Every finding on record at Alois Alzheimer's Care Center

Based on medical record record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report allegations of abuse to the state agency in a timely manner, This affected three (Residents #19, Resident #29 and Resident #42) of three residents investigated for abuse. The facility census was 87 residents. Findings include: 1.Review of the medical record for Resident #29 revealed an admission date of 02/02/25 with diagnoses including Alzheimer's Disease, depression, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 06/17/26 revealed the resident had severe cognitive impairment required moderate to maximum staff assistance with activities of daily living (ADLS). Review of the facility SRI for Resident #29 dated 05/28/29 at 3:39 P.M. revealed staff witnessed and reported an allegation of physical abuse per Certified Nursing Assistant (CNA) #451 towards Resident #29 which occurred on 05/27/26. Interview on 06/30/26 at 11:57 A.M. with Licensed Practical Nurse (LPN) #425 confirmed on 05/27/26 in the common area at dinner time she witnessed CNA #451 pull Resident #29 up roughly by the resident's arms with the resident demonstrating some resistance to CNA #451's intervention. LPN #425 stated she reported the incident to Scheduler #573 on 06/30/26 around 6:45 P.M. Interview on 06/30/26 at 3:06 P.M. with Scheduler #573 confirmed LPN #425 notified her on 05/27/26 of an incident of rough handling per CNA #451 towards Resident #29. Scheduler #573 stated she notified the Director of Nursing (DON) by phone of the incident of rough handling per CNA #451 towards Resident #29. Scheduler #573 moved CNA #451's assignment to a different unit. Interview on 06/30/26 at 3:40 P.M with the DON confirmed Scheduler #573 called her at dinner time but cannot recall Scheduler #573 sharing any abuse concerns with her. The DON verified CNA #451 was allowed to complete her shift on 05/27/26 after the incident involving Resident #29 and was also allowed to return to work on 05/28/26 at 7:00 A.M. The DON stated Human Resources suspended CNA #451 on 05/28/26 at 9:58 A.M. Interview on 07/01/26 at 3:36 P.M. with the Administrator on 07/01/26 at 3:36 P.M. confirmed staff did not report the allegation of abuse per CNA #451 towards Resident #29 on 05/27/26. The Administrator stated Scheduler #573 reported the incident to him during morning rounds on 05/28/26 and he immediately spoke with the DON and the Human Resource Manager (HRM) and had CNA #451 brought in and suspended. The Administrator verified the facility did not report the allegation of abuse per CNA #451 towards Resident #29 on 05/27/26 until 05/28/26 at 3:39 P.M. 2. Review of medical record for Resident #42 revealed as admitted to facility on 06/26/24 with diagnoses including frontal temporal dementia, conversion disorder, and Lewy body dementia. Review of the MDS assessment for Resident #42 dated 06/11/26 revealed the resident was severely cognitively impaired and was dependent for ADLS. Review of the nurse progress notes for Resident #42 revealed the resident was transferred to the hospital on [DATE] and was readmitted to the facility 07/03/26. Review of the facility SRIs dated 07/03/26 to 07/06/26 revealed there were no SRIs filed regarding Resident #42. Interview on 07/06/26 at 11:13 A.M. with the DON confirmed she became aware the hospital had alleged the facility had been abusive and neglectful towards Resident #42. The DON verified Resident #42's family member notified LPN #563 on 07/03/26 the hospital suspected the facility had been abusive and neglectful towards the resident, but that the family member did not believe any abuse or neglect had occurred. The DON stated the facility did not investigate or report the allegation due to the resident's family member concluding no abuse or neglect had occurred. Interview on 07/06/26 at 12:33 P.M. with the Administrator confirmed he was unaware Resident #42's family reported to LPN #563 that the hospital alleged the facility had been abusive and neglectful towards Resident #42. The Administrator verified the facility did not initiate an SRI to report the allegation to the state agency. 3. Review of medical record for Resident # 19 revealed an admission date of 10/12/23 with diagnoses including dementia, osteoporosis, cerebral aneurysm and heart disease. Review the MDS assessment for Resident #19 dated 05/04/26 revealed resident had severe cognitive impairment and was dependent for ADLs. Review of progress note for Resident #19 dated 06/17/26 at 8:22 A.M. revealed the night shift nurse reported Resident #19 had an injury to right ankle thought to have been caused during a transfer. Review of the facility SRIs dated 06/17/26 to 07/06/26 revealed there were no SRIs filed regarding Resident #19. Interview on 07/01/26 at 2:57 P.M. with the DON and Corporate Nurse #587 confirmed the DON received a call from the facility on 06/17/26 at 4:30 A.M. regarding Resident #19's right ankle injury. The staff got an order for an x-ray which showed a right ankle fracture. Resident #19 was sent to the hospital and returned on 06/18/26 with an air splint to the ankle. The DON confirmed the facility did not report an injury of unknown origin to the state agency. Interview on 07/01/26 at 10:15 A.M. with CNA # 307 confirmed he had cared for Resident #19 from 11:00 P.M. to 7:00 A.M. on 06/16/26. CNA #307 stated he had not transferred the resident in or out of bed during his shift. CNA #307 stated at 2:00 A.M. he checked on the resident, and she was dry and did not require incontinence care. CNA #307 stated at 4:30 A.M. he noted Resident #19 yelled out in pain when he went to reposition the resident and the resident's right ankle was swollen and discolored so he immediately notified the nurse who came and assessed the resident. Interview on 07/06/26 at 11:19 A.M. with CNA #379 confirmed she had cared for Resident #19 on 06/16/26 from 7:00 A.M. to 7:00 P.M. and the resident had no falls or incidents. CNA #379 stated she transferred the resident to her bed via Hoyer lift after dinner on 06/16/26 with no issues. CNA #379 denied knowing anything that happened during her shift that would have caused an injury. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation undated revealed if a staff member is accused or suspected of abuse, they are to be immediately removed from the facility pending the outcome of the investigation and the Administrator is to be notified immediately of any allegations of abuse. Allegations of abuse should be reported immediately to the state agency. Injuries of unknown source were to be investigated and reported to the state agency. This deficiency represents noncompliance investigated under Complaint Number 3053673 and Complaint Number 3045219.

Based on medical record record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to protect residents during abuse investigation and failed to thoroughly investigate allegations of abuse, neglect, and injuries of unknown source. This affected three (Residents #19, Resident #29 and Resident #42) of three residents investigated for abuse. The facility census was 87 residents. Findings include: 1.Review of the medical record for Resident #29 revealed an admission date of 02/02/25 with diagnoses including Alzheimer's Disease, depression, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 06/17/26 revealed the resident had severe cognitive impairment required moderate to maximum staff assistance with activities of daily living (ADLS). Review of the facility SRI for Resident #29 dated 05/28/29 at 3:39 P.M. revealed staff witnessed and reported an allegation of physical abuse per Certified Nursing Assistant (CNA) #451 towards Resident #29 which occurred on 05/27/26. Interview on 06/30/26 at 11:57 A.M. with Licensed Practical Nurse (LPN) #425 confirmed on 05/27/26 in the common area at dinner time she witnessed CNA #451 dinner pull Resident #29 up roughly by the resident's arms with the resident demonstrating some resistance to CNA #451's intervention. LPN #425 stated she reported the incident to Scheduler #573 on 06/30/26 around 6:45 P.M. Interview on 06/30/26 at 3:06 P.M. with Scheduler #573 confirmed LPN #425 notified her on 05/27/26 of an incident of rough handling per CNA #451 towards Resident #29. Scheduler #573 stated she notified the Director of Nursing (DON) by phone of the incident of rough handling per CNA #451 towards Resident #29. Scheduler #573 moved CNA #451's assignment to a different unit. Interview on 06/30/26 at 3:40 P.M with the DON confirmed Scheduler #573 called her at dinner time but cannot recall Scheduler #573 sharing any abuse concerns with her. The DON verified CNA #451 was allowed to complete her shift on 05/27/26 after the incident involving Resident #29 and was also allowed to return to work on 05/28/26 at 7:00 A.M. The DON stated Human Resources suspended CNA #451 on 05/28/26 at 9:58 A.M. Interview on 07/01/26 at 3:36 P.M. with the Administrator on 07/01/26 at 3:36 P.M. confirmed staff did not report the allegation of abuse per CNA #451 towards Resident #29 on 05/27/26. The Administrator stated Scheduler #573 reported the incident to him during morning rounds on 05/28/26 and he immediately spoke with the DON and the Human Resource Manager (HRM) and had CNA #451 brought in and suspended. The Administrator verified the facility did not suspend CNA #451, the alleged perpetrator (AP), immediately after the alleged abuse was identified and the AP was permitted to work with residents for the remainder of the shift on 05/27/26 and on 05/28/26 from 7:00 A.M. to 9:58 A.M. 2. Review of medical record for Resident #42 revealed as admitted to facility on 06/26/24 with diagnoses including frontal temporal dementia, conversion disorder, and Lewy body dementia. Review of the MDS assessment for Resident #42 dated 06/11/26 revealed the resident was severely cognitively impaired and was dependent for ADLS. Review of the nurse progress notes for Resident #42 revealed the resident was transferred to the hospital on [DATE] and was readmitted to the facility 07/03/26. Review of the facility SRIs dated 07/03/26 to 07/06/26 revealed there were no SRIs filed regarding Resident #42. Interview on 07/06/26 at 11:13 A.M. with the DON confirmed she became aware the hospital had alleged the facility had been abusive and neglectful towards Resident #42. The DON verified Resident #42's family member notified LPN #563 on 07/03/26 the hospital suspected the facility had been abusive and neglectful towards the resident, but that the family member did not believe any abuse or neglect had occurred. The DON stated the facility did not investigate or report the allegation due to the resident's family member concluding no abuse or neglect had occurred. Interview on 07/06/26 at 12:33 P.M. with the Administrator confirmed he was unaware Resident #42's family reported to LPN #563 that the hospital alleged the facility had been abusive and neglectful towards Resident #42. The Administrator verified the facility did not initiate an SRI to report the allegation to the state agency nor did the facility conduct an investigation regarding possible abuse and neglect towards Resident #42. 3. Review of medical record for Resident # 19 revealed an admission date of 10/12/23 with diagnoses including dementia, osteoporosis, cerebral aneurysm and heart disease. Review the MDS assessment for Resident #19 dated 05/04/26 revealed resident had severe cognitive impairment and was dependent for ADLs. Review of progress note for Resident #19 dated 06/17/26 at 8:22 A.M. revealed the night shift nurse reported Resident #19 had an injury to right ankle thought to have been caused during a transfer. Review of the facility SRIs dated 06/17/26 to 07/06/26 revealed there were no SRIs filed regarding Resident #19. Interview on 07/01/26 at 2:57 P.M. with the DON and Corporate Nurse #587 confirmed the DON received a call from the facility on 06/17/26 at 4:30 A.M. regarding Resident #19's right ankle injury. The staff got an order for an x-ray which showed a right ankle fracture. Resident #19 was sent to the hospital and returned on 06/18/26 with an air splint to the ankle. The DON confirmed the facility did not investigate the injury of unknown source for Resident #19. Interview on 07/01/26 at 10:15 A.M. with CNA # 307 confirmed he had cared for Resident #19 from 11:00 P.M. to 7:00 A.M. on 06/16/26. CNA #307 stated he had not transferred the resident in or out of bed during his shift. CNA #307 stated at 2:00 A.M. he checked on the resident, and she was dry and did not require incontinence care. CNA #307 stated at 4:30 A.M. he noted Resident #19 yelled out in pain when he went to reposition the resident and the resident's right ankle was swollen and discolored so he immediately notified the nurse who came and assessed the resident. Interview on 07/06/26 at 11:19 A.M. with CNA #379 confirmed she had cared for Resident #19 on 06/16/26 from 7:00 A.M. to 7:00 P.M. and the resident had no falls or incidents. CNA #379 stated she transferred the resident to her bed via Hoyer lift after dinner on 06/16/26 with no issues. CNA #379 denied knowing anything that happened during her shift that would have caused an injury. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation undated revealed if a staff member is accused or suspected of abuse, they are to be immediately removed from the facility pending the outcome of the investigation and the Administrator is to be notified immediately of any allegations of abuse. Allegations of abuse should be reported immediately to the state agency. Injuries of unknown source were to be investigated and reported to the state agency. This deficiency represents noncompliance investigated under Complaint Number 3053673 and Complaint Number 3045219.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a clean, safe, and sanitary manner. This had the potential to affect all of the residents residing in the facility. The facility census was 77 residents.Findings include:1.Observation on 09/15/25 at 9:06 A.M. with Dietary Manager (DM) #372 of the kitchen revealed the dry storage area contained the following items: a box of baking soda open to air with an expiration date of January 2025, an open and undated two-quart container of soy sauce, an open and undated open 64 ounce bottle of syrup, an open and undated bag of breadcrumbs. Interview on 09/15/25 at 9:09 A.M. with DM #372 confirmed the expired, open, and undated items in the dry storage should have been discarded. 2.Observation on 09/15/25 at 9:15 A.M. with DM #372 revealed the walk-in freezer contained the following items: a box of open pie dough with ice crystals over much of the pie dough, a box of pretzel dough open to air, a bag of open and undated beef patties, a bag of open and undated hotdogs.Interview on 09/15/25 at 9:17 A.M. with DM #372 confirmed the items observed in the walk-in freezer had not been properly stored and should have been discarded. 3.Observation on 09/15/25 at 9:23 AM with DM #372 revealed the walk-in refrigerator contained the following: an box 30 eggs with a use-by date of 08/12/25, a container of coleslaw with a date of 09/05/25. Interview on 09/15/25 at 9:25 A.M. with DM #372 confirmed the items were expired and should have been discarded.4. Observation on 09/15/25 at 9:33 A.M. with DM #372 revealed the stand-up freezer contained the following items: an open and undated box of veggie burgers, a plastic bag of tater tot which were open to air. Interview on 09/15/25 at 9:26 A.M. confirmed the veggie burgers and tater tots were not properly stored and should have been discarded.Review of the facility policy titled Food Storage dated November 2024 revealed dry food should be labeled and dated, and food should be rotated using first in - first out method. All foods stored in the refrigerator or freezer should be covered, labeled and dated. 5. Observation on 09/16/25 at 10:28 A.M. revealed the Woods unit stand-up refrigerator/freezer contained the following items: an undated and unlabeled container of strawberries, two ice cream cups with no lids open and uncovered with spoons in them. Interview on 09/16/25 at 10:30 A.M. with Licensed Practical Nurse (LPN) #378 confirmed the strawberries and ice cream cups in the Woods unit refrigerator/freezer were not properly stored and should have been discarded. 6. Observation on 09/16/25 at 10:41 A.M. revealed the Commons unit stand-up refrigerator/freezer contained the following items: an unlabeled and undated bag of cupcakes, a open and undated bottle of honey mustard, an undated open to air package of cheese, two undated frozen beverages with straws, a carton of unlabeled and undated strawberry ice cream. Interview on 09/16/25 at 10:42 A.M. with LPN #286 confirmed the items observed in the Commons unit refrigerator/freezer were not properly stored and should have been discarded. 7. Interview on 09/16/25 at 10:57 A.M. revealed the Gardens unit stand-up refrigerator contained a sleeve of cookies, open to air and undated. Interview on 09/16/25 at 10:58 A.M. with LPN #410 confirmed the cookies in the Gardens unit refrigerator freezer were not properly stored and should have been discarded. Review of the policy labeled Foods Brought in by Family/Visitor Policy dated November 2023 revealed food brought in by family or visitors should be stored in a safe and sanitary manner.

Based on observation, staff interview, and review of the facility policy, the facility to ensure insulin was properly stored. This affected four (Residents #5, #12, #15, #61) of eight residents observed for insulin storage. The facility also failed to discard expired tuberculosis (TB) testing solution. This had to potential to affect all of the residents residing in the facility. The facility census was 77 residents. Findings include: 1.Observation on [DATE] at 4:37 P.M with Registered Nurse (RN) #230 revealed the Woods unit medication cart contained the following: a vial of insulin glargine for Resident #12 with an open date of [DATE], a vial of insulin aspart for Resident #12 with an open date of [DATE], an open vial of NovoLog insulin for Resident #61 with no open date, a vial of insulin lispro for Resident #15 with an open date of [DATE]. Interview on [DATE] at 4:38 P.M with RN #230 confirmed the expired insulin for Residents #12and #15 should have been discarded. RN #320 further confirmed the insulin for Resident #61 had no open date and should also be discarded because there was no way to know the proper expiration date. Observation on [DATE] at 4:50 P.M with RN #230 revealed in the Garden unit medication cart contained an open undated insulin lispro for Resident #5. Interview on [DATE] at 4:51 P.M with RN #230 confirmed the insulin lispro for Resident #5 was opened and had no open date. Review of facility policy tiled Medications with Shortened Expiration Dates revealed insulin should be disposed after 28 days of first use. 2. Observation on [DATE] at 4:53 P.M with RN #230 revealed Meadows unit medication refrigerator contained an open and undated vial of TB testing solution. Interview on [DATE] at 4:54 P.M with RN #230 confirmed the TB testing solution in the Meadows unit was opened and undated. Observation on [DATE] at 5:08 P.M with RN #230 revealed in the Commons unit Medication Refrigerator contained an open vial of TB testing solution dated on [DATE]. Interview on [DATE] at 5:09 P.M with RN #230 confirmed the TB testing solution in the Commons unit medication refrigerator was expired and should have been discarded. Review of facility policy titled Storage of Medications dated [DATE] revealed all medications should be labeled with an opened date to ensure that no outdated or deteriorated medications are stored.

Based on observation, staff interview, review of Material Safety Data Sheets (MSDS), and review of the facility policy, the facility failed to ensure hazardous materials were stored safely. This had the potential to affect 14 facility-identified (Residents #13, #19, #26, #32, #33, #35, #37, #47, #54, #62, #63, #73, #75, and #76) who were cognitively impaired and independently mobile. The facility census was 77 residents.Findings include:1.Observation on 09/15/25 at 10:24 A.M. of the Terrace unit dining room revealed there was a unsecured container of Micro-Kill Two Germicidal Wipes sitting on the countertop near a sink. There was a bottle of Virex TB Disinfectant in an unsecured cabinet above the countertop. Both containers had warning labels indicating the contents could be hazardous to humans. Interview on 09/15/25 at 10:27 A.M. with Registered Nurse (RN) Unit Manager #230 verified the wipes and disinfectant should have been stored in a secure location. 2. Observation on 09/15/25 at 10:35 A.M. of the Gardens unit revealed a bottle of TB-CIDE QUAT and a bottle of Virex TB Disinfectant in an unsecured cabinet under the sink in the dining room. Both bottles of disinfectant had hazard to humans warning labels. Interview on 09/15/25 at 10:38 A.M. with RN #242 verified the bottles of disinfectant should be stored in a secure location. Review of the MSDS for the Micro-Kill Two Germicidal Wipes, revised 12/27/23 revealed the wipes could cause harmful effects via skin, eyes, inhalation, or ingestion. Review of the MSDS for the Virex TB Disinfectant revised 07/31/24 revealed the disinfectant could cause harmful effects via skin, eyes, inhalation, or ingestion. Review of the MSDS for the TB-CIDE QUAT revised 12/02/19 revealed the disinfectant could cause harmful effects via eyes, skin, inhalation, or ingestion. Review of the undated facility policy titled Facility Environment - Hazards revealed the facility would ensure the environment was free of accident hazards.

Based on medical record review and staff interview the facility failed to ensure Preadmission Screening and Resident Review (PASARR) assessment were completed accurately. This affected three (Residents #6, #25, #60) of six residents reviewed for PASARR completion. The facility census was 77 residents. Findings include: 1.Review of the medical record for Resident #6 revealed an admission date of 12/04/22 with diagnoses including Parkinson's disease, nontraumatic acute subdural hemorrhage, and major depressive disorder. Review of the PASARR for Resident #6 dated 12/04/22 revealed the resident's diagnosis of major depressive disorder and the resident's order for Seroquel (an antipsychotic medication) were not included in the PASARR. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 07/14/25 revealed the resident had severe cognitive impairment and was dependent on staff assistance for activities of daily living (ADLs.) Interview on 09/18/25 at 11:52 A.M with Social Service Director (SSD) #434 confirmed Resident #6's diagnosis of major depressive disorder and the medication Seroquel were not included in the resident's PASARR dated 12/04/22. 2.Review of the medical record for Resident #25 revealed an admission date of 07/09/25 with diagnoses including Alzheimer's disease, generalized anxiety disorder, and depression. Review of the PASARR for Resident #25 dated 05/03/25 revealed the resident's diagnosis of generalized anxiety disorder and the resident' use of Buspar (an anti-anxiety medication) were not included. Review of the MDS assessment for Resident #25 dated 07/14/25 revealed the resident had severe cognitive impairment and required staff assistance with ADLs. Interview on 09/18/25 at 11:55 A.M with SSD #434 confirmed Resident #25's diagnosis of generalized anxiety disorder and the resident's use of Buspar were not included on the PASARR for the resident dated 05/30/25. 3. Review of the medical record for Resident #60 revealed an admission date of 02/21/25 with diagnoses including Alzheimer's disease, and major depressive disorder. Review of the PASARR for Resident #60 dated 02/21/25 revealed the resident's use of Ativan (an-anti-anxiety medication) and Zoloft (an antidepressant medication) were included in the assessment. Review of the MDS assessment for Resident #60 dated 02/21/25 revealed the resident was cognitively impaired and required extensive assistance with ADLs. Interview on 09/18/25 at 11:57 A.M with SSD #434 confirmed Resident #60's use of Ativan and Zoloft were not included on the PASSAR for the resident dated 02/21/25.

Based on record review, policy review, and staff interview, the facility failed to provide a Resident, a Resident's Representative, and the Office of the Long-term Care Ombudsman with an emergency discharge notice. This affected one resident (#91) out of three residents reviewed. The facility census was 68. Findings Include: Record review for Resident #91 revealed she was admitted to the facility on [DATE] and discharged to the hospital on 07/11/23 and was not permitted to return to the facility. The resident's diagnoses included dementia with behavioral disturbance, hyperlipidemia, major depressive disorder, anxiety disorder, symbolic dysfunction, and essential primary hypertension. Further record review revealed the facility failed to issue an emergency discharge notice to Resident #91, Resident #91's representative, or the Office of Long-term Care Ombudsman office in writing. Review of hospital notes dated 07/06/23 for Resident #91 and identified by the facility as part of their admission paperwork, revealed the resident was readmitted to the hospital from another long-term care facility on 07/03/23 for a psychiatric admission related to inappropriate and sexually aggressive behaviors at her previous extended care facility (ECF). The resident was reported to have been grabbing people and being naked in bed with males. Notes indicated the ECF could no longer manage the resident. An assessment revealed the resident was calm, pleasant, confused and alert to person and alert to being in the hospital. Medications were reconciled and upon discharge, the hospital staff would seek alternative placement in new facility. Review of the discharge return not anticipated (DRNA) Minimum Data Set (MDS) assessment 3.0 for Resident #91, dated 07/11/23, revealed the resident had impaired cognition. The assessment revealed Resident # 91 displayed behaviors towards another person. Review of the progress note for Resident # 91, dated 07/11/23, revealed the Social Service Director (SSD) notified Resident #91's representative of their inability to provide the appropriate care for Resident #91 via phone call and the facility discharged Resident #91 to the hospital. Review of facility document titled Transfer/Discharge Report dated 07/11/23 and timed 5:48 P.M. revealed the resident was discharged to an acute hospital. Review of the hospital notes for Resident #91 dated 07/12/23, revealed the resident was seen in the emergency room for need of care coordination. The resident was at her baseline with no complaints and the resident was discharged back to the facility. When the transport serviced arrived at the facility, the facility refused to accept her, and the resident was returned to the emergency room . The Resident was very familiar to the psychiatric staff and hospital admitted the resident for history of dementia with continued management and investigation. Interview with Admissions Director (AD) # 133 on 09/06/23 at 10:48 A.M. confirmed the facility was aware of Resident #91's sexual behavior prior to admission to the facility; however, noted the facility was not aware of her exit seeking behaviors. Once the facility learned of the resident's exit seeking behaviors, the resident had to be moved from a mostly female populated nursing unit to the secured unit. AD #133 stated the secured unit consisted of both males and females and the facility was unable to ensure the safety of male residents related to the sexual behaviors of Resident #91. Therefore, the facility discharged Resident #91 to the hospital and refused to allow Resident #91 to return to the facility. AD #133 stated she did not complete the notifications and was not aware if anyone else completed the notifications. Interview Director of Clinical Services (DCS) #501 on 09/06/23 at 11:10 A.M. confirmed he spoke to the hospital regarding Resident #91's discharge to the hospital on 07/11/23. DCS #501 stated the facility did not feel they were given all the required information prior to accepting Resident #91 to the facility on [DATE]. DCS #501 confirmed the Resident, Resident's representative or the Long-term Ombudsman's office were not notified in writing of Resident #91's emergency discharge notice. Review of the facility policy titled, Facility Initiated Discharge and Discharge Notification Policy, undated, revealed the facility will provide a thirty-day notice of discharge to Residents and Resident Representatives of an impending discharge. Further review of the policy revealed the timing of the notice is subject to change under specific circumstances. The policy states, under the following circumstances, the notice will be given as soon as practicable before the transfer or discharge: The safety of individuals in the facility would be endangered. The resident has not resided in the facility for thirty days. This deficiency represents non-compliance investigated under Complaint Number OH00145014

Based on record review, hospital records review, facility policy review, and staff interview, the facility failed to allow a resident to return to the facility following a hospital evaluation. This affected one resident (#91) out of three residents reviewed. The facility census was 68. Findings Include: Record review for Resident #91 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on 07/11/23 and was not permitted to return to the facility. The resident's diagnoses included dementia with behavioral disturbance, hyperlipidemia, major depressive disorder, anxiety disorder, symbolic dysfunction, and essential primary hypertension. Review of the Discharge Return Not Anticipated (DRNA) Minimum Data Set (MDS) assessment 3.0 dated 07/11/23 for Resident #91, revealed the resident had impaired cognition. The assessment revealed Resident # 91 displayed behaviors towards another person. Review of the progress note dated 07/11/23 for Resident #91, revealed the Social Service Director (SSD) notified Resident #91's representative of their inability to provide the appropriate care for Resident #91 via a phone call and then discharged Resident #91 to the hospital. Review of facility document titled Transfer/Discharge Report dated 07/11/23 and timed 5:48 P.M. revealed Resident #91 was discharged to an acute hospital. Review of the hospital notes for Resident #91 dated 07/12/23, revealed the resident was seen in the emergency room for need of care coordination. The resident was at her baseline with no complaints and the resident was discharged back to the facility. When the transport serviced arrived at the facility, the facility refused to accept her, and the resident was returned to the emergency room . Resident was admitted for continued management and investigation. Interview with Admissions Director (AD) # 133 on 09/06/23 at 10:48 A.M. confirmed the facility was aware of Resident #91's sexual behavior prior to admission to the facility; however, the facility was not aware of the residents exit seeking behaviors. Once the facility learned of her behaviors, the resident had to be moved from a mostly female populated nursing unit to the secured unit. AD #133 stated the secure unit consisted of both males and females and the facility was unable to ensure the safety of male residents related to the sexual behaviors of Resident #91. AD #133 verified the facility discharged Resident #91 to the hospital and refused to allow Resident #91 to return to the facility. Interview with Director of Clinical Services (DCS) #501 on 09/06/23 at 11:10 A.M. confirmed he spoke to the hospital regarding Resident #91's discharge to the hospital on 07/11/23. DCS #501 stated the facility did not feel they were given all the required information prior to accepting Resident #91 to the facility on [DATE]. DCS #501 confirmed the facility did allow Resident #91 to return to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00145014

Based on observation, record review and staff interview, the facility failed to ensure resident call lights were in reach. This affected two Residents (#47 and #48) out of 24 residents reviewed for call lights. The facility census was 51. Findings include: 1. Review of the Resident #47's chart revealed Resident #47 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #47 required extensive assistance with bed mobility, transfers, toileting, and dressing. Resident #47 also required supervision with eating and Resident #47 required limited assistance with personal hygiene. Review of Resident #47's call light care plan dated 03/02/22 revealed Resident #47 had a potential for falls with a history of falls. Interventions included encourage Resident #47 to use the call light for assistance and keep the call light within reach. Observation of Resident #47 on 09/19/22 at 12:27 P.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Observation of Resident #47 on 09/21/22 at 2:56 P.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Interview on 09/21/22 at 4:31 P.M. with Licensed Practical Nurse (LPN) #70 verified Resident #47 was able to use a call light. Observation of Resident #47 on 09/22/22 at 8:16 A.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Interview on 09/22/22 at 8:16 A.M. with LPN #51 verified Resident #47's was laying in her bed with her call light out of reach on the ground by the curtain. Review of the call lights policy dated November 2021 revealed the residents will have a means of directly contacting staffing when in their rooms. 2. Review of the medical record for Resident #48 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. Resident #48 was assessed to require one-person extensive assistance with transfers, dressing, toileting, and bathing, and supervision with eating. Review of the care plan dated 09/08/22 revealed Resident #48 had impaired physical mobility related to right hip fracture. Interventions included call light in reach, assist with activities of daily living as needed, notify charge nurse of complaint of pain, non-compliance with weight bearing status, and any reddened areas noted. Observation on 09/19/22 at 1:58 P.M. revealed Resident #48 was in bed with call light not in reach. Call light was on the floor behind nightstand. Observation on 09/21/22 at 2:52 P.M. of call light on the floor behind nightstand and out of reach of Resident #48. Interview on 09/21/22 at 2:48 P.M. with the Administrator revealed Resident #48 was able to use call light properly. Interview on 09/21/22 at 3:04 P.M. with the LPN #51 verified Resident #48's call light was on the floor behind the nightstand and out of reach. Review of the facility policy, Call Light Policy & Procedure, dated November 2021 revealed residents will have a means of directly contacting staff when in their rooms and toilet and bathing facilities. All resident rooms, toilets, and bathing facilities will be equipped with call systems that sound at the nurse's station. Call lights will be answered in a timely manner.

Based on record review, staff interviews, and policy review, the facility failed to complete a baseline care plan for pressure ulcers. This affected one Resident (#199) out of one resident reviewed for pressure ulcers. Facility census was 51. Findings include: Review of the medical record for Resident #199 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 99. This resident was assessed to require supervision with transfers and toileting independent with dressing and eating, and one-person physical assistance with bathing. Review of the baseline care plan dated 09/15/22 revealed Resident #199 did not have a care plan in place for stage two pressure ulcer to the coccyx. Review of the progress note dated 09/15/22 at 5:38 P.M. revealed Resident #199 had an area to left buttock, which measured two centimeters (cm) length by one cm width and one and a half cm depth. Treatment included [MEDICATION(S)] to be applied to wound bed and covered with foam dressing every day and as needed. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/21/22 at 2:17 P.M. of a treatment to the coccyx of Resident #199 completed by Director of Nursing (DON) and Licensed Practical Nurse (LPN) #42 revealed dressing change was completed per physician orders. Interview on 09/21/22 at 3:38 P.M. with DON verified Resident #199 did not have a baseline care plan for his pressure ulcer. DON stated interventions and treatments were initiated when Resident #199 entered the facility.

Based on observation, record review and staff interview, the facility failed to ensure resident mobility and fall care plans were implemented. This affected two Residents (#47 and #48) out of 14 residents reviewed for care plans. The facility census was 51. Findings include: 1. Review of the Resident #47's chart revealed Resident #47 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #47 required extensive assistance with bed mobility, transfers, toileting, and dressing. Resident #47 also required supervision with eating and Resident #47 required limited assistance with personal hygiene. Review of Resident #47's call light care plan dated 03/02/22 revealed Resident #47 had a potential for falls with a history of falls. Interventions included encourage Resident #47 to use the call light for assistance and keep the call light within reach. Observation of Resident #47 on 09/19/22 at 12:27 P.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Observation of Resident #47 on 09/21/22 at 2:56 P.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Interview on 09/21/22 at 4:31 P.M. with Licensed Practical Nurse (LPN) #70 verified Resident #47 was able to use a call light. Observation of Resident #47 on 09/22/22 at 8:16 A.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Interview on 09/22/22 at 8:16 A.M. with LPN #51 verified Resident #47's was laying in her bed with her call light out of reach on the ground by the curtain. Review of the call lights policy dated November 2021 revealed the residents will have a means of directly contacting staffing when in their rooms. Review of the facility policy titled, Care Planning - Interdisciplinary Team, dated 05/08/22 revealed the facility will be responsible for the development of an individualized comprehensive care plan for each resident. 2. Review of the medical record for Resident #48 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. Resident #48 was assessed to require one-person extensive assistance with transfers, dressing, toileting, and bathing, and supervision with eating. Review of the care plan dated 09/08/22 revealed Resident #48 had impaired physical mobility related to right hip fracture. Interventions included call light in reach, assist with activities of daily living as needed, notify charge nurse of complaint of pain, non-compliance with weight bearing status, and any reddened areas noted. Observation on 09/19/22 at 1:58 P.M. revealed Resident #48 was in bed with call light not in reach. Call light was on the floor behind nightstand. Observation on 09/21/22 at 2:52 P.M. of call light on the floor behind nightstand and out of reach of Resident #48. Interview on 09/21/22 at 2:48 P.M. with the Administrator revealed Resident #48 was able to use call light properly. Interview on 09/21/22 at 3:04 P.M. with the LPN #51 verified Resident #48's call light was on the floor behind the nightstand and out of reach. LPN #51 verified call light was to be in reach of Resident #48 per care plan. Review of the facility policy titled, Care Planning - Interdisciplinary Team, dated 05/08/22 revealed a comprehensive care plan for each resident was developed within seven days of completion the resident assessment. The comprehensive care plan will be updated on an ongoing basis as changes in the resident's treatment plan and preferences can occur. To ensure care plan implementation, staff will be provided with access to the resident care plan interventions via the electronic medical record.

Based on record review and staff interview, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected three Residents (#3, #17 and #47) out of six residents reviewed for unnecessary medications. The facility census was 51. Findings include: 1. Review of the Resident #17's chart revealed Resident #17 admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, [CONDITION(S)] disorders, personal history of Coronavirus (COVID-19), dysphagia, anxiety disorder, [CONDITION(S)], acute recurrent sinusitis, dizziness and giddiness, and benign neoplasm of prostate. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #17 required limited assistance with bed mobility, and toileting. Resident #17 required supervision with transfers, dressing, eating, and personal hygiene. Review of Resident #17's pharmacy recommendation dated 04/24/22 revealed Resident #17 had an order for [MEDICATION(S)] (anxiety) 25 milligrams (mg) every six hours as needed (PRN) for anxiety and agitation. The pharmacy recommendation stated a duration or rational needed to be added to the order. Further review of the pharmacy recommendation revealed Physician #400 addressed the pharmacy recommendation on 06/17/22 and reported this medication was required for more than 14 days due to chronic anxiety and agitation. The medication was effective and will be continued indefinitely. The physician will review medications with visits and attempt a gradual dose reduction at least annual unless contraindicated. 2. Review of the Resident #47's chart revealed Resident #47 admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, personal history of COVID-19, [CONDITION(S)], need for assistance with personal care, muscle weakness, type two diabetes mellitus, essential hypertension, [CONDITION(S)], delusional disorders, pain in left hip, pain in left shoulder, disease of pancreas and transient cerebral ischemic attack. Review of Resident #47's quarterly MDS assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #47 required extensive assistance with bed mobility, transfers, toileting, and dressing. Resident #47 also required supervision with eating and Resident #47 required limited assistance with personal hygiene. Review of Resident #47's pharmacy recommendation dated 04/24/22 revealed the resident was currently receiving [MEDICATION(S)] ([CONDITION(S)] replacement). Please consider adding [CONDITION(S)] stimulating hormone (TSH) level to the next laboratory (lab) day and periodically thereafter to monitor the [CONDITION(S)] levels. Further review of the pharmacy recommendation revealed Physician #400 addressed the pharmacy recommendation on 06/17/22 and agreed with the commendation. Interview with the Director of Nursing (DON) on 09/21/22 at 8:37 A.M. revealed Resident #17 and Resident #47's pharmacy reviews dated 04/24/22 were not addressed until 06/17/22. The DON stated the physician had 30 days to address pharmacy recommendations at the facility. Review of the consulting pharmacist monthly drug regimen review dated 11/21/21 revealed the resident's attending physician will review the irregularity report on the next patient visit and will document in the medical record that the identified irregularity had been reviewed and what action has been taken to address it. If there was to be no change, the attending physician should document his or her rationale in the resident's medical record. 3. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included melas syndrome, cortical [CONDITION(S)], type one diabetes mellitus, seizures, [CONDITION(S)], major depressive disorder, and generalized anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 99. Resident #3 was assessed to require two-person extensive assistance with transfers and toileting, one-person extensive assistance with dressing and eating, one-person total dependence with bathing. Review of the care plan dated 08/12/22 revealed Resident #3 had potential of adverse medication side effects related to refusal of medications. Interventions included medications as ordered, monitor for side effects/effectiveness of medications and notify physician as needed. Staff to monitor lab results and report to physician as ordered. Staff to report to change nurse change in condition, lethargy, complain of blurred vision, and headaches. Review of the physician order dated 12/27/21 revealed Resident #3 was ordered [MEDICATION(S)] (anti-depressant) extended release (ER) 24-hour 100 milligrams (mg), give 100 mg by mouth one time a day related to major depressive disorder. Review of the physician order dated 01/15/22 revealed Resident #3 was ordered [MEDICATION(S)] (anti-depressant) 7.5 mg, give 7.5 mg by mouth at bedtime for appetite stimulant. Review of the physician order dated 08/25/22 revealed Resident #3 was ordered [MEDICATION(S)] (anti-psychotic) 100 mg, give 100 mg by mouth two times a day related to Melas Syndrome. Review of the pharmacy medication recommendation dated 05/22/22 revealed Resident #3 was currently prescribed [MEDICATION(S)] 100 mg by mouth daily and [MEDICATION(S)] 75 mg by mouth twice a day. Recommendation was to evaluate for a dose reduction to determine the lowest effective dose. The facility responded on 06/17/22 that Resident #3 was well-controlled with current medication and will continue to monitor. Interview on 09/22/22 12:38 PM with the Administrator confirmed pharmacy recommendation was not addressed in a timely manner. Review of the facility policy titled, Consulting Pharmacist Monthly Drug Regimen Review, dated 11/11/21 revealed the consulting pharmacist must conduct a monthly drug regime review and report any identified medication irregularities in accordance with this policy. The written report shall be completed and sent to the resident's attending physician. the Director of Nursing (DON), and the Medical Director within seven days of the review (unless the irregularity requires urgent action.)

Based on record review and staff interview, the facility failed to ensure a resident that received [CONDITION(S)] medications had an appropriate diagnosis and indications for use. This affected one Resident (#104) out of six residents reviewed for unnecessary medications. The facility census was 51. Findings include: Review of the Resident #104's chart revealed Resident #104 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, need for assistance with personal care, chronic kidney disease stage three, dementia in other diseases classified elsewhere, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified convulsions, and [CONDITION(S)] in chronic kidney disease. Review of Resident #104's Minimum Data Set (MDS) assessment was not completed due to Resident #104 being newly admitted to the facility. Review of Resident #104's admission assessment dated [DATE] revealed Resident #104 was severely cognitively impaired, and Resident #104 required limited assistance with bed mobility. Resident #104 also required supervision with transfers, and eating and extensive assistance with dressing, toileting, and personal hygiene. Review of Resident #104's care plan dated 09/21/22 revealed Resident #104 received [CONDITION(S)] medication. Interventions included administer medications as ordered, monitor and record occurrences of targeted behavior symptoms, encourage residents to attend activities, provide psychological care if symptoms become worse and medication is ineffective with family's permission and staff to be aware of increased risk for falls while on the medication. Review of Resident #104's physician order dated 09/18/22 revealed Resident #104 was ordered to give [MEDICATION(S)] (anti-psychotic) 12.5 milligrams (mg) by mouth two times a day related to Alzheimer's disease with late onset. Review of the [MEDICATION(S)] manufacture prescribing information dated April 2008 revealed Warning: increased mortality in elderly patients with dementia. Warning: increased mortality in elderly patients with dementia related [CONDITION(S)]. Interview with the Director of Nursing (DON) on 09/21/22 at 4:03 P.M. verified Resident #104 was prescribed [MEDICATION(S)] for Alzheimer's disease. Interview with the Administrator on 09/22/22 at 12:38 P.M. verified Resident #104 was prescribed [MEDICATION(S)] for Alzheimer's disease. The Administrator also confirmed [MEDICATION(S)] had a warning stating that the use of [MEDICATION(S)] in elderly patients with dementia could cause increased mortality. The Administrator reported Resident #104's diagnosis on his [MEDICATION(S)] was changed on 09/22/22. Review of the facility's [CONDITION(S)] drugs policy dated 11/20/21 revealed the facility will ensure that residents who have not used [CONDITION(S)] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use [CONDITION(S)] drugs receive behavioral interventions.