Every finding on record at Wesley Glen Health Services Corp

Based on observation, resident and staff interview, and policy review, the facility failed to ensure food was served at a palliative and safe food temperature. This had the potential to affect all 51 residents in the facility who the facility identified to receive food from the kitchen. Findings include: Interview on 04/21/25 at 1:35 P.M. with Resident #37 stated the food was not hot enough when it comes to his room. Interview on 04/23/25 at 2:19 P.M. with Registered Nurse (RN) #321 stated Resident #37 has complained about the temperature of his food. Interview on 04/23/25 at 2:41 P.M. with Certified Nursing Assistant (CNA) #227 stated she receives complaints from residents about the temperature of food. CNA #227 stated she always warms up Resident #37's food. Interview on 04/23/25 at 4:37 P.M. with Dining Services Director (DSD) #276 stated hot food should be served to residents at a minimum of 135 degrees Fahrenheit (F) and cold food should be served to residents at 41 degrees F or below. Observation of the second floor tray line was made on 04/23/25 at 5:02 P.M. with Universal Dining Server #331 who was taking temperatures of the food. The dinner menu consisted of shrimp alfredo, Italian wedding soup, and Normandy vegetables. A test tray was requested, and DSD #276 took temperatures of the food being placed on the test tray on 04/23/25 at 6:12 P.M. DSD #276 confirmed the normandy vegetables were 145 degrees F, shrimp alfredo 140 degrees F, and Italian wedding soup was 137 degrees F. The tray was then placed immediately on the meal cart. The meal cart left the kitchen on 04/23/25 at 6:15 P.M. The meal cart arrived on the hallway on 04/23/25 at 6:17 P.M. Observation of the test tray revealed it was served on 04/23/25 at 6:27 P.M. after all other hall trays were served. DSD #276 took temperatures and confirmed the normandy vegetables were 120 degrees F, shrimp alfredo was 123 degrees F, and the Italian wedding soup was 130 degrees F. The food was tasted and the normandy vegetables and shrimp alfredo were cold and the Italian wedding soup was lukewarm. DSD #276 confirmed the food temperatures of the test tray. Interview on 04/24/25 at 11:34 A.M. with DSD #276 stated the goal was to serve the food at 135 degrees F. Review of the undated Meal Delivery Timeliness and Temperature Documentation policy revealed the dining services team will ensure proper delivery of food at the proper temperature to the service areas. The policy also stated to check temperatures of all hot foods before delivery. Apply additional heat to any items below goal serving temperature.

Based on observations, staff interviews, and policy reviews, the facility did not maintain a clean sanitary kitchen, store food in a safe manner, and serve foods to the residents in a sanitary manner. This had the potential to affect all 51 residents in the facility who the facility identified receive food from the kitchen. Findings include: 1. Observation and interview on 04/21/25 at 10:53 A.M. with Dining Services Director (DSD) #276 of the second floor kitchen verified the interior ambient temperature of the sandwich cooler was 52 degrees Fahrenheit (F) . Observation and interview on 04/21/25 at 11:01 A.M. with DSD #276 and Dining Operations Manager (DOM) #303 confirmed the food located within the sandwich cooler on the second floor was above the appropriate food holding temperature. The sliced tomatoes were 47 degrees F and the hard boiled eggs were 46 degree F, sliced turkey 50 degrees F, chicken salad 46 degrees F, sliced American cheese was 46 degrees F and skim milk was 61 degrees F. Observation and interview on 04/22/25 at 4:46 P.M. with DSD #276 of the second floor sandwich cooler revealed hardboiled eggs were 42 degrees F, egg salad was holding at 43 degrees F, sliced turkey was 42 degrees F, and sliced tomatoes were 43 degrees F. Interview on 04/24/25 at 11:34 A.M. with DSD #275 revealed food shall be held in a cooler at 41 degrees F or below. Review of the undated Food Storage - Refrigeration (Dining) policy revealed potentially hazardous foods (PHF) and Time/Temperature Control for Safety (TCS) foods must be maintained at or below 41 degrees F, unless otherwise specified by law. Review of the undated General Food Preparation, Service and Handling policy revealed all cold meat/fish/poultry salads, potato/vegetable salads, egg salads, cream filled pastries and other TCS foods shall be prepared from chilled products and refrigerated at 41 F or below. 2. Observations of the kitchen on 04/21/25 from 9:50 A.M. to 10:16 A.M. with Dining Services Director (DSD) #276 and Dining Operations Manager (DOM) #303 revealed in the walk-in cooler, there were cheeses stored with the following issues: a large block of unnamed cheese that was plastic wrapped and did not have a datemark; a large block of fontina cheese was opened and not labeled; another unnamed cheese that was unlabeled and undated; and a package of shaved parmesan cheese was opened and did not have a datemark. There was also pot roast, which was wrapped without a datemark, andouille sausage was dated 02/25/25 and pork loin that was dated 04/19/25 to 05/19/25. The walk-in cooler and walk-in produce cooler walls and ceiling were dirty and flaking rust. DSD #276 and DOM #303 confirmed the food items did not have datemarks, some had missing labels, the pot roast did not have a date, the andouille sausage was out of date, and the label was incorrect for the pork loin. DSD #276 stated the datemark shouldn't be a month. DSD #276 confirmed there was a rust issue and they were working on it. DSD #276 also confirmed the ceiling was dusty as well. Observation of kitchen on 04/21/25 at 10:15 A.M. with DSD #276 confirmed there was a hole in the floor, under the oven, that was collecting food debris. DSD #276 stated this was an ongoing maintenance issue that has being going on for a few months. Review of the undated Cleaning and Sanitation - Contact Surfaces policy revealed nonfood contact surfaces of equipment shall be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris. Review of the undated Food Storage - Refrigeration (Dining) policy revealed all refrigerator units should be always kept clean and in good working condition. Review of the undated Food Storage - Refrigeration (Dining) policy revealed all time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored in refrigerator. 52017 3. Observations on 04/21/25 from 11:05 A.M. to 11:10 A.M. revealed Activities Assistant (AA) #460 was passing out blueberry muffins to the residents attending the activity. While passing out blueberry muffins to the residents, AA #460 had no gloves on. AA #460 was observed giving Resident #14 a muffin; she peeled back the muffin wrapping, touching the muffin with her non-gloved thumbs and then wiped Resident #14's shirt. Then, without washing her hands or putting gloves on her hands, she proceeded to unwrap Residents #32, #22, and #5's muffins with her unwashed, ungloved hands, and touched the muffins with her thumbs. In addition to touching the muffins with unwashed/ungloved hands, AA #460 touched Resident #22's hand to help her hold the muffin. Interview on 04/21/25 at 11:11 A.M. with AA #460 confirmed she did not wear gloves, sanitize or wash hands between residents after touching their muffins and touching residents when serving muffins to them. Review of undated facility policy titled Hand Hygiene revealed all associates shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Associates are to clean hands: before, during and after preparing food, before and after contact with the resident, and between direct contact with different residents.

Based on observation, staff interview, medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to appropriately disinfect equipment during a wound care treatment and ensure the resident's wound did not touch a dirty surface during the wound treatment. The facility also failed to ensure a resident who received medications intravenously and had a wound had enhanced barrier precautions (EBP) in place. This affected one (Resident #13) of one resident reviewed for wound care treatment and one (Resident #155) of one resident reviewed for EBP. The facility identified eight residents (#13, #28, #33, #103, #104, #105, #108 and #155) who received wound dressing changes on the second floor. The facility census was 51. Findings include: 1. Review of Resident #13's medical record revealed she was admitted on [DATE] with diagnoses including diabetes mellitus type II, sternal fracture, multiple rib fractures and moderate protein malnutrition. Review of the physician's orders dated April 2025, revealed a treatment order to cleanse the right lateral shin wound with wound cleanser, pat dry, apply Medi honey and calcium alginate and cover with CDD (composite double-layered dressing), change daily. Observation of wound treatment on 04/24/25 at 10:35 A.M. revealed Registered Nurse (RN) #321 was going to provide wound care to Resident #13's right lateral shin wound. RN #321 placed treatment supplies along with scissors on Resident #13's bed side table upon entering the room. RN #321 did not clean or disinfect the scissors and began cut off Resident #13's old dressing that had visible drainage seen on the outside of the old calcium alginate dressing. Resident #13 was positioned in her recliner chair with her feet elevated, and the side of the wound area was directly touching the surface of her recliner chair when the soiled dressing was removed. RN #13 did not disinfect the scissors after use and placed the scissors back on Resident #13's bedside tray. During application of the clean dressing, RN #321 used the same scissors that she had used to cut off the soiled dressing, to cut off a piece of the clean calcium alginate and then she applied it to Resident #13's wound. RN #321 did not disinfect the scissors after use with Resident #13's wound and placed them back into the treatment cart. Interview with RN #321 on 04/24/25 at 10:55 A.M. confirmed Resident #13's wound touched directly on the uncleaned surface of the recliner chair, and did not disinfect the scissors prior to use, and after the scissors touched Resident #13's dirty dressing and before she used the same scissors for the clean dressing. RN #321 stated she uses the same scissors to complete wound treatments for all eight residents who require wound treatments on her assignment. Review of undated facility policy titled Cleaning and Disinfecting Resident Rooms and Medical Equipment revealed reusable equipment such as scissors and clamps should be disinfected before use and after contamination. Disinfect using Environmental Protected Agency (EPA) disinfectant such as a Sanicloth. 37100 2. Record review revealed Resident #155 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 04/02/25, revealed Resident #155 was cognitively intact. Review of the physician orders dated 04/18/25 revealed Resident #155 received some medications ordered to be administered intravenously including alteplase injection solution reconstituted two milligrams (mg) (used to dissolve blood clots), piperacillin sod-tazobactam intravenous solution reconstituted (antibiotic) 4-0.5 grams for a wound infection, and heparin sodium (anticoagulant) five milliliters (ml). There were no physician orders for Resident #155 to be on EBP until 04/22/25. Observations on 04/21/25 at 9:30 A.M. and 2:45 P.M. revealed there were no signs or equipment in or around Resident #155's room to indicate she was on EBP. Interview with Registered Nurse (RN) #265 on 04/21/25 at 2:45 P.M. confirmed Resident #155 did not have a physician order, or a sign on Resident #155's door for EBP, and there was personal protective equipment (PPE) at Resident #155's room for staff to wear during resident care. RN #265 confirmed Resident #155 had a wound and was on intravenous antibiotics for a wound infection. Interview with Director of Nursing (DON) on 04/23/25 at 3:20 P.M. confirmed there were no orders in place until 04/22/25 for Resident #155 to be on EBP. The DON confirmed there should have been EBP in place on 04/18/25. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Review of the facility's Enhanced Barrier Precautions policy, undated, revealed the definition of EBP was the expansion of the use of PPE and refer to the use of gown and gloves during high contact residents care activities that provide opportunities for transfer of MRDOs to staff hands and clothing. EBP will be implemented for residents with open wounds requiring dressing and indwelling medical devices.

Based on observation, and resident and staff interview, the facility failed to maintain the patient care equipment in safe operating condition. This had the potential to affect 27 residents who resided on the second floor and utilized the second floor spa. The facility census was 51. Findings include: Interview on 04/21/25 at 5:04 P.M. with Resident #103 revealed the grab bar in the spa room next to the toilet was shaky and coming off the wall. Observation and interview on 04/24/25 at 9:37 A.M. with Maintenance Technician (MT) #444 verified the second floor spa room grab bar next to the toilet was very loose. MT #444 stated he doesn't know how to fix it as they have tried all the fasteners they have. Interview on 04/24/25 at 1:49 P.M. with Maintenance Director #450 confirmed the grab bar was broken. Maintenance Director #450 stated if he was aware of an issue, it was fixed the same day or the next day as they were on call seven days a week.

Based on medical record review and staff interview, the facility failed to ensure the resident's had care plans in place for pain management, enhanced barrier precautions, and an acute infection. This affected two (Residents #10 and #31) of 18 residents reviewed for care plans. The facility census was 51. Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included wedge compression fracture of second lumbar vertebra. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a significant cognitive impairment. Review of Resident #10 current physician orders revealed the following medications order for low back pain: diclofenac sodium external gel one percent and Tylenol extra strength 500 milligrams (mg). Review of Resident #10's care plan revealed there was no care plan in place for pain management/treatment. Interview with Director of Nursing (DON) on 04/24/25 at 3:31 P.M. confirmed Resident #10 did not have a pain care plan. The DON confirmed there should be a pain care plan in place for Resident #10. 2. Record review revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had a mild cognitive impairment. Review of the physician orders dated 03/29/25 revealed Resident #31 was placed on enhanced barrier precautions (EBP) on 03/29/25. There was also an order for Levaquin (antibiotic) 750 milligrams (mg) for seven days related to pneumonia, which started on 04/12/25. Review of Resident #31's care plans revealed there were no antibiotic and EBP care plans developed/initiated. Interview with the Director of Nursing (DON) on 04/23/25 at 3:11 P.M. confirmed Resident #31 did not have a care plan in place for antibiotic use and EBP. The DON confirmed Resident #31 should have been care plans for antibiotic use and EBP.

Based on observation, medical record review, and staff interview, the facility failed to ensure fall interventions were in place for a resident who was at a high risk for falls. This affected one (Resident #40) of two residents reviewed for falls. The facility census was 51. Findings include: Review of Resident #40's medical record revealed she was admitted on [DATE]. Diagnoses included diabetes mellitus, myocardial infarction, depression, frequent falls, and acute ischemic cerebrovascular accident. Review of the comprehensive care plan dated 11/03/24 revealed Resident #40 was at risk for falls. An intervention was added on 11/07/24 to apply a perimeter mattress to the resident's bed. Review of the fall risk assessments, dated 11/07/24 and 03/03/25 revealed Resident #40 was at a high risk for falls. Review of Certified Nursing Aide (CNA) Kardex, dated 04/23/25 revealed a perimeter mattress to bed was listed under the safety section. Observation on 04/23/25 at 7:30 A.M. revealed Resident #40 was sleeping in a low bed with no perimeter mattress in place. Observation on 04/23/25 at 4:57 P.M. revealed Resident #40's bed with no perimeter mattress in place. Interview with Director of Nursing (DON) on 04/23/25 at 4:45 P.M. revealed CNA's should use the resident's Kardex for activities of daily living levels and to view current fall interventions that should be in place. Interview with Licensed Practical Nurse (LPN) #233 on 04/23/25 at 5:05 P.M. confirmed Resident #40 did not have a perimeter mattress on her bed. LPN #233 stated Resident #40 had a room change in January 2025 and Resident #40 did have a perimeter mattress in her previous room. LPN #233 stated maybe hospice did not bring it down.

Based on record review, observation, resident and staff interview, and policy review, the facility failed to honor the resident's food requests or preferences. This affected two (Resident #24 and #103) of three residents reviewed for food preferences. The facility census was 51. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnoses included intellectual disabilities and type II diabetes mellitus. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and required partial/moderate assistance for eating, Review of the care plan revealed Resident #24 was at risk for altered nutrition status due to a history of a feeding tube that has been removed and a mechanically altered diet. Resident #24 liked small individual bowls for her food. An intervention included foods in individual bowls. Observation on 04/23/25 at 6:34 P.M. revealed Resident #24's dinner revealed her food was served on a plate all together and not in bowls. Her dinner meal ticket stated to give food in separate bowls. Interview and observation on 04/23/25 at 6:38 P.M. with Dining Operations Manager #290 verified Resident #24 did not receive her food in separate bowls. 2. Review of the medical record for Resident #103 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease and morbid obesity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 was cognitively intact and required setup or clean-up assistance for eating. Interview on 04/21/25 at 1:34 P.M. with Resident #103 revealed the kitchen was her biggest issue as they never get her food choices correct 100% of the time. Observation on 04/22/25 at 5:50 P.M. revealed Resident #103 received her meal tray and she did not get glazed carrots and received cranberry juice. Her dinner meal ticket had a write in for glazed carrots and the ticket stated Does not want juice. Interview and observation on 04/22/25 at 5:54 P.M. with Dining Operations Manager #290 verified Resident #103 does not receive glazed carrots on her meal tray and verified Resident #103 requested the carrots. Dining Operations Manager #290 also confirmed Resident #103 received cranberry juice and her tray ticket stated that she did not want juice. Review of the undated Resident Food Choices, Preferences, Alternates, and Portion Sizes policy revealed residents are served meals that comply with their diet restrictions, allergies and food preferences; however, a resident's right to choose menu items must be upheld whenever possible.

Based on record review, staff interview, and policy review, the facility failed to notify the responsible party of changes in a resident's condition. This affected one (Resident #90) of three residents reviewed for notification of change. The facility census was 46. Findings include: Review of Resident #90's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included senile degeneration of brain, adult failure to thrive, fracture of the lower end of right humerus subsequent encounter for fracture with routine healing, and seizures. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired. Review of Certified Nurse Practitioner (CNP) #640's progress note dated 12/28/22 revealed concerns with unapproximated surgical wound and stated will contact surgeon and if unable to consult, will send to emergency room (ER). CNP #640 discussed concerns regarding incision with nursing and the Director of Nursing (DON) that day (12/28/22). Review of the progress note dated 12/30/23 revealed Resident #90 was transported to acute hospital emergency room (ER) per surgeon's request to have open surgical wound assessed. The medical record was silent to the responsible party being notified of the resident's surgical wound being unapproximated nor to the resident being discharged to the hospital. Review of Resident #90's weekly skin assessment dated [DATE] revealed bruising and edema to right lower leg continues. The medical record was silent to the family being notified of the change in Resident #90's right lower leg. Interview with the DON on 06/06/23 at 1:12 P.M. confirmed there was no documentation the family was notified of Resident #90's change in the incision on 12/28/22, and no documentation the family was notified that Resident #90 was transferred to theER on [DATE]. Subsequent interview with the DON on 06/06/23 at 1:18 P.M. confirmed there was no documentation the family was notified of the bruising and swelling to Resident #90's right lower extremity documented on 03/08/23. Review of the undated policy titled Notification And Reporting Of Changes In Health Status, Illness, Injury And Death Of A Resident revealed appropriate associates will promptly inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) regarding the following: a significant change in the resident's physical, mental, or psychosocial status such as a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. This deficiency represents non-compliance investigated under Complaint Number OH00143042.

Based on record review, staff interview, interview with Hospice staff, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to timely report an injury of unknown origin to State Survey Agency. This affected one (#90) of one resident reviewed for injury of unknown origin. The facility census was 46. Findings include: Review of Resident #90's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included senile degeneration of brain, adult failure to thrive, and seizures. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired and had no behaviors. Resident #90 was dependent on staff for ambulation and toileting and required extensive assistance from staff with bed mobility, transfers and dressing. Resident #90 was receiving hospice care. Review of the weekly skin assessment dated [DATE] revealed Resident #90 had no new skin alterations, and no areas of skin abnormality were documented on the assessment. Review of the hospice provider progress note dated 03/05/23 at 10:06 A.M. revealed the facility staff reported Resident #90 with a new onset of right leg pain which started on the evening on 03/04/23. The leg was described as swollen and warm to touch. Resident #90 with Tylenol order in place for pain. Hospice Nurse to visit to assess Resident #90's right leg and any further medication needs for pain control. Review of the weekly skin assessment dated [DATE] revealed bruising and edema to the right lower leg continued. No areas of additional skin abnormality were documented on the assessment. Review of the hospice progress note dated 03/09/23 at 11:25 A.M. revealed the hospice nurse spoke with the Certified Nurse Practitioner (CNP) caring for Resident #90 to update her on the new Tylenol order and a new X-ray was ordered. Review of Physician #630's progress note dated 03/09/23 revealed the hospice nurse called related to Resident #90 needing a right lower leg X-ray related to pain and ecchymosis. Resident #90 was documented as unreliable due to cognition. Resident #90 previously reported as high fall risk due to attempts to get out of bed without requesting help, no record of recent falls of trauma noted found per nursing. Physician #630 documented past medical history did not include diagnoses of osteopenia or osteoporosis. Under the assessment and plan, Physician #630 documented Resident #90 had pain in the right lower leg and the right lower leg had scattered ecchymosis. Resident #90 stated the leg was painful to bend at the knee and bilateral lower extremities had positive dorsi and plantar flexion documented. Physician #630 stated X-ray results were pending. Review of the progress note dated 03/13/23 at 7:26 P.M. revealed the X-ray result to the right hip received with the conclusion of internally fixed right proximal femoral fracture deformity without adverse features. The right knee X-ray findings were an acute non-displaced proximal plateau tibial fracture. Ostopenia was shown on the x-ray results but the facility did not obtain the x-rays until 03/13/23, this was nine days after the initial injury to Resident #90's leg was found. Review of the facility's SRI dated 03/04/23 to 03/13/23 revealed Resident #90's injury of unknown origin was not reported to the State Survey Agency. Interview with the Director of Nursing (DON) on 05/24/23 at 1:20 P.M. verified the X-ray did not state pathological fracture and verified there was no injury of unknown origin reported to the State Survey Agency. The DON stated the facility felt the fracture was caused by the osteoporosis and osteopenia. Telephone interview on 05/24/23 at 2:29 P.M. with Hospice Case Manager Registered Nurse (HCMRN) #600 revealed the hospice staff had made visits to assess Resident #90's right lower leg. HCMRN #600 stated the leg was documented as swollen with bruising and there was no facility documentation or report of a fall or other injury to Resident #90. HCMRN #600 reported the family declined to have the leg X-rayed at this time but wanted the resident pain to be managed by pain medication. HCMRN #600 stated she made the second after hours visit three days later and the facility staff reported to her the residents was stating she had increased pain in the leg, the leg documentation included that the resident had bruising to the leg, but no documentation of why the resident had bruising. Review of the undated policy titled Abuse, Neglect, Exploitation, and Mistreatment of Residents and Misappropriation of Resident Property revealed the purpose of this policy is to provide a systematic approach to abuse and neglect detection and prevention. It is the responsibility of Associates and volunteers to immediately report all such allegations to the Administrator or designee. The Administrator or designee will report to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. An injury is classified as an Injury of Unknown Source when all the following conditions are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of a Resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator will ensure that reporters are free from retaliation or reprisal. The Administrator/designee is responsible for ensuring allegations are reported to the state agency immediately. When possible, ODH will be notified by using the online Enhanced Information Dissemination & Collection (EIDC) system. The Community will submit an online Self-Reported Incident form in accordance with ODH's then-current instructions. In the event of an internet outage or similar failure, the Community will temporarily notify the ODH District Office of the allegation via alternative method (e.g., phone), and will then submit the Self-Reported Incident online once service is restored. Only the Administrator or someone specifically designated by the Administrator is authorized to submit a Self-Reported Incident form to ODH. This deficiency represents non-compliance investigated under Complaint Number OH00143042.

Based on record review, staff interview, review of the facility's Self-Reported Incidents (SRI), interview with Hospice staff, and policy review, the facility failed to report an injury of unknown origin to the State Survey Agency and investigate the injury of unknown origin for a resident. This affected one (#90) of one resident reviewed for injury of unknown origin. The facility census was 46. Findings include: Review of Resident #90's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included senile degeneration of brain, adult failure to thrive, and seizures. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired and had no behaviors. Resident #90 was dependent on staff for ambulation and toileting and required extensive assistance from staff with bed mobility, transfers and dressing. Resident #90 was receiving hospice care. Review of the weekly skin assessment dated [DATE] revealed Resident #90 had no new skin alterations, and no areas of skin abnormality were documented on the assessment. Review of the hospice provider progress note dated 03/05/23 at 10:06 A.M. revealed the facility staff reported Resident #90 with a new onset of right leg pain which started on the evening on 03/04/23. The leg was described as swollen and warm to touch. Resident #90 with Tylenol order in place for pain. Hospice Nurse to visit to assess Resident #90's right leg and any further medication needs for pain control. Review of the weekly skin assessment dated [DATE] revealed bruising and edema to the right lower leg continued. No areas of additional skin abnormality were documented on the assessment. Review of the hospice progress note dated 03/09/23 at 11:25 A.M. revealed the hospice nurse spoke with the Certified Nurse Practitioner (CNP) caring for Resident #90 to update her on the new Tylenol order and a new X-ray was ordered. Review of Physician #630's progress note dated 03/09/23 revealed the hospice nurse called related to Resident #90 needing a right lower leg X-ray related to pain and ecchymosis. Resident #90 was documented as unreliable due to cognition. Resident #90 previously reported as high fall risk due to attempts to get out of bed without requesting help, no record of recent falls of trauma noted found per nursing. Physician #630 documented past medical history did not include diagnoses of osteopenia or osteoporosis. Under the assessment and plan, Physician #630 documented Resident #90 had pain in the right lower leg and the right lower leg had scattered ecchymosis. Resident #90 stated the leg was painful to bend at the knee and bilateral lower extremities had positive dorsi and plantar flexion documented. Physician #630 stated X-ray results were pending. Review of the progress note dated 03/13/23 at 7:26 P.M. revealed the X-ray result to the right hip received with the conclusion of internally fixed right proximal femoral fracture deformity without adverse features. The right knee X-ray findings were an acute non-displaced proximal plateau tibial fracture. Ostopenia was shown on the x-ray results but the facility did not obtain the x-rays until 03/13/23, this was nine days after the initial injury to Resident #90's leg was found. The facility was unable to provide the facility's investigation into Resident #90's injury of unknown origin to the State Survey Agency on 05/24/23. Review of the facility's SRI dated 03/04/23 to 03/13/23 revealed Resident #90's injury of unknown origin was not reported to the State Survey Agency. Interview with the Director of Nursing (DON) on 05/24/23 at 1:20 P.M. verified the X-ray did not state pathological fracture and verified there was no injury of unknown origin reported to the State Survey Agency. The DON verified the facility did not complete an investigation of Resident #90's injury of unknown origin because the facility felt the fracture was caused by the osteoporosis and osteopenia. The DON stated Resident #90 had no fall or reported injury. If Resident #90 had a fall, Resident #90 lacked the ability to get herself off the floor and staff would have then been aware of a fall but staff denied helping Resident #90 off the floor. Telephone interview on 05/24/23 at 2:29 P.M. with Hospice Case Manager Registered Nurse (HCMRN) #600 revealed the hospice staff had made visits to assess Resident #90's right lower leg. HCMRN #600 stated the leg was documented as swollen with bruising and there was no facility documentation or report of a fall or other injury to Resident #90. HCMRN #600 reported the family declined to have the leg X-rayed at the initial assessment but wanted the resident's pain to be managed by pain medication. HCMRN #600 stated she made the second visit three days later and the facility staff reported to her the residents was stating she had increased pain in the leg, the leg documentation included the resident had bruising to the leg, but no documentation of why the resident had bruising. Review of the undated policy titled Abuse, Neglect, Exploitation, and Mistreatment of Residents and Misappropriation of Resident Property revealed this Community will not tolerate abuse, neglect, exploitation and mistreatment of its Residents or the misappropriation of Resident property and will take necessary steps to provide protections for the health, welfare and rights of each Resident residing in the Community. An injury is classified as an Injury of Unknown Source when all the following conditions are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. All alleged violations involving Abuse, Neglect, Exploitation or Mistreatment of a Resident, or Misappropriation of Resident Property, including Injuries of Unknown Source will be investigated in accordance with this procedure. Once the Administrator and Ohio Department of Health (ODH) are notified, an investigation of the allegation/violation will be conducted by the Administrator/Designee. The focus of the investigation should be to determine if abuse, neglect, exploitation, mistreatment and/or misappropriation of Resident property has occurred, the extent, and cause. The investigation must be completed within five working days, unless there are special circumstances causing the investigation to continue beyond 5 working days (e.g., quantifying amounts misappropriated if accountant needs more time. Evidence of the investigation should be documented. The person investigating the incident should generally take the following actions: a. Interview and obtain or document statements from the Resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the Resident the day of the incident (including other Residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. b. If there are no direct witnesses, then the interviews may be expanded, for example, to cover all employees on the unit, or, as appropriate, the shift. For Injuries of Unknown Source, the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. c. Interviews may also be conducted with Residents who reside on the same unit and/or have similar care needs as the alleged victim. d. Examine the alleged victim for signs of injury, including a physical examination or psychosocial assessment if needed. e. Obtain all medical reports and statements from physicians and/or hospitals if applicable. f. Review the Resident's records. This violation represents non-compliance investigated under Complaint Number OH00143042.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure fall interventions were in place for a resident at risk for falls and who had a history of falling. This affected one (#100) of three residents reviewed for falls. The facility census was 46. Findings include: Review of Resident #100's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included syncope, dementia, weakness, and osteoporosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had severe cognitive impairment and required extensive assistance from staff for bed mobility, toileting, and transfers. Resident #100 had a fall since admission to the facility and had a fall prior to admission. Review of the care plan revealed Resident #100 was at risk for falls. Interventions included a dropped wheelchair seat and dycem to the wheelchair and a reclining chair. Review of the progress note dated 04/02/23 at 5:54 P.M. revealed the nurse was called to Resident #100's room by a State tested Nursing Assistant (STNA) and Resident #100 was found lying on the floor beside the reclining chair. Resident #100 was assessed and no injuries were noted, vital signs were normal and neurological checks were initiated. The intervention for the fall was to provide dycem to the wheelchair and reclining chair. Review of Resident #100's physician orders dated 04/03/23 revealed an order for dycem to the reclining chair and wheelchair at all times. Observation of Resident #100 on 06/06/23 at 11:30 A.M. revealed the resident was sitting in his wheelchair and no dycem was observed in the wheelchair. Interview on 06/06/23 at 11:30 A.M. with Activities Worker #590 verified Resident #100 did not have any dycem to his wheelchair. Observation and interview of Resident #100 with the Director of Nursing (DON) on 06/06/23 at 11:40 A.M. verified Resident #100's wheelchair seat was dropped, but no dycem was in the wheelchair. The DON verified Resident #100 should have dycem in the wheelchair and verified it was not present. Review of the undated policy titled Resident Falls revealed to ensure the safety of our residents through assessments, monitoring, supervision, and assistance to prevent the occurrence of falls. The Nurse Manager or designee will complete the Fall Risk Assessment. Based on the results of the assessment, the nurse will determine what factor places the resident at the greatest risk and select an appropriate intervention to prevent a fall. A care plan will be written that identifies the risk factor and provides a list of appropriate interventions. This deficiency represents non-compliance investigated under Complaint Number OH00143042.

Based on medical record review, review of the call light audits, resident and staff interview, and policy review, the facility failed to ensure call lights were answered timely. This affected two residents (#19 and #58) out of three residents reviewed. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #19 revealed an admitted on 11/06/20. Diagnoses included spinal stenosis, type II diabetes mellitus, dysphagia, weakness, edema, and encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #19 required extensive assistance from two staff to complete transfers and physical assistance in part of bathing from one staff. Review of the call light audits completed on 01/01/23 revealed Resident #19 activated her call light pendant on 01/01/23 at 12:13 A.M. and answered at 12:29 A.M. (16 minutes later) and activated the pendant again at 12:37 A.M. and answered at 1:04 A.M. (27 minutes later). Interview on 03/28/23 at 12:56 P.M., with Resident #19 revealed she no longer used her call light because when she used to press the call light pendant, the staff had not responded. Resident #19 stated she would prefer to have some assistance at times but does things on her own because the staff do not respond to the call lights. Interview on 03/28/23 at 10:29 A.M., with the Director of Nursing (DON) verified the call light response times had been identified by the facility as a concern. The facility implemented a plan to improve call light response times. The facility was installing a visual alert to the outside of the resident rooms. The installation was in progress on the upstairs floor and the alert outside the resident rooms would also be added to the first floor rooms. The facility also added pull cords and push buttons in resident rooms as well. Prior to the additional equipment, the residents had a call light pendant to wear around their necks or wrists. The DON expected call light response times to be 15 minutes or less on average. The facility had educated staff on the importance of timely answering call lights and had also disciplined some staff who were identified as not responding to call lights in a timely manner. 2. Review of the medical record for Resident #58 revealed an admitted on 12/25/21. Diagnoses included acute and chronic respiratory failure with hypoxia, heart failure, obstructive sleep apnea, cerebral infarction, type II diabetes mellitus, peripheral vascular disease, encephalopathy (a brain disease), weakness, and a need for assistance with personal care. Review of the quarterly MDS assessment dated [DATE] revealed Resident #58 had impaired cognition and scored a ten out of 15 on the BIMS assessment. Resident #58 was totally dependent on one to two staff to complete Activities of Daily Living (ADL). Review of the call light audits completed on 01/01/23, 02/01/23, and 02/28/23 revealed Resident #58's call light pendant was activated on 01/01/23 at 1:02 P.M. and answered at 1:31 P.M. (29 minutes later), activated on 02/01/23 at 3:16 P.M. and answered at 3:32 P.M. (16 minutes later), and activated on 02/28/23 at 8:23 A.M. and answered at 9:16 A.M. (53 minutes later). Interview on 03/29/23 at 11:29 A.M., with Resident #58 revealed responses to his call light were slow. The resident stated the typical wait period was 15 minutes but he has had to wait for up to two hours for a response before. The resident stated he required two staff and a mechanical lift to transfer him. Interview on 03/28/23 at 10:29 A.M., with the DON verified call light response times had been identified by the facility as a concern. The facility implemented a plan to improve call light response times. The facility was installing a visual alert to the outside of the resident rooms. The installation was in progress on the upstairs floor and the alert outside the resident rooms would also be added to the first floor rooms. The facility also added pull cords and push buttons in resident rooms as well. Prior to the additional equipment, the residents had a call light pendant to wear around their necks or wrists. The DON expected call light response times to be 15 minutes or less on average. The facility had educated staff on the importance of timely answering call lights and had also disciplined some staff who were identified as not responding to call lights in a timely manner. Review of the facility policy, Resident Call System, undated revealed if a State tested Nursing Assistant (STNA) or a nurse is unable to respond to alert, then supervisor's alert will be activated. The call system must be canceled in the resident's room, bathroom, or the pendant. This deficiency represents non-compliance in Master Complaint Number OH00141162, and Complaint Numbers OH00140722, and OH00137052

Based on observations, review of the facility's policy, staff interviews, review of online resources at Center for Medicaid and Medicare Services (CMS) and Centers for Disease Control and Prevention (CDC), and record review, the facility failed to maintain infection control protocols and wear the appropriate Personal Protective Equipment (PPE) in resident rooms that were in quarantine to prevent the potential spread of COVID-19. This affected one (Residents #160) of two residents reviewed for transmission based precautions (TBP). This had the potential to affect all 45 residents residing in the facility. Findings include: Review of the medical record for Resident #160 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 was cognitively intact and required extensive assistance of one staff member for mobility. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed Resident #160 was placed in quarantine for 10 days due to vaccination status. This physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/06/22 at 12:38 P.M. revealed State tested Nursing Aide (STNA) #42 entered Resident #160's room wearing a surgical mask and face shield for PPE. Resident #160 was having a hard time understanding STNA #160, so STNA #42 removed her mask. Interview on 09/06/22 at 1:25 P.M. with the Director of Nursing (DON) revealed Resident #160 should be in quarantine due to being unvaccinated for COVID-19 and a new admission. The DON verified Resident #160 had not been in placed in quarantine upon admission on 09/02/22. The DON verified Resident #160 went four days without being in quarantine and was placed in quarantine on 09/06/22 after surveyor intervention. The DON confirmed staff should be wearing N-95, gown, gloves, and a face shield when entering Resident #160's room. Observation and interview on 09/08/22 at 5:37 P.M. with STNA #39 revealed staff wore surgical mask into a Resident #160's room. STNA #39 confirmed isolation boxes do not have N-95 masks in them and staff were to place a second surgical mask over their original surgical mask and remove the second mask upon exit from the resident's room. Review of an online resource from CMS titled COVID-19 Nursing Home Data at https://data.cms.gov/COVID-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a high (red) community transmission rate of COVID 19. Review on an online resource per the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, last updated 02/02/22, revealed the recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic to implement source control measures. Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for healthcare professionals include: A NIOSH-approved N95 or equivalent or higher-level respirator or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators or a well-fitting facemask. Health Care Professionals (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [CONDITION(S)]-CoV-2 infection. If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also, wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, last updated 02/02/22, revealed under the section titled New Admission and Residents who Leave the Facility, all residents who are not up to date with recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section. Review of the facility's policy titled Transmission Based Precautions, dated 05/01/22, revealed PPE should be maintained in the isolation carts including gowns, gloves, masks, etc. A notice should be posted to the door identifying CDC category of transmission based precautions and instructions to see the nurse prior to entering. Don appropriate PPE prior to entering the environment.

Based on staff interview, review of the facility's Self-Reported Incidents (SRI), review of the facility's policy, and medical record review, the facility failed to timely report an allegation of sexual abuse to the State Survey Agency, the Ohio Department of Health. This affected one (Resident #162) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the Resident #162's medical record revealed an admitted [DATE]. Resident #162 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility's SRI Control Number 1 revealed the was submitted on 02/22/22 at 10:52 A.M. The SRI was related Resident #162 reporting an allegation of sexual abuse against STNA #66. Review of the facility's investigation related to SRI control number 1, revealed at the end of day shift, Resident #162 was crying and reported to an state tested nursing aide (STNA) that a man had been trying to rape her in her room. She identified the man as STNA #66 . STNA #66 was sent home immediately. Interview on 09/08/22 at 3:35 P.M. with the Administrator and the Director of Nursing (DON) confirmed they did not notify the Ohio Department of Health of the abuse when the allegation was reported on 02/21/22. Review of the facility's undated policy titled Abuse, Neglect, Exploitation, and Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .)

Based on medical record review, review of the facility's Self-Reported Incidents (SRI), staff interview and review of the facility's policy, the facility failed to complete a thorough investigation regarding a resident's allegation of sexual abuse. This affected one (Resident #162) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the Resident #162's medical record revealed an admitted [DATE]. Resident #162 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility's SRI Control Number 1 revealed the was submitted on 02/22/22 at 10:52 A.M. The SRI involved Resident #162 reporting an allegation of sexual abuse against State tested Nursing Aide (STNA) #66. On 02/21/22 at the end of day shift, Resident #162 was crying and reported to an STNA a man had been trying to rape her in her room. Review of facility's investigation of SRI Control Number 1 revealed the facility interviewed four alert and oriented residents who resided on Resident #165's unit. The facility did not assess additional residents who were unable to answer questions about being abused. There was no evidence that Resident #162 was physically assessed for any injuries related to abuse on 02/21/22. Resident #162's medical record did not have documentation regarding Resident #162 alleging she was was crying and alleged a man had been trying to rape her. There was no documentation Resident #162's representative, or her physician were notified of the sexual abuse allegation. There was no evidence Resident #162 was physically assessed for any injuries related to abuse on 02/21/22. Interview on 09/08/22 at 3:35 P.M. with the Administrator and the Director of Nursing (DON) confirmed the facility did not complete any physical assessments for signs of abuse on Resident #162 and confused residents involving the SRI control number 1. The Administrator and DON confirmed the allegation of abuse or the investigation was not documented in Resident #162's medical record. Review of the facility's undated policy titled Abuse, Neglect, Exploitation, and Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigation includes physical examination of the alleged victim for signs and injury, or a psychological assessment if needed. A resident's nurses' notes will include the results of the resident's assessment, notification of the physician and the resident's representative, and any treatment provided involving the allegation.

Based on resident, family, and staff interviews, review of the facility's policy, and record review, the facility failed to ensure medications were administered as physician ordered. This affected two (Residents #149 and #159) of five residents reviewed for medication. The facility census was 45. Findings include 1. Review of the medical record for Resident #159 revealed an admitted [DATE] at 5:54 P.M. Diagnoses included back pain, anxiety, and surgical stabilization of rib fractures for ribs five, six, seven, eight, and nine. Review of the hospital discharge referral documents dated 08/28/22 revealed Resident #159 had a historical diagnosis of back pain with multiple acute rib fractures requiring surgical revision and a diagnosis of anxiety. Resident was on several pain medications during her hospitalization and was weaning off intravenous (IV) [MEDICATION(S)] (treats moderate to severe pain) and transitioning to oral [MEDICATION(S)] (treats moderate to severe pain). Review of the hospital discharge summary dated 09/04/22 revealed the discharge medications included [MEDICATION(S)] five milligram (mg) tablet immediate release with instructions to provide every six hours as needed (PRN) for pain and [MEDICATION(S)] one mg tablet with instruction to provide every six hours as needed (PRN) for anxiety. The discharge summary revealed Resident #159 last received pain medications at 2:15 P.M. at the hospital. Review of the facility's physician order dated 09/04/22 revealed Resident #159 was ordered [MEDICATION(S)] five mg tablet with instructions for oral tablet every six hours PRN and [MEDICATION(S)] tablet one tablet PRN every six hours for anxiety. Review of the plan of care dated 09/04/22 revealed Resident #159 was at risk for discomfort with interventions to administer medication as ordered, complete a pain assessment, offer non-pharmacological interventions and notify the physician of changes in pain. Review of the admission assessment dated [DATE] revealed Resident #159 had verbal indicators of pain. Resident #159 described the pain of ribs aching from her fractures. Review of the progress notes dated 09/05/22 at 2:27 A.M. revealed Resident #159 had verbal indicators of pain. The progress note dated 09/05/22 at 11:54 A.M. revealed Resident #159 had verbal indicators of pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #159 was cognitively intact. Review of the Medication Administration Record (MAR) dated 09/04/22 to 09/07/22 revealed Resident #159 was not given any pain medication ([MEDICATION(S)]) on 09/04/22 and the first time this medication was given since admission was 09/05/22 at 11:00 A.M. when Resident #159's pain was rated an eight, from a scale of zero (no pain) to a ten (most severe pain). Additionally, Resident #159 was not given any anxiety medication ([MEDICATION(S)]) on 09/04/22 and the first time this medication was given since admission was 09/05/22 at 11:00 A.M. Interview on 09/06/22 at 1:45 P.M. with Resident #159 revealed she admitted on [DATE] around dinner time and was requesting anxiety and pain medication. Resident #159 reported she was informed by nursing staff she would have to wait until the pharmacy could process the scripts and deliver to the facility. Resident #159 reported she was crying and yelling out in pain and it made her anxious. Resident #159 stated she went almost 24 hours without pain or anxiety medications. Interview on 09/12/22 at 10:00 A.M. with Nurse Practitioner (NP) #200 revealed she had no knowledge of a delay in medication for Resident #159. NP #200 stated waiting 18 to 24 hours for pain and anxiety medications seemed like a long time. Interview on 09/12/22 at 10:28 A.M. with Registered Nurse (RN) #20 revealed she was assisting the other nurse but denied any involvement in the admission assessment, verifying medications, or calling the medical team. Interview on 09/12/22 at 10:37 A.M. with RN #21 revealed she completed the intake assessment while the other nurse reviewed the medications and hospital paperwork. RN #21 denied contacting the physician regarding her medications during the remainder of her shift and revealed no knowledge of issues with Resident #159's medications. RN #21 stated Resident #159 verbalized pain and anxiety during her intake and RN #21 reported she informed Resident #159 the facility was waiting on medication from the pharmacy. RN #21 stated the facility had a process to obtain single dose medications in case of emergencies and revealed knowledge of this process but denied putting in a request for Resident #159 to get her pain and anxiety medications timely. RN #21 verified Resident #159 did not receive any pain or anxiety medications during her shift. Interview on 09/12/22 at 11:06 A.M. with the Director of Nursing (DON) stated he was unaware of the delay in Resident #159 receiving her medications. The DON stated he would expect staff to assess the resident and if pain or anxiety medication was needed, the staff should follow the process to contact the pharmacy for emergency approval to use the E box. The DON acknowledged the medications were administered the next day but did not know reason for delay. Review of the facility's undated policy titled Pain Management revealed pain assessments should be completed at admission and periodically as needed. Incorporate a resident interview in the pain assessment as well as observations regarding pain characteristics. Notify the physician and as appropriate obtain an order for pain medication and notify physician if ordered medications for pain are not effective. 2. Review of the medical record for Resident #149 revealed an admitted [DATE]. Diagnoses included dementia with Lewy bodies, acute embolism with [CONDITION(S)] of right popliteal vein. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #149 was cognitively intact. Review of the physician's orders dated 08/26/22 revealed Resident #149 was ordered [MEDICATION(S)] HCI Solution 0.15 percent (%) two sprays in each nostril at bedtime for allergies. Review of the medication administration review (MAR) from 08/26/22 to 09/07/22 revealed [MEDICATION(S)] HCI Solution 0.15 % two sprays in each nostril at bedtime was not administered on 08/26/22, 08/27/22, 08/29/22, 08/31/22, 09/01/22 and 09/06/22. The code marked on the MAR said, other-see nursing note. Review of the progress notes dated 08/26/22 to 09/07/22 revealed there was no documentation related to [MEDICATION(S)] HCl Solution not being administered to Resident #149. Interview with Resident #149 and family member revealed they have requested home medications be added to his physician orders and provided while at the facility including the allergy medication [MEDICATION(S)] HCl solution. Resident #149 reported he was not consistently getting this medication. Interview on 09/12/22 at 3:34 P.M. with the Director of Nursing (DON) and Administrator revealed Resident #149's wife was bringing in the Azeleastine HCL solution medication to provide to Resident #149 and when she did not provide it, Resident #149 would not receive it. They confirmed it was not being administered as physician ordered. Review of the facility's undated policy titled Automated Dispensing Machine for First Dose and Emergency Medications revealed the community may use automated dispensing system for the first dose and emergency medications when permitted. The pharmacy must provide authorization for emergency use medications.

Based on medical record review, staff interview, and policy review, the facility failed to administer a pneumonia vaccine to a resident. This affected one (Resident #8) of five residents reviewed for immunizations. The facility census was 45. Findings include: Medical record review for Resident #8 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review for Resident #8 revealed a consent for the pneumonia vaccine dated 09/29/20 by Resident #8's Power of Attorney (POA). Review of Resident #8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of immunizations in Resident #8's electronic medical record revealed it was silent for documentation of the pneumonia vaccine. Interview on 09/12/22 at 12:44 P.M. with the Director of Nursing (DON) revealed the facility offers the pneumonia vaccine to residents. The facility reviews the residents' records periodically for pneumonia vaccine status and offers the vaccine if indicated. Subsequent interview on 09/12/22 at 2:17 P.M. with the DON revealed the facility was unable to provide evidence of historical pneumonia vaccine status for Resident #8. Review of the facility's undated policy titled Pneumoccocal Vaccine revealed the facility is to offer the pneumoccal vaccine immunizations to all residents as recommended by the Centers for Disease Control and Prevention (CDC). Residents should be evaluated for indications to receive the pneumonia vaccine upon admission and immunization records will be reviewed annually.

Based on medical record review, review of a facility investigation, review of security footage, staff interview and policy review, the facility failed to ensure Resident #45 received adequate supervision to prevent elopement. This affected one (#45) of three residents reviewed for elopement risks. The census was 42. Finding include: Review of the medical record for the Resident #45 revealed an admitted [DATE] and discharged to another skilled nursing facility on 05/14/21. Diagnoses included hypertension, [CONDITION(S)], and dementia. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 05/10/21, revealed the resident had a brief interview for mental status (BIMS) score of four out of 15 indicating the resident had severely impaired cognition. The MDS identified the resident needed limited assistance with bed mobility and transfer and supervision for walking. Review of the elopement risk assessment dated [DATE] revealed Resident #45 had dementia and a history of wandering. Intervention identified were exit and stairwell alarms and frequent monitoring, every two hours. Review of the plan of care dated 05/04/21 revealed Resident #45 was at risk for elopement/wandering behavior due to dementia. Interventions included check every two hours, wanderguard placed on ankle, and diversionary activities such as TV or offering reading materials. Care plan dated 05/07/21 revealed intervention of redirecting away from exit doors when wandering. Review of the nurse's notes dated 05/04/21 at 5:29 P.M. revealed Resident #45 was very confused and was walking around from room to room. Resident #45 was caught by social worker trying to elope. Resident #45 was moved to a room closer to the nurse's station. The resident kept stating he wants to leave to his apartment. Resident #45's daughter was called and informed of resident's behavior. Wanderguard was placed on his right ankle for his safety due to trying to elope. Director of Nursing (DON) was informed. Review of physician orders dated 05/04/21 identified orders for placement of wanderguard to resident's ankle. There was no order for checking for functioning, placement, and skin integrity every shift or was there any record that the device was monitored for functioning. Review of nurses noted dated 05/08/21 at 7:40 P.M. revealed the resident was found outside walking the parking lot. Resident #45 was brought back in and 15-minute checks initiated and a State tested Nursing (STNA) was assigned to monitor outside of Resident #45's door. Review of Resident #45's Treatment Administration Record (TAR) dated 05/09/21 revealed an order for 15-minute checks related to elopement for one day starting 05/09/21 at 7:00 A.M. Review of the nursing notes dated 05/13/21 at 4:34 A.M. revealed Registered Nurse (RN) #115 had administered medication to Resident #45 on 05/12/21 at 8:30 P.M. and continued with the medication pass. At 9:00 P.M. RN #115 noticed Resident #45 was not in his room. The assigned STNA stated they had just assisted the resident to the bathroom and place him on the toilet. Staff conducted an immediate search of the floor. When Resident #45 was not found on the floor a Code Pink was called. The entire staff search the facility and the local police were call. Resident #45 was found by the police at 11:30 P.M. down the street from the facility. Resident #45 stated he wanted to go for a walk. Review of the elopement risk assessment dated [DATE] revealed the resident was at risk for elopement. Resident #45 was found to have poor decision making, lack of safety awareness and no insight to self-limitations. The elopement risk assessment identified the resident had an elopement history at home and of leaving the facility without needed supervision. Interventions identified on the elopement risk assessment include exit and stairwell alarms, frequent monitoring, personalization of room with familiar objects and photos, and staff aware of resident's wander risk. Further record review revealed Resident #45 was discharged to another skilled nursing facility on 05/14/21. The discharge was previously planned/arranged. Review of the elopement investigation dated 05/12/21 revealed Resident #45 was residing on the second floor of the Skilled Nursing unit. Per the investigation report Resident #45 took elevator to first floor, exited the front doors, and walked outside down a neighborhood street. The Administrator was immediately notified, and the missing persons plan was activated. The Administrator and several department heads reported to the building upon notification of the incident to assist with the missing person's plan. Staff immediately completed a search of all buildings and grounds of the campus. Police were contacted and the search was expanded as per policy to surrounding neighborhoods. Resident #45 was found sitting in neighboring yard approximately four houses down the street. Emergency Medical Technicians (EMT's) on the scene conducted an assessment of the residents condition, no injury noted and he was cleared to return to his room. Family present during search and follow up. At the time of the elopement Resident #45 knew the zip code for the area as he was a resident in the area for many years. The wanderguard does not alarm when entering the elevator or exiting the front door only on exiting the doors on the floor. Staff were conducting two-hour check on Resident #45. Per the investigation report the resident was found at 10:50 P.M. by police. Plan of care was updated for 24-hour observation of Resident #45 until planned discharge. The sign next to the elevator stating that the code was the zip code was removed but the code has not been changed. Review of the security footage time stamped at 05/12/21 at 9:12 P.M. of the front door entrance area revealed a resident, identified as Resident #45 by the DON, was walking out the front door. No other security footage of the resident was recorded. Interview with Administrator on 06/01/21 at 12:41 P.M. revealed when staff discovered Resident #45 eloped a Code Pink was called on 05/12/21 at 9:20 P.M., Administrator was called at 9:25 P.M., Police were called at 9:35 P.M. and Resident #45 was found at 10:50 P.M. The Administrator was with the police when the Resident #45 was found. The police report has been requested and is pending at this time. Interview on 05/27/21 at 2:03 P.M. with DON and Administrator revealed Resident #45 entered the elevator on the second floor and exited out the front doors on 05/08/21. The investigation findings were that a sensor on the elevator was malfunctioning and was replaced on 05/10/21. The Administrator revealed during the interview a sign was located next to the elevator doors stating that the code to operate the doors was the zip code. Per the Administrator and DON, the staff were aware Resident #45 resided in the area for many years and had an apartment nearby. The DON and Administrator stated Resident #45 punch in the zip code to access the elevator on the second floor. Interview on 05/27/21 at 2:55 P.M. with Director of Planning, (DOP) revealed the security camera footage showed Resident #45 walking out of the facility's front door on 05/12/21 at 9:12 P.M. DOP verified there was no security footage of the second floor elevator or any other footage of Resident #45 on 05/12/21. Interview with the Administrator on 05/27/21 at 3:30 P.M. confirmed there was no monitoring record of the wanderguard device for functioning and placement for Resident #45. Review of a facility policy titled CODE PINK Missing Person revised 05/14/21 revealed because our residents matter to all of us at The Wesley Communities, it is the responsibility of all staff to provide a safe environment for all residents. This includes to locate and quickly secure the safety of missing residents. The policy provided instructions for staff to follow in the event that a resident is missing. This deficiency substantiates Complaint Number OH 702.

Based on observation, staff interview, and facility policy review, the facility failed to maintain infection control by failing to disinfect a glucometer (to measure blood sugar/accucheck) in between resident uses, failed to complete hand hygiene, failed to wear gloves, and failed to avoid direct contact between bare hands and medications. This affected three Residents (#3, #7, and #14) of three observed during medication administration. The facility census was 42. Findings include: Observation on 04/29/21 at 8:12 A.M., revealed Licensed Practical Nurse (LPN) #101 began to prepare medications for administration to Resident #3 without performing hand hygiene. A blood pressure measurement was obtained and the medication was then administered to the resident. The LPN was not observed to complete hand hygiene and she then began to prepare medications for Resident #14. The LPN put the ordered medication for Resident #14 in her bare hand and then placed the medication in the medication cup. She then used a glucometer to check Resident #14's blood sugar level without the use of gloves, or completing hand hygiene. The glucometer was not disinfected prior to the use, or after the use on Resident #14. The LPN was then observed using the same glucometer without disinfecting it on Resident #7. LPN #101 was observed completing the accucheck without gloves, then returned to the nursing medication cart without performing hand hygiene, and without disinfecting the glucometer. Interview on 04/29/21 at approximately 8:40 A.M. with LPN #101 confirmed all the above findings, and confirmed the facility policy was to wear gloves during an accucheck, perform hand hygiene before, and after medication preparation, complete hand hygiene before and after direct contact with each resident, disinfect the equipment such as the glucometer between residents. Review of facility policy titled, Obtaining a Fingerstick Glucose Level,, dated October 2017, revealed to always ensure blood glucose meters intended for reuse are cleaned and disinfected between resident uses, wear clean gloves, clean and disinfect reusable equipment between uses according to the manufactures instructions and current infection control standards of practice, and wash hands was listed as the last step in the procedure. Review of facility policy titled, Handwashing/Hand Hygiene, dated October 2017, revealed to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; i. After contact with a resident's intact skin; k. After handling used dressings, contaminated equipment's, etc.; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves. This deficiency was based on an incidental finding discovered during the coarse of the investigation of Complaint #OH 693.

Based on medical record review, observation, staff interview, review of manufacturer's instructions for FlexPens, and facility policy review, the facility failed to ensure a medication error rate less than five percent. There were four errors of 30 opportunities which resulted in a medication error rate of 13.3%. This affected two Residents (#3 and #14) of three observed during medication administration. The facility's census was 42. Findings include: 1. Review of Resident #14's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the residents physician orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of medication administration on 04/29/21 at 8:12 A.M. with Licensed Practical Nurse (LPN) #101 revealed the LPN failed to administer Resident #14's [MEDICATION(S)] as ordered. The LPN confirmed the [MEDICATION(S)] was not administered because it was unavailable. 2. Review of Resident #3 medical record revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the residents physician orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of medication administration on 04/29/21 at 8:40 P.M. with LPN #101 revealed the LPN failed to administer Resident #3's [MEDICATION(S)] as ordered. The resident was also given an Aspirin 81 mg, [MEDICATION(S)]-coated tablet, instead of the ordered chewable 81 mg of Aspirin. Additionally, the Resident was given the ordered 26 units of [MEDICATION(S)], via the [MEDICATION(S)], however the [MEDICATION(S)] was not primed to ensure the resident received the full ordered dose of insulin. Interview with LPN #101 at the time of the observation confirmed the above observed medication errors. Review of facility policy titled, Medication Administration Policy, undated revealed The individual administering the medication must check the label to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication. Review of the facility policy titled, Use of [MEDICATION(S)] for Insulin, with a revised date of 2017, revealed manufacturers instructions were to be followed when administering to a resident. Review of the [MEDICATION(S)] manufacturer instructions, undated, attached to the facility policy titled, Use of [MEDICATION(S)] for Insulin, revealed the insulin [MEDICATION(S)] needed to be primed prior to administering the insulin. This deficiency substantiates complaint number OH 693.

Based on medical record review, staff interview and review of the facility's policy, the facility failed to provide timely assistance with toileting to prevent the resident from falling. This caused actual physical harm to Resident #27 when she self-toileted herself since the staff didn't answer her call light timely resulting in the resident falling, sustaining a fracture to her left wrist. This affected one (Resident #27) of one resident reviewed for accidents. The facility identified 26 residents at risk for falls. Findings include: Review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed she had a severe cognitive impairment and required total dependence on staff for transfers and extensive assistance from staff for toilet use. Review of the fall risk assessments, dated [DATE], [DATE], and 02/07/20, revealed she was at moderate risk for falls. Review of the resident's care plan revealed there was no fall care plan and there were no interventions in place to aide in the prevention of the resident from falling despite the resident being assessed at a moderate risk for falls. Review of a progress note, dated 02/07/20, revealed Resident #27 was noted to be sitting on the floor in the bathroom in front of her wheelchair. Her right hand was holding the rail and the left arm was on the wheelchair. She had on non-skid footwear and there was adequate light. The progress note indicated Resident #27 stated she wanted to use the bathroom but could not transfer herself. A head-to-toe assessment was completed, and no visible injuries were noted. She was able to move all extremities. She was assisted with a mechanical lift to the bed by three staff members. Resident #27 denied pain. She was educated to call for help with transfers so the staff could assist her. Review of an incident report, dated 02/07/20, revealed on 02/07/20, Resident #27 was noted to be on the floor in her bathroom in front of her wheelchair. Her right hand was on the rail while the left hand was on the wheelchair. She stated she wanted to use the bathroom but could not transfer herself. The report indicated she was educated to call for help with transfers so staff can assist her. It documented Resident #27 self-transferred to the toilet because she was waiting too long for staff to answer her call light and could no longer hold her bladder. The report stated Resident #27 had, waited too long due to mealtime congestion and was to be scheduled for toileting after meals. Review of a physician's orders [REDACTED].#27 to the bathroom after each meal three times a day for post fall intervention. Review of the nursing note, dated 02/10/20 at 9:26 A.M., revealed Resident #27's daughter notified the nurse that Resident #27 had been complaining of left wrist pain since falling on 02/07/20. The nurse assessed Resident #27. The left wrist was swollen and sore to touch. The note stated her wrist was painful when she tried to hold onto the lift. A new order was obtained for an x-ray of the left wrist. A nursing progress note, dated 02/10/20 at 11:04 A.M., revealed the x-ray of Resident #27's wrist revealed a [MEDICAL CONDITION] shaft of the radius. An order was received to send the resident to the emergency room for evaluation and splinting of the fracture. A nursing note, dated 02/10/20 at 6:51 P.M., revealed Resident #27 returned to the facility with a new soft cast to her left lower arm. Interview on 0[DATE] at 5:41 P.M. with the Director of Nursing (DON) confirmed Resident #27's care plan lacked a plan and interventions for falls. The DON confirmed she had prior been assessed as being a moderate risk for falls and that a care plan should have been initiated at that time. The DON confirmed a physician order [REDACTED].#27 to the toilet after meals. DON confirmed Resident #27 was severely cognitively impaired and nursing was educating her to use her call light and this was not an effective or appropriate intervention. The DON further confirmed Resident #27 had been waiting with her call light on to use the bathroom for an estimated 30 minutes because staff were assisting with the meal service. He stated an intervention for scheduled toileting after meals was supposed to be implemented but it was not. Review of the facility's policy titled, Accidents and Incidents, dated 10/2017, revealed all accidents involving the residents would be investigated and reported to the Administrator. The policy stated the facility would investigate and generate a report related to the accident/incident and the report would be reviewed by the Safety Committee for trends related to the accident or safety hazards in the facility and to analyze individual resident vulnerabilities.

Based on closed clinical record review, hospital record review, review of facility policy related to falls and facility staff and family interviews, the facility failed to provide adequate supervision of a resident transferred to a geri/Broda chair. This resulted in harm when the resident fell out of the chair, sustained a laceration to her head and fractured her hip resulting in severe pain and subsequent hospitalization . This affected one (#73) of three residents reviewed for falls and supervision. The facility census was 70. Findings include: Review of the closed clinical record of Resident #73 revealed the resident was admitted to the facility on [DATE] and had cumulative [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, was totally dependent on staff for activities of daily living, required two person assistance with bed mobility and transfers and had impairments on both sides to the upper and lower extremities. Review of Resident #73's plan of care related to risk for falls revealed interventions of a Broda/geri-chair and mechanical lift transfer. Review of progress notes dated 12/30/13 revealed Resident #73 was observed laying on her right side on the floor, in her room, next to her Broda/geri-chair at 4:30 p.m. The resident was noted with a laceration to the forehead that measured 4.5 centimeters (cm) by 2 cm. and had scattered bruising noted. Steri-strips were applied to the laceration. Resident #73 was noted to grimace with right hip movement and palpitation. The physician and family were notified of the incident and an x-ray was ordered. The next progress note was dated 12/31/13 and stated Resident #73 was sent to a hospital via critical care around 11:00 p.m. on 12/30/13. The 12/31/13 note further stated the resident had sustained a fall on first shift, x-rays were taken and revealed an acute right hip fracture. Review of the radiology report dated 12/30/13 revealed the results of the x-ray were faxed to the facility at 10:11 p.m. The results of the x-ray revealed Resident #73 had an acute right hip fracture. A CAT scan was recommended for further evaluation. Review of hospital records dated 12/30/13 revealed Resident #73 was admitted to the hospital with [REDACTED]. The hospital records further revealed there were no plans for intervention and the resident was a high risk with a poor prognosis. On 01/02/14 it was noted the resident was continuing to decline and was admitted to the in-house hospice unit for palliative care. Interview with State tested Nurse Aide (STNA) #40 on 01/29/14 at 3:10 p.m. revealed she was the STNA assigned to the care of Resident #73 on 12/30/13. STNA #40 revealed she transferred Resident #73 from her bed to her Broda/geri chair for dinner at 4:30 p.m. STNA #40 stated she went to get a washcloth to wash the resident's face and when she came back the resident was on the floor, face first, bleeding from her forehead. STNA #40 confirmed Resident #73 required two persons for transfers with a mechanical lift. STNA #40 stated she did not use a mechanical lift to transfer the resident and transferred the resident by herself by picking the resident up and placing her in the Broda/geri-chair. STNA #40 further confirmed she did not recline the Broda/geri chair back and left the chair in an upright position when she went to get the washcloth. STNA confirmed the resident was not directly supervised at that time. STNA #40 stated she was trained in orientation to always recline a Broda/geri-chair after transferring a resident to prevent the resident from falling forward. STNA #10 stated Resident #73 was crying out in pain every time staff touched or repositioned her after the fall. Interview with Licensed Practical Nurse (LPN) #20 on 01/29/14 at 4:25 p.m. revealed she was nurse assigned to the care of Resident #73 on 12/30/13 when the resident fell out of the Broda/geri-chair. LPN #20 stated Resident #73 had a big laceration on her forehead and it was bleeding. LPN #20 stated she applied steri-strips to the laceration to stop the bleeding. She stated the resident was noted groaning. LPN #20 stated she administered Tylenol to the resident at 5:00 p.m. however, this was not documented in the resident's closed clinical record. LPN #20 stated she called the doctor to get an order for [REDACTED]. LPN #20 further stated Resident #73's head was still bleeding and the steri-strips were not doing a good job so she applied new steri-strips. LPN #20 stated when the x-ray technician arrived the resident was in a lot of pain. She stated she did not give the resident any more pain medication. LPN #20 verified Resident #73 required two person assistance with a mechanical lift for safe transfers and that residents were to be reclined in Broda/geri-chairs to ensure safety. Interview with LPN #10 on 01/20/14 at 4:40 p.m. revealed she was the nurse on duty for night shift the evening Resident #73 fell out of the Broda/geri-chair. LPN #10 stated she was informed in change of shift report by LPN #20 that Resident #73 had fallen out of her Broda/geri-chair and that she was fine. LPN #10 stated she started passing medications to other residents and around 8:00 p.m. the resident's daughter came to her and asked if Resident #73 could have something for pain as she was moaning and crying out in pain. LPN #10 stated she reviewed Resident #73's record to check for medications she had received since the fall and noted no pain medication was documented as given. LPN #10 stated she gave Resident #73 narcotic pain medication (Vicodin) around 8:20 p.m. LPN #10 stated when she went to administer the pain medication she could tell the resident was in a lot of pain. Interview with the Director of Nursing (DON) on 01/29/14 at 3:30 p.m. confirmed Resident #73 was not transferred appropriately and the Broda/geri-chair was not reclined back as it should have been at the time of the resident's fall. The DON stated STNA #40 turned her back on the resident and the resident fell face forward out of the Broda/geri-chair. The DON verified the STNA's are trained in orientation to transfer residents who use a Broda/geri-chair with two persons assistance and the use of a mechanical lift. The DON further verified the Broda/geri-chairs are to be reclined back to keep residents safe and from falling out. Interview with Resident #73's daughter on 01/29/14 at 3:45 p.m. revealed she was notified by the facility of the resident's fall on 12/30/13 around 5:00 p.m. She stated she was informed by LPN #20 she was sure the resident did not have a fracture. Resident #73's daughter stated she came to the facility around 7:00 p.m. to check on the resident and noted the resident was in a lot of pain. She further revealed Resident #73 screamed out in pain whenever staff came in to change or reposition her. She stated the resident screamed when the x-ray was taken. Resident #73's daughter stated she was not sure exactly what time the x-ray was taken, however she knew it was after 7:00 p.m. as she didn't arrive to the facility until that time. She stated she went to LPN #10 who was now in charge of the resident's care at that time and asked if the resident could have something for pain and as the resident was screaming and crying in pain. The daughter stated LPN #10 looked at the resident's record and stated she could have something for pain as she had not had anything for pain since she fell . The daughter stated the resident was administered something for pain around 8:20 p.m. The daughter stated the resident seemed to finally have some relief from the pain medication and she went home. She stated she was then notified around 10:40 p.m. by LPN #10 that the x-ray results came back and the resident had a hip fracture and was sent to the emergency room for evaluation and treatment. Resident #73's daughter stated the hospital informed her the resident had a heart attack and it was unable to be determined if it happened before the fall or after she fell . The daughter stated the hospital informed her the resident was too weak to recover from the injuries from the fall. Interview with Resident #73's physician (MD) #1 on 01/30/14 at 11:10 a.m. revealed she remembered being notified Resident #73 had fallen out of her Broda/geri-chair. MD #1 stated she did not order any pain medication as the resident already had Tylenol and Vicodin ordered for pain. MD #1 stated she informed the nurse to keep the resident comfortable. She stated when the x-ray result came back indicating Resident #73 had fractured her hip she left it up to the resident's daughter to decide if she wanted the resident sent out to the hospital for an evaluation and treatment. Review of facility's policy titled, Fall and Accident Prevention, dated 01/31/08 revealed the policy stated the facility must ensure the resident's environment remains as free of accident hazards as is possible. The facility will identify each resident who is at risk for falls and will plan care and implement interventions to prevent falls. The facility must ensure that each resident receives adequate supervision and assistive devices to prevent accidents. This certification deficiency substantiates Complaint Control Number OH 303.