with LPN #34 on 02/01/22 and after Surveyor shared the document with physician, for authenticity of the signature/initials on the form, Physician #100 stated the initials belonged to her but she did not remember the fax from LPN #34 or being notified of residents assessment. Physician #100 stated she learned on 03/05/22 that the X-ray was not able to be completed right away due to weather conditions and further stated she was never alerted to the delay in X-ray. Interview with NP #101 on 03/15/22 at 2:35 P.M. indicated she had no memory or record on her phone of staff calling her about X-ray not being able to be completed for Resident #10's left arm. NP #101 stated the only thing she recalled was staff called her on 02/04/22 when X-ray results came back with fractured arm, and she ordered staff to send resident to the hospital. Review of facility document titled Return Fax dated 02/01/22 and untimed, indicated LPN #34 created a handwritten note in nurse's comments which indicated Resident #10 complained of left arm pain during care and could she order an X-ray. Handwritten notes under physician response indicated ok, left humerus. Notes indicated Physician #100 signed the document. Review of 10/18/02 facility policy titled Change in Condition indicated the facility shall notify the physician with all changes in resident's condition and of any other situations requiring notification. Notes indicated a life-threatening condition indicated a resident with broken bones. This deficiency substantiates complaint Number OH 274.

Based on observation and staff interview, the facility failed to ensure hot water was maintained at a safe temperature. This affected seven (#14, #15, #16, #27, #43, #51 and #62) of nine residents reviewed for accidents and had the potential to affect 11 residents identified by the facility as cognitively impaired and independently mobile. The facility census was 92. Findings include: 1. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A wheelchair was utilized for mobility. Review of the quarterly dementia unit assessment, dated 08/15/19, revealed Resident #14 was confused to time and place, had poor safety awareness, impaired decision making skills, and had delusional thoughts and beliefs. Continued placement to the dementia unit was recommended for poor safety awareness and impaired decision making skills. Observation on 09/09/19 at 3:15 P.M. of the hot water in Resident #14's bathroom sink revealed visible steam and inability to hold hand under water due to hot temperature. Subsequent observation on 09/10/19 at 11:48 [NAME]M. of the hot water in Resident #14's bathroom sink with Maintenance (MTN) #14 revealed a temperature of 127 degrees Fahrenheit (F), obtained by MTN #14. Observation on 09/10/19 at 3:15 P.M. revealed Resident #14 independently propelling self in wheelchair throughout the secure dementia unit. 2. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly dementia unit assessment, dated 07/18/19, revealed Resident #15 was at risk for elopement related to impaired cognition and being unaware of safety needs. Observation on 09/09/19 at 3:28 P.M. revealed the water in Resident #15's bathroom sink was hot to the touch. Subsequent observation on 09/09/19 at 3:32 P.M. with MTN #14 whom measured the hot water temperature in Resident #15's sink revealed a temperature of 126 degrees F. Observation on 09/09/19 at 3:49 P.M. revealed Resident #15 was ambulating independently without any assistive devices throughout the halls on the secure dementia unit. 3. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 06/02/19, revealed the resident had moderately impaired cognitive skills for daily decision making, limited assistance was required with bed mobility, transfers, and toileting, supervision was required with eating, and personal hygiene, and Resident #16 did not required any assistive devices with locomotion. Review of the quarterly dementia unit assessment, dated 08/28/19, revealed Resident #16 was unhappy with dementia unit placement and denied cognitive deficits. Resident #16 talked frequently about wanting to go home and continued placement was recommended due to being an elopement risks. Observation on 09/09/19 at 3:37 P.M. of Resident #16's bathroom sink with MTN #14 revealed a water temperature of 127 degrees F, obtained by MTN #14. Interview with MTN #14, at the time of the observation, reported there was one circulating pump so all the hot water temperatures would be consistent as Resident #16's room was furthest away from the hot water source. Interview on 09/12/19 at 9:59 [NAME]M. with Licensed Practical Nurse (LPN) #71 reported Resident #16 ambulated and utilized the bathroom independently. 4. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 06/20/19, revealed the resident had moderately impaired cognitive skills for daily decision making. She required extensive assistance was needed with bed mobility, transfers, and toileting. Resident #27 was totally dependent upon staff for personal hygiene and a walker and wheelchair were utilized for mobility. Review of quarterly dementia unit assessment, dated 08/22/19, revealed Resident #27 displayed exit seeking behaviors and had poor safety awareness. Continued placement on the secured unit was recommended due to confusion and disorientation to time and place. Observation on 09/09/19 at 3:39 P.M. of Resident #27's sink with MTN #14 revealed a water temperature of 124 degrees F, obtained by MTN #14. Observation on 09/10/19 at 3:24 P.M. revealed Resident #27 independently propelling self throughout the secure dementia unit, attempting to exit unit activating door alarms. 5. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 07/09/19, revealed the resident had severely impaired cognitive skills for daily decision making and extensive assistance was required with bed mobility, transfers, toileting, and personal hygiene. Resident #43 ambulated without any assistive devices. Review of the quarterly dementia unit assessment, dated 07/03/19, revealed Resident #43 wandered with exit seeking, verbal and physical aggressive behaviors. Continued placement on the memory care unit was recommended due to confusion, disorientation, impaired safety awareness and exit seeking behaviors. Observation on 09/09/19 at 3:34 P.M. of Resident #43's bathroom sink water with MTN #14 revealed a hot water temperature of 126 degrees F, obtained by MTN #14. Observation on 09/10/19 at 5:31 P.M. revealed Resident #43 was ambulating throughout the unit independently without any assistive devices. 6. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 07/12/19, revealed the resident had severely impaired cognitive skills for daily decision making, limited assistance was required with bed mobility, transfers, toileting, and extensive assistance was required with personal hygiene. A walker and wheelchair were utilized for mobility. Review of the quarterly dementia unit assessment, dated 08/22/19, revealed Resident #51 was confused to time and place with impaired safety awareness. Continued placement to the memory care unit was required due to impaired decision making. Observation on 09/09/19 at 3:15 P.M. of Resident #51's bathroom sink revealed steam visible from hot water and inability to keep hand under water due to hot temperature. Subsequent observation on 09/09/19 at 11:48 [NAME]M. of the hot water in Resident #51's bathroom sink with Maintenance (MTN) #14 revealed a temperature of 127 degrees Fahrenheit (F), obtained by MTN #14. Observation on 09/10/19 at 6:05 P.M. revealed Resident #51 ambulating independently with a rolling walker. 7. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 07/20/19, revealed the resident had severely impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility and personal hygiene, and limited assistance was required with transfers and toileting. No mobility devices were needed for mobility. Review of the quarterly dementia unit assessment, dated 07/25/19, revealed Resident #62 was confused to time, place and exhibited exit seeking behaviors. Continued placement to the memory care unit was recommended due to impaired cognition and poor safety awareness. Observation on 09/09/19 at 3:39 P.M. of Resident #62's sink with MTN #14 revealed a hot water temperature of 124 degrees F, obtained by MTN #14. Interview with MTN #14, at the time of the observation, reported water temperatures varied dependent upon how much water was being utilized and was in circulation. Interview on 09/12/19 at 10:00 [NAME]M. with LPN #71 reported Resident #62 ambulated independently without assistive devices.

Based on staff interview and record review, the facility failed to ensure residents and resident representatives were notified in writing of reasons for a transfer to the hospital. This affected two (#54 and #346) of five residents reviewed for hospitalization . The facility census was 92. Findings include: 1. Medical record review for Resident #54 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 07/15/19, revealed the resident had severely impaired cognitive skills for daily decision making. Review of nursing progress note dated 07/06/19 at 8:40 P.M. revealed Resident #54 was transported to the hospital. Review of progress note dated 07/07/19 at 4:12 [NAME]M. revealed Resident #54 was admitted to the hospital with [REDACTED]. The returned to the facility on [DATE]. Further medical record review revealed there was no record of Resident #54 or the resident's representative being notified in writing of the reason for the resident's hospitalization . Interview on 09/12/19 at 11:56 [NAME]M. with the Director of Nursing (DON) confirmed the resident and resident representative were not notified in writing of reasons for transfer to the hospital on [DATE]. 2. Review of Resident #346's medical record revealed being admitted on [DATE] with [DIAGNOSES REDACTED].#346 was discharged to the hospital on [DATE] at 4:45 [NAME]M. Review of Resident #346's progress note, dated 09/05/19, revealed the resident was transferred to the hospital on [DATE] at 4:45 [NAME]M. via emergency medical transportation. There was no evidence the resident or the resident's representative was notified in writing of the reason the resident was transferred to the hospital. Interview on 09/10/19 at 4:42 P.M. with Social Services (SS) #8 confirmed the facility does not mail the transfer/discharge notices to the resident's representative. Interview with the Director of Nursing (DON) on 09/10/19 at 3:50 P.M. confirmed the facility did not have a procedure to send transfer/discharge notices to the resident's representative.

Based on observation, staff interview, record review, and review of manufacturer drug administration instructions, the facility failed to ensure insulin was administered correctly via a KwikPen. This affected one (Resident #83) of three residents observed for medication administration. The facility identified seven residents prescribed insulin via a pen on the 400 unit. The facility census was 91. Findings include: Medical record review revealed Resident #83 had a physician order [REDACTED]. Observation on 09/11/19 at 7:31 [NAME]M. revealed Registered Nurse (RN) #32 administered Basaglar Kwikpen insulin 32 units subcutaneous in the left abdomen. RN #32 did not prime the pen when preparing the medication, prior to administration. Interview on 09/11/19 at 9:44 [NAME]M. with RN #32 reported she had never primed an insulin pen and didn't have any knowledge of need to prime insulin pens. Review of Basaglar KwikPen instruction for use revealed prime the pen before each injection. Priming means removing the air from the needle and cartridge than may collect during normal use. It is important to prime the pen before each infection so it will work correctly. If the pen is not primed before each injection, too much or too little insulin may be administered.

Based on record review, resident and staff interviews and review of facility policy, the facility failed to ensure allegations of misappropriation of missing money were reported to the State Survey Agency within 24 hours after the allegation was discovered. This affected one (Resident #83) of one resident reviewed for personal property. The facility census was 92. Findings include: Record review revealed Resident #83 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of Resident #83's quarterly Minimum Data Set (MDS) assessment, dated 08/13/19, revealed the resident was cognitively intact. Review of Resident #83's resident funds statement from (MONTH) 2019 through (MONTH) 2019 revealed withdrawals on 01/07/19 in the amount of $700 and another on 01/16/19 in the amount of $500. Interview with Resident #83 on 09/09/19 at 10:18 [NAME]M. revealed the resident had withdrawn money several months ago, to purchase a new tablet. Resident #83 stated she had withdrawn $400 to purchase the tablet and that money had been missing. Resident #83 stated she had informed the director of the facility and the director had asked if she wanted to call the police but since she didn't know when the money went missing or who took it she declined to call the police. Resident #83 stated the facility did nothing about her money. Interview on 09/10/19 at 2:26 P.M. with Licensed Practical Nurse (LPN) #19 who stated she recalled the incident which involved the missing money of Resident #83 but not the particular details. Interview on 09/10/19 at 3:42 P.M. with the Director of Nursing (DON) who stated she was unaware of Resident #83 having any missing money. The DON stated for missing items, there was a theft / missing items report that was filled out with social services. The DON stated for items that had been reported as misappropriated and/or stolen the facility would file a Self-Reported Incident (SRI). Follow up interview on 09/11/19 at 9:53 [NAME]M. with Resident #83 to clarify whom she first reported the incident to and the resident revealed she had first reported the incident to LPN #19. Then the Licensed Nursing Home Administrator (LNHA) then came to talk to Resident #83 and asked if she wanted to call the police. Resident #83 declined to call the police. Interview on 09/11/19 at 1:02 P.M. with the LNHA who stated on 01/21/19 it was reported to LPN #19 by Resident #83 that she had $400 missing. The LNHA stated when the resident spoke to him, Resident #83 stated it was $300 that was missing. LNHA stated he did not complete an SRI for several reasons. One reason was because the amounts reported were conflicting. The LNHA stated the resident had a history of [REDACTED]. had visited and the resident had admitted to giving her son some money but the facility had no way to verify how much that was. Interview on 09/11/19 at 4:23 P.M. with Resident #83 who stated she had not given her son any money as reported by the LNHA related to the missing money. Review of the facility's policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16 revealed in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: Ensure that all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator or designee of the facility and to other officials, including the State Survey Agency, in accordance with the State Law.

Based on record review, observations, interviews, and policy review the facility failed to ensure infection control policies and practices were observed while disposing of infectious waste from a resident in contact isolation for extended-spectrum beta-lactimases (ESBL). This affected one Resident (#87) of one resident reviewed for isolation. The facility also failed to ensure staff wore disposable gowns when reaching into the hazardous trash. This had the potential to affect all residents. The facility census was 98. Findings include: 1. Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed a urine specimen culture collected on 07/19/18 at 11:00 P.M. positive for escherichia coli ESBL. During an observation on 07/26/18 at 10:37 A.M. revealed State tested Nursing Assistant (STNA) Supervisor #46 did not wash her hands after removing disposable gloves after transporting biohazard containers from Resident #87's room to the laundry decontamination room. Interview of Licensed Practical Nurse (LPN) #3 on 07/26/18 at 12:55 P.M. verified Resident #87 was in isolation for ESBL and was incontinent of bowel and bladder. 2. During an observation on 07/26/18 at 10:38 A.M. revealed Environmental Services Technician (EST) #32 leaned into a red biohazard barrel to retrieve loose contaminated contact isolation trash within the barrel. EST #32 did not have a disposable gown on but did have gloves on. EST #32 placed the retrieved loose trash in a clear bag, tied the clear bag, and placed it within a red plastic biohazard bag. EST #32 then tied the red plastic biohazard bag, placed it back in the red biohazard barrel, and replaced the lid to the barrel. After removing her gloves, EST #32 washed her hands with soap and water and re-gloved. EST #32 wheeled the red biohazard barrel to the elevator, up to the first floor, and out the rear exit. EST #32 removed the red biohazard bag from the red biohazard barrel and threw it in a large blue garbage bin for standard trash. EST #32 removed her gloves, threw them in the blue garbage bin, and re-entered the building, wheeling the red biohazard barrel back to the elevator and down to the laundry decontamination room. EST #32 washed hands with soap and water, re-gloved, and decontaminated red barrel. EST #32 removed gloves and washed her hands with soap and water. During an interview on 07/26/18 at 10:38 A.M., EST #32 stated the facility policy did not require her to wear a disposable gown when dealing with contaminated isolation materials. During an interview with the Director of Nurse (DON) on 07/26/18 at 1:29 P.M., she stated STNA Supervisor #46 should have washed her hands after de-gloving and EST #32 should have worn a disposable gown when reaching into the barrel to collect the hazardous disposable trash. The DON also confirmed the red bag of hazardous trash should not have been placed in general trash bin, but in the biohazard room per facility policy. Review of facility policy titled, Infectious Waste, Handling revealed disposable items, which are contaminated with excretions or secretions from residents believed to be infectious, must be placed in red plastic bags and sealed, and stored in a secured area until removal from the premises by an authorized vendor.

Based on review of a self reported incident (SRI) and facility investigation, staff interview, medical record review, review of facility narcotic medication count sheets, review of pharmacy delivery documentation and policy review, the facility failed to ensure two residents medications were free from diversion/misappropriation. This affected two (#63 and #76) out of three residents reviewed. The facility identified seven SRI's from (MONTH) (YEAR) to present. Facility census was 88. Findings include: 1. Resident # 63 was admitted to the facility on [DATE] for heart failure. Her quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident understood others, made herself understood, but was moderately impaired for daily decision making skills. She did not have signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. She did not reject care or have behaviors. She needed limited to extensive one staff assistance with all activities of daily living (ADL) except she only needed supervision with eating and personal hygiene. The MDS documented she was not on scheduled pain or as needed (PRN) medication in the last five days. The resident had occasional pain scored at a four on a scale of one to 10 in the last five days that made it hard for her to sleep and limited here day-to-day activities. The MDS documented she had received scheduled pain medication in the last five days. The MDS also documented she had received opioids every day for the last seven days. Her MDS [DIAGNOSES REDACTED]. Review of Pharmacy Proof of Delivery revealed the facility received 60 tablets of [MEDICATION NAME] for Resident #63 on 12/29/17, 01/11/18, and 01/27/18. Review of the facility's Shift Change Controlled Substance Inventory Log dated 02/15/18 revealed Licensed Practical Nurse (LPN) #45 documented she removed an empty pack of [MEDICATION NAME] ([MEDICATION NAME]) from the medication cart that belonged to Resident #63. Review of the SRI/facility investigation dated 02/19/18, revealed a concern was brought to the Director of Nursing (DON) regarding a medication discrepancy for Resident #63. The count sheet for this resident identified that employee Licensed Practical Nurse (LPN) #45 had removed an empty card of [MEDICATION NAME] when in fact the card contained medications. An audit was immediately initiated on Resident #63's medications which revealed a discrepancy of 123 [MEDICATION NAME] pills being unaccounted for. The Administrator was immediately notified and the alleged perpetrator, LPN # 45, was immediately suspended at that time pending further investigation. An audit was initiated of narcotic medication counts and shift change narcotic inventory log for all medication carts. This audit identified that one other resident of the same unit, Resident #76, had 30 [MEDICATION NAME] pills unaccounted for. Both residents were assessed for pain and interviewed for issues with unaddressed pain with no relevant findings. Other residents residing on this unit were assessed for pain and interviewed for issues with unaddressed pain with no relevant findings. The physician for both residents were notified with no new orders. Also the resident representatives for both residents were notified and the Police Department was called. Upon interview, LPN #45 denied misappropriation of narcotics but resigned from her position effective immediately. The facility notified the pharmacy and replenished the missing medications, crediting the payer for the accounts of those that were identified as missing. Interview with the DON and the Corporate Registered Nurse (RN) #20 on 03/15/18 at 10:39 A.M. and review of the investigation file, the DON stated she became suspicious of former LPN #45 in (MONTH) (YEAR) when she returned from having a few days off after her father passed away. She stated it was reported to her that the charge nurse, LPN #45, had let a floor nurse go home early on 02/15/18 for no apparent reason. The DON stated there was not an emergency and the floor nurse was not sick. She stated LPN #45 worked the floor giving care, doing treatment, and administering medication. The DON stated that was weird so on 02/19/18 she started reviewing charts and medication counts. The DON stated Resident #63 was admitted to the facility on [DATE] and on 12/29/17 the facility received 60 [MEDICATION NAME] pills for her. She stated there were 30 pills on two different sheets. The DON stated Resident #63 did not request any [MEDICATION NAME] December. The DON stated on 01/11/18 pharmacy sent 60 more [MEDICATION NAME] pills and on 01/27/18 pharmacy sent 60 more [MEDICATION NAME] pills. The DON stated in (MONTH) Resident #63 only received [MEDICATION NAME] four times and three times in February. She stated her investigation showed Resident #63 had received 180 [MEDICATION NAME], was administered nine, there were 48 [MEDICATION NAME] in the medication cart, and 123 missing [MEDICATION NAME]. The DON stated LPN #45 had documented she had removed an empty card of [MEDICATION NAME] for Resident # 63 but in truth the card was full. The DON also stated in LPN #45 office she found the reorder sheet for the pharmacy, so LPN #45 had reordered the [MEDICATION NAME] on 01/11/18 and never placed them in the medication cart. The DON stated LPN #45 had removed Resident #63's [MEDICATION NAME] pills and the narcotic count sheets so that no one even knew they were missing. Corporate RN #20 stated they could not prove LPN #45 took the [MEDICATION NAME] but they felt confident she had. RN #20 stated Resident #63's [MEDICATION NAME]'s were gone. RN #20 stated when her and the DON interviewed LPN #45 she denied taking the pills and she kept saying I can't explain. She also repeatedly said I don't know and I don't recall. RN #20 stated they suspended LPN #45, sent her for drug test, reported it to the pharmacy, called the police, called the medical director, inserviced all the staff, reviewed all the narcotics on the unit, and reported it to the board of nursing. The DON stated Resident #63's [MEDICATION NAME] was missing but they could not prove LPN # 45 took it. She stated we did not substantiate the SRI because we couldn't prove who took it. She stated LPN #45's drug test came back positive for marijuana. She stated LPN #45 resigned on 02/23/18. 2. Resident #76 was admitted to the facility on [DATE] with age related [MEDICAL CONDITION]. Her quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had unclear speech, sometimes understood others, sometimes made herself understood, and was moderately impaired for daily decision making skills. She had signs and symptoms of [MEDICAL CONDITION] such as fluctuating inattention, disorganized thinking, and altered level of consciousness. She did not have signs or symptoms of [MEDICAL CONDITION], did not reject care, and did not have behaviors. She was totally dependent or needed extensive one to two staff assistance with all activities of daily living (ADL). The MDS also documented she had not received any opioids in the last seven days. Her MDS [DIAGNOSES REDACTED]., anxiety, and depression. Review of the Pharmacy Proof of Delivery revealed the facility received on 02/05/18 documented Resident #76 had received 60 [MEDICATION NAME]'s. Review of the facility's Shift Change Controlled Substance Inventory Log dated 02/05/18 revealed Resident # 76's [MEDICATION NAME] was not logged in when it was received. Interview with the Director of Nursing (DON) and the Corporate Registered Nurse (RN) #20 on 03/15/18 at 10:39 A.M. stated as she was reviewing charts and narcotic counts on 02/19/18 she discovered missing [MEDICATION NAME] for Resident #76. The DON said on 02/05/18 the pharmacy delivered 60 [MEDICATION NAME] for Resident #76. She stated the nurse who received them from the pharmacy was not working on Resident #76 hall so she gave them to the unit manager, LPN #45, to take to the other nurse. LPN #45 did not give them to the other nurse, she did put a pack of 30 [MEDICATION NAME] in the medication cart but not the 60 and she didn't put in any count sheets. The DON said 30 of Resident #76's [MEDICATION NAME] were definitely gone (missing). The DON stated she reviewed all residents on the 400 unit where LPN #45 was the unit manager, she immediately inserviced all nursing staff, she monitored daily on all units since then and would continue to monitor for 30 days then once a week for 30 days. The DON also said they revised their policy so that two nurses have to receive medication from the pharmacy. The DON stated they did not add Resident #76 to the SRI and did not initiate a new SRI for Resident #76. She stated they added in the narrative that Resident #76 also had missing [MEDICATION NAME]. Review of facility Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy dated 11/28/16 documented on page 2 section D that misappropriation of resident's property was the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. On page 5 section E under 2a it documented that allegations had to be reported to the State Survey Agency. This deficiency substantiated Complaint Number OH 528.

Based on review of a self reported incident (SRI) and facility investigation, staff interview, medical record review, review of facility narcotic medication count sheets, review of pharmacy delivery documentation and policy review, the facility failed to implement their policy to ensure two residents medications were free from diversion/misappropriation. Additionally, the facility failed to implement their policy regarding report of an incident of misappropriation to the Ohio Department of Health. This affected two (#63 and #76) out of three residents reviewed. The facility identified seven SRI's from (MONTH) (YEAR) to present. Facility census was 88. Findings include: 1. Resident # 63 was admitted to the facility on [DATE] for heart failure. Her quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident understood others, made herself understood, but was moderately impaired for daily decision making skills. She did not have signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. She did not reject care or have behaviors. She needed limited to extensive one staff assistance with all activities of daily living (ADL) except she only needed supervision with eating and personal hygiene. The MDS documented she was not on scheduled pain or as needed (PRN) medication in the last five days. The resident had occasional pain scored at a four on a scale of one to 10 in the last five days that made it hard for her to sleep and limited here day-to-day activities. The MDS documented she had received scheduled pain medication in the last five days. The MDS also documented she had received opioids every day for the last seven days. Her MDS [DIAGNOSES REDACTED]. Review of Pharmacy Proof of Delivery revealed the facility received 60 tablets of [MEDICATION NAME] for Resident #63 on 12/29/17, 01/11/18, and 01/27/18. Review of the facility's Shift Change Controlled Substance Inventory Log dated 02/15/18 revealed Licensed Practical Nurse (LPN) #45 documented she removed an empty pack of [MEDICATION NAME] ([MEDICATION NAME]) from the medication cart that belonged to Resident #63. Review of the SRI/facility investigation dated 02/19/18, revealed a concern was brought to the Director of Nursing (DON) regarding a medication discrepancy for Resident #63. The count sheet for this resident identified that employee Licensed Practical Nurse (LPN) #45 had removed an empty card of [MEDICATION NAME] when in fact the card contained medications. An audit was immediately initiated on Resident #63's medications which revealed a discrepancy of 123 [MEDICATION NAME] pills being unaccounted for. The Administrator was immediately notified and the alleged perpetrator, LPN # 45, was immediately suspended at that time pending further investigation. An audit was initiated of narcotic medication counts and shift change narcotic inventory log for all medication carts. This audit identified that one other resident of the same unit, Resident #76, had 30 [MEDICATION NAME] pills unaccounted for. Both residents were assessed for pain and interviewed for issues with unaddressed pain with no relevant findings. Other residents residing on this unit were assessed for pain and interviewed for issues with unaddressed pain with no relevant findings. The physician for both residents were notified with no new orders. Also the resident representatives for both residents were notified and the Police Department was called. Upon interview, LPN #45 denied misappropriation of narcotics but resigned from her position effective immediately. The facility notified the pharmacy and replenished the missing medications, crediting the payer for the accounts of those that were identified as missing. Interview with the DON and the Corporate Registered Nurse (RN) #20 on 03/15/18 at 10:39 A.M. and review of the investigation file, the DON stated she became suspicious of former LPN #45 in (MONTH) (YEAR) when she returned from having a few days off after her father passed away. She stated it was reported to her that the charge nurse, LPN #45, had let a floor nurse go home early on 02/15/18 for no apparent reason. The DON stated there was not an emergency and the floor nurse was not sick. She stated LPN #45 worked the floor giving care, doing treatment, and administering medication. The DON stated that was weird so on 02/19/18 she started reviewing charts and medication counts. The DON stated Resident #63 was admitted to the facility on [DATE] and on 12/29/17 the facility received 60 [MEDICATION NAME] pills for her. She stated there were 30 pills on two different sheets. The DON stated Resident #63 did not request any [MEDICATION NAME] December. The DON stated on 01/11/18 pharmacy sent 60 more [MEDICATION NAME] pills and on 01/27/18 pharmacy sent 60 more [MEDICATION NAME] pills. The DON stated in (MONTH) Resident #63 only received [MEDICATION NAME] four times and three times in February. She stated her investigation showed Resident #63 had received 180 [MEDICATION NAME], was administered nine, there were 48 [MEDICATION NAME] in the medication cart, and 123 missing [MEDICATION NAME]. The DON stated LPN #45 had documented she had removed an empty card of [MEDICATION NAME] for Resident # 63 but in truth the card was full. The DON also stated in LPN #45 office she found the reorder sheet for the pharmacy, so LPN #45 had reordered the [MEDICATION NAME] on 01/11/18 and never placed them in the medication cart. The DON stated LPN #45 had removed Resident #63's [MEDICATION NAME] pills and the narcotic count sheets so that no one even knew they were missing. Corporate RN #20 stated they could not prove LPN #45 took the [MEDICATION NAME] but they felt confident she had. RN #20 stated Resident #63's [MEDICATION NAME]'s were gone. RN #20 stated when her and the DON interviewed LPN #45 she denied taking the pills and she kept saying I can't explain. She also repeatedly said I don't know and I don't recall. RN #20 stated they suspended LPN #45, sent her for drug test, reported it to the pharmacy, called the police, called the medical director, inserviced all the staff, reviewed all the narcotics on the unit, and reported it to the board of nursing. The DON stated Resident #63's [MEDICATION NAME] was missing but they could not prove LPN # 45 took it. She stated we did not substantiate the SRI because we couldn't prove who took it. She stated LPN #45's drug test came back positive for marijuana. She stated LPN #45 resigned on 02/23/18. 2. Resident #76 was admitted to the facility on [DATE] with age related [MEDICAL CONDITION]. Her quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had unclear speech, sometimes understood others, sometimes made herself understood, and was moderately impaired for daily decision making skills. She had signs and symptoms of [MEDICAL CONDITION] such as fluctuating inattention, disorganized thinking, and altered level of consciousness. She did not have signs or symptoms of [MEDICAL CONDITION], did not reject care, and did not have behaviors. She was totally dependent or needed extensive one to two staff assistance with all activities of daily living (ADL). The MDS also documented she had not received any opioids in the last seven days. Her MDS [DIAGNOSES REDACTED]., anxiety, and depression. Review of the Pharmacy Proof of Delivery revealed the facility received on 02/05/18 documented Resident #76 had received 60 [MEDICATION NAME]'s. Review of the facility's Shift Change Controlled Substance Inventory Log dated 02/05/18 revealed Resident # 76's [MEDICATION NAME] was not logged in when it was received. Interview with the Director of Nursing (DON) and the Corporate Registered Nurse (RN) #20 on 03/15/18 at 10:39 A.M. stated as she was reviewing charts and narcotic counts on 02/19/18 she discovered missing [MEDICATION NAME] for Resident #76. The DON said on 02/05/18 the pharmacy delivered 60 [MEDICATION NAME] for Resident #76. She stated the nurse who received them from the pharmacy was not working on Resident #76 hall so she gave them to the unit manager, LPN #45, to take to the other nurse. LPN #45 did not give them to the other nurse, she did put a pack of 30 [MEDICATION NAME] in the medication cart but not the 60 and she didn't put in any count sheets. The DON said 30 of Resident #76's [MEDICATION NAME] were definitely gone (missing). The DON stated she reviewed all residents on the 400 unit where LPN #45 was the unit manager, she immediately inserviced all nursing staff, she monitored daily on all units since then and would continue to monitor for 30 days then once a week for 30 days. The DON also said they revised their policy so that two nurses have to receive medication from the pharmacy. The DON stated they did not add Resident #76 to the SRI and did not initiate a new SRI for Resident #76. She stated they added in the narrative that Resident #76 also had missing [MEDICATION NAME]. Review of facility Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy dated 11/28/16 documented on page 2 section D that misappropriation of resident's property was the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. On page 5 section E under 2a it documented that allegations had to be reported to the State Survey Agency. This deficiency substantiated Complaint Number OH 528.

Based on review of facility Self Reported Incidents (SRI), record review, staff interview and policy review, the facility failed to self report to the Ohio Department of Health (ODH) an incident of misappropriation of narcotic medication. This affect one (#76) out of three residents reviewed. The facility identified seven SRI's from (MONTH) (YEAR) to present. Facility census was 88. Findings include: Resident #76 was admitted to the facility on [DATE] with age related [MEDICAL CONDITION]. Her quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had unclear speech, sometimes understood others, sometimes made herself understood, and was moderately impaired for daily decision making skills. She had signs and symptoms of [MEDICAL CONDITION] such as fluctuating inattention, disorganized thinking, and altered level of consciousness. She did not have signs or symptoms of [MEDICAL CONDITION], did not reject care, and did not have behaviors. She was totally dependent or needed extensive one to two staff assistance with all activities of daily living (ADL). The MDS also documented she had not received any opioids in the last seven days. Her MDS [DIAGNOSES REDACTED]., anxiety, and depression. Interview with the Director of Nursing (DON) on 03/15/17 at 10:39 AM stated as she was reviewing charts and narcotic counts on 02/19/18 she discovered missing [MEDICATION NAME] for Resident #76. The DON said on 02/05/18 the pharmacy delivered 60 [MEDICATION NAME] for Resident #76. She stated the nurse who received them from the pharmacy was not working on Resident #76 hall so she gave them to the unit manager, LPN #45, to take to the other nurse. LPN #45 did not give them to the other nurse, she did put a pack of 30 [MEDICATION NAME] in the medication cart but not the 60 and she didn't put in any count sheets. The DON said 30 of Resident #76's [MEDICATION NAME] were definitely gone (missing). The DON stated there was a misappropriation SRI regarding this incident and involving Resident #63; however, the DON stated they did not add Resident #76 to the SRI and did not initiate a new SRI for Resident #76. She stated they added in the narrative that Resident #76 also had missing [MEDICATION NAME]. She stated it was the policy to report all incidents of misappropriation. Review of SRI's revealed the facility did not report the misappropriation of narcotic medication for Resident # 76. Review of facility Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy dated 11/28/16 documented on page 2 section D that misappropriation of resident's property was the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. On page 5 section E under 2a it documented that allegations had to be reported to the State Survey Agency. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observations and interviews, the facility failed to ensure ceiling tiles were maintained in good repair. This affected four (#12, #13, #14, #15) of 33 Residents on the 200 hall and eight (#3, #5, #6, #7, #8, #9, #10, #11) of 30 Residents on the 400 hall. The facility census was 96. Findings include: Observation on 10/29/17 at 8:48 A.M. during an initial tour of the facility revealed three ceiling tiles were stained upon entrance to Residents #8 and #9's room and one ceiling tile was stained upon entrance to Residents #3 and 10's room. At 9:01 A.M., a large ceiling tile was missing in the hallway outside of room 412. At 9:36 A.M., a large water stain was observed on the ceiling tile near the smoke detector upon the entrance to Residents #12 and #13's room and at 9:38 A.M. a large stained ceiling tile near the smoke detector was observed at the entrance to Residents #14 and #15's room. All the stains appeared to be from water. Interview on 10/29/17 at 9:20 A.M. with Resident #5 reported the pipes had leaked in the ceiling for the last three months and sometimes dripped on the floor. The resident stated the Administrator was informed and stated he would have the pipe and ceiling tiles fixed, however nothing was ever done. Observation at the time of the interview revealed large dark stains on three ceiling tiles, upon entrance to the room, which appeared to be from water. A facility tour on 10/29/17 at 3:20 P.M. with the Administrator revealed two circular water stains on two ceiling tiles upon entrance to Residents #6 and #7's room, one stained ceiling tile upon entrance to Residents #8 and #9's room, one stained ceiling tile upon entrance to Residents #3 and 10's room, three large stains to three ceiling tiles upon entrance to Resident #5 and #11's room, two large circular stains on the ceiling tile near the smoke detector upon entrance to Residents #12 and 13's room, and one large circular stain on one ceiling tile upon entrance to Residents #14 and 15's room. The Administrator verified all observed ceiling tiles and reported there were numerous water lines in the ceiling and he was unaware of the problem. This deficiency substantiates Complaint Number OH 202.

Based on record review, observations and staff interview, the facility failed to provide non-pharmacological interventions to one resident prior to the administration of as needed anti-anxiety medication. This affected one (#125) of five residents reviewed for unnecessary medications. The facility census was 96. Findings include: Review of Resident #125's record indicated the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the care plan dated 03/15/17 through 06/30/17, indicated Resident #125 was at risk for adverse effects related to psychoactive medication use. The care plan indicated the resident would be assessed for non-drug approaches to deal with behaviors and implement as needed. Review of the Medication Administration Record [REDACTED]. No non pharmacological interventions were documented as offered to Resident #125 prior to the anti-anxiety medication administration on 03/15/17, 03/16/17, 03/18/17, 03/19/17 , 03/23/17, for one dose on 03/24/17, for one dose on 03/29/17 and for both doses on 03/30/17. Review of the MAR for April 2017, indicated the resident received doses of the as needed [MEDICATION NAME] on 04/01/17, 04/02/17, 04/06/17, twice on 04/07/17 twice, 04/08/17, 04/09/17, 04/11/17, 04/12/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/17/17, 04/18/17, twice on 04/19/17, 04/20/17 , 04/21/17 , 04/24/17, 04/25/17 , and on 04/29/17. No non pharmacological interventions were documented as offered to Resident #125 prior to the anti-anxiety medication administration on 04/01/17, 04/02/17, 04/06/17, 04/07/17, 04/09/17, 04/11/17, 04/12/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/17/17, 04/20/17, 04/24/17, and on 04/29/17. Review of the MAR for 05/01/17 through 05/15/17, indicated the resident received doses of the as needed [MEDICATION NAME] on 05/01/17, 05/06/17 and on 05/15/17. No non pharmacological interventions were documented as offered to Resident #125 prior to the anti-anxiety medication administration on all three days. On 05/16/17 at 4:36 P.M., Resident #125 was observed dressed with long pants and shoes, calmly sitting in a recliner with her arms crossed in the common area while several other residents were eating their evening meal. On 05/17/17 at 10:54 A.M., Resident #125 was observed sitting in a common area at at table quietly looking at a magazine. Interview on 05/17/17 at 11:21 A.M. with Unit Manager/Licensed Practical Nurse (LPN )# 88 ,verified the facility had no documentation that non pharmacological interventions were documented as offered to Resident #125 prior to the anti-anxiety medication administration.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for the use of [MEDICAL CONDITION] medications. This affected one (Resident #18) of 16 stage two sample residents reviewed for behaviors. The facility census was 94. Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly comprehensive assessment completed on 10/02/14 revealed the resident as being severely cognitively impaired. Record review revealed Resident #18 was documented as demonstrating behaviors including verbal behaviors directed towards others, physical behaviors directed towards others, rejection of care and exit seeking behaviors during current stay at the facility. Resident #18 was receiving psychiatric services, including [MEDICAL CONDITION] MEDICATION ORDERS FOR [REDACTED] Upon admission, Resident #18 had a physician order [REDACTED]. On 11/05/14, the treating psychiatrist ordered [MEDICATION NAME] sprinkles, a mood stabilizing medication,125 mg (milligrams) once per day by mouth be started. On 12/01/14, the treating psychiatrist increased the dose of the ordered [MEDICATION NAME] to 250 mg by mouth once per day. Record review of Resident #18 ' s comprehensive plan of care revealed no focus or concern, goals or interventions related to the use of [MEDICAL CONDITION] medications had been identified. This was verified by ADON #3 on 12/04/14 at 9:20 A.M. During an interview on 12/04/14 at 10:45 A.M., Assessment Nurse #9 reported that the [MEDICAL CONDITION] medication usage was present in the resident's plan of care as an intervention for the resident's placement in a secured unit. Assessment Nurse #9 verified that there was no other documentation of a comprehensive care plan related to the use of [MEDICAL CONDITION] medication for Resident #14.

Based on record review and staff interview, the facility failed to follow physician orders [REDACTED]. This affected one (Resident #18) of 16 stage two residents reviewed for behaviors. The facility census was 94. Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly comprehensive assessment completed on 10/02/14 documented the resident was severely cognitively impaired. Further medical record review revealed Resident #18 was documented as demonstrating behaviors including verbal behaviors directed towards others, physical behaviors directed towards others, rejection of care and exit seeking behaviors during current stay at the facility. Resident #18 was receiving psychiatric services, including [MEDICAL CONDITION] medications for management of these behaviors. Upon admission, Resident #18 had a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR for November 2014 documented Resident #18 received [MEDICATION NAME] intramuscular on ten occasions: 11/06/14, 11/11/14, 11/14/14, 11/16/14, 11/20/14, 11/21/14, 11/23/14, 11/24/14, 11/28/14 and 11/30/14. The resident's medication administration records, progress notes and behavioral intervention logs for as needed medication for October, November and December 2014 were reviewed. The record review revealed the oral [MEDICATION NAME] was documented as being offered and declined prior to administration of the [MEDICATION NAME] on 10/08/14 and 11/16/14. No documentation was located indicating the oral [MEDICATION NAME] was offered to Resident #18 prior to administering the medication intramuscular on the other fourteen occasions the [MEDICATION NAME] was administered intramuscularly. An interview was conducted with Licensed Practical Nurse (LPN) #5 on 12/03/14 at 9:25 A.M. revealed awareness of the need to attempt to administer the oral [MEDICATION NAME] to Resident #18 prior to administering the medication intramuscular. LPN #5 further stated that the offering and refusal of the oral [MEDICATION NAME] is documented in the electronic progress notes. An interview was conducted with the Director of Nursing (DON) on 12/03/14 at 4:43 P.M. revealed the facility does not require nursing staff to document if an "as needed" medication is offered to a resident and they refuse the medication. The DON further stated that it is implied the nursing staff offered the oral form of the [MEDICATION NAME] prior to administering the intramuscular form of the medication to Resident #18. The DON stated that the facility does not administer emergency medications so when the nursing staff administer the medication intramuscularly that this would be due to resident choosing to receive it in this form and declining in the oral form. An interview conducted with Psychiatrist #1 revealed the intramuscular [MEDICATION NAME] was only to be administered to Resident #18 when the resident was very agitated and would not take the medication by mouth. Psychiatrist #1 further stated that it was the expectation that the oral, less invasive, form of the medication would always be attempted prior to administration of the intramuscular form and that was why the [MEDICATION NAME] intramuscular for Resident #18 was written to require that attempt. Psychiatrist #1 stated that the facility staff had informed him of Resident #18's behaviors, but had no recollection of being notified of the frequency the as needed [MEDICATION NAME] was being administered orally or intramuscularly. A review of the policy for medication administration the facility utilizes, titled "Select RX Pharmacy Med Pass General Guidelines", dated February 2014, revealed "refusal of medication(s) should be identified by circling initials and documenting on the back of the MAR (medication administration record)."

Based on review of medical records, review of the Nursing Policy/Procedure Manual, interviews with staff, and observation of resident, the facility failed to maintain complete clinical records with sufficient information to reflect the effectiveness of pharmaceutical treatments. The facility failed to consistently document non-pharmacological interventions prior administration of [MEDICAL CONDITION] medications. This affected three (#62, #90 and #113) of five residents reviewed for unnecessary medications. Findings include: 1. Review of the comprehensive assessment for Resident #62 revealed she required extensive assistance for mobility, transfers, dressing, toileting, personal hygiene. Resident #62 had a depressed mood, lack of interests, [MEDICAL CONDITION], difficulty concentrating, and slow speech. She was mildly cognitively impaired. Her [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Resident #62 also had an order for [REDACTED]. Review of Resident #62's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of SR's Care Plan for signs and symptoms of depression revealed the interventions, "Assess for depression/anxiety", and "Monitor for adverse effects of medications". Review of SR's Care Plan for adverse effects related to psychoactive medication use revealed the intervention, "Assess behaviors for which drugs are being given. Monitor and record frequency of occurrence". Review of SR's Care Plan for risk for pain and discomfort revealed the interventions, "Monitor for effectiveness of interventions. Monitor for side effects " , and " Pain assessments per facility policies". Review of Progress Notes for Resident #62 from 07/20/13 through 08/21/13 revealed there was no documentation for the effectiveness of the [MEDICATION NAME], Mirtazepine, and [MEDICATION NAME]. The Progress Notes dated 07/20/13, 07/21/13, 07/22/13, 07/23/13, 07/24/13, 07/25/13, 07/26/13. 07/27/13, 07/28/13, 07/29/13, 07/30/13, 07/31/13, 08/01/13, 08/02/13, 08/04/13, 08/05/13, 08/06/13, 08/07/13, 08/08/13, 08/09/13, 08/10/13, 08/11/13, 08/12/13, 08/13/13, 08/14/13, 08/18/13 also contained no documentation of the effectiveness of the narcotic pain medication, [MEDICATION NAME] with [MEDICATION NAME]. Review of Resident #62's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"as needed" [MEDICATION NAME] was administered 08/04/13, 08/08/13, 08/12/13, 08/17/13, and 08/18/13. Review of the Progress notes and the "Behavior Intervention Log for PRN Medications" for Resident #62 contained no documentation for behavior exhibited, non-pharmacological interventions, or effectiveness of the [MEDICATION NAME] administered 08/04/13, 08/12/13, 08/17/13. During an interview on 08/21/13 at 2:30 P.M., RN #24 revealed she and other nurses do not document the effectiveness of routine narcotic pain medication administered routinely. During an interview on 08/21/13 at 3:35 P.M., the Director of Nursing (DON) revealed the facility did not have a written policy regarding the administration of [MEDICAL CONDITION] medications, however, the charge nurse was to perform and document non-pharmaceutical interventions prior administration of a [MEDICAL CONDITION] medication. In addition, the charge nurse was to document the administration, reason the medication was needed, and effectiveness of the pharmaceutical intervention. The DON acknowledged that had not been done for Resident #62 during the past 31 days. On 08/20/13 at 3:30 P.M., observation revealed Resident #62 in the dining room, calm and alert, without any signs of discomfort either physical or emotional. Resident #62's speech was clear and Resident #62 engaged appropriately in conversation. On 08/21/13 at 1:15 P.M., observation revealed Resident #62 was located in the television room on 200 Unit, alert, seated upright in her wheelchair, actively watching a television program with four other residents. Resident #62 appeared calm and comfortable, without any signs or symptoms of distress or discomfort. On 08/22/13 at 12:30 P.M.,observation revealed Resident #62 was located in the main dining room with multiple other residents for lunch meal. She presented alert, calm, without any signs or symptoms of pain, discomfort, or distress. Review of the facility's Nursing Policy/Procedure Manual for Management of the Resident in Pain, revised March 2011, revealed "Document assessments, interventions, evaluations, and resident care", and "assess the level of pain". 2. A record review revealed Resident #90 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly comprehensive assessment dated [DATE] revealed the resident was cognitively impaired with physical and verbal behavior towards others and self and rejection of care for one to three days of the assessment week with wandering noted daily. The medication assessment revealed the resident was on antipsychotic medications for seven of seven days and antidepressant medications for six of seven days. The plan of care for psychoactive medications dated 07/12/12, revealed interventions to assess for non-drug approaches to deal with problem behaviors and implement as needed. A review of the physician order [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., and on 08/05/13 at 8:00 P.M.. The record contained no documentation of the non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. On 08/21/13 at 2:50 P.M., an interview with LPN #50 revealed the nurses attempted non-pharmacological interventions prior to the use of as needed [MEDICATION NAME] for increased anxiety. LPN #50 confirmed the record contained no documentation for the documented interventions attempted prior to the administration of [MEDICATION NAME] 1 mg on 08/05/13 at 8:00 P.M.. 3. On 08/21/13 a record review revealed Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission comprehensive assessment dated [DATE] revealed the resident was cognitively impaired, no behaviors and totally dependent for activities of daily living. The medication assessment revealed the resident was on antipsychotic medications for seven of seven days and anti-anxiety medications for five of seven days and antibiotics for seven of seven days. The plan of care for psychoactive medications dated 06/04/13, revealed interventions to assess for non-drug approaches to deal with problem behaviors and implement as needed. . The physician order [REDACTED]. The MAR indicated [REDACTED].M., for anxiety. The record contained no documentation of non-pharmacological interventions attempted prior to the administration of as needed [MEDICATION NAME]. On 08/21/13 at 2:50 P.M., an interview with LPN #50 revealed the nurses attempted non-pharmacological interventions prior to the use of as needed [MEDICATION NAME] for increased anxiety. LPN #50 confirmed the record contained no documentation of interventions attempted prior to the administration of [MEDICATION NAME] 1 mg on 08/07/13 at 7:00 P.M.

Based on observation, record review and staff interviews the facility failed to ensure their medication administration error rate was less than five percent. The facility medication administration error rate was 11.5 percent. The facility failed to follow physician orders [REDACTED]. This effected three (#13, #73 and #5) of eight residents who received medications from six different nurses. There were 26 medications administered. The census was 87. Findings include: 1. On 08/20/13 at 4:11 PM, Resident #13 received his medications from Registered Nurse #24 (RN) #24. RN#24 administered two tablets of Oyster Shell Calcium with Vitamin D. Each tablet was 250 milligrams and the nurse gave a total of 500 milligrams of the supplement. Review of Resident #13 [DIAGNOSES REDACTED]. The physician ordered Resident #13 would receive 1000 milligrams calcium. On 08/21/13 at 4:29 PM an interview was conducted with RN #24. She affirmed she had administered two tablets of 250 milligram Oyster Shell Calcium with Vitamin D for a total of 500 milligrams. RN #24 affirmed the physician had ordered to administer two tablets of 500 milligrams of Oyster Shell Calcium with Vitamin D 500. She stated this was a medication error on her and said she misread the Medication Administration Record. RN #24 affirmed the resident should have received four tablets of the 250 mg Calcium with Vitamin D. 2. On 08/21/13 Resident #73 received his medications from Licensed Practical Nurse #58 (LPN) #58. At this time the nurse assessed Resident #73 blood pressure as 179/80. LPN#58 administered his medications and began to administer medications to the next resident. Review of Resident #73 [DIAGNOSES REDACTED]. The physician orders [REDACTED]. Resident #73 systolic blood pressure was 179. On 08/21/13 at 9:02 AM an interview with LPN #58 revealed she had not seen this physician order [REDACTED]. LPN #58 stated she had never seen or administered a medication for [MEDICATION NAME]. She said she should have looked at orders before she administered Resident #73 medication. On 08/21/13 at 1:10 PM an interview with the Director of Nursing (DON) revealed the physician was notified of Resident #73 blood pressure of 179/80. Resident #73 blood pressure was mildly relieved at 162/80, 30 minutes after PRN [MEDICATION NAME] 0.1 milligram was administered. 3. On 08/21/13 at 5:22 PM, LPN #5 was going to administer the physician ordered medication to Resident #5. The medication was [MEDICATION NAME], an anti-depressant, and was scheduled to be administered every 12 hours at 6:00 AM and 6:00 PM. LPN #5 stated the [MEDICATION NAME] medication was not in the cart. She checked the emergency box and the [MEDICATION NAME] medication was not in the box. LPN #5 affirmed the [MEDICATION NAME] medication was not available for the resident. The nurse stated either it was not ordered or it was ordered and had not come in from the pharmacy. Review of Resident #5 [DIAGNOSES REDACTED]. The physician had ordered the medication to be given at 6:00 AM and 6:00 PM. Interview with LPN#59 on 08/21/13 at 5:35 PM revealed she had called the pharmacy and the medication was being sent to the facility STAT within four hours. Nursing notes dated 08/21/13 at 6:35 PM Pharmacy stated the [MEDICATION NAME] was refilled on 07/21/13 and a request to be refilled was done on 08/05/13. The pharmacy did not send the medication due to billing of insurance reasons. These notes revealed the pharmacy computer should have done an auto refill on the day it was actually due to be refilled but did not.

Based on record review and staff interviews, the facility failed to follow physician orders [REDACTED]. This affected one (#113) of five residents reviewed for unnecessary medications. There were 87 residents who resided in the facility. Findings included: Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A laboratory report for a TSH level dated 05/22/13 revealed a blood level of 51.270 (0.340 - 5.600 ulU/ml) designated as high. A telephone order dated 05/28/13 revealed an order for [REDACTED]. On 08/21/13 at 2:53 P.M., an interview with Licensed Practical Nurse (LPN) #50 revealed the laboratory reporting system is on line and staff must manually input needed lab orders for each resident. The TSH level was entered into the computer system on 05/29/13 and the TSH should have been drawn on 07/29/13. LPN #50 confirmed the record record contained no documentation a TSH level was drawn in July 2013 as ordered. LPN #50 stated there was not a written policy to cover entering physician orders [REDACTED].

Based on record review, observations, and resident and staff interviews, the facility failed to provide nail care for a dependent resident. This affected one (#113) of five residents reviewed for consulting services that were triggered for resident care. There were 87 residents who resided in the facility. Findings included: Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission assessment dated [DATE] revealed the resident was cognitively impaired and totally dependent for activities of daily living. The record contained no documentation podiatry services had been provided or a consent was obtained for podiatry services from the responsible party. On 08/21/13 2:53 P.M., observations of the toes of Resident #113 with LPN #50 revealed the toe nails were long and extended past the end of the resident's toes on the second, third, fourth and fifth toes of each foot but not curved over end of toes. The right great toe had a bunion which caused the toe nail to bend into the second toe. The great toe nail was slightly touching the second toe. The toe nails were thick and yellowish. On 08/21/13 at 2:55 P.M., an interview with LPN #50 confirmed the consent for ancillary services was not signed by the responsible party for the resident and confirmed the resident had not had the toe nails trimmed since admission. LPN #50 stated since the resident was not diabetic, nursing could cut the toenails. A review of the facility policy for care of finger nails and toenails dated July 2006 revealed nails of a non-diabetic resident could be trimmed by the nursing staff. Proper nail care can aid in the prevention of skin problems around the nail bed.

Based on observation, medical record review and staff interview, the facility failed to assess the use of a front release seatbelt to a wheelchair as a restraint nor did they obtain a consent from a legal surrogate or representative. This involved one (#71) of three residents reviewed for physical restraints. The facility identified 13 residents that currently had in place a seat belt that they could not release. Facility census was 93. Findings include: Review of the medical record indicated Resident #71 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's care plan for falls identified the resident was at risk for falls related to the use of [MEDICAL CONDITION] medications, impaired balance, poor coordination, unsteady gait, involuntary movements, neurological impairment and dementia. Interventions included rest periods, reinforce need to call for assistance, proper non slip footwear, transfer and change positions slowly, landing strips to floor next to the bed, clutter free environment, personal body alarm to bed and chair and padded top right corner of night stand. Per the medical record on 01/27/12 at 11:02 P.M., the resident was observed to be sitting on the floor in an upright position on his buttocks with his legs out in front of him and his arms were at his side and no visible injuries were noted. The resident was assessed to have become weak and so he sat down. A new intervention was added to have the resident sit in a wheelchair with a sit upon alarm and for physical therapy to evaluate the resident. On 04/07/12 at 3:25 P.M., the resident was noted to be sitting on his knees in the doorway of a room and his alarm was sounding. The resident stated that he was trying to get out of his chair and he got stuck, the resident had no visible injuries. The new interventions were to place the resident on 15 minute checks and to have physical therapy and occupational therapy to evaluate. On 04/10/12 at 1:28 P.M., staff responded to the alarm sounding. Resident was noted sitting on the floor in an up right position on his bottom with both legs out stretched with his wheelchair laying on it's side next to him, he was alert and talking to staff. Resident stated he got up to get his walker and lost his balance when he leaned on the arm of his wheelchair. The resident suffered no visible injuries. On 05/03/12 at 2:00 P.M., Resident #71, was found in the entry way to his room laying on his left side with his wheelchair locked behind him. Resident stated he was trying to get some papers and he went down. The pull tab alarm was observed in place but not sounding. The alarm was found to have malfunctioned and was discarded at that time and a new pull tab alarm was placed on the wheelchair and on the resident. The resident suffered no visible injuries. On 05/13/12 at 4:50 P.M., the resident was found sitting on the floor with his legs outstretched in front of him. His wheelchair was behind him and the alarm was sounding. The resident stated he stood up and lost his balance and went down on his bottom. When the physician was notified he ordered the alarm discontinued and a front release seatbelt to be applied to his wheelchair to prevent unassisted ambulation due to unsteady gait. On 05/30/12 at 11:38 A.M., the resident was observed to be in a wheelchair with a front releasing seatbelt that had the resident secured in his wheelchair. Nurse aide (NA) #10, was questioned if the resident could remove the seat belt and indicated that he could not. She further indicated that staff had to apply it and take it off. NA #10 then asked the resident to remove the seatbelt, but he was unable to. He only picked up the belt but did not attempt to unbuckle it. On 05/30/12 at 11:45 A.M., during an interview with the Unit Manager #91, the assessment for the use of the restraint was requested. The unit manager #91 provided a restraint-enabler decision tree dated 05/13/12 that listed the device as a front release seat belt. The assessment indicated that the resident was not prevented from performing an action that he was otherwise capable of performing and that the seat belt enabled the resident to be independent with wheelchair mobility. When questioned about the resident being unable to remove the seatbelt and how did the seat belt not keep him restrained from performing the task of standing and ambulating, the unit manager stated that since the resident was unable to ambulate safely, the seat belt just enabled him from falling. The Unit Manager also confirmed that there had not been any consent obtained for the use of the restraint, nor had the risk of the use of a restraint been explained to the resident's family member. On 05/31/12 at 2:00 P.M., an interview with the physical therapist confirmed that the resident was dropped from therapy recently due to not making any progress in therapy. When questioned if physical therapy had recommend the front releasing seat belt, the physical therapist stated no physical therapy had no part in the decision.