Every finding on record at Woodland Country Manor Inc

Based on record review and staff interviews, the facility failed to ensure services were provided by a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all residents residing in the facility. The facility census was 52.Findings include:Review of the schedules and timecard punches from 10/21/25 to 12/01/25 revealed there was only documentation of hours for one RN (#378). RN #378 worked less than eight hours on 10/22/25, 10/26/25, 10/27/25, 10/29/25, 11/02/25, 11/03/25, 11/05/25, 11/06/25, 11/10/25, 11/13/25, 11/15/25, 11/16/25, 11/18/25, 11/20/25, 11/24/25, and 11/25/25.Interview on 12/01/25 at 3:39 P.M., the Administrator verified the facility had been unable to meet the requirements for RN coverage. The Administrator stated the facility only had one RN (#378) that was not salaried and part of management because of a lack of applications for the position.

Based on record review, staff interview and review of online resources from Centers for Disease Control (CDC), the facility failed to have a comprehensive Water Management Plan to assess, measure, monitor and prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. This had the potential to affect all 52 residents in the facility.Findings include: Review of the Water Flushing & Temperature Monitoring forms revealed in January 2025 one resident room (312) had the shower water ran for five minutes with a temperature of 101 degrees Fahrenheit (F) on 01/09/25, one resident room (104) had the sink water ran for six minutes with a temperature of 102 degrees F on 01/24/25, and one resident room (205) had the toileting flushed. Review of the Water Flushing & Temperature Monitoring forms revealed in February 2025 one resident room (104) had the sink water ran for four minutes with a temperature of 115 degrees F on 02/05/25, one resident room (210) had the sink water ran for seven minutes with a temperature of 112 degrees F on 02/13/25, and one resident room (304) had the sink water ran for six minutes with a temperature of 113 F degrees on 02/21/25. Review of the Water Flushing & Temperature Monitoring forms revealed in March 2025 Rooms #106, #205, #214, #315, #318 sinks and showers were flushed for five minutes and temperatures ranged from 110 to 112 degrees F. Review of the Water Flushing & Temperature Monitoring forms revealed in April 2025 the activities room sink was run for 11 minutes with a temperature of 111 degrees F on 04/01/25, the kitchen water was run for seven minutes with a temperature of 109 degrees F on 04/09/25. Review of the Water Flushing & Temperature Monitoring Forms revealed in May 2025 one resident room (510) had the shower water ran for six minutes with a temperature of 110 degrees F on 05/05/25, one resident room (302) had the sink water ran for five minutes with a temperature of 110 degrees F on 05/12/25, one resident room (214) had the sink water ran for eight minutes with a temperature of 112 degrees F on 05/19/25, and one resident room (106) had the shower water ran for four minutes with a temperature of 113 degrees F on 05/26/25. Review of the Monthly Flushing Logs revealed on 06/02/25 the 300 area / outlet was flushed, on 06/09/25 the 200 area / outlet was flushed, and on 06/23/25 the 100 area / outlet was flushed, on 07/03/25 the rehab area / outlet was flushed, on 07/16/25 the kitchen area / outlet was flushed, on 07/25/25 the activities area / outlet was flushed, on 08/04/25 the 300 area / outlet was flushed, on 08/11/25 the 200 area / outlet was flushed, on 08/18/25 the 100 area / outlet was flushed, 09/01/25 the 300 area / outlet was flushed, on 09/08/25 the 200 area / outlet was flushed, on 09/15/25 the 100 area / outlet was flushed, on 10/09/25 the office wing was flushed, and on 10/17/25 the conference room was flushed. Review of the facility's Infection Control Manual on 12/02/25 at 3:00 P.M., revealed no Water Management Plan to monitor and prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water systems. Interview on 12/02/25 at 3:12 P.M., Licensed Practical Nurse (LPN) #383 confirmed she is the Infection control nurse for the facility. LPN #383 verified the facility did not have a Water Management Plan in place to monitor and prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. Review of online resources from the CDC (https://www.cdc.gov/control-legionella/php/wmp/wmp-steps.html) titled Steps to Develop a Water Management Program revealed multi-step process that required continuous review. An approved plan consisted of the following seven steps to building an effective Legionella water management program: 1) Establish a Water Management Program team.2) .Describe the building water systems.3) Identify areas where Legionella could grow and spread4) Decide where to apply and how to monitor control measures.5) Establish interventions when control limits aren't met.6) Make sure the program runs as designed and is effective.7) Document and communicate all the activities.

Based on record review, staff interview, physician services interview, and policy review, the facility failed to complete thorough investigations following a resident's falls and do neurological (neuro) checks following a resident's fall. This affected one (Resident #57) of seven residents reviewed for accidents. The facility census was 52. Findings include: Review of the medical record for Resident #57 revealed an admission date of 12/27/22. Diagnosis included multiple fractures of pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. There was no documented history of seizures. Review of the Incidents Log dated 04/01/25 through 09/29/25, revealed Resident #57 had un-witnessed falls on 05/08/25, 05/09/25, 06/27/25, 06/30/25, 07/13/25, 07/14/25, and 08/15/25. Resident #57 had a witnessed fall on 08/31/25.Review of the Falls Report revealed Resident #57 had falls on 05/08/25, 05/09/25, 06/27/25, 06/30/25, 07/13/25, 07/14/25, and 08/15/25. Thorough investigations, neuro checks and fall assessments were not completed. There was also no Interdisciplinary Team (IDT) follow-up.Review of the Falls Report revealed Resident #57 had a fall on 07/14/25 at 4:45 A.M. when the resident was found on the floor lying beside her bed. Resident#57 was sent to the emergency room (ER) due to hip pain and diagnosed with a pelvic ring fracture. The fall intervention implemented was to educate the staff on placement of pressure alarms on the resident's wheelchair and bed. Resident #57 had an additional fall on 08/31/25 at 5:17 P.M. in the dining room where she fell from her wheelchair and was sent to the hospital. Following the fall on 08/31/25, a thorough investigation to determine a root cause analysis was not completed. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed resident had moderate cognitive impairment and was dependent on staff for assistance with oral hygiene, toileting hygiene, showering, personal hygiene, and transfers. Interview on 12/01/25 at 2:00 P.M., Director of Nursing (DON) stated Resident #57 had an unwitnessed fall from her bed on 07/14/25 and sustained a pelvic fracture. The intervention was to educate the staff on placement of pressure alarms on the resident's wheelchair and bed and for the alarms to be in place at all times. The DON stated Resident #57 fell out of her wheelchair in the dining room on 08/31/25 after suffering a seizure. The DON also confirmed there were no neuro checks completed following Resident #57's falls on 05/08/25, 05/09/25, 06/27/25, 06/30/25, 07/13/25, and 08/15/25. The DON also verified thorough investigations or fall assessments were not completed following the resident's falls. Interview on 12/01/25 at 2:15 P.M., LPN #375 stated when Resident #57 fell out of her bed on 07/14/25 at 4:45 A.M., the pressure alarm was not in place. LPN #375 stated Resident #57 was sent to the ER and found to have a pelvic fracture. Interview on 12/02/25 at 10:02 A.M., Nurse Practitioner (NP) #395 stated Resident #57 was a very high fall risk, and the pressure alarms were to be used to try and prevent falls. NP #395 stated neuro-checks should be completed on any un-witnessed falls and if the resident was unable to say what happened. Interview on 12/02/25 at 10:37 A.M., the DON verified Resident #57 had an unwitnessed fall in the dining room on 08/31/25 and she did not get witness statements from any of the employees. The DON stated she completed the incident report instead of the nurse who was working at the time of the fall. The DON stated she noted the resident had a seizure, then fell, but she has no documented evidence confirming the resident had a seizure which caused the fall. Interview on 12/02/25 at 10:50 A.M., Certified Nursing Assistant (CNA) #300 stated she was working the evening of 08/31/25 when Resident #57 fell in the dining room. CNA #300 stated she was not in the dining room when the resident fell, but she heard the alarms going off and the dietary staff yelling. CNA #300 stated when she arrived in the dining room, the resident was on the floor having a seizure. Interview on 12/02/25 at 12:21 P.M. LPN #356 stated she was the nurse on duty on 08/31/25 when Resident #57 fell from her wheelchair in the dining room. LPN #356 stated Dietary Staff #386 told her Resident #57 stood up, was shaking, and fell to the ground. Review of the Fall and Incident Protocol dated 04/01/25, revealed when a fall occurs, a resident will be assessed for injuries prior to moving resident, neuro checks will be started if assessment indicates resident hit their head, and physician will be notified of the fall and related injuries.Review of the Fall Policy dated 06/01/25, revealed residents will be safe and free of injury while allowing residents to be as mobile as they choose. After a resident's fall a fall evaluation will be completed in the risk management system, cranial checks will be initiated if indicated, and a new fall intervention will be initiated.

Based on record review, review of a Self-Reported Incident (SRI) and investigation, policy review, resident and staff interviews, and observations, the facility failed to ensure staff provided adequate supervision to prevent a resident from leaving the facility unsupervised and failed to conduct a thorough investigation into the resident's elopement. This affected one (Resident #27) of three residents reviewed for elopement. The facility identified 11 residents at risk for elopement. The facility census was 51. Findings include: Record review for Resident #27 revealed the resident was admitted to facility on 03/13/25. Diagnoses included dementia, delirium, insomnia, depression, and auditory hallucinations. Review of the physician orders dated 03/14/25 revealed Resident #27 was to wear a wanderguard to the left ankle. Review of the care plan dated 03/18/25 revealed Resident #27 was an elopement risk/wanderer due to disoriented to place, impaired safety awareness, and wandered aimlessly. The goals were for Resident #28 will not leave the facility unattended and the resident's safety will be maintained. Interventions included to distract the resident from wandering, provide structured activities, and the resident's triggers for wandering/eloping are wanting to go back home. The resident's behavior is de-escalated by one-to-one talks and walking the halls with her, and wander alert device. On 05/17/25, a new intervention was implemented to have dietary staff lock the dining room windows and pull blinds before leaving at 7:00 P.M. On 05/19/25, a new intervention was implemented to add motion detector in bedroom window sill. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 suffered with sleep disturbance, being short tempered, and a history of wandering. Resident #27 had impaired cognition. Review of the elopement risk assessment dated [DATE] revealed Resident #27 was at risk for elopement. Review of the progress note dated 05/16/25 revealed staff discovered Resident #27 missing from her room around 2:00 A.M. during resident checks. Staff were able to locate Resident #27 outside of the building, wearing a wander guard monitoring device, in a parking lot next to the facilities assisted living (AL) unit around 2:45 A.M. Resident #27 willingly returned to facility with Certified Nursing Assistant (CNA) #50. Review of the facilities SRI and investigation dated 05/16/25 revealed there was an allegation of neglect reported to the State Survey Agency. Resident #27 was found outside the facility and the facility suspected that no alarms sounded. Allegedly, Resident #27 went out the dining room window. The facility's investigation only had two witness statements which were from Licensed Practical Nurses (LPN) #11 and #21. The facilities investigation did not include specific times Resident #27 was last seen or details of how the resident was found. There were no specific identifications of staff involved in the incident. There were no other staff interviews who were working the evening and night shift. There was no evidence the dining room window was assessed on how the resident could elope using that window, and/or an assessment of the windows throughout the facility, and any new interventions on prevention of other residents eloping from the dining room window, and/or other windows of the facilities. Review of the nursing schedules revealed CNAs #63, #66, #60, #68, #49, and #50 worked on 05/16/25 at 2:00 A.M. and there was no evidence the staff had been interviewed or witness statements obtained. Interview on 05/28/25 at 9:17 A.M. with Resident #27 revealed she had left the facility a few days ago by climbing out a low window. Resident #27 stated her brothers had arranged the plan for her to meet them, prompting her to leave the facility. Resident #27 stated she got into her brother's car and put her coat inside the car. Resident #27 stated her medical doctor found her outside the facility and assisted her back into the building. Observation of the dining room windows on 05/28/25 at 9:20 A.M. revealed the window which Resident #27 used to get outside of the facility was closed and locked. The window was unlocked and opened by the Administrator, and the screen easily removed. The Administrator verified Resident #27 could have opened the locked window and exited through the open window as the window was large enough and could be easily unlocked. Interview on 05/28/25 at 11:35 A.M. with the Director of Nursing (DON) stated the DON was notified of Resident #27's elopement the morning of 05/16/25. The DON confirmed Resident #27 had left the building early in the morning 05/16/25 via window in the dining room. The DON stated Resident #27 had a history of having long periods of being awake, wandering and exit seeking, then sleeping for long periods of time. The DON stated Resident #27 regularly expresses her desire to return home and has a history of attempts to leave the facility. Interview on 05/28/25 at 11:51 A.M. with Social Services (SS) #91 revealed the investigation had been done by herself under the direction of the Administrator who was training her on doing an investigation of an elopement. SS #91 confirmed she only obtained two LPN (#11 and #21) witness statements regarding the events leading up to and including finding Resident #27. SS #91 denied she interviewed or obtained witness statements from any other staff. Interview on 05/28/25 at 12:05 P.M. with LPN #7 stated Resident #27 was continually packing her things and saying she was leaving to go home. LPN #7 stated Resident #27 was exit seeking throughout most days, with staff intervening to keep her in the building or bring her back in the building when she gets out an exit door. Interview on 05/28/25 at 12:57 P.M. with CNA #63 stated Resident #27 left the building in the early morning on 05/16/25, without an alarm sounding to alert staff that she was outside. CNA #50 found Resident #27 in the parking lot behind the facilities AL unit on 05/16/25 around 2:45 A.M. CNA #63 confirmed once Resident #27 returned to the facility, Resident #27 was able to lead them to the window which she used to get out of the facility. CNA #63 stated she had provided SS #91 a statement about the situation several days after the incident and was not interviewed. Interview on 05/28/25 at 12:58 P.M. with CNA #68 stated she last observed Resident #27 at 1:30 A.M. wandering in the hallways with her coat, which was common. At rounding at 2:00 A.M., Resident #27 was not in her room. CNA #68 stated she assisted with inside room searches. Resident #27 returned inside of the facility without injuries at around 3:00 A.M. CNA #68 stated she had not been interviewed by any manager. Interview on 05/28/25 at 1:17 P.M. with CNA #66 stated Resident #27 was in the hallway around 2:00 A.M. and had was found by CNA #50 around 3:00 A.M. in the parking lot. CNA #66 assisted in searching the facility and observed Resident #27 returning into the facility with CNA #50. Resident #27 was self-ambulating and had no visible injuries. CNA #66 stated she a had not been interviewed by the managers and not documented her observations of 05/16/25. Interview on 05/28/25 at 1:30 P.M. with CNA #50 stated Resident #27 was walking around the hallway at 2:00 A.M., which was usual for Resident #27. CNA #50 stated Resident #27 was not in her room at about 2:30 A.M. and began the inside search and then began outside search. The weather was cool and not raining. Resident #27 was found around 3:00 A.M. in the facilities AL parking lot near an employee car, standing with the car door slightly opened. Resident #27's coat was in the passenger seat. Resident #27 ambulated back into the facility without difficulty and there were no apparent injuries or complaints of pain. CNA #50 stated she had submitted a written statement to SS #91. It was discovered the dining room window was opened, and the screen had been put back in position. Interview on 05/28/25 at 1:11 P.M. with Maintenance Director #92 stated he had been unaware of the elopement situation involving Resident #27 until recently and he had no discussions about window security with other managers at the time of the elopement. Maintenance Director #92 verified a resident could unlock the top window locking mechanism and climb through the larger dining room windows. Review of the facility's policy titled Elopement Policies and Procedures dated 02/26/25 revealed the facilities staff are to immediately implement policies and procedures for locating a resident in a timely manner in the event of elopement A complete and thorough investigation of the elopement along with an accident /incident report are to be completed in a timely manner. This deficiency represents non-compliance investigated under Control Number OH00165841.

Based on review of personal files and staff interview, the facility failed to ensure nurse aides working in the facility did not work for greater than four months without becoming a State tested Nursing Assistant. This had the potential to affect all the residents residing in the facility. The census was 57. Findings include: Review of the personnel file for Nursing Assistant (NA) #50 revealed employee was hired 06/01/15 and had not taken the nurse aide test. Review of the personnel file for NA #70 revealed employee was hired 01/27/18 and was scheduled to take the nurse aide test on 02/28/20. Review of the personnel file for NA #20 revealed employee was hired 03/25/19 and was scheduled to take the nurse aide test on 02/28/20. Review of the personnel file for NA #170 revealed employee was hired 05/16/19 and had not taken the nurse aide test. Interviews on 02/06/20 at 6:12 [NAME]M. with NA #70 and at 6:14 [NAME]M. with NA #20 confirmed they had worked at the facility as nursing assistants on the skilled side of the building for over four month, and they had passed the nurse aide class but had not yet passed the nurse aide test. Interview on 02/06/20 at 1:17 P.M. with the Administrator confirmed NAs #20, #50, #70, and #170 had worked in the facility as nursing assistants on the skilled nursing side of the building for over four months but had not passed the nurse aide test. The Administrator confirmed this had the potential to affect all 57 residents residing in the facility. This deficiency substantiates Complaint Number OH 721.

Based on medical record review, review of self-reported incidents (SRI's), staff interview, and review of facility policy, the facility failed to protect other residents from resident to resident physical abuse during an abuse investigation. This affected one (#6) of two SRI's reviewed and had the potential to affect the 24 other residents residing on the 300 Hall (#3, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30). The facility census was 57. Findings include: Review of the medical record for Resident #6 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #6 dated 08/27/19 revealed resident was cognitively impaired, was totally dependent on the assistance of two staff for bed mobility and transfers and was coded as negative for the presence of behaviors. Review of the nurse progress note for Resident #6 dated 08/11/19 revealed another resident (Resident #7) was yelling and pushed herself in her wheelchair up to Resident #6 and was swatting resident with her hands making contact with her face. Review of the medical record for Resident #7 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS for Resident #7 dated 12/16/19 revealed resident was cognitively impaired and required extensive assistance with activities of daily living. Review of nurse progress note for Resident #7 dated 08/11/19 revealed resident was in the lobby yelling and wheeled herself up to another resident (Resident #6) swatting her face and making contact twice. Review of plan of care for Resident #7 last updated 10/02/19 revealed resident had a self-care performance deficit related to aggressive behavior, confusion, and impaired balance. The following intervention was added to Resident #7's care plan on 08/11/19: if resident is agitated and yelling move her away from other residents. Review of facility SRI dated 08/12/19 revealed the facility reported an allegation of resident to resident physical abuse which occurred on 08/11/19 at approximately 11:00 [NAME]M. in the morning when Resident #7 hit Resident #6 in the face. Further review of the SRI revealed the facility substantiated physical abuse and as a result the facility educated staff all staff on the agitation of the perpetrator (Resident #7). Further review of SRI revealed staff were educated to remove Resident #7 from the area and should see if a staff member or activity person can calm or entertain the resident. Interview on 02/06/20 at 2:03 P.M. with the Administrator confirmed the facility investigated the resident to resident altercation between Resident #6 and Resident #7 and had substantiated physical abuse on the part of Resident #7 towards Resident #6. Further interview with the Administrator confirmed the facility had no documentation of the staff education regarding responding to Resident #7's agitation and the facility had not provided any additional education to staff on abuse prevention following the incident of substantiated abuse. Administrator confirmed the facility had not implemented any increased monitoring of Resident #7 during the abuse investigation such as one-on-one (1:1) supervision or every 15-minute checks. The Administrator confirmed this had the potential to affect 24 other residents residing on the 300 Hall (#3, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30) where Resident #7 resided. Review of facility policy titled Abuse Prohibition Policy dated 08/06/19 revealed the facility would protect residents from abuse from anyone, including other residents and would protect residents involved in a case of suspected abuse from potential additional harm. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, review of self-reported incidents (SRI's) staff interview, and review of facility policy, the facility failed to prevent resident to resident physical abuse. This affected one (#6) of two SRI's reviewed. The facility census was 57. Findings include: Review of the medical record for Resident #6 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #6 dated 08/27/19 revealed resident was cognitively impaired, was totally dependent on the assistance of two staff for bed mobility and transfers and was coded as negative for the presence of behaviors. Review of the nurse progress note for Resident #6 dated 08/11/19 revealed another resident (Resident #7) was yelling and pushed herself in her wheelchair up to Resident #6 and was swatting resident with her hands making contact with her face. Review of the medical record for Resident #7 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS for Resident #7 dated 12/16/19 revealed resident was cognitively impaired and required extensive assistance with activities of daily living. Review of nurse progress note for Resident #7 dated 08/11/19 revealed resident was in the lobby yelling and wheeled herself up to another resident (Resident #6) swatting her face and making contact twice. Review of plan of care for Resident #7 last updated 10/02/19 revealed resident had a self-care performance deficit related to aggressive behavior, confusion, and impaired balance. The following intervention was added to Resident #7's care plan on 08/11/19: if resident is agitated and yelling move her away from other residents. Review of facility SRI dated 08/12/19 revealed the facility reported an allegation of resident to resident physical abuse which occurred on 08/11/19 at approximately 11:00 [NAME]M. in the morning when Resident #7 hit Resident #6 in the face. Further review of the SRI revealed the facility substantiated physical abuse and as a result the facility educated staff all staff on the agitation of the perpetrator (Resident #7). Further review of SRI revealed staff were educated to remove Resident #7 from the area and should see if a staff member or activity person can calm or entertain the resident. Interview on 02/06/20 at 2:03 P.M. with the Administrator confirmed the facility investigated the resident to resident altercation between Resident #6 and Resident #7 and had substantiated physical abuse on the part of Resident #7 towards Resident #6. Further interview with the Administrator confirmed the facility had no documentation of the staff education regarding responding to Resident #7's agitation and the facility had not provided any additional education to staff on abuse prevention following the incident of substantiated abuse. Review of facility policy titled Abuse Prohibition Policy dated 08/06/19 revealed the facility would protect residents from abuse from anyone, including other residents. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, review of self-reported incidents (SRI's), staff interview, and review of facility policy, the facility failed to report an allegation of resident to resident physical abuse in a timely manner. This affected one (#6) of two SRI's reviewed. The facility census was 57. Findings include: Review of the medical record for Resident #6 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #6 dated 08/27/19 revealed resident was cognitively impaired, was totally dependent on the assistance of two staff for bed mobility and transfers and was coded as negative for the presence of behaviors. Review of the nurse progress note for Resident #6 dated 08/11/19 timed at 11:00 [NAME]M. revealed another resident (Resident #7) was yelling and pushed herself in her wheelchair up to Resident #6 and was swatting resident with her hands making contact with her face. Review of the medical record for Resident #7 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS for Resident #7 dated 12/16/19 revealed resident was cognitively impaired and required extensive assistance with activities of daily living. Review of nurse progress note for Resident #7 dated 08/11/19 timed at 11:00 [NAME]M. revealed resident was in the lobby yelling and wheeled herself up to another resident (Resident #6) swatting her face and making contact twice. Review of plan of care for Resident #7 last updated 10/02/19 revealed resident had a self-care performance deficit related to aggressive behavior, confusion, and impaired balance. Interventions included the following: if resident is resisting care, stop if able and return later with a different caregiver, if resident is agitated and yelling move her away from other residents. Review of facility SRI initial report dated 08/12/19 timed at 2:09 P.M. revealed the facility reported an allegation of resident to resident physical abuse which had occurred on 08/11/19 at approximately 11:00 [NAME]M. in the morning when Resident #7 hit Resident #6 in the face. Interview on 02/06/20 at 2:03 P.M. with the Administrator confirmed the facility the allegation of resident to resident physical abuse between Residents #6 and #7 occurred on 08/11/19 at approximately 11:00 [NAME]M. but was not reported to the state agency until 2:00 P.M. on 08/12/19. Review of facility policy titled Abuse Prohibition Policy dated 08/06/19 revealed the facility would report allegations of abuse to the state agency within 24 hours. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and review of facility policy, the facility failed to implement their policy by conducting an investigation and follow up for a resident who eloped from the facility. This affected one (#3) of three residents reviewed for elopement. The census was 57. Findings include: Review of the medical record for Resident #3 revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #3 dated 11/06/19 revealed the resident was cognitively impaired, not coded for wandering, and required extensive assistance of two staff with transfers but used a wheelchair for mobility and was self-sufficient once in her chair. Review of the care plan for Resident #3 dated 09/05/19 revealed resident had impaired cognitive functioning. Interventions included the following: provide supervision with decision making, cue, reorient and supervise as needed, keep routine consistent. Review of the elopement risk screening assessment for Resident #3 dated 01/23/20 revealed resident was not at risk for elopement. Review of the nurse progress note for Resident #3 dated 01/24/20 timed at 1:30 P.M. revealed the resident got out into the parking lot and was redirected back inside. Review of clinical dashboard notes in the electronic medical record dated 01/24/20 revealed a note from Licensed Practical Nurse (LPN) #10 indicating Resident #3 had gotten outside and staff should monitor her to prevent recurrence. Review of the shift to shift report sheet for the facility dated 01/25/20 revealed Resident #3 had an elopement attempt on 01/24/20 and staff should monitor if resident tries to go outside. Review of the nurse progress note for Resident #3 dated 01/26/20 timed at 2:10 [NAME]M. revealed resident exhibited no exit seeking behaviors. Review of the medical record for Resident #3 revealed the resident's elopement risk assessment was not updated following the elopement attempt, the resident's care plan was not reviewed and updated as needed, and there was no investigation regarding the elopement on 01/24/20. Interview on 02/06/20 at 946 [NAME]M. with the Administrator confirmed there had been no recent resident elopements from the facility in the past three months to her knowledge. Interview on 02/06/20 at 9:56 [NAME]M. with the Administrator confirmed she was not aware of Resident #3's elopement from the facility on 01/24/20 until 02/06/20. Interview on 02/06/20 at 10:00 [NAME]M. with Licensed Practical Nurse (LPN) #80, the Assistant Director of Nursing (ADON) confirmed she was aware of Resident #3's elopement on 01/24/20. LPN #80 confirmed the facility had not investigated the incident or reassessed the resident for elopement risk or reviewed and updated the resident's care plan. Interview on 02/06/20 at 10:20 [NAME]M. with State tested Nursing Assistant (STNA) #30 confirmed Resident #3 was found out in the parking lot on 01/24/20. STNA #30 further confirmed Resident #3 can propel herself in her wheelchair and she saw someone bringing her back into the building on 01/24/20 sometime after lunch following the elopement attempt. STNA #30 could not recall who assisted Resident #3 back into the building. Interview on 02/06/20 at 10:43 [NAME]M. with LPN #10 confirmed Resident #3 was able to propel herself in her wheelchair and on 01/24/20 at approximately 1:20 P.M. a vendor wheeled Resident #3 into the building from the parking lot and informed the nurse she had found the resident unattended outside. LPN #10 confirmed she could not recall the name of the vendor and she reported the incident to the Director of Nursing (DON). Review of facility policy titled Elopement undated revealed staff observing a confused or wandering resident attempting to leave the premises should attempt to prevent departure and should the attempt fail staff member should obtain assistance of other staff to return the resident. Upon return of the resident to the facility the facility will complete a thorough investigation of the elopement in order to prevent future occurrences. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on review of the daily posted staffing information, observation, and staff interview, the facility failed to post the current daily staffing information in a prominent location visible and accessible to residents, staff, and visitors. This had the potential to affect all the residents residing in the facility. The census was 57. Findings include: Review of the daily posted staffing information revealed the staffing was posted for 02/05/20. Observation of the daily posted staffing information on 02/06/20 at 9:27 [NAME]M. with Licensed Practical Nurse (LPN) #80 revealed the staffing information was hanging on a billboard in the nurses' station and was located at a height of approximately seven feet from the ground. Interview on 02/06/20 at 9:27 [NAME]M. with LPN #80 confirmed the daily posted staffing information did reflect the current date nor was it posted in a location visible and easily accessible to residents, staff, and visitors. The facility confirmed this had the potential to affect all 57 residents residing in the facility. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on review of the facility's Legionella plan and staff interview, the facility failed to implement the Legionella water plan. This had the potential to affect all 60 resident of the facility. Findings include: Review of the facility Legionella plan revealed the facility would monitor the water sources for potential areas of Legionella growth through chlorine testing, routine testing of water temperatures, monitoring and flushing pipes in rooms and or areas of the building which were are not in use, and the motoring of decorative fountains and water fountains for use and evidence of debris and bioilm. Interview with the Administrator on 05/09/19 at 11:25 A.M., confirmed the facility was not doing any testing/monitoring for Legionella. The Administrator revealed the facility was working with outside resources to better understand the process to ensure compliance with the program.

Based on observation and staff interview, the facility failed to secure biohazards from resident access. This had the potential to affect nine (#2, #3, #7, #16, #19, #23, #31, #43, and #53,) the facility identified as independently ambulatory and having the dexterity to open doors on the 100/200 Hall. The facility census was 57. Findings Include: Observation on 04/24/18 at 3:45 P.M. of the Server Storage Room in the breezeway between 100/200 Hall and the 500 Hall revealed the door was unsecured/unlocked and unmarked. Inside the room was one full bio-hazard box that was taped shut and one opened bio-hazard box that contained a full closed sharps container. Interview with Administrative Staff #1 on 04/24/18 at 4:01 P.M. verified the room was unsecured/unlocked and the room contained biohazard storage. The facility identified nine residents (#2, #3, #7, #16, #19, #23, #31, #43, and #53,) were independently ambulatory and able to open the storage room door who resided on the 100/200 Hall.

Based on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to complete an assessment of the ability to self administer medications for one (#207) out of seven residents screened. The total facility census was 57. Findings Include: Review of Resident #207's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of Resident 207's medical record revealed no documentation the resident was assessed as safe to self administer medications. Review of nurses notes from 04/20/18 to present revealed no documentation Resident #207 had been screened for safe self medication administration or had received education regarding safe self administration of medication. Observation on 04/23/18 at 1:49 P.M. of Resident #207's room revealed a bottle of antacid liquid at the bedside. Interview on 04/23/18 at 1:49 P.M., Resident #207 stated his/her son brought in the antacid and he/she takes it whenever he/she wants. Interview with Licensed Practical Nurse (LPN) #66 on 04/23/18 at 1:55 P.M. verified Resident #207 had an order to keep the [MEDICATION NAME] at the bedside. Interview on 04/25/18 at 4:15 P.M., Licensed Social Worker (LSW) #30 and LPN #17 revealed the LSW typically completes a self administration of medication assessment with residents who are wanting to self administer medications. LSW #30 verified she has not completed a self administration assessment in a long time at the facility. LPN #17 verified Resident #207 was self administering [MEDICATION NAME]. LSW #30 verified she was not informed of this and had not performed a self administration assessment on the resident. Review of the policy titled Bedside Medication and Self-Administration of Medications revealed Each resident who desires to self-administer medication will be permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. The policy indicated each resident was offered the opportunity to self-administer his/her medications during the routine assessment by the facility's interdisciplinary team (IDT). If the resident desires to self-administer medications, an assessment is conducted by the IDT of the resident's cognitive, physical and visual ability to carry out this responsibility. The results of the IDT assessment are recorded on the Medication Self-Administration Assessment form, which is placed on the resident's medical record.

Based on record review, obervation, and staff interview, the facility failed to notify the family and physician when a pressure ulcer went from a stage II ulcer to an unstageable ulcer for one (#210) of two residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The total facility census was 57. Findings include: Review of Resident #210's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment, dated 04/02/18, revealed the resident had cognitive impairment. The resident had three stage II pressure ulcers present on admission. Review of skin wound notes provided, dated 04/07/18, revealed the resident was admitted with three stage II pressure ulcers. The area to the left inner buttock measured 2.0 centimeters (cm) by 0.5 cm with a pink superficial tissue wound bed. The right inner buttock measured 0.3 cm by 2.0 cm with pink superficial tissue wound bed. The coccyx ulcer measured 0.8 cm by 0.1 cm with red superficial wound bed. The note indicated a treatment of [REDACTED]. Review of skin wound note dated 04/17/18 revealed the coccyx pressure ulcer was 1.0 cm by 0.1 cm with white slough covering 100% of wound bed. The coccyx wound was classified as unstageable. The note indicated to continue Derma Med as ordered. The note does not indicate the physician or family was notified of the change in the status of the coccyx wound. Observation on 04/26/18 at 10:20 A.M. revealed Registered Nurse (RN) #76 performing wound care to Resident #210's pressure ulcers. The inner buttock wounds, both right and left, were superficial in nature with pink wound beds. The coccyx wound was observed to have a pink peri wound with a wound bed that was a light white color. No slough was observed in the wound bed. Interview on 04/26/18 at 11:43 A.M., Licensed Practical Nurse #19 verified the medical record had no evidence the family and physician were notified of the coccyx wound being assessed by the facility as unstageable on 04/17/18.

Based on medical record review and staff interview, the facility failed to accurately code Minimum Data Set assessment to identify a fall with injury, contractures, and hospice services for three (#33, #45 and #35) of 22 residents reviewed in the final sample. The facility census was 57. Findings include: 1. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] with a fractured femur. Review of the nurse's notes dated 02/03/18 indicated Resident #33 was found on the floor of the room next to the bed on his/her back screaming out in pain. The resident stated he/she was trying to transfer from the bed to the wheelchair. The resident was transferred to the hospital and found to have a left femur fracture. Review of the Minimum Data Set (MDS) assessment, dated 03/07/18, did not indicate Resident #33 had a fall resulting in a fracture. Interview on 04/24/18 at 5:18 P.M., the Assistant Director of Nursing (ADON) #17 verified the resident's fall with fracture was not coded on the MDS assessment of 03/07/18. 2. Review of Resident #45's medical record revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 03/19/18, assessed the resident as having severe cognitive impairment. The MDS indicated the resident had no impairment in functional limitation in range of motion. Review of a physical therapy assessment dated [DATE] indicated the resident had impaired range of motion in both lower extremities. Review of a Rehabilitation/Restorative Service Delivery Record, dated 04/12/18, indicated the resident's legs were so contracted the staff could hardly put on his moon boots and it was hard to stretch out his leg without knowing if you were hurting in him. Interview on 04/26/18 at 2:00 P.M., ADON #17 verified she did not code Resident #45's as having contractures on the 03/19/18 MDS assessment. ADON # 17 further stated she codes contractures if the resident has a [DIAGNOSES REDACTED]. ADON #17 stated she never physically assessed Resident #45 herself. 3. Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Hospice services were in place at the time of the admission. Review of the MDS assessment, dated 02/26/18, was not coded to indicate hospice services were being provided at the time of the time of assessment. Interview on 04/25/18 at 1:55 P.M., Licensed Practical Nurse (LPN) #17 verified hospice services were not coded on Resident #25's MDS assessment dated [DATE].

Based on record review, resident interview, and staff interview, the facility failed to develop a plan of care to address for pain for one (#33) of five individuals reviewed for unnecessary medications. The census was 57. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] with a fractured femur. The resident had physician orders [REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 03/07/18, indicated the resident had moderately impaired cognitive skills and had pain frequently. Review of the Medication Administration Record [REDACTED]. Review of the current plan of care did not contain any focus to address the resident's pain. Interview on 04/23/18 at 11:56 A.M., Resident # 33 stated she was having pain. Interview on 04/26/18 at 12:14 P.M., Licensed Practical Nurse (LPN) #19 verified Resident #33's plan of care did not address her pain.

Based on record review, observation, and staff interview, the facility failed to provide treatments to pressure ulcers for one (#210) of two residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The facility census was 57. Findings Include: Review of Resident #210's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment, dated 04/02/18, revealed the resident had cognitive impairment. The resident had three stage II pressure ulcers present on admission and pressure ulcer care. Review of resident skin assessment, dated 04/02/18, revealed the resident had open areas present on the inner buttock and coccyx. Review of the physician orders [REDACTED]. On 04/06/18 Derma Med cream (skin protectant cream) was ordered to the right and left inner buttock. Review of Resident #210's Treatment Administration Record (TAR) revealed no treatments were completed to the inner right or left buttock until 04/06/18, four days after the resident was admitted to the facility with the pressure ulcers present. The TAR had no documentation of any treatment to the resident's coccyx pressure ulcer. Review of skin wound notes provided, dated 04/07/18, revealed the resident was admitted with three stage II pressure ulcers. The area to the left inner buttock measured 2.0 centimeters (cm) by 0.5 cm with a pink superficial tissue wound bed. The right inner buttock measured 0.3 cm by 2.0 cm with pink superficial tissue wound bed. The coccyx ulcer measured 0.8 cm by 0.1 cm with red superficial wound bed. The note indicated a treatment of [REDACTED]. The note documented the family and physician were notified. Review of the skin wound note dated 04/11/18 revealed the area to the left inner buttock measured 1.6 cm by 0.5 cm with a pink superficial tissue wound bed. The right inner buttock measured 0.3 cm by 2.0 cm with pink superficial tissue wound bed. The coccyx ulcer measured 1.0 cm by 0.1 cm with red superficial wound bed. The note indicates to continue with Derma Med as ordered. Review of skin wound note dated 04/17/18 revealed the coccyx pressure ulcer was 1.0 cm by 0.1 cm with white slough covering 100% of wound bed. The coccyx wound was classified as unstageable. The note indicated to continue Derma Med as ordered. The note does not indicate the physician or family was notified of the change in the status of the coccyx wound. Review of Resident #210's physician orders [REDACTED]. Observation on 04/26/18 at 10:20 A.M. revealed Registered Nurse (RN) #76 performing wound care to Resident #210's pressure ulcers. The inner buttock wounds, both right and left, were superficial in nature with pink wound beds. The coccyx wound was observed to have a pink peri wound with a wound bed that was a light white color. No slough was observed in the wound bed. Interview on 04/25/18 at 3:15 P.M., RN #76 verified there was no documented initiation of treatment to the resident's left and right buttock wounds from admission until 04/06/18. RN #76 verified there was no documented evidence of any treatment performed to Resident #201's coccyx. Interview on 04/25/18 at 3:30 P.M., Licensed Practical Nurse #19 stated the Derma Med was a house order and would not have required a written order for use. LPN #19 stated the staff would just document the Derma Med treatment on the TAR. LPN #19 verified the Derma Med was not documented as being applied to Resident #210's coccyx pressure ulcer. LPN #19 also verified the Derma Med was not documented as being applied to the right and left buttock pressure ulcers until 04/06/18.

Based on record review and staff interview, the facility failed to follow physician orders [REDACTED].#33) of five residents review for unnecessary medications. The facility census was 57. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] with a fractured femur. Review of physician orders [REDACTED].>The medical record indicated from 03/01/18 through 04/25/18 the resident had only had her vital signs, including blood pressure measurements, taken once per month. Interview on 04/25/18 at 12:25 P.M., Licensed Practical Nurse (LPN) #19 verified the resident's weekly blood pressure measurement were not taken. LPN #19 stated this must have been missed during the monthly change over.

Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five percent. This resulted in four medication errors of 36 opportunities, resulting in a 11.11% medication error rate. This affected two (#43 and #80) of five residents observed during medication administration. The facility census was 54. Findings include: Observation of the medication administration on 02/22/17 at 7:37 A.M. with Licensed Practical Nurse (LPN) #15. Resident #43 was observed receiving the medication Potassium Chloride 10 milliequivants (meq) ER (Electrolyte supplement). Review of Resident's #43's medications orders revealed Potassium Chloride 10 meq was not ordered in the care of Resident #43. Additionally Resident #43 was ordered to receive [MEDICATION NAME] 10 milligram (mg) during the morning medication pass that which was omitted by LPN #15 on 02/22/17 during the morning medication pass. Observation of Resident #80's morning medication administration completed by LPN #15 at 7:58 A.M. revealed the resident received [MEDICATION NAME] 10 mg (anti-depressant medication) one tablet, and [MEDICATION NAME] 10 mg, two tablets (Urinary [MEDICATION NAME] agent). Review of Resident #80's medical record reveled the resident was ordered to receive [MEDICATION NAME] 40 mg at the morning medication pass, and [MEDICATION NAME] 10 mg one tablet at the morning medication pass. Interview with LPN #15 on 02/22/17 at 9:35 A.M.,verified Resident #43 received Potassium Chloride 10 meq ER in error and did not receive [MEDICATION NAME] 10 mg as ordered during the morning medication pass on 02/22/17. LPN #15 also verified Resident #80 received two [MEDICATION NAME] 10 mg tablets instead of the ordered one tablet, and Resident #80 received [MEDICATION NAME] 10 mg instead of the ordered [MEDICATION NAME] 40 mg during the morning medication pass on 02/22/17.

Based on observation and staff interview, the facility failed to have correct staffing information posted and the posting was not accessible to visitors and residents. This had the potential to affect all 54 of 54 residents residing in the facility. Findings include: Observation during the initial tour of the facility completed on 02/21/17 at 9:15 A.M. revealed the nursing staffing information was unable to be located. The Administrator was asked where the staffing information posting was located and she stated it was at the nurses station by the time clock. Observation on 02/21/17 at 9:35 A.M. of the 100/200 nursing station and the time clock revealed the staffing posting was not able to be located. The Director of Nursing (DON ) was asked at that time where the staffing posting was kept, and she opened the cabinet door above the desk next to the time clock and removed a form. The form was titled Daily Staffing, with the current date on the form, however, there was no census, no facility name nor were the hours of care provided by each nursing discipline listed on the form. The form had the hallways listed and the nurses and State tested Nursing Assistants (STNA) names and the shift they work. Interview with the DON on 02/21/17 at 9:35 A.M., verified the staffing posting was inside the cabinet and not easily accessible for visitors or residents to view, and the hours each staff member worked were not on the form, and the form did not include all the required elements.