Every finding on record at Arbors at Streetsboro

Based on observation, record review, review of fire department and hospital records, facility policy review, and interview, the facility failed to ensure Resident #59's physician orders were followed and care planned interventions were implemented to ensure comprehensive monitoring and evaluation was provided for Resident #59, who had an implanted cardiac pacemaker to prevent complications. An additional example was the facility failed to ensure Resident #22's physician orders were followed and care planned interventions implemented to timely treat a right lateral calf wound. This affected two resident's (#22 and #59) of three residents reviewed for quality of care. The facility identified four residents with pacemakers residing in the facility. Actual Harm occurred on [DATE] at 5:30 P.M. when Resident #59 was observed to be lethargic, had clammy skin, was sweating, unable to swallow, and his oxygen saturation level was unable to be obtained. Resident #59 was placed on five liters of oxygen per minute via nasal cannula and Emergency Medical Services (EMS) was contacted. EMS completed a 12-lead electrocardiogram and noted the resident had bradycardia (indicating the heart rate was less than 60 beats per minute; when symptomatic, bradycardia can indicate a failure of the heart to pump sufficient oxygenated blood to the body). Resident #59 was urgently transported to the local hospital where he was admitted with bradycardia and concerns his implanted cardiac pacemaker battery had died and was not working appropriately. Resident #59 required inpatient care to treat his heart failure and required surgery to have a new cardiac pacemaker implanted on [DATE]. Resident #59 returned to the facility following his hospitalization. In addition, a concern that did not rise to the level of Actual Harm was identified when the facility failed to ensure a wound culture was completed for the correct wound for Resident #22. This affected one resident (#22) out of two residents reviewed for wounds. The facility census was 55.Findings include:1. Review of Resident #59's medical record revealed an admission date of [DATE] with diagnoses including chronic combined systolic (congestive) and diastolic (congestive) heart failure (CHF), Alzheimer's Disease, paroxysmal atrial fibrillation, dementia, cardiomyopathy, and type II diabetes mellitus with diabetic peripheral angiopathy.Review of Resident #59's Device Clinic report dated [DATE] included Resident #59's pacemaker battery had 17 months remaining, and there was normal device function. The report noted device clinic staff reprogramed the left ventricular (LV) pulse width for more battery longevity, re-demonstrated alert tones for patient and caregiver, and the next remote device check was in two to three months.Review of Resident #59's care plan dated [DATE] included Resident #59 was at risk for fluid volume imbalance related to diuretic use, CHF and other diagnoses. The care plan included Resident #59 was non-compliant with fluid restrictions and takes water on own frequently. Interventions included observing and documenting non-compliance. Review of Resident #59's care plan initiated revised [DATE] included Resident #59 had impaired cardiovascular status related to arrhythmias, atrial fibrillation, cardiomyopathy, pacemaker placement and other diagnoses. The goal developed was for Resident #59 to have reduced complications related to altered cardiac status through the next review date of [DATE]. Interventions included to administer medications as ordered, observe for side effects and report to the physician or nurse practitioner; observe for and report to the physician or nurse practitioner signs and symptoms of congestive heart failure (CHF) such as dependent edema of the legs and feet, shortness of breath upon exertion, increased weakness or fatigue, weight gain unrelated to intake, crackles and/or wheezes upon auscultation of the lungs; observe weight as ordered and as needed; provide oxygen as ordered and observe oxygen saturation levels as needed. There was no evidence of an intervention to check Resident #59's pacemaker function. Review of Resident #59's physician orders dated [DATE] included to obtain daily weights and to notify the provider of weight gain of three or more pounds in a 24-hour period or five or more pounds in a one-week period.Review of Resident #59's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had moderate cognitive impairment. Resident #59 used a wheelchair and required supervision or touching assistance for toileting and personal hygiene. Resident #59 required partial to moderate (staff) assistance with lower body dressing. Resident #59 had an indwelling catheter and was frequently incontinent of bowel.Review of Resident #59's Medication Administration Record (MAR) for [DATE] revealed no indication the resident had his daily weight monitored or recorded on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] as ordered by the physician.Review of Resident #59's progress notes dated [DATE] through [DATE] revealed there was no evidence Resident #59 refused to have his weight checked on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. There was no evidence that the physician or nurse practitioner were notified Resident #59 did not have his weight checked. There was no evidence Resident #59 was encouraged to have his weight checked daily or that there had been any additional attempts made to obtain the resident's ordered daily weights.Review of Resident #59's progress note dated [DATE] at 5:14 A.M. included Resident #59's physician was notified of a weight of 209.6 pounds and swollen legs. Resident #59's physician was notified that his last weight on [DATE] (the record indicated this weight was recorded on [DATE]) was 202.8 pounds and his weight on [DATE] was 198 pounds. The note concluded by noting the nurse was awaiting a physician response and would notify the oncoming nurse of status. Review of Resident #59's progress notes dated [DATE] at 5:14 A.M. through [DATE] at 11:47 A.M. revealed no evidence of a response received from the resident's physician for the weight gain of 6.8 pounds.However, review of Resident #59's physician orders dated [DATE] revealed a new order for the resident to receive Furosemide (an oral diuretic medication) oral tablet 40 milligrams (mg) by mouth two times a day for edema until [DATE].Review of Resident #59's progress notes dated [DATE] at 12:40 P.M. included an unnamed respiratory therapy staff notified the nurse that Resident #59's oxygen saturation level was 77 percent on room air, supplemental oxygen at two liters per minute was applied, and the resident's oxygen saturation level improved to 94 percent. Resident #59's abdomen was distended, was painful to touch, and he was very lethargic. Blood and a clot were noted in Resident #59's urinary catheter bag. The on-call nurse practitioner was contacted, and orders were received to transport Resident #59 to the ER for evaluation and treatment. Resident #59's returned to the facility the same day after the hospital addressed urinary concerns.Review of Resident #59's progress note dated [DATE] at 11:15 A.M. included Resident #59 returned to the facility via hospital transport. Resident #59 had an indwelling catheter replaced and arrived using oxygen at two liters per minute via nasal cannula. The discharge paperwork did not include findings to support oxygen therapy needed. A call was placed to the hospital ED and the nurse at the hospital was unsure why Resident #59 was placed on oxygen and he did not need it when she took care of him.Review of Resident #59's progress note dated [DATE] at 10:30 A.M. included Resident #59 needed oxygen because his oxygen saturation level was 77 percent on room air and new rhonchi (adventitious lung sounds which are caused by airway obstruction from mucus or fluid in the bronchi) were noted bilaterally. Resident #59's oxygen saturation level on oxygen at two liters per minute via nasal cannula was 93 percent.Review of Resident #59's late entry progress note dated [DATE] at 2:43 P.M. included on [DATE] at 9:30 A.M. Resident #59's right abdominal area was swollen, and he complained of right abdominal pain. The resident had returned from the hospital the night prior with an indwelling catheter. Nurse Practitioner (NP) #300 was contacted and ordered Resident #59 to be transported to the ER for evaluation or continued urinary concerns and to have his lungs evaluated for fluid. Review of Resident #59's local fire department EMS report dated [DATE] included a call was received at 10:43 A.M. and patient contact with EMS began at 10:50 A.M. Upon EMS arrival, Resident #59 appeared slightly short of breath with notable right-sided abdominal distention that was rigid and tender to the touch. Resident #59 had bilateral lower leg edema, and blood was coming from his catheter. Resident #59 was transported to the local ED. Review of Resident #59's progress notes dated [DATE] at 2:43 P.M. included the ER was contacted and Resident #59 was being admitted to the hospital for acute and chronic CHF.Review of Resident #59's After Visit Summary dated [DATE] included Resident #59 had heart failure and had the presence of a pacemaker. Resident #59 had a referral to Cardiology for CHF management and heart failure. Resident #59's Power of Attorney (POA) reported Resident #59 had abdominal pain and a cough since Saturday ([DATE]). The abdominal pain and cough continued and Resident #59 was transported to the ED via EMS on [DATE] and received IV Lasix (diuretic) for CHF. The AVS summary included - For heart failure patients, daily weight monitoring was crucial. The AVS stated to call the doctor if you experience a weight gain of two to three pounds or more per day over a two-day period or five pounds in a week. Common heart failure symptoms included fatigue and weakness, swelling in the abdomen, legs, ankles and feet and difficulty concentrating or decreased alertness. If any of these symptoms suddenly became worse or new signs and symptoms were developed it might mean the existing heart failure was getting worse and not responding to treatment. The AVS noted Resident #59 had acute on chronic congestive heart failure and he had elevated troponin levels (a protein released into the bloodstream when heart muscle is damaged) likely due to demand ischemia. Resident #59's EKG during his hospital stay showed a complete LBBB (left bundle branch block which is an electrical conduction disorder where the left ventricle of the heart receives signals late which causes uncoordinated and inefficient contractions) with a notation that a pacemaker may be used for treatment and sinus rhythm with first degree AV block (a heart condition where electrical signals are delayed). Review of Resident #59's progress note dated [DATE] at 4:27 P.M. revealed he returned to the facility and had diagnoses including chronic CHF and pleural effusions. Resident #59 had a moist non-productive cough and was using oxygen at two to four liters per minute via nasal cannula.Review of Resident #59's progress notes, MAR and recorded weights did not reveal evidence Resident #59's weight was checked on [DATE], [DATE], or [DATE].Review of Resident #59's progress note dated [DATE] at 3:57 P.M. included at 7:45 A.M. Resident #59 was lethargic and was evaluated. Resident #59 responded appropriately with tactile stimuli, had slight tenting on the chest wall, skin was w/p/d (warm, pale, and dry), lungs had slight rhonchi in the lower lobes with a productive cough. The nurse practitioner (unidentified) gave orders. Resident #59's temperature was 97.0 degrees Fahrenheit, his pulse was 52 (bradycardia), respirations 18, and blood pressure was 121/59. At 11:30 A.M., Resident #59 was sitting in his wheelchair, ate his lunch, and was taken to participate in activities.Review of Resident #59's medical record dated [DATE] through [DATE] revealed no evidence facility staff arranged for additional visits to the device clinic for the resident or that any remote checks were completed in the facility for the resident's pacemaker during this time period.Review of Resident #59's progress note dated [DATE] at 12:43 P.M. revealed a referral was faxed to the hospital scheduling department for a cardiology consultation. Review of Resident #59's local fire department EMS report dated [DATE] included a call was received at 5:14 P.M. and patient contact began at 5:19 P.M. Resident #59 was found sitting in a wheelchair, was on an oxygen concentrator, and was diaphoretic. Resident #59 was hypoglycemic and bradycardic and was transported to the ED.Review of Resident #59's progress note dated [DATE] at 6:17 P.M. included Resident #59's blood sugar at 4:00 P.M. was 370 and he was administered insulin per sliding scale. At 5:30 P.M., Resident #59 opened his eyes to tactile stimuli then went back to sleep. His skin was clammy, he was sweating, and he was unable to swallow. Sugar was administered via his drink with minimal responsiveness. Resident #59's temperature was 97.6 degrees Fahrenheit, pulse 52, respirations 20, and blood pressure was 102/62. Resident #59's oxygen saturation level was unable to be obtained, and he was placed on five liters of oxygen per minute via nasal cannula. 911 was called and Resident #59 was transported to the hospital. Review of Resident #59's After Visit Summary dated [DATE] through [DATE] included Resident #59's admission diagnosis was bradycardia. Resident #59 had sinus bradycardia at 44 beats per minute and a LBBB. Resident #59's pacemaker was attempted to be interrogated, but there were concerns the battery had died. The case was discussed with cardiology, and he would be admitted for further care. Resident #59's POA was notified of concerns about his pacemaker not working appropriately and she was agreeable with bloodwork and an interrogation. Resident #59 had bradycardia and pacemaker malfunction. Resident #59's pacemaker report indicated the battery may have run out sometime in 2025. Resident #59 required surgery to implant a new cardiac pacemaker which was completed on [DATE]. Resident #59 was discharged from the hospital back to the facility on [DATE] with a referral to hospice services and an appointment for a cardiac device check scheduled at the device clinic on [DATE] at 8:00 A.M. Review of Resident #59's progress note dated [DATE] at 6:06 P.M. included Resident #59 returned to the facility at about 4:45 P.M. Resident #59 was very lethargic but responded to staff. A small area was noted on Resident #59's left upper chest from the pacemaker replacement at the hospital. Resident #59 was lying in bed resting quietly with his eyes closed.On [DATE] at 9:44 A.M. Resident #59 was observed sitting in his wheelchair and asked for help to use the bathroom. Resident #59 asked for blinds to his windows be opened so he could see outside. Resident #59 was pleasant and answered questions appropriately.On [DATE] at 9:44 A.M. interview with Licensed Practical Nurse (LPN) #238 revealed Resident #59 was back to himself now and was eating and acting like he used to act. LPN #238 stated Resident #59's pacemaker battery died, and he needed to have it (pacemaker) replaced about two weeks ago and he was much better now. LPN #238 stated Resident #59's decline was absolutely related to his pacemaker not working. LPN #238 indicated Resident #59 was put on hospice because staff thought he was dying. Interview on [DATE] at 11:05 A.M. with Resident #59's POA, POA #600 revealed Resident #59's catheter was put in wrong and he had to go to the hospital on [DATE]. POA #600 stated Resident #59 had to be transported to the hospital on [DATE] because he was filling up with fluid from his CHF. POA #600 indicated Resident #59 was out of it, restless, delusional, and in bad shape when he was at the hospital and the physician recommended hospice services. POA #600 stated Resident #59 was in the hospital when they found out his pacemaker was not working and put a new one in. He came back to the facility from the hospital on [DATE]. POA #600 stated after Resident #59's pacemaker battery was replaced, he was improving.Interview on [DATE] at 4:12 P.M. with Certified Nursing Assistant (CNA) #263 revealed Resident #59 was taken to the hospital about two weeks ago but he did not know why he was taken to the hospital. When Resident #59 returned to the facility from the hospital, we thought he was going to die, and he was put on hospice services. CNA #263 indicated Resident #59 had suddenly begun feeling better, talking more clearly, pressing his call light, and now he was eating and allowing staff to provide his care. CNA #263 stated before Resident #59 went to the hospital he was shaky but now he was better and not shaking.Interview on [DATE] at 4:51 P.M. with Hospice Nurse (HN) #601 revealed Resident #59 was admitted to hospice services on [DATE] because he had signs and symptoms of end of life. Resident #59 was unresponsive and the even more care (EMC) program was initiated because he appeared to be actively passing. HN #601 revealed Resident #59 bounced back starting on [DATE] when Resident #59 began talking, drinking fluids and then he started going to activities and was back to his baseline. Interview on [DATE] at 8:47 A.M. with the Director of Nursing (DON) revealed she was not sure whether Resident #59's pacemaker's battery died and she would investigate it. The DON stated all residents with pacemakers should have pacemaker checks in place. A follow up interview on [DATE] at 11:18 A.M. with the DON revealed after looking into Resident #59's record, she found out his pacemaker was last checked on [DATE]. The DON stated Resident #59 had a device in his room to check his pacemaker remotely, but the device was not working. The DON stated there should have been remote checks done on Resident #59's pacemaker.Observation on [DATE] at 11:25 A.M. of Resident #59's pacemaker check device with the DON revealed the device was about 12 inches by 12 inches in size, had the cord wrapped around it, appeared dirty, and was not plugged in when the DON found it in Resident #59's room. The DON stated this was the old pacemaker check device and she did not know if Resident #59 was discharged from the hospital with a new pacemaker check device since having his device recently replaced.Interview on [DATE] at 12:05 P.M. with LPN #208 revealed she did not know Resident #59 had a pacemaker and she did not assist him with remote checks every three months to ensure his pacemaker was functioning properly.Interview on [DATE] at 2:06 P.M. with LPN #238 revealed she never checked Resident #59's pacemaker remotely because she did not know he had a pacemaker. LPN #238 stated usually the nurse manager would let her know if a resident needed to have remote pacemaker checks completed.Interview on [DATE] at 4:16 P.M. with Clinical Administrative Assistant (CAA) #602 from the Device Clinic with Regional Director of Clinical Services (RDCS) #301 revealed she just ordered Resident #59 a new pacemaker bedside monitor because the monitors were not always given to the residents when they left the hospital. CAA #602 stated she did not know why Resident #59 did not return to the Device Clinic since [DATE], but he had health issues and could not always get to the clinic. CAA #602 stated Resident #59 was mailed missed appointment letters, but the system at the Device Clinic was updated and she could not look up past appointment details. CAA #602 stated Resident #59 was scheduled for an in-person appointment at the clinic in [DATE] and if everything was working properly and nothing was found on the remote transmission then he could have remote checks every three months and in-person visits once a year. CAA #602 indicated she set up appointments before the residents left the device clinic, she gave them the remote dates for the bedside monitor check, and she tried to call and reschedule if there were missed appointments. CAA #602 revealed the Device Clinic had a lot of residents, more than a thousand, and sometimes residents including Resident #59 were lost in follow-up. CAA #602 indicated that the bedside monitor needed to stay plugged into an electrical outlet next to Resident #59's bed, had to be within range of Resident #59 and every single night a scan was completed by the pacemaker company and if anything was detected the Device Clinic was automatically notified. CAA #602 revealed the bedside monitor had to always be plugged in because there were software updates to keep the monitor current and when it was unplugged the monitor did not work properly and could not scan daily. CAA #602 stated there was a series of steps to take for the remote checks and if the bedside monitor was plugged in it would tell the battery life. When the battery was getting low the pacemaker had an audible alert that could be heard by the resident and his caregivers, and there was about two to three months left of battery life after the audible alert was heard. After three months, the pacemaker would just stop working.Review of the facility undated Hospitality Guide included the resident had upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that comprised necessary and appropriate care consistent with the program for which the resident contracted. 2. Review of Resident #22's medical record revealed an admission date of [DATE] and diagnoses included cerebral infarction due to embolism of the left middle cerebral artery, chronic respiratory failure, dependence on a ventilator, osteomyelitis of vertebra, the sacral and sacrococcygeal region, and was in a persistent vegetative state.Review of Resident #22's care plan dated [DATE] and revised [DATE] included Resident #22 had impaired skin integrity related to his diagnoses. Resident #22 had a sacrum pressure ulcer and a right lateral leg non-pressure chronic open wound. Resident #22 would show signs of healing and/or improvement to the extent allowed by the resident's diagnoses. Resident #22's identified skin impairment would be free of signs and symptoms of infection through the next review. Interventions included to administer treatments per orders, labs as ordered, and to notify the physician or the nurse practitioner of signs and symptoms of infection.Review of Resident #22's Annual Minimum Data Set (MDS) assessment dated [DATE] included Resident #22 was unable to be interviewed, and a Brief Interview for Mental Status was not conducted. Resident #22 had impairments of both sides of his upper and lower extremities. Resident #22 used a wheelchair and was dependent upon staff for Activity's of Daily Living (ADL) and bed mobility. The assessment also noted Resident #22 had a pressure ulcer. Review of Resident #22's wound notes dated [DATE] included Resident #22 had a medial sacral chronic stage four pressure injury, pressure ulcer. There was a moderate amount of serosanguineous drainage which had no odor. There was no change noted in the wound progression. The peri wound skin did not exhibit signs or symptoms of infection.Review of Resident #22's wound notes dated [DATE] included Resident #22 had a right lateral calf chronic full-thickness non-pressure wound. Necrotic tendon, necrotic muscle and necrotic adipose tissues were exposed. There was a large amount of purulent drainage noted which had no odor. The wound was deteriorating and the peri wound skin presented with signs and symptoms of infection. Resident #22 had signs and symptoms present and a wound culture for a culture and sensitivity was pending. The wound culture and sensitivity was to be collected on [DATE] for send out with the facility labs.Review of Resident #22's wound physician orders dated [DATE] included Resident #22 had a right lateral calf wound and a wound culture for gram stain, culture and sensitivity for aerobic and anaerobic bacteria was ordered to be obtained on [DATE] to send with routine lab pickup that day.Review of Resident #22's physician orders dated [DATE] revealed a one time order to obtain a wound culture to the sacrum on Sunday ([DATE]) to send out Monday ([DATE]), though the wound order dated [DATE] stated to obtain a culture from the wound of the right lateral calf, not the sacrum.Review of Resident #22's Treatment Administration Record (TAR) dated [DATE] revealed at 5:27 A.M. a wound culture was collected from Resident #22's sacrum and sent to the lab. There was no documented evidence of a wound culture completed for Resident #22's right lateral calf wound.Interview on [DATE] at 3:19 P.M. of Regional Director of Clinical Services (RDCS) #301 confirmed Resident #22 was supposed to have a wound culture collected on [DATE] from the right lateral calf, but the wound culture was incorrectly collected from the sacrum. RDCS #301 stated the specimen should have been collected from the right lateral calf wound and she was correcting the order in Resident #22's physician orders and a wound culture would be collected from Resident #22's right lateral calf and sent to the lab.Review of the facility policy titled Wound Treatment Management revised [DATE] included to promote wound healing of various types of wounds, it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. Treatment decisions would be based on characteristics of the wound including the presence of infection or the need to address bacterial bioburden.This deficiency represents non-compliance investigated under Complaint Number 2647655.

Based on observation, record review, review of a fire department transportation reports, review of hospital After Visit Summaries, and interview, the facility failed to ensure residents were provided adequate monitoring and/or care per physician order to timely identify and seek interventions for complications of the residents urinary status including symptoms of a urinary tract infection. This affected two residents (#59 and #70) of three reviewed for urinary tract infections. The facility census was 55.Actual Harm occurred on 01/20/26 when Resident #70 began showing signs and symptoms of a urinary tract infection (UTI). However, the resident was not appropriately evaluated or monitored after showing these symptoms and began showing a change in condition on 01/22/26 when his right arm began to shake. The resident was subsequently transferred to the hospital on [DATE] and was diagnosed with acute cystitis, urinary tract infection (UTI), sepsis with acute organ dysfunction (multi), acute hypoxic respiratory failure and acute decompensated heart failure.Actual Harm occurred beginning on 01/24/26 at 2:06 P.M. when Resident #59 notified the nurse his catheter was pulled out the night before; a new catheter was inserted and after the new catheter was inserted, blood was observed. However, there was no evidence Resident #59 was monitored for blood in his urine until 01/25/26 at 11:47 A.M. when the resident had minimal urine output recorded and was found lethargic, his abdomen was distended and painful to touch, and there was blood and blood clots observed in his urinary catheter bag. Resident #59 was transported to the emergency department (ED) where his urinary catheter was identified to be misplaced. The catheter was removed and a new catheter was inserted. Findings include: 1. Review of Resident #59's medical record revealed an admission date of 08/23/19 with diagnoses including chronic combined systolic (congestive) and diastolic (congestive) heart failure, Alzheimer's Disease, obstructive and reflux uropathy, malignant neoplasm of the prostate, type two diabetes mellitus with diabetic peripheral angiopathy without gangrene, dementia, and cardiomyopathy.Review of Resident #59's care plan dated 11/15/24, revised on 11/12/25, included Resident #59 had a need for an indwelling catheter, size 18 French (F) with a 10 cubic centimeter (cc) balloon related to prostate cancer and obstructive uropathy. The care plan included Resident #59 refused a leg bag and refused to allow his catheter to be placed appropriately through his pant leg. The goal developed was for Resident #59 to have reduced catheter-related complications through the next review. Interventions included to observe for signs and symptoms of urinary tract infection (UTI) and report blood in urine, cloudiness, foul smell, fever, or change in mental status to the physician, assist Resident #59 with indwelling catheter care as needed, and change catheter and drainage system as clinically indicated per orders.Review of Resident #59's care plan dated 11/15/24 included Resident #59 was at risk for a fluid volume imbalance related to his diagnoses. The care plan included Resident #59 was noncompliant with fluid restrictions and obtained water on his own frequently. The goal developed was for Resident #59 to have reduced signs and symptoms of fluid deficit including decreased urine output. Interventions included to observe and report to the physician or nurse practitioner, as needed, signs and symptoms of dehydration including decreased or no urine output and concentrated urine.Review of Resident #59's physician orders dated 11/12/25 included orders to change the indwelling catheter, 18 French with a 10 cc balloon, related to obstructive uropathy as clinically indicated for signs and symptoms of obstruction such as leakage, increased sediment, infection, or if the closed system was compromised.Review of Resident #59's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had moderate cognitive impairment. Resident #59 used a wheelchair and required supervision or touching assistance for toileting and personal hygiene and required partial to moderate assistance with lower body dressing. The assessment noted Resident #59 had an indwelling catheter and was frequently incontinent of bowel.Review of Resident #59's physician orders revealed orders dated 01/16/26 for Lidocaine Pain Relief patch 4 percent (%), with instructions to apply to lower back topically one time a day for back pain and apply on the morning and take off at bedtime, and Acetaminophen 325 milligrams (mg) with instructions to give two tablets by mouth every six hours as needed for mild pain. Further review of the physician orders dated 01/16/26 through 01/19/26 revealed no documented evidence of an order for a urine specimen for urinalysis and culture and sensitivity during this time. Review of Resident #59's progress notes dated 01/19/26 at 4:18 P.M. revealed Resident #59 had increased pain to an unidentified area, not relieved by Tylenol (Acetaminophen), a Lidocaine patch, or repositioning. The progress note included Resident #59 had new orders for as needed Ibuprofen and a urine specimen for urinalysis and culture and sensitivity.Review of Resident #59's progress notes dated 01/19/26 at 4:18 P.M. through 01/22/26 at 1:30 A.M. revealed no documented evidence of attempts made to collect Resident #59's urine for urinalysis and culture and sensitivity.Review of Resident #59's progress notes dated 01/20/26 at 10:30 A.M. included a Lidocaine Pain Relief patch 4% was applied to Resident #59's lower back for complaints of back pain. Resident #59 stated this did not help and a message was sent to the provider. Review of Resident #59's progress notes dated 01/21/26 at 10:20 P.M. revealed Resident #59 was administered two tablets of Acetaminophen 325 (mg) for pain in the lower back rated from a one to three out of ten (on a pain scale where zero was no pain and 10 being the worst pain). The medication was documented as effective.Review of Resident #59's aide charting indicated aides were to monitor fluid output every twelve hours. Review of the urine output documentation dated 01/21/26 at 3:33 P.M. revealed only 20 cubic centimeters (cc) of urine output was recorded. There was no urine output recorded on 01/22/26 at 7:06 A.M. as staff noted the resident had refused. Review of Resident #59's progress notes dated 01/21/26 at 3:33 P.M. through 01/23/26 at 5:54 A.M. revealed no documented evidence Resident #59 had urine output recorded.Review of Resident #59's physician orders dated 01/21/26 at 4:15 P.M. revealed an order to obtain urine for urinalysis and culture and sensitivity.Review of Resident #59's progress note dated 01/22/26 at 1:30 A.M. included Resident #59's urine specimen was unable to be sent to the lab because the lab representative left before Resident #59's urine specimen was collected. The catheter was clamped off and waiting for urine to accumulate but the lab collector left before there was enough urine to collect. There was no documented evidence in the progress note indicating how long the catheter was clamped and waiting for urine to accumulate. Review of Resident #59's progress notes dated 01/22/26 at 4:21 A.M. included two tablets of Acetaminophen 325 mg were administered to Resident #59 for complaints of pain rated a one to three out of 10, for pain in the lower back. Resident #59 rated his follow up pain at a two out of 10.Review of Resident #59's progress notes dated 01/22/26 at 6:54 A.M. included an unidentified physician representative spoke with Resident #59 and told the nurse she thought Resident #59 stated his pain was fine and controlled. The physician representative was informed Resident #59 was up all night complaining of pain and his medications were not effective. Gabapentin 100 mg by mouth was prescribed daily at bedtime for back pain.Review of Resident #59's Treatment Administration Record (TAR) revealed a urine specimen for urinalysis (UA) and culture and sensitivity (C and S) was collected on 01/22/26 at 2:22 P.M.Review of Resident #59's progress note dated 01/22/26 at 2:23 P.M. documented Resident #59's indwelling catheter and catheter bag were changed with no issues. Pale, yellow urine drained immediately and a urine sample was collected for UA C and S to be sent out on 01/23/26. A stat lock (a medical stabilization device used to secure an indwelling catheter to a patient's skin using an adhesive pad and a locking plastic clip) was placed on Resident #59's left leg to hold the indwelling catheter in place. Resident #59 denied pain or discomfort at this time. There was no documentation indicating why Resident #59's catheter needed to be changed at this time.Review of Resident #59's progress notes dated 01/22/26 at 2:34 P.M. revealed Ibuprofen 200 mg was administered for complaints of back pain rated a five out of a 10. All non-pharmacological interventions were ineffective. Resident #59's follow up pain scale was 0 indicating the Ibuprofen was effective.Review of Resident #59's progress notes dated 01/23/26 at 2:43 A.M. revealed Resident #59 was administered two Acetaminophen 325 mg tablets for complaints of pain in the lower back. Resident #59 rated his pain as one to three on a zero to 10 pain scale. Resident #59's follow up pain check revealed the Acetaminophen was effective.Review of Resident #59's progress notes dated 01/23/26 at 4:50 A.M. included Resident #59 was administered an Ibuprofen 200 mg tablet for pain in the lower back. Resident #59's pain level was not documented. Resident #59's follow up pain check revealed the Ibuprofen was effective.Review of Resident #59's progress notes dated 01/23/26 at 1:25 P.M. revealed Resident #59 was administered two Acetaminophen 325 mg tablets for complaints of pain of one to three out of 10. Resident #59's follow up pain check revealed his pain was rated at a two.Review of Resident #59's progress notes dated 01/24/26 at 6:45 A.M. revealed Resident #59 was administered Ibuprofen 200 mg and his follow up pain check was rated a five out of a 10.Review of Resident #59's TAR revealed on 01/24/26 at 2:04 P.M. Resident #59's indwelling catheter was changed.Review of Resident #59's progress notes dated 01/24/26 at 2:06 P.M. revealed on 01/24/26 at 12:00 P.M. Resident #59 notified the nurse that his indwelling catheter was pulled out the night before. A new order was received insert a 16 French catheter with a 15 cc balloon inside of Resident #59. The catheter was placed and Resident #59's catheter had red blood in it due to the pulling of the previous catheter. Resident #59 complained of a burning sensation that went away after a while. Pain medication was given. It noted that staff would continue to monitor. There was no evidence in Resident #59's medical record including progress notes dated 01/23/26 at 1:25 P.M. through 01/24/26 at 2:06 P.M. the resident's indwelling catheter was pulled out the night before or why the catheter was changed.Review of Resident #59's progress notes dated 01/24/26 at 2:06 P.M. through 01/25/26 at 11:47 A.M. revealed no documented evidence that Resident #59 was evaluated and monitored for blood in his urine. There was no evidence Resident #59's physician was notified of the blood in his urine.Review of Resident #59's aide charting for urine output revealed from 01/24/26 at 4:32 P.M. through 01/25/26 at 4:39 A.M. there was no urine output recorded. On 01/25/26 at 4:39 A.M., 300 cc of urine was recorded. There was no additional urine recorded from 01/25/26 at 4:39 A.M. through 01/25/26 at 12:40 P.M. when Resident #59 was transported to the local emergency room (ER).Review of Resident #59's local fire department [NAME] Review Transportation Report dated 01/25/26 included a call was received at 10:39 A.M. and emergency medical services (EMS) had patient contact at 10:49 A.M. Resident #59 complained of bad pain and the staff at the facility stated Resident #59 was having issues with his urinary catheter. Resident #59's indwelling catheter had fallen out several times recently and staff denied Resident #59 pulled his catheter out. Staff stated they attempted to put more air in the balloon to keep it secure. Staff stated Resident #59 had straight blood in his indwelling catheter last night. Staff believed he had some urine output since placement, but there was no urine currently in the bag. Resident #59's abdomen was distended in the right quadrants, not firm, and his abdomen was tender in all quadrants.Review of Resident #59's progress note dated 01/25/26 at 11:47 A.M. revealed Respiratory Therapist #272 walked into Resident #59's room and noticed blood and blood clots in Resident #59's urine catheter bag. Resident #59 was very lethargic, and his abdomen was extended and painful to touch. Resident #59's oxygen saturation level was 77 percent (%) (normal ranges from around 95% to 100%) on room air and oxygen at two liter per minute was applied. Resident #59's oxygen saturation level was 94 percent on oxygen two liters per minute, pulse 76 beats per minute (bpm) (normal ranges from 60 to 100 bpm), respirations 20 breaths per minute (normal ranges from 12 to 20 breaths per minute), and temperature was 100.3 Fahrenheit (F) (normal ranges from around 97 degrees F to 99 degrees F). Resident #59 was transported to the hospital.Review of Resident #59's progress note dated 01/25/26 at 12:40 P.M. included Respiratory Therapist #272 notified the nurse Resident #59's oxygen saturation level was 77% on room air, oxygen two liters per minute was applied and his oxygen saturation level improved to 94%. Resident #59's abdomen was distended, was painful to touch and he was very lethargic. Blood and a clot were noted in Resident #59's urinary catheter bag. The resident's unidentified on-call Nurse Practitioner was contacted and orders were given to transport Resident #59 to the ER for evaluation and treatment.Review of Resident #59's hospital notes dated 01/25/26 revealed Resident #59 was diagnosed with a urinary tract infection associated with his indwelling urethral catheter, a problem with his indwelling catheter and a urethral injury. The facility was experiencing clogging of Resident #59's catheter, the facility took Resident #59's catheter out put a new one in and now the new catheter was draining minimal urine. Resident #59's catheter was removed, and a new urethral catheter was inserted in the ED. The notes included Resident #59 had a urine specimen collected for urinalysis and reflex culture. Resident #59's urine specimen for urinalysis was abnormal. Resident #59's white blood cell (WBC) counts were greater than 50 cells per HPF (high-power field) (normal was 1 to 5 cells), and a finding greater than 50 WBC's indicated high levels of inflammation or infection within the urinary tract. Resident #59's red blood cell (RBC) counts were greater than 20 cells per HPF (normal was 0 to 3 per HPF, and greater than 3 to 5 per HPF was flagged as high and often indicated a urinary tract infection). Resident #59's urine was dark-brown, turbid, and had over three plus blood (indicating a significant amount of blood) in the urine. Resident #59 had a computed tomography (CT) scan of the abdomen and pelvis and there was a suspected type two posterior urethral injury (severe iatrogenic urethral trauma, can be caused by a malplaced or improperly handled catheter) with fluid-filled peripheral enhancing outpouching along the course of the prostatic urethra, newly seen since 11/14/24. It noted that enhancement along the margin of the collection may be due to the healing response, inflammation, or infection. A urologic consultation was completed, and the urologist found Resident #59 did not require emergent urological intervention and could follow up as an outpatient. Discharge instructions included to schedule an appointment as soon as possible for a visit in one week, and noted Resident #59 was discharged with antibiotics for a UTI and to follow up with the ED if symptoms worsen. Review of Resident #59's progress note dated 01/25/26 11:15 P.M. included Resident #59 returned to the facility via hospital transport. Resident #59 had his indwelling catheter replaced and it was draining appropriately. Hematuria (blood in the urine) was noted related to the urethral injury.Review of Resident #59's aide charting revealed no documented evidence urine output was documented from 01/25/26 at 11:15 P.M. through 01/26/25 at 10:50 A.M. when EMS arrived to transport Resident #59 back to the ED.Review of Resident #59's progress notes dated 01/25/26 at 11:15 P.M. through 01/26/25 at 9:30 A.M. revealed no documented evidence Resident #59 was monitored and evaluated for a change of condition including blood and urine in his indwelling catheter.Review of Resident #59's late entry progress notes dated 01/26/26 at 2:43 P.M. included on 01/26/26 at 9:30 A.M., Resident #59's right abdominal area was swollen and he complained of right abdominal pain. The note referenced how Resident #59 returned from the hospital last night [indicating 01/25/26] with an indwelling catheter and a CT scan stated the catheter was not in the correct place and Resident #59 needed to follow up with the urology service to have his indwelling catheter placed in the correct position. Nurse Practitioner (NP) #300 was contacted [regarding the new abdominal swelling and complaints of right abdominal pain] and ordered Resident #59 to be transported to the ED to have correct placement of his indwelling catheter and to have his lungs evaluated for fluid. Review of Resident #59's local fire department [NAME] Review Transportation Report dated 01/26/26 included a call was received from the facility at 10:43 A.M and patient contact was at 10:50 A.M. The report noted that Resident #59 had catheter issues and the facility advised that Resident #59 was sent back from the hospital with the catheter in wrong, and Resident #59 had abdominal distention that was not normal. Resident #59 appeared slightly short of breath with notable right-sided abdominal distention that was rigged and tender to touch. There was blood coming from his catheter. Resident #59 was transported to the ED.Review of Resident #59's hospital notes dated 01/27/26 through 01/30/26 included Resident #59 had a history of urinary retention with an indwelling catheter and urethral stricture. Resident #59's Power of Attorney (POA) stated Resident #59 was not feeling well and reported abdominal pain and a cough since 01/24/26. Resident #59 had an indwelling catheter placed at the facility, it was malplaced and hematuria was noted on 01/25/26. Resident #59 was transported to the ED on 01/25/26 and was found to have a UTI, a new indwelling catheter was placed, and he was given a prescription for Augmentin (an antibiotic medication). Resident #59's abdominal pain and cough continued when he returned to the facility [on 01/25/26] and on 01/26/26 he was transferred from the facility to the ED via EMS. Resident #59 was transported to the hospital, and he was positive for dysuria, hematuria, penile pain, and had bleeding around the tip of the urethra. The note also included back tenderness was present. Resident #59 was admitted to the hospital and diagnoses included UTI. Resident #59 was ordered intravenous (IV) Ertapenem (an antibiotic medication) 1 gram (g) per 50 milliliters (ml), for one week from 01/28/26 through 02/03/26 via a midline catheter, for a UTI. Resident #59 needed to follow up with urology for outpatient management of his urethral injury.An observation on 02/19/26 at 9:44 A.M. of Resident #59 revealed he was sitting in his wheelchair and asked for help to use the bathroom. An interview on 02/19/26 at 11:05 A.M. with Power of Attorney (POA) #600 revealed she was Resident #59's POA. POA #600 stated the facility put Resident #59's catheter in wrong and on 01/25/26 he was transported to the ED. POA #600 indicated Resident #59 returned to the facility and had to be transported a second time to the ED due to issues with his catheter. POA #600 stated it was very upsetting that the facility put his catheter in wrong and he had to go to the ED because of it.An interview on 02/23/26 at 8:58 A.M. with Respiratory Therapist (RT) #272 revealed on 01/25/26 she walked by Resident #59's room and noticed the resident was still in bed and that was unusual for him because he usually got himself up. RT #272 indicated she entered Resident #59's room to check on him and noticed blood and clots in his urinary catheter bag. RT #272 stated she tried to wake Resident #59 up, but he was very lethargic and his abdomen was swollen. RT #272 called Licensed Practical Nurse (LPN) #238 to his room, and LPN #238 checked Resident #59's vital signs, he had a fever of 100.3 degrees F and his oxygen saturation level was 77%. Resident #59 was transported to the ED via EMS.An interview on 02/23/26 at 12:05 P.M. with LPN #208 revealed on 01/26/26 Resident #59 was having pain in his abdomen, there was a bulge and the right side was swollen. Resident #59 was holding his abdomen, was in pain, was confused and he did not say how bad his pain was. LPN #208 stated Resident #59 said ow when she touched his abdomen. LPN #208 stated Resident #59 never had a bump in his abdomen before and she read Resident #59's hospital notes from 01/25/26, the CT scan showed the catheter was not in the correct place, and the ED physician took out the catheter that was in the wrong place and put a new catheter in. LPN #208 stated no one told her this information, but she read it when she reviewed the hospital notes. LPN #208 contacted Nurse Practitioner #300 on 01/26/26 and Resident #59 was sent to the ED via 911. Resident #59 was sent back to the facility on [DATE] and was supposed to have a follow-up appointment with a urologist. LPN #208 revealed the nurse had a difficult time putting Resident #59's catheter in on 01/24/26, there was no urine coming out, and Resident #59 was transported to the ED on 01/25/26.An interview on 02/23/26 at 5:15 P.M. with Regional Director of Clinical Services (RDCS) #301 confirmed the above findings and she stated she did not find additional information to add. Review of the facility policy titled Catheter Care Procedure-Urinary revised 12/28/23 included it was the policy of the facility to provide catheter care to all residents that had an indwelling catheter in an effort to reduce bladder and kidney infections, while maintaining their dignity and privacy. Residents with an indwelling catheter would be provided catheter care in accordance with current clinical standards. This might include every shift and as needed and per request. Catheters should be emptied every shift or as needed and urinary output should be recorded per facility protocol. 2. Review of Resident #70's closed medical record revealed an admission date of 09/04/25 and a discharge date of 01/24/26. Resident #70's diagnoses included chronic systolic (congestive) heart failure (CHF), type two diabetes mellitus with diabetic chronic kidney disease and diabetic retinopathy with macular edema and acquired absence of the right leg above the knee. Review of Resident #70's care plan dated 09/05/25 included Resident #70 was at risk for fluid volume deficit (the care plan did not specify what the fluid volume deficit was related to). It noted Resident #70 would maintain moist mucous membranes and good skin turgor through the next review. Interventions included to encourage Resident #70 to drink fluids of choice unless contraindicated and assist as needed, and to observe and report to the physician or nurse practitioner, as needed, for signs and symptoms of dehydration such as decreased or no urine output, concentrated urine, strong odor etcetera.Review of Resident #70's care plan dated 09/04/25 through 01/24/26 revealed no documented evidence of a care plan related to urinary and bowel incontinence or interventions to monitor Resident #70 for signs and symptoms of urinary tract infection (UTI) such as pain and burning during urination.Review of Resident #70's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #70 was cognitively intact. The assessment revealed Resident #70 had impairment on both sides of the lower extremities and used a wheelchair. Resident #70 was dependent on staff for toileting hygiene and required substantial to maximum (staff) assistance with bathing and lower body dressing. The assessment included Resident #70 was always incontinent of urine and bowel.Review of Resident #70's progress note dated 01/20/26 at 11:53 P.M. included Resident #70 stated he was having burning when urinating. Resident #70 stated he noticed the burning at 10:30 P.M. when he used the restroom. An unidentified on-call nurse practitioner was notified. Resident #70 stated his pain was rated a six out of a 10 (on a zero to 10 pain scale, zero being no pain and 10 being the worst pain). There was no documented evidence that the on-call nurse practitioner gave orders related to Resident #70's burning and pain when urinating, including a urine specimen to be collected for urinalysis or urine culture and sensitivity.Review of Resident #70's progress notes, physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR), dated 01/20/26 at 11:53 P.M. through 01/24/26 at 8:44 P.M., revealed no documented evidence Resident #70 was evaluated or monitored for pain on urination. There was no evidence that a urine specimen for urinalysis (UA) and culture and sensitivity (C&S) was ordered or collected and sent to the lab.Review of Resident #70's progress note dated 01/22/26 at 2:03 A.M. included Resident #70 was complaining of his right arm shaking. Visible shaking was present. Resident #70's blood sugar was 70 milligrams per deciliter (mg/dL) (normal ranges from around 70 to 100 mg/dL), and he refused to have his blood pressure and pulse checked. Resident #70 took a sip of coke and refused to take additional sips when the nurse encouraged him to do so. Resident #70 denied pain and denied needing pain medication. Resident #70 stated his arm had shaken in the past a few times, but he was unsure of the cause. The nurse asked Resident #70 what would help him, he stated lying in bed would help, and the nurse assisted him to bed. There were no further complaints. Additionally, there was no documented evidence that Resident #70's physician was notified of Resident #70's right arm shaking.Review of Resident #70's progress note dated 01/22/26 at 2:03 A.M. through 01/24/26 at 8:44 P.M. did not reveal evidence Resident #70 was monitored and evaluated for any type of change in condition. Review of Resident #70's progress notes from 01/23/26 revealed no documented evidence of emesis.Review of Resident #70's progress note dated 01/24/26 at 8:44 P.M. included Resident #70 stated he had been feeling shaky for the past five to seven days and was demanding to be transferred to the hospital. Resident #70's blood sugar was 143 mg/dL, blood pressure 148/77 millimeters of Mercury (mmHg) (normal ranges around 120/80 mmHg), and temperature 98.9 Fahrenheit (F) (normal ranges from around 97 degrees F to 99 degrees F). The on-call physician was notified and gave orders to send Resident #70 to the emergency department (ED) for evaluation and treatment.Review of Resident #70's progress note dated 01/24/26 at 8:50 P.M. revealed a private ambulance company was contacted to transport Resident #70 to the ED.Review of Resident #70's Pre-Hospital Care Report Summary dated 01/24/26 included at 9:31 P.M., a call was received by the facility and patient contact was at 11:13 P.M. A squad was dispatched to the facility to transport Resident #70 to the ED for complaints of weakness. Resident #70 was alert and oriented times four (person, place, time, situation). Resident #70 was speaking in full and complete sentences. Resident #70 stated his arms had been weak and shaky since yesterday (01/23/25). Resident #70 denied pain, headache, dizziness, nausea and or any other complaints. Resident #70 was transported to the ED. Review of Resident #70's hospital report dated 01/24/26 at 11:45 P.M. included Resident #70 presented with rigors and had a past medical history including peripheral artery disease and was status post above the knee amputation on the right side, type two diabetes mellitus complicated by neuropathy. Resident #70 had congestive heart failure (CHF), coronary artery disease and was status post coronary artery bypass grafting (CABG) and implantable cardioverter-defibrillator (ICD). Resident #70 presented from the facility with concern for shaking of his hands throughout the day yesterday (01/23/26). At that time Resident #70 denied acute concerns. Work up in the ED revealed the resident was positive for a UTI and Resident #70 was found to have elevated troponin [indicating potential heart muscle damage] and was hypoxic (low levels of oxygen). Resident #70 refused supplemental oxygen even after being informed of negative consequences including death. Resident #70 was diaphoretic and started projectile vomiting. Resident #70 endorsed having an episode of emesis at the facility yesterday. Resident #70's assessment included acute cystitis, sepsis with acute organ dysfunction (multi) for which blood and wound cultures were obtained and antibiotics administered, acute hypoxic respiratory failure and acute decompensated heart failure.Further review of Resident #70's medical records revealed no additional documentation was available for review.An interview on 02/19/26 at 5:15 P.M. with Licensed Practical Nurse (LPN) #238 revealed she sent Resident #70 to the hospital on [DATE]. LPN #238 stated she was taking care of Resident #70 when he complained of burning on urination and rated his pain a six out of a 10. LPN #238 stated she called an unidentified nurse practitioner about the resident's pain and burning on urination. LPN #238 stated she thought Resident #70 did not want to have a urine specimen collected for urinalysis and culture and sensitivity because he said he was feeling fine. LPN #238 revealed she was almost positive she was given an order for a urine culture and Resident #70 said no he did not want one; however, she confirmed she did not document she was given an order or that Resident #70 refused to have a urine specimen collected. LPN #238 stated as far as she knew no urine specimen was sent to the lab for analysis. LPN #238 stated Resident #70 sometimes refused to have care completed and then stated Resident #70 had passed away at the hospital around 02/02/26.An interview on 02/23/26 at 5:15 P.M. with Regional Director of Clinical Services #301 revealed she could find no additional information and confirmed there was no evidence Resident #70 was monitored or evaluated for pain and burning upon urination, no evidence a urine specimen was ordered or collected and sent to the lab for a urinalysis or C&S and no evidence Resident #70 was monitored for shaking of his right arm or that the physician was aware of it.Review of the facility policy titled Notification of Changes revised 08/29/24 included the purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician, and notified, consistent with his or her authority the resident's representative when there was a change requiring notification. This deficiency represents non-compliance investigated under Complaint Number 2647655.

Based on record review, interview and review of facility policy, the facility did not ensure a designated Infection Preventionist provided oversight, monitoring and management of all components of the Infection Prevention and Control Program. This had the potential to affect all 55 residents in the facility. Findings Include: Review of immunization records for Resident #5, #16, #24, #40 and #61 revealed concerns with an unidentified staff member completing vaccination education and consent forms with the residents and/or responsible parties as followed: Review of Resident #5's immunization consent forms for Covid-19, influenza and pneumococcal vaccine's revealed education and all three consents were provided to the resident's daughter on 02/05/26 and the staff member obtaining verbal consent was not identified on the forms. There was no witness signature on the forms. Review of Resident #16's immunization consent forms for Covid-19, influenza and pneumococcal vaccine's revealed education and all three consents were provided to the resident's responsible party on 09/19/25 and the staff member obtaining verbal consent was not identified on the forms. There was no witness signature on the forms. Review of Resident #24's immunization consent forms for Covid-19, influenza and pneumococcal vaccine's revealed education and all three consents were provided to the resident's responsible party on 09/17/25 and the staff member obtaining verbal consent was not identified on the forms. There was no witness signature on the forms. Review of Resident #40's immunization consent forms for Covid-19, influenza and pneumococcal vaccine's revealed education and all three consents were provided to the resident's responsible party on 09/16/25 and the staff member obtaining verbal consent was not identified on the forms. There was no witness signature on the forms. Review of Resident #61's immunization consent forms for Covid-19, influenza and pneumococcal vaccines revealed the resident was their own responsible party and gave verbal consent for vaccinations on 09/15/25. The staff member providing education and obtaining verbal consent was not identified on the forms. There was no witness signature on the forms. In addition, Review of the facility's Infection Surveillance Report dated November 2025, December 2025, and January 2026 revealed in the month of November 2025 there were 28 identified infections requiring antibiotic use. Eighteen of the infections were checked did not meet McGeer's criteria for antibiotic use. In December 2025 there were 22 identified infections. Eighteen of the infections were checked did not meet McGeer's criteria for antibiotic use. In January 2026 there were 18 identified infections. Thirteen of the infections were checked did not meet McGreer's criteria for antibiotic use. The report did not indicate if any follow-upevaluation had been completed regarding the infections not meeting the standards for antibiotic use. Review of the facility's Annual Long Term Care Facility Self-Assessment Tool, dated 09/03/25, revealed Regional Director of Clinical Services (RDCS) #301 was listed as the Infection Preventionist for the facility. An interview was conducted on 02/19/26 at 4:10 P.M. with the Administrator who revealed RDCS #301 was the Infection Preventionist for the facility, but the Administrator was unsure if she was in the facility at least part-time. The Administrator stated she believed Licensed Practical Nurse (LPN) #235 who worked full-time in the facility was also an Infection Preventionist as well as the Minimum Data Set (MDS) nurse for the facility. The Administrator provided a certificate for LPN #235 to verify LPN #235 had been certified as an Infection Preventionist. An interview on 02/25/26 at 4:05 P.M. with RDCS #301 confirmed the facility did not have at least a part-time Infection Preventionist in place to ensure the infection prevention and control program was being consistently implemented and monitored in the facility. RCDS #301 stated LPN #235 worked full-time as the MDS nurse and helped with the infection control log, but did not oversee the infection prevention and control program in the facility. RDCS #301 statedthe facility usually had the Staff Development Coordinator (SDC) assume the role of the Infection Preventionist or had several people in the role of the Infection Preventionist but they had not lasted with the facility. RDCS #301 stated the facility just hired a new Infection Preventionist who started the previous week, and the facility had three other nurses besides herself working as the Infection Preventionist in the past year. RDCS #301 confirmed the immunization consents for Resident #61, #40, #24, #16 and #5 were not completed by an identifiable staff person and confirmed the infection surveillance report identified 49 infections that did not meet McGreer's criteria for antibiotic use with no evidence of follow-up on the report. Review of the facility's Infection Prevention and Control Program, last revised 12/27/23, revealed the Infection Preventionist (IP) is responsible for oversight of the Infection Control program and serves a consultant for staff on infectious disease, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigation of exposures of infectious diseases. The IP serves as leader of the antibiotic stewardship program. The IP is responsible for oversight of the Covid-19, influenza and pneumococcal vaccinations.

Based on interview, record review, and review of the facility policy, the facility failed to ensure Resident's #17, #33, #59, #66, #67 and #70's physician orders were followed for medication administration. This affected six residents (Resident's #17, #33, #59, #66, #67 and #70) out of six reviewed for medication administration and had the potential to affect all twelve residents residing on the 400 nursing unit. The facility census was 55.Findings include: 1. Review of Resident #70's medical record revealed an admission date of 09/04/25 and a discharge date of 01/24/26. Resident #70's diagnoses included chronic systolic (congestive) heart failure (CHF), type two diabetes mellitus with diabetic chronic kidney disease and diabetic retinopathy with macular edema, and acquired absence of the right leg above the knee. Review of Resident #70's physician orders dated 09/04/25 revealed insulin lispro subcutaneous solution pen-injector 100 units per milliliter (ml) with instructions to inject per sliding scale, if Resident #70's blood sugar was 150 to 199 administer three units insulin, if it was 200 to 249 administer six units, if it was 250 to 299 administer nine units, if it was 300 to 349 administer 12 units, if it was 350 to 400 administer 15 units and above 400 give 18 units and call the physician, subcutaneously before meals and at bedtime for type two diabetes mellitus. Review of Resident #70's Medication Administration Record (MAR) dated 10/30/25 revealed there was no evidence insulin lispro subcutaneous solution pen-injector 100 units per ml was administered per sliding scale at 11:00 A.M before the lunch meal or at 4:00 P.M. before the dinner meal. There was no evidence Resident #70's blood sugars were checked at 11:00 A.M. and 4:00 P.M. as ordered. Review of Resident #70's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #70 was cognitively intact. Resident #70 had impairment on both sides of the lower extremities and used a wheelchair. Resident #70 was dependent on staff for toileting hygiene and required substantial to maximum assistance with bathing and lower body dressing. It noted that Resident #70 was always incontinent of urine and bowel. 2. Review of Resident #59's medical record revealed an admission date of 08/23/19 and diagnoses included chronic combined systolic (congestive) and diastolic (congestive) heart failure, Alzheimer's Disease, paroxysmal atrial fibrillation, type two diabetes mellitus with diabetic peripheral angiopathy without gangrene, dementia, and cardiomyopathy. Review of Resident #59's physician orders dated 11/15/24 revealed Novolog flex-pen subcutaneous solution pen-injector 100 units per ml subcutaneously before meals and at bedtime for diabetes mellitus, with instructions to inject per sliding scale. If Resident #59's blood sugar was 180 to 240 inject two units, if it was 241 to 300 administer four units, if it was 301 to 360 administer six units, if it was 361 to 400 administer eight units and above 400 call the physician. Review of Resident #59's MAR dated 10/30/25 revealed no evidence at 11:00 A.M. that Resident #59's blood sugar was checked and insulin was administered per sliding scale as ordered. Review of Resident #59's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had moderate cognitive impairment. Resident #59 used a wheelchair and required supervision or touching assistance for toileting and personal hygiene. Resident #59 required partial to moderate assistance with lower body dressing. Resident #59 had an indwelling catheter and was frequently incontinent of bowel. 3. Review of Resident #66's medical record revealed an admission date of 08/21/20 and a discharge date of 11/03/25. Resident #66's diagnoses included Alzheimer's Disease, dementia, type two diabetes mellitus and chronic diastolic (congestive) heart failure. Review of Resident #66's physician orders dated 08/13/25 revealed insulin glargine-yfgn 100 units per ml pen with instructions to inject 16 units subcutaneously one time a day related to type two diabetes mellitus with hyperglycemia. Review of Resident #66's MAR dated 10/30/25 revealed there was no evidence insulin glargine-yfgn was administered at 9:00 A.M. as ordered. 4. Review of Resident #67's medical record revealed an admission date of 07/18/25 and a discharge date of 01/13/26. Resident #67's diagnoses included unspecified convulsions, multiple fractures of the pelvis with stable disruption of the pelvic ring, initial encounter for closed fracture, and obesity. Review of Resident #67's physician orders dated 07/20/25 revealed orders for a Phenobarbital oral tablet 32.4 mg with instructions to give one tablet orally every eight hours for seizures. Review of Resident #67's MAR dated 10/30/25 did not reveal evidence Resident #67 was administered Phenobarbital 32.4 mg at 2:00 P.M. as ordered. Review of Resident #67's Controlled Drug Record dated 10/30/25 at 2:00 P.M. did not reveal evidence Resident #67's Phenobarbital 32.4 mg was signed off it was administered. 5. Review of Resident #17's medical record revealed an admission date of 10/03/23 and diagnoses included rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites, [NAME]-Danlos syndrome, and major depressive disorder. Review of Resident #17's physician orders dated 03/12/25 revealed orders for Oxycodone oral capsule 5 mg with instructions to give one by mouth three times a day for pain. Review of Resident #17's MAR dated 10/30/25 at 2:00 P.M. revealed there was no evidence Oxycodone 5 mg was administered as ordered. Review of Resident #17's Controlled Drug Record dated 10/30/25 at 2:00 P.M. did not reveal evidence Resident #17's Oxycodone 5 mg was signed off it was administered. Interview on 02/23/26 at 10:14 A.M. of Licensed Practical Nurse (LPN) #608 revealed on 10/30/25, Former Director of Nursing (FDON) #609 had to administer medications on the 400 nursing unit due to a nurse call-off. LPN #608 stated FDON #609 did not pass medications during the time she had the keys to the medication cart. LPN #608 stated he worked night shift and Resident #17 told him she did not receive her Oxycodone 5 mg at 2:00 P.M. as was ordered. LPN #608 indicated he checked Resident #17's MAR and found her Oxycodone was not signed off it was administered, and LPN #608 checked other residents on the nursing unit and found other residents did not receive medications during the time FDON #609 had the keys also. LPN #608 stated FDON #609 was always angry if she had to help out on the nursing units. Interview on 02/24/26 at 10:11 A.M. with Assistant Director of Nursing (ADON) #214 confirmed LPN #608 told her Resident's #17, #59, #66, #67 and #70 who resided on the 400 hall nursing unit did not have their medications signed off on their MAR's. ADON #214 stated she did not remember the date but when she was told about Resident's #17, #59, #66, #67 and #70 not receiving their medications it was way past time for her to leave for the day. LPN #214 stated she thought she told FDON #609 about it before she left, but it might have been the next day that she told FDON #609 that the residents did not receive their medications. ADON #214 stated she did not follow up on the residents not receiving their medications because she told FDON #609 about it. Interview on 02/24/26 at 4:00 P.M. of Regional Director of Clinical Services (RDCS) #301 and the Administrator confirmed there was no evidence on 10/30/25 on day shift that Resident's #17, #59, #66, #67 and #70 were administered their medications but they were unaware this occurred until now. RDCS #301 and the Administrator stated they had no knowledge of staff stating FDON #609 did not pass medications to the residents when she had to pass medications on a nursing unit. Review of the facility policy titled Medication Administration revised 01/17/23 included instructions to compare medication source with the MAR to verify resident's name, form, dose, route, and time of administration. Administer [medications] within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. Administer the medication as ordered in accordance with manufacturer specifications. 6. Review of the medical record for Resident #33 revealed an admission date of 07/07/22. Diagnoses included hypertension, pain, anxiety disorder, aphasia, dysphasia and post traumatic seizures. Review of the October 2025 physician orders revealed Resident #33 had current orders for the following: tube feed to be held times one hour a day, resume tube feed at prescribed rate, flush with 50 ml of water prior to resuming; tube feed to be held times one hour daily, stop tube feed flush with 50 ml water prior to tube feed being turned off; Guaifenesin oral liquid (an expectorant)100 mg/5ml, give 20 ml via Percutaneous Endoscopic Gastrostomy (PEG) tube every 8 hours for congestion; Tylenol oral tablet 325 mg, give 650 mg via PEG-tube three times a day for mild pain/discomfort; enteral feed order every four hours flush tube 160 ml of water; Levetiracetam oral solution (an anti-seizure medication)100 mg/ml, give 5 ml via PEG-tube two times a day related to post traumatic seizures; enteral feed order, every day shift flush tube with 30 ml water before and after medication administration and feedings; enteral feed order every day shift, check residual every shift and record if residual greater than 150 ml, hold feeding and notify physician. Review of the October 2025 Medication Administration Record (MAR) revealed the following orders were not administered to Resident #33 on 10/16/25: enteral feed order every 4 hours flush tube 160 ml water at 5:00 P.M.; Tylenol oral tablet 325 mg, give 650 mg via PEG-tube three times a day for mild pain/discomfort at 1:00 P.M.; Guaifenesin oral liquid 100 mg/5ml, give 20 ml via PEG-tube every 8 hours for congestion at 2:00 P.M.; Levetiracetam oral solution 100 mg/ml, give 5 ml via PEG-tube two times a day related to post traumatic seizures at 6:00 P.M.; Tube-feed to be held times one hour daily one time a day, resume tube-feed at prescribed rate, flush with 50 ml of water prior to resuming at 3:00 P.M.; tube-feed to be held times one hour daily one time a day, stop tube-flush with 50 ml water prior to tube-feed being turned off at 2:00 P.M.; enteral feed order every day shift flush tube with 30 ml of water before and after medication administration and feedings at 7:00 P.M.; and enteral feed order every day shift check residual every shift and record if residual greater than 150 ml, hold feeding and notify MD at 7:00 P.M. Interview and review of the MAR on 02/24/26 at 2:34 P.M. with Licensed Practical Nurse #214 verified the above orders were not marked on the MAR as being completed. This deficiency represents non-compliance investigated under Complaint Number 2647655 and 2659281.

Based on record review, observation, interview, and policy review, the facility failed to ensure resident room refrigerators were monitored, cleaned and outdated food items were disposed of appropriately. This affected five residents (#18, #39, #45, #55, and #59) of six residents whose room refrigerators were observed. The facility identified 13 residents (#1, #15, #18, #28, #35, #38, #39, #43, #45, #48, #55, #59 and #60) who had in-room refrigerators. The facility census was 55.Findings include: Interview on 02/24/26 at 10:42 A.M. with District Foodservice Manager #302 revealed the food service department was managed by a contracted agency and their staff do not go into resident rooms. District Foodservice Manager #302 was unsure if the facility had resident refrigerators or unit refrigerators since their department does not monitor them.1. Review of the resident record for Resident #18 revealed and admission date of 02/04/23. Diagnoses included but were not limited to anoxic brain damage, congestive heart failure, and vascular dementia. Resident #18 was noted to receive a no added salt diet. Review of the 02/14/26 Quarterly Minimum Data Set (MDS) 3.0 for Resident #18 revealed a Brief Interview of Mental Status (BIMS) of 13 which indicated intact cognition. Resident #18 was noted to require set up assistance for meals. Observation on 02/24/26 at 11:06 A.M. with admission Coordinator #207 of Resident #18's refrigerator revealed two one-ounce (oz) packets of sour cream with a use by date of 02/16/26, an 18 oz jar of black raspberry jam with the a use by date of 01/20/26, a 32 oz jar of pickled cauliflower with visible mold inside the jar with no evident use by date on the jar nor an open date, a half-pound open package of chopped deli ham with a use by date of 02/19/26, and another half-pound open package of chopped deli ham with a use by date of 02/06/26.2. Review of the resident record for Resident #39 revealed an admission date of 04/19/21. Diagnoses included but were not limited to chronic obstructive pulmonary disease, cardiomyopathy, and morbid obesity. Resident #39 was noted to receive a controlled carbohydrate diet. Review of the 01/24/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #39 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Resident #39 was noted to require set up assistance for meals. Observation on 02/24/26 at 11:11 A.M. with admission Coordinator #207 of Resident #39's refrigerator revealed one 14 oz bottle of mustard with a use by date of 12/03/25. Interview at the time of observation with Resident #39 revealed staff checks the refrigerator frequently but was unsure if food expiration dates were checked. 3. Review of the resident record for Resident #55 revealed an admission date of 02/20/15. Diagnoses included but were not limited to Alzheimer's disease, cerebrovascular disease, dementia in other diseases, hemiplegia, and type II diabetes mellitus. Resident #39 was noted to receive a regular diet. Review of the 02/08/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #55 revealed a Brief Interview of Mental Status (BIMS) 3.0 of 12 which indicated moderate cognitive impairment. Resident #39 was noted to require set up assistance for meals. Observation on 02/24/26 at 11:14 A.M. with admission Coordinator #207 revealed Resident #55's room refrigerator had multiple dried stains in the refrigerator and was not clean. 4. Review of the resident record for Resident #59 revealed an admission date of 01/30/26. Diagnoses included but were not limited to type II diabetes mellitus, Alzheimer's dementia and obesity. Resident #59 was noted to receive a regular diet. Review of the 02/08/26 Significant change Minimum Data Set (MDS) 3.0 for Resident #59 revealed a Brief Interview of Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. Resident #59 was noted to require set up assistance for meals. Observation on 02/24/26 at 11:23 A.M. with admission Coordinator #207 revealed Resident #59's refrigerator was dirty with multiple dried stains on the inside.5. Review of the resident record for Resident #45 revealed and admission date of 11/27/24. Diagnoses included but were not limited to mononeuropathy of bilateral lower limbs, and epilepsy. Resident #45 was noted to receive a regular diet. Review of the 02/02/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #45 revealed a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. Resident #59 was noted to require set up for meals. Observation on 02/24/26 at 11:30 A.M. with admission Coordinator #207 revealed Resident #45's refrigerator revealed it was dirty with multiple dried stains, contained a 14 oz squeeze bottle of mayonnaise with a use by date of 02/16/26, a 24 oz jar of sliced dill pickle spears with a use by date of 09/16/25, an open package of American cheese slices with five slices with a use by date of 02/21/26, and an opened and undated 16 oz container of spinach/artichoke dip with a use by date of 10/10/25.Interview at the time of the observation with Resident #45 revealed staff check the refrigerator temperature almost daily, but do not clean it. Resident #45 stated there are multiple dried spills on the bottom in the in the drawer but due to being in a wheelchair, he is unable to clean the refrigerator and staff do not offer to clean it, they just check the temperature.Interview with Admissions Coordinator #207 following observation the resident refrigerators listed above confirmed the above listed expired foods and cleanliness issues for the observed resident refrigerators.Interview on 02/25/26 at 8:08 A.M. with Transportation Staff #243 revealed he is responsible for checking the resident room refrigerator temperatures and sometimes he cleans the refrigerators. Transportation Staff #243 stated residents have reduced mobility and drop food in the refrigerator and if he sees the refrigerator is dirty, he cleans it. Transportation #243 stated sometimes residents tell him not to touch their food. A follow up interview on 02/25/26 at 1:28 P.M. with Transportation Staff #243 confirmed when a resident has told him not to touch or remove their food, he had not reported it to management for over a year.Review of the 07/01/25 revised facility policy called; Use and Storage of Food Brought in by Family or Visitors revealed it is the right of the residents of this facility to have food [NAME] in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident.All items not maintained are subjected to being thrown away if not removed by the resident and/or resident representative. The facility policy did not specify how frequently refrigerators would be cleaned or monitored.

Based on interview, record review, and policy review, the facility failed to implement an effective antibiotic stewardship program. This affected 21 (#70, #25, #27, #50, #59, #15, #18, #22, #67, #49, #61, #19, #3, #4, #42, #16, #1, #43, #51, #34 and #7) residents of 55 residents in the facility with the potential to affect all residents residing in the facility. The facility census was 55.Findings Include:Review of the infection surveillance logs for November 2025 through January 2026 revealed the following residents did not meet McGreers criteria for antibiotic use and there was no documentation regarding what the facility did to find out why the criteria was not met: Resident #70 was diagnosed with a wound infection on 11/06/25 that was a Healthcare-Associated Infection and did not meet the criteria for antibiotic use. He was prescribed Cephalexin 500 milligrams (mg) twice a day from 11/06/25 through 11/13 25. No organism was reported. Resident #25 was diagnosed with a fungal skin infection (no area identified) on 11/06/25 and was classified as a Healthcare-Associated Infection which did not meet criteria for antibiotic use. The resident was placed on topical Nystatin to be applied twice a day beginning 11/05/25 through 11/10/25. The resident was also placed on Fluconazole 200 mg orally from 11/05/25 through 11/13/25 Resident #59 was diagnosed with Catheter Associated Urinary Tract Infection (UTI) on 11/09/25 and it was a Healthcare-Associated Infection and did not meet criteria for an antibiotic. No organism was identified. The resident was placed on Cefdinir 300 mg orally twice a day from 11/11/25 through 11/14/25. Resident #15 was diagnosed with a Catheter Associated UTI on 11/13/25 and was a Healthcare Associated Infection which did not meet criteria for an antibiotic. The resident was started on Meropenem 1 gram intravenously (IV) every eight hours from 11/20/25 through 11/27/25. Resident #18 was diagnosed with a skin (wound) infection in an unidentified area on 11/13/25 and did not meet criteria for antibiotic use. The wound was listed as a Healthcare Acquired Infection. The resident was started on Cephalexin 500 mg orally twice a day from 11/14/25 through 11/21/25. Resident #22 was diagnosed with an unidentified infection on 11/23/25. The infection site was listed as precautions that was a Healthcare-Associated Infection. The resident was placed on Cefdinir 300 mg orally twice a day and Bactrim DS 800-160 mg two times a day from 11/13/25 through 11/20/25 for both medications. Resident #67 was diagnosed with a symptomatic UTI on 11/18/25 that was a Healthcare-Associated Infection which did not meet criteria for an antibiotic. The resident was placed on Cephalexin 500 mg orally twice a day from 11/20/25 through 11/25/25. Resident #49 was started on a prophylactic antibiotic for a Community-Associated Infection and placed on Bactrim DS once a day from 11/20/25 through 12/04/25. No documentation was listed on the log regarding if the criteria were met for an antibiotic. Resident #61 was diagnosed with a Healthcare-Associated Infection of pneumonia on 11/26/25. Criteria for an antibiotic was not met. The resident was placed on Levofloxacin 500 mg orally one time a day from 11/27/25 through 12/03/25. No associated organism was listed. Resident # 19 was diagnosed with a throat infection on 11/26/26 and was a Healthcare-Associated Infection and did not meet criteria for antibiotic use. No organism was identified. The resident was placed on Augmentin 875-125 mg orally every 12 hours twice a day. Resident #3 was diagnosed with a symptomatic urinary tract infection (UTI) on 11/28/25 and was a Healthcare-Associate Infection (HAI). It did not meet criteria for an antibiotic. The organism was Enterobacter Cloacae. Cefdinir 300 milligrams orally every evening was ordered and was administered 12/5/25 through 12/22/25. Resident #42 was diagnosed with Pharyngitis on 12/03/25 and was a Healthcare Associate Infection that did not meet the criteria for antibiotic used. The resident was placed on Augmentin 875-125 mg orally every 12 hours from 12/03/25 through 12/10/25. Resident #4 was diagnosed with a symptomatic UTI on 12/04/25 and was a Healthcare Associated Infection that did not meet criteria for antibiotic use. Klebsiella Pneumoniae was identified as the organism causing the infection. The resident was started on Macrobid 100 mg orally twice a day from 12/08/25 through 12/18/25. Resident #16 was diagnosed with symptomatic UTI on 12/04/25 and was a Healthcare Associated Infection which not meet criteria for antibiotic use. The identified organism was Serratia Marcescens. The resident was placed on Cefdinir 300 mg orally twice a day from 12/09/25 through 12/16/25. Resident #1 was diagnosed with a fungal skin infection on 12/05/25 and was a Healthcare Associated Infection that did not meet the criteria for antibiotic use. The resident was started on Fluconazole 150 mg every 72 hours from 12/04/25 through 12/13/25. The resident was also started on Nystatin Powder 1,000,000 units per gram 1000 mg twice a day from 12/03/25 through 12/17/25. Resident #43 was diagnosed with a Catheter Associated UTI on 12/05/25 and was a Healthcare Associated Infection that did not meet criteria for antibiotic use. The resident was started on Cefpodoxime Proxetil 200 mg twice a day from 12/15/25 through 12/19/25 and was started on a second round from 12/23/25 through 12/28/25. Resident #70 was diagnosed with a wound infection on 12/15/25 and was a Healthcare Associated Infection that did not meet the criteria for antibiotic use. The organism identified was Pseudomonas Aeruginosa. The resident was started on Ceftriaxone 2 grams/50 milliliters (ml) of dextrose solution every evening from 12/25/25 through 01/03/26. The resident also was started on Ceftazidime 2 grams per 50 ml dextrose solution once a day from 12/24/25 through 12/25/25. Resident #51 was diagnosed with a fungal skin infection on 12/18/25 and was a Healthcare Associated Infection that did not meet the criteria for antibiotic use. Nystatin cream 1,000,000 units per gram 1% was ordered to be applied twice a day from 12/18/25 through 01/01/26. Resident #19 was diagnosed with a skin infection of the throat on 12/18/25 and was a Healthcare Associated Infection that did not meet criteria for antibiotic use. The resident was started on Augmentin 875-125 mg orally every 12 hours from 12/18/25 through 12/28/25. Resident #34 was diagnosed with a wound infection on 12/18/25 and was a Healthcare Associated Infection that did not meet criteria for antibiotic use. No organism was identified. Doxycycline 100 mg orally twice a day form 12/18/25 through 12/19/25. Resident #7 was diagnosed with a skin infection of the throat on 12/23/25 and was a Healthcare Associated Infection which not meet criteria for antibiotic use. The resident was started on Azithromycin 250 mg orally once a day from 12/25/25 through 12/29/25 as well as a one time dose on 12/24/25. Resident #67 was diagnosed with a UTI on 12/31/25 and was a Healthcare Associated Infection that did not meet criteria for an antibiotic. No organism was identified. The resident was started on Cephalexin 500 mg orally twice a day from 12/31/25 through 01/03/26. Resident #22 was diagnosed with an unknown infection labeled Precautions and was a Healthcare Associated Infection that was not marked as meeting criteria for antibiotic use or did not meet criteria for antibiotic use. Organism was listed as other. The resident was started on Cefdinir 300 mg orally twice a day from 12/31/25 through 01/07/26. The resident was also placed on Bactrim DS from 12/31/25 through 01/07/26. Resident #22 was diagnosed with a wound infection on 01/01/26 and was a Healthcare Associated Infection which did not meet criteria for antibiotic use. The organism was Klebsiella Pneumoniae. The resident was started on Vancomycin 250 mg per 5 ml four times a day on 01/09/26 then started again on 01/17/26 through 01/24/26. The resident also received Ertapenem Sodium 1 gram once a day from 01/08/26 through 01/18/26. Resident #50 was diagnosed with a skin infection to the throat on 01/02/26 which was a Healthcare Associated Infection and did not meet criteria for antibiotic use. The resident was started on Amoxicillin 500 mg three times a day from 01/02/26 through 01/09/26. Resident #67 was diagnosed with a wound infection on 01/08/26 and was a Healthcare Associated Infection which did not meet criteria for antibiotic use. No organism was identified. The resident was started on Metronidazole 500 mg every night shift from 01/09/26 through 01/16/26. Resident #43 was diagnosed with catheter associated UTI on 01/09/26 and was a Healthcare Associated Infection that did not meet criteria for antibiotic use. The identified organism was Enterococcus Faecium and was placed on Linezolid 600 mg orally twice a day from 01/12/26 through 01/22/26. Resident #61 was diagnosed with Cellulitis to an unknown location on 01/13/26 and was a Healthcare Associated Infection which not meet criteria for antibiotic use. The resident was started on Doxycycline 100 mg orally twice a day from 01/20/26 through 02/06/26. The resident also received Cephalexin 500 mg orally four times a day from 01/14/26 through 01/19/26. Resident #27 was diagnosed with a symptomatic UTI on 01/13/26 and was a Healthcare Associated Infection which did not meet criteria for antibiotic use. The identified organism was Escherichia Coli. The resident was started on Cefdinir 300 mg two times a day from 01/12/26 through 01/19/26. An interview with RDCS #301 on 02/25/26 at 4:05 P.M. confirmed the findings on the infection surveillance logs for November 2025 through January 2026. RDCS #301 revealed the reason there were so many residents who were marked did not meet McGeers criteria was due to staff not documenting or assessing the residents symptoms related to the infection. RDCS #301 stated they have begun education of the staff regarding what needs to be documented. Review of the facility's Antibiotic Stewardship Program policy, last revised 12/13/23, revealed the antibiotic stewardship program is part of the facility's overall infection prevention and control program. The purpose is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Infection Preventionist coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff. The Medical Director serves as the primary medical point of contact for the program and serves as a liaison between the facility and other medical staff members. The Consultant Pharmacist reviews the antibiotics prescribed to the residents during their medication regimen review and serves as a resource for questions related to antibiotics. The program includes antibiotic use protocols and a system to monitor antibiotic usage. The nursing staff evaluates residents who are suspected to have an infection. Laboratory testing shall be in accordance with current standards of practice. The facility uses McGeer's Criteria to define infections. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. Prescriptions for antibiotics must specify the dose, duration, and indication for use. The facility will monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. All antibiotic orders will be reviewed for appropriateness. Monitor during each monthly medication regiment review when the resident has ben prescribed or is taking an antibiotic regimen review as requested by the Quality Assurance committee. Antibiotic use shall be measured by monthly prevalence, antibiotic starts, and/or antibiotic days of therapy. At least one outcome measure associated with antibiotic use will be tracked as part of the Quality Assurance program monthly.

Based on record review, interview, review of the facility self-reported incidents (SRIs) facility policy review, the facility did not ensure a thorough investigation was completed for Resident #7 for an allegation of misappropriation and Resident #67 for an allegation of staff-to-resident physical abuse. This affected two resident (#7 and #67) of the four residents reviewed for abuse. The census in the facility was 55.Findings include:1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including morbid obesity, peripheral vascular disease, major depressive disorder, gastroesophageal reflux disease, chronic pain, hypertension, insomnia, and hypothyroidism. Review of the Quarterly Minimum Data Set (MDS) 3.0 for Resident #7 dated 01/03/26 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Review of the care plan dated 11/18/25 revealed Resident #7 required one person assist for bathing, bed mobility, dressing, personal hygiene, toileting, and a two person assist for transfers. Review of the facility SRI tracking number 268983 filed on 12/23/25, revealed on 12/22/25, Resident #7 made an allegation of misappropriation. The resident stated she was missing 15 dollars. She was unsure of when it went missing stating sometime between now and two weeks ago. Registered Nurse (RN) #247 reported the incident to the Director of Nursing (DON) on 12/22/25, and she told RN #247 to write a statement and have the resident do the same. Review of the SRI revealed there were no other staff interviews to review. The facility conducted interviews of all interviewable residents in the 200 hall, and all reported no money was missing from their room. The facility reimbursed the missing money and reminded Resident #7 to utilize her lock box in her room. The facility concluded as a result of its investigation that the misappropriation was unsubstantiated. Review of the staff statement dated 12/22/25 from RN #247 revealed around 9:45 P.M. Resident #7 informed RN #247 she thought 15 dollars was stolen from her room. Resident #7 told the nurse she normally has her wallet pinned to her shirt, but when she showers, she removes it and leaves it on her bedside table. Resident #7 said the last time she checked her coin purse was about two weeks prior to reporting the incident. RN #247 immediately reported the incident to the DON at 9:46 P.M. The DON informed her to write a statement and have the resident write one as well and place it under the DONs office door. Review of the Social Service progress note dated 12/23/25 at 1:28 P.M. revealed an interview with Resident #7 who noticed 15 dollars missing on 12/22/25, but stated it was last visualized two weeks earlier. The resident does have a lock box in her room, but she stated she had not utilized it as of late. Interview on 02/23/26 at 10:00 A.M. with the Administrator revealed that she was still waiting for a response from the previous Administrator regarding other staff interviews. (She reached out to the previous administrator to see if there were staff interviews for SRI tracking number 268983). A follow-up interview on 02/23/26 with the Administrator at 1:15 P.M. confirmed she had no other information or evidence to provide. Review of the facilities Abuse, Neglect, and Exploitation policy, revised on 01/10/24, revealed in section IV number 4. Identify and interview all involved people, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Section IV number 5. Provide complete and thorough documentation of the investigation. 2. Review of Resident #67's medical record revealed an admission date of 07/18/25 and a discharge date of 01/13/26. Resident #67's diagnoses included unspecified convulsions, multiple fractures of the pelvis with stable disruption of the pelvic ring, initial encounter for closed fracture, and obesity. Review of Resident #67's care plan dated 07/18/25 included Resident #67 had an impaired musculoskeletal status related to recent back surgery. Resident #67 would be free of complications related to the altered musculoskeletal status through the next review. Interventions included to encourage Resident #67 to take her time to complete tasks and do not rush. Review of Resident #67's progress notes dated 08/14/25 at 4:10 P.M. included Resident #67 made an allegation of abuse regarding rough care during incontinence care. The allegation was reported to the State Agency and an investigation was initiated. Resident #67 was very thankful. Resident #67's responsible party and the Nurse Practitioner (NP) were notified. Review of SRI tracking number #264034 dated 08/14/25 included Resident #67 made an allegation of physical abuse by facility staff and provided meaningful information when interviewed. Resident #67 stated the incident occurred on 08/13/25 at 9:50 P.M. in her room. Resident #67 told the Speech Therapist (ST) that staff rushed her during incontinence care. Resident #67 stated staff flipped her, and she was sliding and it hurt her. Certified Nursing Assistant (CNA) #606 was suspended pending an investigation. CNA #607 was also present and was questioned. CNAs #606 and #607 stated Resident #67 expressed she was having pelvic pain, but she did not voice complaints regarding the care. CNA #607 stated Resident #67 asked them to slow down, so the CNA's kept pausing to give Resident #67 time to adjust, but she did not ask them to stop or say the care was rough. The allegation of abuse was unsubstantiated. Residents were questioned regarding abuse and neglect, and residents unable to be interviewed were provided with skin checks. (Note: the SRI did not include evidence that additional residents were interviewed and did not provide evidence that residents unable to be interviewed were provided with skin checks). Resident #67's skin assessment stated there were no new abnormal skin areas. There were no additional skin checks provided. The SRI did not include evidence that the nurse who was assigned to Resident #67 during the time of the alleged abuse was interviewed or wrote a witness statement. There was no evidence additional staff were interviewed or wrote witness statements related to Resident #67's allegation of abuse. Review of Resident #67's witness statement dated 08/14/26 included the aides woke Resident #67 up to change her, and she was fast asleep. It was 9:50 P.M., and they said they had to change her. One lady said Resident #67 was too slow, grabbed her and flipped her, and she was sliding out of bed, but they grabbed her before she hit the floor. It was so painful. Resident #67 stated the aides were CNA #607 and a younger girl. Resident #67 asked why are you hurting me, and they stated they had to hurry. CNA #607's witness statement dated 08/14/25 included when Resident #67 was rolled over to complete care, she complained of hip pain. CNA #607 wrote they kept pausing during Resident #67's care, and Resident #67 did not tell them to stop or voice concerns with the care. CNA #606's witness statement dated 08/14/25 included CNA s #606 and #607 provided Resident #67's care, she was turned and she said her hip hurt a little, and when she was turned onto her back the pain resolved. CNA #606 wrote they did not indicate she was too slow, and Resident #67 did not indicate the aides were rough. Review of Resident #67's progress notes dated 08/15/25 at 9:51 A.M. included Resident #67 was sitting in bed eating breakfast. Resident #67 smiled, demonstrated appropriate affect, maintained eye contact and engaged in conversation. Resident #67 denied concerns concerning her physical, emotional, psychological and social well-being. Resident #67 denied fear or concerns regarding her safety. Resident #67 stated I know nobody tried to hurt me. Resident #67 denied need for additional services. Review of Resident #67's Quarterly MDS assessment dated [DATE] included Resident #67 had moderate cognitive impairment. Resident #67 was dependent on staff for toileting hygiene and bathing. Resident #67 was always incontinent of bowel and bladder. Interview on 02/24/26 at 1:42 P.M. of Assistant Director of Nursing (ADON) #214 revealed she was told by the former DON to get witness statements from CNA #606 and #607 regarding Resident #67's allegation of abuse. ADON #214 indicated the ST gave her Resident #67's written statement, and she gave the witness statements to the former DON and the former Administrator. ADON #214 stated she did not complete skin assessments of additional residents and confirmed she did not interview other residents related to the allegation of physical abuse. ADON #214 stated CNAs #606 and #607 no longer worked at the facility. Interview on 02/24/26 at 2:40 P.M. of Regional Director of Clinical Services (RDCS) #301 revealed she spoke with Resident #67 about her allegation that CNA #606 was rough with her. RDCS #301 stated she talked to Resident #67 to gather more information, and the former DON did the investigation. RDCS #301 indicated she did not have additional information related to the investigation and confirmed there was no evidence additional residents, nurses or other staff were interviewed and no evidence they wrote witness statements. Review of the facility policy titled Abuse, Neglect and Exploitation, revised 01/10/2024, included investigation of alleged abuse, neglect and exploitation included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Providing complete and thorough documentation of the investigation.

Based on record review, interview and job description review, the facility failed to ensure Resident #5 received a complete dietary assessment. This affected one resident (#5) of three residents reviewed for nutritional assessments. The facility census was 55.Findings include:Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, gastric reflux, high blood pressure, atrial fibrillation, and heart disease. The resident was admitted to the secured dementia unit.Review of the weights for Resident #5 revealed upon admission on [DATE] the resident's weight was 190.8 pounds. The most recent weight obtained on 02/12/26 was 189.0 pounds.Review of the physician's order for Resident #5 revealed on 12/17/25 an order was written for a regular diet, regular texture, and thin liquids.Review of Resident #5's assessments revealed a Nutrition Data Collection/Evaluation-V2 was completed on 12/18/25 by Former Registered Dietitian (FRD) #304 revealed the diet order was a regular diet, regular texture, regular fluid, thin consistency. His height was 69 inches, and his weight was 190.8 pounds. No updated labs were available for FRD #304 to review. The resident's caloric needs per day were 1740 to 2610 calories. His protein needs were 87 grams to 104 grams per day. His fluid needs were 2610 milliliters per day. FRD #304 recommended to continue with his current nutrition plan of care and will continue to monitor diet, intake, weight, labs, skin concerns, medications and nutritional status. FRD #304 added a comment of went to speak with resident and door was shut with enhanced barrier precautions. Please speak to resident for follow up. Enhanced Barrier Precautions (EBP) are infection control measures in nursing homes, requiring gown and glove use during high-contact care for residents with chronic wounds, indwelling devices, or known multidrug-resistant organisms to help prevent further transmission to others. No other dietary assessments were completed.Review of the nursing progress notes for Resident #5 revealed no dietary progress notes had been documented since admission.Review of the job description for the facility registered dietitian revealed the dietitian is required to complete comprehensive nutrition assessments, including comprehensive Minimum Data Set (MDS) assessments, assessing residents and developing care plans in accordance with federal and state regulatory guidance. The dietitian consults with residents, families, or the interdisciplinary team as needed regarding the plan of care for residents. The dietitian reviews therapeutic and regular diet plans and menus to ensure that they are in compliance with the physician's orders. Interview with Regional Director of Clinical Services (RDCS) #301 on 02/25/26 at 2:00 P.M. confirmed she was unable to find any other dietary assessments for Resident #5. FRD #304 was the prior dietitian for the facility and was released from her contract. RDCS #301 said she had no idea why FDR #304 would not enter a room where a resident was on EBP precautions. Registered Dietician (RD) #303 started working for the facility approximately three weeks earlier, will be in the facility on 02/26/26, and will assess Resident #5 upon arrival. RD #303 had not assessed the resident since she assumed the dietitian position.

Based on medical record review, interview and policy review, the facility failed to ensure a comprehensive care plan was completed for one resident (#24) of 32 residents reviewed for care plans. The facility census was 55.Findings include: Review of medical record for Resident #24 revealed an admission date of 07/02/25. Diagnoses included but were not limited to Alzheimer's dementia, dementia with behaviors, type II diabetes mellitus, oppositional defiant disorder and depression.Review of the 01/08/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #24 revealed a Brief Interview of Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. Resident #24 was noted to feel down, have trouble falling asleep, and had a poor appetite during 12 to 14 days during the 14-day review period. Resident #24 was noted to require supervision for most activities of daily living and moderate assistance for bathing. Resident #24 was also noted to receive antipsychotic, antianxiety, and antiplatelet medications.Review of Resident #24's care plan which was last reviewed on 01/22/26 revealed no evidence of a care plan for monitoring of an antipsychotic, antidepressant, or anticoagulant medications or interventions.Interview on 02/25/26 at 3:15 P.M. with the Director of Nursing (DON) confirmed she was unable to provide evidence of an antipsychotic, anticoagulant, or antidepressant care plan for Resident #24 as required. Review of the 06/30/22 revised facility policy called Comprehensive Care Plans revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. (Minimum Data Set).

Based on observations, interviews, record review, and policy review the facility failed to ensure staff did not assist Resident #5 with exiting the secured dementia unit without verifying he was a resident. In addition, the facility failed to ensure safe smoking interventions were in place for Resident #55 during an observed smoking activity. This affected two residents (Resident #5 and #55) of three residents reviewed for accidents. The facility identified eight residents (Resident #14, #38, #42, #44, #49, #51, #53, and #55) who smoked. The facility census was 55.Findings Include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, gastric reflux, high blood pressure, atrial fibrillation, and heart disease. The resident was admitted to the secured dementia unit. Review of the physician orders revealed no order for the resident to reside on the secured dementia unit. Review of the 12/16/25 nursing admission assessment under Risk of Elopement/Wandering assessment revealed the resident was not cognitively impaired, with poor decision making skills. The resident was assessed to not have a diagnosis of dementia, organic brain syndrome, Alzheimer's Disease, hallucinations, or anxiety. No unsafe behaviors were assessed at present. The resident was admitted to the secured dementia unit. No admission baseline care plan for elopement was initiated. Review of Resident #5's comprehensive admission Minimum Data Set (MDS) 3.0 assessment, dated 12/23/25, revealed the resident was moderately cognitively impaired, had no behaviors, and was independently mobile Review of Housekeeping (Hskg) #285's written statement, dated 12/20/25, revealed he was assigned to clean three units, one of which was the secured dementia unit. The first unit he cleaned was the secured dementia unit. When he attempted to exit the unit, he saw a gentleman standing near the exit door carrying a suitcase. Hskg #285 had not seen Resident #5 before and believed him to be a guest or visitor. The resident appeared calm and composed and politely asked to be let out. The resident spoke clearly and appropriately. Hskg #285 unlocked the door and allowed the resident to exit and then returned to his duties. Review of the written statement dated 12/20/25 from Certified Nursing Assistant (CNA) #204 revealed the incident occurred on 12/20/25. Resident #5 exited the secured dementia unit after Housekeeping (Hskg) #285, who was unaware the residents on the unit were not permitted to leave unless with a staff member of the unit. Resident #5 had been demonstrating exit seeking behaviors, pacing the hallway with a suitcase, going back and forth from room to door stating I need to get to the airport. At approximately 2:28 P.M. Resident #5 was seen exiting the unit and started heading toward the nurses' station. CNA #204 noticed the resident and called for help and returned the resident to the secured dementia unit. The statement revealed the elopement was reported on 12/20/25 to the charge nurse but the Director of Nursing (DON) was not notified until 12/21/25. The DON then notified the Medical Director. The camera footage from the unit was reviewed on 12/22/25 and showed Hskg #285 opened the door and allowed the resident to exit the unit. Review of the nursing progress notes revealed on 12/21/25 at 12:07 P.M. Licensed Practical Nurse (LPN) #265 was informed Resident #5 had followed someone out the door of the secured unit (while the resident was) carrying a suitcase and stating he had to go to the airport. The resident was helped back down the hallway to the memory care unit. The doctor and the resident's daughter were aware of the incident. There was no mention of exit seeking behavior or the resident exiting the secured unit on 12/20/25. Interview with the Administrator on 02/23/26 at 4:45 P.M. verified the resident did leave the secured unit because Hskg #285 let him out since they didn't know he was a resident on the secured unit. The Administrator verified staff returned the resident to the secured unit immediately. Review of the facility's Unsafe Wandering & Elopement Prevention policy, last revised 01/01/2022, revealed all residents who are at risk for harm because of unsafe wandering will be assessed by the Interdisciplinary Team (IDT). The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Interventions for unsafe wandering and elopement attempts will be entered onto the resident's care plan and medical record. Should an elopement episode occur, the contributing factors as well as the interventions tired, will be documented in the nurses' notes. Review of the facility's undated Memory Care Unit admission Determination policy revealed when determining if an individual will be admitted the facility takes into account the specific care needs of the individual and if the facility can meet those needs; the physical characteristics of the facility and its capacity to meet the identified needs; the staffing level and skill of unit personnel to meet the individual's needs; and the overall clinical stability of the resident's current condition. The admission Committee reviews the pre-admission paperwork/referral for admission determination. The committee includes but is not limited to the program director, the DON/Unit Manager, Social Service Director, the Admissions Coordinator, and the Administrator. 2.Record review of Resident #55 revealed an admission date of 02/20/2015. Diagnosis included but were not limited to Alzheimer's disease, transient ischemic attack and cerebral infarction. Review of Resident #55 care plan with a revision date of 1/12/26 revealed Resident #55 must wear a smoking apron (while smoking). Review of smoking assessment dated [DATE] and 02/17/26 revealed that Resident #55 should have a smoking apron on while smoking. Smoking assessment also revealed Resident #55 was not able to safely light her cigarettes and needed a smoking aide while smoking. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 Brief Interview of Mental Status (BIMS) was a 12 which indicated moderate cognitive impairment. Resident #55 was noted to be dependent for Activities of Daily Living (ADLs). On 02/17/26 at 11:05 A.M. an observation was done during the 11:00 A.M. smoke time. Residents in attendance were #14, #38, #42, #44, #49, #51, #53, and #55. There were two activity assistants monitoring the smoking break, Activity Assistant #201 and #209. Resident #55 was observed smoking without an apron and was received cues from the aides to ash (place her ashes from the cigarette in the ashtray) her cigarette. Interview with Resident #55 revealed no concerns with the smoking activity. On 02/17/26 at 11:15 A.M. an interview with Activity Assistant #201 revealed that she didn't know if Resident #55 should be wearing an apron. On 02/17/26 at 2:55 P.M. an interview with the Administrator confirmed that Resident #55 should have been wearing an apron while smoking. Review of the 12/31/25 facility policy called Smoking Policy Smoking Campus-Residents revealed it is the policy of the facility to establish and maintain safe resident smoking practices. Under smoking times number four indicated that any person of person providing smoking supervision to residents must be instructed in smoking regulation prior to rendering such service.

Based on record review, interview, incident review and facility policy review, the facility failed to ensure sufficient supervision was maintained to prevent Resident #5 from exiting the secured dementia unit. This affected one resident (#5) of two residents reviewed for dementia care. The facility census was 55. Findings include:Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, gastric reflux, high blood pressure, atrial fibrillation, and heart disease. The resident was admitted to the secured dementia unit.Review of the nursing admission assessment dated [DATE] revealed the Risk of Elopement/Wandering assessment revealed Resident #5 was not cognitively impaired with poor decision making skills. The resident was assessed to not have a diagnosis of dementia, organic brain syndrome, Alzheimer's Disease, hallucinations, or anxiety. No unsafe behaviors were assessed as present. The resident was admitted to the secured dementia unit. No admission baseline care plan for elopement was initiated.Review of the written statement dated 12/20/25 from Certified Nursing Assistant (CNA) #204 revealed an incident occurred on 12/20/25. Resident #5 exited the secured dementia unit after Housekeeping (Hskg) #285 who was unaware the residents on the unit were not permitted to leave unless they were with a staff member of the unit. Resident #5 had been demonstrating exit seeking behaviors, pacing the hallway with a suitcase, going back and forth from room to door and stating, I need to get to the airport.Review of Hskg #285's written statement dated 12/20/25 revealed he was assigned to clean the secured dementia unit. When he exited the unit, he saw a gentleman standing near the exit door carrying a suitcase. Hskg #285 had not seen Resident #5 before and believed him to be a guest or visitor. The resident appeared calm and composed and politely asked to be let out. The resident spoke clearly and appropriately. Hskg #285 unlocked the door and allowed the resident to exit and then returned to his duties.Review of the nursing progress notes revealed on 12/21/25 at 12:07 P.M. Licensed Practical Nurse (LPN) #265 was informed Resident #5 had followed someone out the door of the secured unit carrying a suitcase and stating he had to go to the airport. The resident was helped back down the hallway to the memory care unit. The resident's daughter was notified of the incident. No documentation was located regarding Resident #5's exit seeking behaviors on 12/20/25. The Director of Nursing (DON) was not notified by staff of Resident #5 leaving the secured dementia unit until 12/22/25. The DON notified the medical director and the administrator on 12/22/25.Review of Resident #5's comprehensive admission Minimum Data Set (MDS) 3.0 assessment, dated 12/23/25, revealed the resident was moderately cognitively impaired, had no behaviors, and was independently mobile.Review of the care plans for Resident #5 revealed an elopement care plan was initiated on 12/29/25 due to the resident's exit seeking behavior. Interventions put in place to deal with his exit seeking behaviors were to redirect and divert the resident's attention, distract the resident when he was wandering/insistent on leaving the facility by offering pleasant diversions, structured activities, food, conversation, television, books, etc. The resident was to be evaluated for the need for a Wanderguard (a device that prevents an exit seeking resident from being able to leave the facility), and to promptly check when the alarm system goes off to ensure the resident was safe and remained in the facility.Observation of the secured unit on 02/17/26 at 10:57 A.M. revealed the ventilator unit hallway led to the secured dementia unit. A code had to be entered to access the common area of the secured dementia unit. The nurses' station was located in the common area and a hall leading out of the common area is where the residents' rooms were located. The residents' rooms were unable to be observed from the common area. The end of the hallway exits to the rest of the nursing area. A code must also be entered to exit the unit.Interview with the Administrator on 02/19/26 at 3:15 P.M. revealed Resident #5 did not elope; he just left the secured dementia unit on 12/20/25, and staff immediately returned him to the unit. The investigation into the resident leaving the unit was requested and what measures were put into place to prevent future occurrences. The Administrator said they did a past noncompliance investigation on 12/21/25 along with audits after the incident. The Administrator again stated the resident did not elope as he did not leave the facility. All staff were educated on elopement including housekeeping and laundry as they are a contracted service. Interview with the Administrator on 02/23/26 at 4:45 P.M. revealed they chose not to add a Wanderguard to Resident #5's plan of care because he resides on the secured unit. The resident did manage to leave the unit because Hskg #285 let him out because he looked and acted normal. The Administrator said the secured dementia unit was not set up to alarm when a Wanderguard was in use and a resident approached the secured dementia unit's exit. The Administrator confirmed the unit does not necessarily need to be wired to the alarm, but for a resident new to the facility that staff may not recognize, it would prevent a resident from being able to exit the facility and keep the resident safe. The Administrator said she would have to take the idea to the corporate team. They have also included contracted staff to attend new employee orientation.Review of Hskg #285's dementia education revealed on 10/01/25 at 7:30 A.M. he watched a Dementia Overview video. No other information was available.Review of the facility's Unsafe Wandering & Elopement Prevention policy, last revised 01/01/2022, revealed all residents who are at risk for harm because of unsafe wandering will be assessed by the Interdisciplinary Team (IDT). The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Interventions for unsafe wandering and elopement attempts will be entered into the resident's care plan and medical record. Should an elopement episode occur, the contributing factors as well as the interventions tried, will be documented in the nurses' notes. Review of the facility's undated Memory Care Unit admission Determination policy revealed when determining if an individual will be admitted the facility takes into account the specific care needs of the individual and if the facility can meet those needs; the physical characteristics of the facility and its capacity to meet the identified needs; the staffing level and skill of unit personnel to meet the individual's needs; and the overall clinical stability of the resident's current condition. The admission Committee reviews the pre-admission paperwork/referral for admission determination. The committee includes but is not limited to the program director, the DON/Unit Manager, Social Service Director, the Admissions Coordinator, and the Administrator.

Based on review of medical records, interview, review of pharmacy recommendations, and policy review, the facility failed to ensure pharmacy recommendations were acknowledged and addressed timely for two residents (Residents #4 and #24) out of five reviewed for unnecessary medications. The facility also failed to monitor one resident (Resident #61) of two residents reviewed for blood glucose levels. The facility census was 55.Findings Include:1.Review of medical record for Resident #24 revealed an admission date of 07/02/25. Diagnoses included but were not limited to Alzheimer's dementia, dementia with behaviors, type two diabetes mellitus, oppositional defiant disorder and depression. Review of the 01/08/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #24 revealed a Brief Interview of Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. Resident #24 was noted to require supervision for most activities of daily living and moderate assistance for bathing. Resident #24 was also noted to feel down, have trouble falling asleep, poor appetite 12 – 14 of the 14-day review period and receive antipsychotic, antianxiety, and antiplatelet medications. a. Review of the 07/02/25 physician order for Resident #24 revealed an order for 200 milligrams (mg) oral tablet of Seroquel (generic form is Quetiapine Fumarate, an antipsychotic) to be given by mouth at bedtime for mood disorder. Review of the pharmacy recommendation dated 07/03/25 for Resident #24 revealed a recommendation for Seroquel plus Trileptal to add for behavior and side effect monitoring. The form did not have evidence of a completed date or physician signature. Review of the 07/02/25 physician order for Resident #24 revealed an order for one oral tablet of 150 mg of Trileptal (generic is Oxcarbazepine, an anticonvulsant) to be given by mouth two times a day for mood disorder. A second order dated 07/02/25 for Resident #24 revealed an order for one oral tablet of 75 mg Oxcarbazepine to be given by mouth two times a day for mood disorder. Review of the pharmacy recommendation dated 07/03/25 for Resident #24 revealed a recommendation for Seroquel plus Trileptal to add behavior and side effect monitoring. The form did not have evidence of a completed date or physician signature. Review of the 08/14/25 physician order for Resident #24 revealed an order to observe the resident closely for significant side effects of anti-psychotic medication and report to the physician. Side effects included but were not limited to seizures. b. Review of the 07/02/25 physician order for Resident #24 revealed an order to give 17 grams (gm) by mouth of MiraLAX (laxative used for constipation) oral Powder 17gm/scoop every 24 hours as needed for constipation. Review of the pharmacy recommendation dated 07/03/25 for Resident #24 revealed a recommendation to clarify the MiraLAX order to include administer with four to eight ounces of liquid. The form did not have evidence of a completed date or physician signature. Review of the 08/12/25 physician order for Resident #24 revealed an order to give 17 grams by mouth of MiraLAX oral Powder 17gm/scoop every 24 hours as needed for constipation. The order was updated to administer with four to eight ounces of liquid. c. Review of the 07/03/25 physician order for Resident #24 revealed an order to give one 81 milligram tablet of aspirin by mouth one time a day for heart health. (The order was discontinued on 08/12/25.) Review of the pharmacy recommendation dated 07/06/25 for Resident #24 revealed a recommendation to clarify the order for aspirin tablet with instructions to give 81 mg by mouth one time a day. Recommendations were made to clarify the dosage formulation for low dose aspirin (i.e. chewable, enteric coated) in the order. Physician recommendation was signed on 08/12/25 with instructions to change to aspirin 81 milligram oral enteric coated tablet to be taken by mouth daily. Review of the 08/13/25 physician order for Resident #24 revealed an order to give one tablet by mouth of aspirin low dose oral tablet chewable 81 milligram one time a day related to chronic atrial fibrillation. The order was not for the enteric coated tablet. d. Review of the 07/02/25 physician order for Resident #24 revealed an order for a 12.5 milligram tablet of Coreg (generic is Carvedilol used to monitor blood pressure) by mouth one tablet twice daily. Review of the pharmacy recommendation dated 07/03/25 for Resident #24 revealed a recommendation for Coreg. Recommendation stated medication should be administered with meals. Please update administration times. The form did not have evidence of a completed date or physician signature. Review of the 08/12/25 physician order for Resident #24 revealed an order for 12.5 milligram tablet of Coreg by mouth one tablet twice daily with meals. e. Review of the 07/03/25 physician order for Resident #24 revealed an order to give 75 mg of Plavix (Generic is Clopidogrel Bisulfate, a blood thinner) oral tablet by mouth one time a day for cerebrovascular accident prevention. Review of the pharmacy recommendation dated 07/03/25 for Resident #24 revealed a recommendation for Plavix plus aspirin to add monitor for signs and symptoms of bleeding/bruising; monitor for thromboembolism. The physician gave a verbal order on 08/14/25. The form did not have evidence of a completed date or physician signature. Review of the 08/14/25 physician order for Resident #24 revealed an order to monitor signs and symptoms of bleeding/bruising every shift. For gross bleeding call 911. Review of the 09/27/25 physician order for Resident #24 revealed an order to give one 25 mg tablet of Zoloft (generic is Sertraline Hydrochloride used for depression) oral tablet by mouth one time a day related to dementia with behaviors. The order was discontinued on 11/19/25. Review of the pharmacy recommendation dated 10/29/25 for Resident #24 revealed a recommendation to clarify the diagnosis for the order for Zoloft (Sertraline Hydrochloride). The physician acknowledged the order on 12/02/25 to add a diagnosis of depression. Review of the 12/03/25 physician order for Resident #24 revealed an order to give one 25 mg tablet of Zoloft (Generic is Sertraline Hydrochloride) oral tablet by mouth one time a day for depression. Interview on 02/23/26 at 3:51 P.M. with Regional Director of Clinical Services #301 confirmed the pharmacy recommendations for Resident #24 were not signed by the physician in less than 30 days. Review of the 12/28/23 revised facility policy titled, Addressing Medication Regimen Review Irregularities revealed it is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident to identify irregularities and respond in a timely manner to prevent the occurrence of an adverse drug event. Any irregularities noted by the pharmacist during this review must be documented on a separate, written report which may be in paper or electronic form. The attending physician must document in the resident 's medical record that the identified irregularity has been reviewed and what, if any, action, has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rational in the resident's medical record. The requirements associated with the MRR apply to all residents, whether short or long stay. The attending physician shall sign the form upon the next visit to the facility. 2. Resident #61 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes, bipolar disorder with psychotic features, post-traumatic stress disorder, obstructive sleep apnea, morbid obesity, and was ventilator dependent. Review of the comprehensive Minimum Data Set (MDS) 3.0 comprehensive quarterly assessment dated [DATE] for Resident #61 revealed the resident was cognitively intact, took medication for diabetes. Review of the Self Med Administration assessment dated [DATE] revealed Resident #61 was able to identify the medications he was ordered and was able to state why he took the medication. The medications were assessed to kept in a secure, locked area. Review of the physician's orders for Resident #61 revealed staff were to observe resident for symptoms of both low blood sugar levels and high blood sugar levels. An order dated 04/04/25 indicated the resident may self administer his medication which are stored in a lock box in his room. Nurses were to validate administration and blood sugar readings with the resident as scheduled. An order dated 01/19/26 indicated the resident was to receive Humalog insulin per a sliding scale order based on his blood glucose level. The resident was to check his blood sugars before meals and at bedtime. Insulin was to be administered subcutaneously in the following amounts depending on the blood glucose level: 180 to 240: Administer two units of Humalog insulin 241 to 300: Administer four units of Humalog insulin 301 to 360: Administer six units of Humalog insulin 361 to 400: Administer eight units of Humalog insulin The orders further stated the resident may check his blood glucose levels and administer his own insulin unsupervised. The nurse must obtain from the resident his blood glucose level and how many units of insulin he administered and document the information in the medical record. The resident also had an order dated 02/17/26 for Mounjaro (a medication used to treat diabetes as well as for weight loss) 7.5 milligrams (mg)/0.5 milliliters (ml) injected subcutaneously once a week on Mondays for both diabetes and weight loss. Review of the Medication Administration Record (MAR) from December 2025 through February 2026 for Resident #61 revealed no documentation regarding the blood glucose levels or how much insulin was administered. Review of the vitals section of the electronic medical record for Resident #61 revealed blood glucoses were entered but were not entered four times a day as ordered by the physician. No documentation was entered as to how much insulin was administered by the resident. Interview with Regional Director of Clinical Services (RDCS) #301 on 02/23/26 at 5:05 P.M. confirmed nursing should be documenting Resident #61's blood glucose levels and the amount of insulin administered as ordered by the physician. Review of the facility's policy titled Addressing Medication Regimen Review Irregularities, last revised 12/28/23, revealed the pharmacist may identify and report irregularities in one or more categories including the use of a medication without evidence of adequate monitoring. 3.Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses include but not limited to dementia, psychotic disturbance, mood disturbance, anxiety, diabetes type two, chronic kidney disease, atrial fibrillation, hypothyroidism, ulcerative colitis, metabolic encephalopathy, alcohol dependence, and hypokalemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired and required the assistance of supervision and some assistance completing activities of daily living. Review of the physician orders dated 04/09/25 for Resident #4 revealed an order for two capsules of 20 milligrams (mg) Omeprazole (a proton pump inhibitor medication) to be given by mouth once daily. Review of the pharmacist recommendation dated 09/22/25 revealed Resident #4 had a physician order dated 04/09/25 for medication Omeprazole 20 mg (medication used to treat gastroesophageal reflux disease, dose was two capsules by mouth one time a day) The pharmacist noted the resident was ordered a high dose of a proton pump inhibitor. The pharmacist recommended a dose reduction to 20 mg by mouth one time a day. Review of the pharmacy recommendation revealed the nurse practitioner agreed with the recommendation and signed it on 10/25/25. Review of the 11/2025 Medication Administration Record (MAR) for Resident #4 revealed the order for two 20 mg capsules daily of Omeprazole continued to be given until 11/05/25 when it was discontinued. Interview on 02/23/26 at 3:51 P.M. with the Regional Director of Clinical Services #301 confirmed the pharmacy recommendations for resident #4 were not signed by the physician in a timely manner.

Based on interview, record review, and facility investigation, the facility failed to ensure nursing documentation was accurate and contained information pertinent to resident care. This affected one resident, (Resident #5) of three residents reviewed for accidents. The facility census was 55. Findings Include:Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, gastric reflux, high blood pressure, atrial fibrillation, and heart disease. The resident was admitted to the secured dementia unit.Review of the physician orders revealed no order for the resident to reside on the secured dementia unit.Review of the 12/16/25 nursing admission assessment under Risk of Elopement/Wandering assessment revealed the resident was not cognitively impaired, with poor decision making skills. The resident was assessed to not have a diagnosis of dementia, organic brain syndrome, Alzheimer's Disease, hallucinations, or anxiety. No unsafe behaviors were assessed at present. The resident was admitted to the secured dementia unit. No admission baseline care plan for elopement was initiated.Review of Resident #5's comprehensive admission Minimum Data Set (MDS) 3.0 assessment, dated 12/23/25, revealed the resident was moderately cognitively impaired, had no behaviors, and was independently mobileReview of Housekeeping (Hskg) #285's written statement, dated 12/20/25, revealed he was assigned to clean three units, one of which was the secured dementia unit. The first unit he cleaned was the secured dementia unit. When he attempted to exit the unit, he saw a gentleman standing near the exit door carrying a suitcase. Hskg #285 had not seen Resident #5 before and believed him to be a guest or visitor. The resident appeared calm and composed and politely asked to be let out. The resident spoke clearly and appropriately. Hskg #285 unlocked the door and allowed the resident to exit and then returned to his duties.Review of the written statement dated 12/20/25 from Certified Nursing Assistant (CNA) #204 revealed the incident occurred on 12/20/25. Resident #5 exited the secured dementia unit after Housekeeping (Hskg) #285, who was unaware the residents on the unit were not permitted to leave unless with a staff member of the unit. Resident #5 had been demonstrating exit seeking behaviors, pacing the hallway with a suitcase, going back and forth from room to door stating I need to get to the airport. At approximately 2:28 P.M. Resident #5 was seen exiting the unit and started heading toward the nurses' station. CNA #204 noticed the resident and called for help and returned the resident to the secured dementia unit. The statement revealed the elopement was reported on 12/20/25 to the charge nurse but the Director of Nursing (DON) was not notified until 12/21/25. The DON then notified the Medical Director. The camera footage from the unit was reviewed on 12/22/25 and showed Hskg #285 opened the door and allowed the resident to exit the unit.Review of the nursing progress notes revealed on 12/21/25 at 12:07 P.M. Licensed Practical Nurse (LPN) #265 was informed Resident #5 had followed someone out the door of the secured unit (while the resident was) carrying a suitcase and stating he had to go to the airport. The resident was helped back down the hallway to the memory care unit. The doctor and the resident's daughter were aware of the incident. There was no mention of exit seeking behavior or the resident exiting the secured unit on 12/20/25.Review of the facility's Unsafe Wandering & Elopement Prevention policy, last revised 01/01/2022, revealed all residents who are at risk for harm because of unsafe wandering will be assessed by the Interdisciplinary Team (IDT). The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Interventions for unsafe wandering and elopement attempts will be entered onto the resident's care plan and medical record. Should an elopement episode occur, the contributing factors as well as the interventions tired, will be documented in the nurses' notes.Review of the facility's undated Memory Care Unit admission Determination policy revealed when determining if an individual will be admitted the facility takes into account the specific care needs of the individual and if the facility can meet those needs; the physical characteristics of the facility and its capacity to meet the identified needs; the staffing level and skill of unit personnel to meet the individual's needs; and the overall clinical stability of the resident's current condition. The admission Committee reviews the pre-admission paperwork/referral for admission determination. The committee includes but is not limited to the program director, the DON/Unit Manager, Social Service Director, the Admissions Coordinator, and the Administrator.Interview with Regional Director of Clinical Services (RDCS) #301 on 02/25/26 at 2:00 P.M. confirmed LPN #265 should have documented Resident #5's exit seeking behaviors, carrying a suitcase around the unit, that he left the unit after Hskg #285 held the door open for him to leave, and that he was safely returned to secured dementia unit by staff not working on the secured unit on the same date as the incident occurred. RDCS #301 also confirmed the admission assessment should have reflected the resident's accurate information.

Based on observation, interview, record review and review of the facility policy the facility failed to collaborate care with hospice, complete a comprehensive assessment and implement care planned interventions for Resident #59 who experienced a change of condition. This affected one resident (Resident #59) out of three residents reviewed for hospice services. The facility census was 55.Findings include:Review of Resident #59's medical record revealed an admission date of 08/23/19 and diagnoses included chronic combined systolic (congestive) and diastolic (congestive) heart failure, type two diabetes mellitus with diabetic peripheral angiopathy without gangrene, Alzheimer's Disease, paroxysmal atrial fibrillation, dementia, and cardiomyopathy.Review of Resident #59's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had moderate cognitive impairment. Resident #59 used a wheelchair and required supervision or touching assistance for toileting and personal hygiene. Resident #59 required partial to moderate assistance with lower body dressing. Resident #59 had an indwelling catheter and was frequently incontinent of bowel.Review of Resident #59's After Visit Summary for a hospital admission [DATE] through 02/07/26 included in the medication list to administer insulin lispro 100 units per milliliter injection, inject zero to five units under the skin three times daily (morning, midday, late afternoon). Take as directed per insulin instructions. Resident #59 was discharged to the facility with hospice, continue Keflex for six more days, continue comfort measures per hospice, hypoglycemic protocol recommended and monitor for hypoglycemia.Review of Resident #59's progress notes dated 02/07/26 at 6:06 P.M. included Resident #59 arrived at the facility via stretcher accompanied by EMT's at approximately 4:45 P.M. Resident #59 was alert, responded to staff, but was very lethargic. Resident #59 did not have pain or signs and symptoms of discomfort. Resident #59 was given oxygen for comfort and Resident #59 was lying quietly with his eyes closed Hospice services were contacted and stated they would be at the facility on 02/08/26 to admit Resident #59 to hospice services.Review of Resident #59's Treatment Administration Record (TAR) dated 02/07/26 through 02/18/26 revealed if Resident #59's blood sugar was less than 70 administer OJ, food or glucose gel per manufacturer recommendations, recheck in 15 minutes, if no improvement notify the physician, every day shift and night shift for monitoring. On 02/08/26, 02/09/26, 02/10/26, 02/11/26, 02/13/26, 02/14/26 on night shift, 02/16/26 on the day shift, 02/17/26 on night shift and 02/18/26 there was no evidence Resident #59's blood sugar was checked. On 02/14/26 on day shift, Resident #59's blood sugar was 269 and there was no evidence the physician or hospice services were notified or insulin was administered. On 02/16/26 on night shift, Resident #59's blood sugar was 156 and there was no evidence the physician or hospice services were notified or insulin was administered. Review of Resident #59's Medication Administration Record (MAR) started and discontinued on 02/08/26 revealed insulin lispro injection solution 100 units per ml, inject per sliding scale. If Resident #59's blood sugar was 151 to 200 administer one unit insulin, if the blood sugar was 201 to 250 administer two units, if the blood sugar was 251 to 300 administer 3 units, if the blood sugar was 301 to 350 administer four units, if the blood sugar was 351 to 400 administer five units of insulin, subcutaneously three times a day for diabetes mellitus. Review of Resident #59's progress notes dated 02/08/26 at 8:57 A.M. included Resident #59 was not safe to swallow and was unable to take oral medications.Review of Resident #59's progress notes dated 02/08/26 at 11:49 A.M. included hospice services assessed Resident #59 and a new order was given to discontinue all routine medications. Ativan and morphine were ordered to be administered as needed. Resident #59 was on the hospice service protocol EMC (even more care) due to status. Resident #59 was able to eat mashed potatoes and ice cream, pudding with his lunch and his status improved throughout the shift. Vital signs were obtained.Review of Resident #59's progress notes dated 02/08/26 at 7:54 P.M. included Resident #59 did better with soft, thin food and food such as ice cream, applesauce, mashed potatoes and gravy were ordered. Resident #59 was able to swallow safely while alert.Review of Resident #59's care plan dated 02/09/26 included Resident #59 had a terminal prognosis with hospice services related to end of left diagnoses Alzheimer's Disease. Resident #59 would have an acceptable comfort level through the next review. Interventions included to administer medications as ordered and observe for effectiveness; collaborate with the palliative/hospice team to ensure Resident #59's emotional, spiritual, intellectual, physical and social needs were met and involve Resident #59, the family, clergy and other team members as needed; notify hospice services of changes in Resident #59's condition or updates.Review of Resident #59's progress notes dated 02/09/26 at 4:07 A.M. revealed due to stabilization of symptoms, continuous 24 hour care was discontinued. Resident #59 was to receive hospice visits three times a day per the hospice updated plan of care.Review of Resident #59's physician orders dated 02/10/26 revealed glucagon injection solution, inject 1 mg intramuscularly as needed for low blood sugar less than 60.Review of Resident #59's progress notes dated 02/11/26 at 3:29 P.M. included Resident #59 was awake, in good spirits and was sitting in his recliner. Resident #59 required two staff for transfers. Resident #59 attended bingo, Resident #59's family was visiting and hospice services were in the facility. Resident #59 continued on antibiotics for a urinary tract infection.Review of Resident #59's progress notes dated 02/11/26 at 4:18 P.M. included hospice services were in the facility and Resident #59 asked where the rest of his medications were beyond his antibiotics and as needed medications. The hospice staff stated she would talk to Resident #59's regular hospice nurse and no new orders were given at this time.Review of Resident #59's progress notes dated 02/11/26 at 4:18 P.M. through 02/17/26 at 4:55 P.M. did not reveal evidence Resident #59's medications were discussed with hospice services including blood sugar checks and insulin administration.Review of Resident #59's hospice Visit Patient Assessment Report dated 02/11/26 at 4:26 P.M. included Resident #59 was cheerful and reported that he loved [NAME] cups candy. Resident #59 inquired why he was not getting his scheduled medications. The hospice nurse explained to him that when he was admitted to hospice care the decision was made to discontinue routine medications and initiate comfort medications. Resident #59 verbalized understanding but wanted to be sure he had as needed medications in place for his bowels and mild pain and asked for something for anxiety. Resident #59 was administered lorazepam for anxiety.Review of Resident #59's hospice Visit Patient Assessment Report dated 02/13/26 at 8:47 A.M. included Hospice Nurse (HN) #601 visited Resident #59 for a daily watch care visit. Resident #59 was sitting in his recliner, was pleasant, disoriented times three with confusion. Resident #59 required meal prep and set up, was consuming a regular diet and his intake was 25 percent. Care was provided and Resident #59 was sitting in his recliner upon hospice departure, his call light was in reach and he had no signs and symptoms of acute distress. Resident #59 received lorazepam for intermittent anxiety.Interview on 02/19/26 at 8:01 A.M. of the Director of Nursing (DON) confirmed Resident #59 had not received insulin or had routine blood sugar checks from 02/08/26 through 02/19/26. The DON stated Resident #59 received hospice services and she would look into why Resident #59 was no longer receiving insulin. Observation on 02/19/26 at 9:44 A.M. of Resident #59 revealed he was sitting in his wheelchair and asked for help to use the bathroom. Resident #59 asked for the blinds to his windows be opened so he could see outside. Resident #59 was pleasant and answered questions appropriately.Interview on 02/19/26 at 9:44 A.M. of Licensed Practical Nurse (LPN) #238 revealed Resident #59 was back to himself now and was eating and acting like he used to act. LPN #238 stated Resident #59's pacemaker battery died, he needed to have it replaced about two weeks ago and he was much better now. LPN #238 stated Resident #59's decline was absolutely related to his pacemaker not working. LPN #238 indicated Resident #59 was put on hospice because we thought he was dying, and he was not receiving any medications or having blood sugars checked because he was receiving hospice services. LPN #238 stated she was confused why Resident #59's blood sugar checks were discontinued. Interview on 02/19/26 at 11:05 A.M. of Resident #59's Power of Attorney (POA) #600 revealed Resident #59's catheter was put in wrong and he had to go to the hospital on [DATE]. POA #600 stated Resident #59 had to be transported to the hospital on [DATE] because he was filling up with fluid from his CHF. POA #600 indicated Resident #59 was out of it, restless, delusional and in bad shape when he was at the hospital and the physician recommended hospice services. POA #600 stated Resident #59 came back to the facility from the hospital on [DATE] and when he was in the hospital, they found out his pacemaker was not working and put a new one in. POA #600 stated after Resident #59's pacemaker battery was replaced he was improving. POA #600 stated she realized that Resident #59's blood sugars were not being checked, she was concerned and told an aide she was concerned, and she was not sure what happened after that. POA #600 could not remember which aide she told. POA #600 stated she was told Resident #59 was going to receive comfort care, but she did not realize that meant he was not going to be given any of his medications including insulin and heart medications.Interview on 02/19/26 at 9:53 A.M. of Nurse Practitioner (NP) #300 revealed Resident #59 was really out of it and unresponsive for awhile when he came back from the hospital and that was why he was put on hospice services. NP #300 stated he was doing better now, not out of the woods, but finger sticks should be started to check his blood sugar.Interview on 02/19/26 at 11:25 A.M. of LPN #236 revealed Resident #59 was on hospice and was taken off his medications including blood sugar checks and insulin. LPN #236 stated she did not know why Resident #59's blood sugars were not being checked, but that was through hospice and hospice would need to be asked that question.Interview on 02/19/26 at 12:00 P.M. of Assistant Clinical Director (ACD) #603 and Team Leader (TL) #604 of hospice services revealed they were not familiar with Resident #59 and Hospice Nurse (HN) #601 was the case manager would have more information. ACD #603 stated Resident #59 was placed on the EMC protocol because he was showing signs of imminent passing. ACD #603 stated if Resident #59 showed improvement then insulin and blood sugar checks could be added back in.Interview on 02/19/26 at 4:12 P.M. of Certified Nursing Assistant (CNA) #263 revealed he was told Resident #59 was probably going to die, his breathing was very low but all of a sudden, about nine days ago, he started pressing his call light, talking more clearly and started feeling better. CNA #263 stated he was eating about 25 to 50 percent of his meals and drank a lot of pop including Pepsi. Interview on 02/19/26 at 4:51 P.M. of Hospice Nurse (HN) #601 revealed Resident #59 was admitted to hospice services on 02/08/26 and he was showing signs and symptoms of end of life, was unresponsive and the EMC program was initiated. HN #601 stated Resident #59 started bouncing back a little bit and she saw improvement on 02/09/26. Resident #59 started talking and drinking fluids and his visits were decreased to three times a day. Resident #59 was then placed on routine visits because he was eating, drinking, talking, going to bingo and was back at his baseline. HN #601 indicated as far as Resident #59's insulin was concerned he was readmitted from the hospital and was not prescribed insulin. HN #601 stated the hospital discontinued Resident #59's medications and when the hospice service received his med list there was no insulin to be administered per sliding scale on it and we did not know he was on insulin. (Note: Resident #59's discharge instructions from the hospital included insulin lispro 100 units per ml, to be administered per sliding scale, three times a day). HN #601 stated she would notify the physician and have Resident #59's insulin administration per sliding scale restarted. Interview on 02/23/26 at 8:47 A.M. of the DON revealed when Resident #59 was placed on hospice services, hospice assessed him and made changes concerning his medications and other things. The DON stated after Resident #59 was placed on hospice services the facility physicians took a back seat and the hospice nurses were in contact with their medical director. The DON stated the facility would talk to the hospice nurse if it was felt a resident needed medications. Resident #59 was waxing and waning the first couple days he was on hospice services then he started improving to how he is now. The DON stated Resident #59 should have been reevaluated by the hospice nurse when he started doing better and she thought he should have been put back on his heart meds and insulin. The DON confirmed there should have been better communication between the facility and hospice services. Review of the facility policy titled Hospice revised 10/26/2023 included when a resident chose to receive hospice care and services, the facility would coordinate and provide care in cooperation with the hospice staff in order to promote the resident's highest practicable physical, mental and psychosocial well-being. The plan of care would include directives for managing pain and other uncomfortable symptoms and would be revised and updated as necessary. The facility would immediately contact and communicate with the hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications or emergent situations. This deficiency represents non-compliance investigated under Complaint Number 2647655.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review and review of Self-Reported Incident (SRI) #261109, the facility failed to treat Resident #19 with respect and dignity. This affected one (Resident #19) of four residents reviewed for resident rights. The facility census was 70. Findings include:Review of the medical record for Resident #19 revealed an admission date of 01/31/17 with diagnoses including diabetes mellitus type two, generalized anxiety disorder, osteoarthritis and pain of the right knee, personality disorder, violent behavior, and major depressive disorder. Review of Resident #19's plan of care reviewed 10/29/24 revealed the resident used a wheelchair for self-propelling, required one person assist with transfers, and had behaviors including refusals of incontinence care and yelling or using profanity towards staff. Review of the Quarterly Minimum Data Set (MDS) assessment completed 06/05/25 revealed no cognitive impairment. Review of SRI tracking #261109 dated 06/02/25 revealed an allegation of physical abuse was reported to administration by Resident #72 who witnessed staff roughly transfer Resident #19 on 05/31/25 into a wheelchair. Video evidence indicated the incident actually occurred on 05/30/25 at 9:17 P.M. and involved Certified Nursing Assistant (CNA) #300 and Licensed Practical Nurse (LPN) #301. Resident #19 was lying on a common area couch and had an episode of incontinence but was resistive to return to her room via the wheelchair for personal care. CNA #300 made attempts and reapproach the resident several times for approximately one hour then asked LPN #301 for advice. Both CNA #300 and LPN #301 transferred Resident #19 together arm-in-arm standing on each of the resident's sides into the wheelchair without foot pedals. The resident would not hold her legs up so the two staff members tipped the wheelchair backwards, and CNA #300 pushed Resident #19 back to her room while LPN #301 held her legs. Review of the written witness statement for LPN #301 dated 06/03/25 indicated CNA #300 reported Resident #19 was incontinent on the couch and refused to get cleaned up saying to leave her alone, so they both tried to under arm her placing her in the chair, but it was difficult. The resident ended up at the tip of the wheelchair so CNA #300 leaned the wheelchair backwards to get Resident #19 into the back of the chair, but the resident was combative trying to kick and jump out of the chair, so LPN #301 grabbed her legs to prevent the resident from hurting herself and they got her back to the room for care. Review of the written witness statement for CNA #300 dated 06/02/25 indicated Resident #19 was incontinent on the couch so the aide tried to get her to go back to her room to get cleaned up but refused. LPN #301 came over to help. We sat the resident up, got on each side of her and picked her up and placed her into the wheelchair. CNA #300 tried to push Resident #19 to her room, but her feet were twisting into the wheels, so the aide held the wheelchair backwards and looked to LPN #301 for direction. LPN #301 told the aide to take Resident #19 back to her room just like that (tipped backwards), and when the resident got back to the room, she swung her nails toward the aide who decided to let Resident 19 cool down before care was provided. Review of a performance improvement form dated 06/06/25 for LPN #301 indicated the nurse was discharged from employment due to advising CNA #300 to transport Resident #19 while tipped backwards in a wheelchair on two wheels and then assisting by holding the resident's legs which was observed on video. Review of a performance improvement form dated 06/06/25 for CNA #300 indicated the aide was discharged from employment due to tipping Resident #19 backwards in the wheelchair onto two wheels and transporting her back to her room which was observed on video. Interview on 07/22/25 at 1:03 P.M. with Administrator verified the above incident findings. The deficient practice was corrected on 06/06/25 when the facility implemented the following corrective actions: CNA #300 and LPN #301 were suspended on 06/02/25 by the Director of Nursing (DON). Staff statements from those involved were obtained by DON on 06/02/25. On 06/02/25 an order was written for psychiatric/psychological services to consult Resident #19 on next facility visit. Resident skin assessments were completed post incident by floor nurses with no new skin issues identified. Resident #19's responsible party and nurse practitioner were notified on 06/02/25 by the DON. Social service designee completed psychosocial visits with Resident #19 on 06/04/25, 06/05/25 and 06/06/25 with no changes from baseline. All residents were interviewed and those who could not be interviewed received comprehensive skin assessments by licensed nurses by 06/04/25 with no variances noted. A root cause analysis was completed on 06/05/25 by the interdisciplinary team (IDT). Police were notified by Regional Director of Clinical Services (RDCS) #303 on 06/05/25 and report completed. All staff were educated by RDCS or designee by 06/06/25 regarding facility abuse policy, including timely reporting, the abuse coordinator and removing residents immediately when abuse identified; resident rights; restraints; and caring for residents with behaviors. Beginning on 06/05/25, online education was assigned entitled, Abuse Prevention, Dealing with Difficult Behaviors, which all staff members completed by 06/06/25. All facility staff completed questionnaires on 06/06/25 to validate learning of abuse reporting and prevention with immediate education provided by DON or designee if incorrect answers were submitted. Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held on 06/06/25 with the interdisciplinary team to ensure compliance with facility abuse policy, timely reporting and resident rights. CNA #300 and LPN #301 were terminated from employment on 06/06/25 by the Administrator and DON. Beginning 06/06/25, the DON or designee audited two staff members daily on various shifts using visual audit to validate resident rights were honored, correct actions in response to resident refusals of care, and residents were free from abuse for four weeks Beginning 06/06/25, the DON or designee interviewed two staff members daily on various shifts on response to resident abuse or denial of rights, and when to notify the abuse coordinator of suspected abuse with immediate education if incorrect responses received for four weeks. Beginning 06/06/25, the DON or designee interviewed 15 residents weekly for four weeks regarding abuse and resident rights being followed. Results of audits were reviewed in a one-month follow-up QAPI Committee meeting with revisions to the plan or changes made in monitoring as deemed by the QAPI committee. This deficiency was an incidental finding identified during the complaint investigation.

Based on observations, interview, record review, and review of the facility policy, the facility failed to maintain a clean and sanitary environment. This affected two (Residents #6 and #67) of 14 residents reviewed for environment and had the potential to affect all residents residing in the facility. The facility census was 70. Findings include: 1. Observation on 07/21/25 at 9:54 A.M. revealed Resident #6 in a wheelchair next to the bed watching television. The room had a distinct odor of urine. The bed covers were pulled away which exposed a wet soiled incontinence pad. The edges of the soiled area were dried and yellowish-brown in color. There were six gnats crawling upon the wet part of the soiled area and two gnats flying above it. Nearby on the floor just outside the bathroom was a small pile of wet soiled clothes. Across the room from the bed near the wall was soiled linen including a towel and washcloth. Interview with Resident #6 at the time of the observation who complained about the bed and indicated having been up in the wheelchair for a long time without it being cleaned up. Interview on 07/21/25 at 10:01 A.M. with Certified Nursing Assistant (CNA) #214 confirmed the observation in Resident #6's room and verified night shift had gotten Resident #6 up and left it that way but had not had an opportunity to fix it yet although it had been a few hours since then. Review of the medical record for Resident #6 revealed an admission date of 07/25/19 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, congestive heart failure and diabetes mellitus type two. The Annual Minimum Data Set (MDS) assessment completed 06/10/25 indicated no cognitive impairment. The plan of care reviewed 06/27/25 specified Resident #6 required one to two staff assistance with all activities of daily living (ADL) and was incontinent of bowel and bladder. 2. Observation on 07/21/25 at 10:13 A.M. of the hallway approximately ten feet from and approaching Resident #67's room revealed a strong unpleasant odor of urine. The resident was not in the room and the odor was more pungent within it. Upon walking on the floor of the room, it was sticky as the sound of adherence and the resistance as shoes pulled away from the floor was felt. The bed covers were pulled back which exposed an incontinence pad with a large, dried area of urine yellowish-brown and dried smudges of feces. The bedside table was sticky with dried spills and a large number of crumbs and debris. Interview at the time of the observation with Licensed Practical Nurse (LPN) #246 verified the observation and indicated Resident #67 had a urinary catheter but would empty the urine bag without assistance and spill it on the floor and/or bed sheets. The resident also had behaviors including refusal of housekeeping or personal care, so staff had to reapproach or clean the room after the resident left the room. Interview on 07/21/25 at 10:56 A.M. with Administrator and Director of Nursing (DON) revealed Resident #67 was considered by staff as a focus resident because of the behaviors, so the staff had to check on the resident more frequently. Review of the medical record for Resident #67 revealed an admission date of 08/23/19 with diagnoses including Alzheimer's disease, dementia, sensorineural hearing loss, urethral stricture, congestive heart failure and diabetes mellitus type two. The Annual MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment and a urinary catheter. The plan of care reviewed 06/10/25 specified Resident #67 required cues and assist as needed to accomplish daily tasks and was known to empty the urinary catheter bag without assistance. Review of the facility policy, Handling Soiled Linen, revised 12/20/23, revealed soiled linen was collected at the bedside or point of use and placed into a linen bag or designated lined receptacle when task was completed. The soiled linen was not kept in a resident's room, bathroom or other care areas. Review of the facility policy, Safe and Homelike Environment, revised 01/01/22, revealed the facility provided and maintained bed and bath linens that were clean and in good condition, and minimized odors by disposing of soiled linens promptly and reporting lingering odors to housekeeping. This deficiency represents non-compliance investigated under Master Complaint Number 2570725 and Complaint Number 1342408 (OH00166879).

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, review of Self-Reported Incident (SRI) #261204, and facility policy review, the facility failed to protect Resident #3 from verbal abuse by a staff member. This affected one (Resident #3) of four residents reviewed for abuse, neglect, misappropriation and exploitation. The facility census was 70. Findings include: Review of the medical record for Resident #3 revealed an admission date of 08/21/20 with diagnoses including Alzheimer's disease with late onset, dementia, diabetes mellitus type two, congestive heart failure, violent behavior, mood affective disorder, major depressive disorder, and nicotine dependence. Review of Resident #3's plan of care reviewed 04/25/25 revealed the resident had behaviors of increased agitation towards others, often unprovoked, verbal aggression and profanity. Review of the Annual Minimum Data Set (MDS) assessment completed 05/06/25 revealed no cognitive impairment. Review of a nursing progress note dated 05/31/25 revealed Resident #3 left outside the therapy room door. When Registered Nurse (RN) #302 asked the resident to stop, she replied shut up. Resident #3 was asked to stop letting ducks in and refused to leave the therapy room. Review of nursing progress notes dated 06/01/25 revealed RN #302 documented while on the phone with the Director of Nursing (DON) residents were in the therapy area and asked to leave but Resident #3 refused. RN #302 informed the resident she could have a police escort out if refusals continued because of safety, letting ducks into the building and administration's request to get all residents out of the therapy area. Resident #3 responded by calling RN #302 a [expletive] and stated, the nurse should make her get out. Resident #3 eventually left the therapy area. While RN #302 was at the medication cart counting narcotics in the nurses' station area, Resident #3 approached RN #302 and informed the nurse she did not want RN #302 in her room or taking care of her anymore. Resident #3 continued to state to RN #302, she don't want no [expletive] in her room, and you are a [expletive]. RN #302 told the resident it was inappropriate talk and furthermore if the resident crossed through the therapy area to the courtyard for any reason including smoking, it would be a direct infarct of the smoking rules and could result in losing smoking privileges. Resident #3 responded to RN #302 to kiss her [expletive] [expletive] and threatened to call her lawyer because RN #302 had no right to take away her smoking privileges because it was her right to do and say what she wanted, then left the nurses' station. Review of SRI tracking #261204 dated 06/04/25 revealed an allegation of verbal abuse was reported to administration via a company compliance hotline by Licensed Practical Nurse (LPN) #301 who reported she witnessed RN #302 on 05/31/25 abuse Resident #3 by calling the resident a hillbilly [expletive], and the DON witnessed it being on the phone at the time. Regional Director of Clinical Services (RDCS) #303 reviewed video evidence and found the incident occurred at approximately 7:30 P.M. to 7:40 P.M. when RN #302 and LPN #248 were seen at the medication cart near the nurses' station closest to the therapy room doors. Resident #3 approached RN #302, stated something, then walked away to the opposite end of the nurses' station nearest the therapy area by 300 hall. RN #302 then reacted by throwing both hands up in the air and pointing at Resident #3 while walking towards her, still using hand gestures continuing to point and reflecting excitability. Next, LPN #257 intervened by redirecting Resident #3 away from RN #302 out of the area toward the resident's room. As Resident #3 walked away, RN #302 continued to point at and use hand gestures but there was no audio as to what was said to the resident. RN #302 then picked up the telephone to make a call while standing at the medication cart with LPN #248. Review of the written witness statement by the DON dated 06/04/25 indicated receiving a phone call at the time of the incident from RN #302 who complained residents had exited out the therapy room doors to smoke which let ducks into the facility, and refused to listen when told to shut the door, leave the area and allow the ducks to exit the building. RN #302 reported Resident #3 was chasing after the ducks and would not listen, but eventually the residents did leave the therapy area and shut the door. RN #302 complained of both Residents #3 and #56 yelling and swearing at her about smoking and it being their right to smoke but Resident #56 did later apologize to her. RN #302 continued to complain about Resident #3 who called her a lesbian and told her they had rights to go smoke. RN #302 reported telling Resident #3 to move away from her and go to her room to defuse the situation. DON denied hearing any verbal interactions between RN #302 and Resident #3 over the telephone. Review of the written telephone interview between RDCS #303 and witness LPN #248 dated 06/04/25 indicated RN #302 was very upset, crying and talking about the workload while they were both counting narcotics at the medication cart when Resident #3 approached and told RN #302, she could not take care of her because of what was said, then called RN #302 a [expletive]. RN #302 informed LPN #248 the resident was calling her a lesbian then RN #302 said to Resident #3, I'm [expletive] married and have seven [expletive] kids. I bet you don't have a [expletive] husband. RN #302 then called Resident #3 a [expletive], so LPN #248 responded to RN #302, hey, hey, hey when it stopped, and Resident #3 then walked away. RN #302 called the DON to report what happened but did not tell the DON she had called Resident #3 names. Review of the written telephone interview between RDCS #303 and witness LPN #243 dated 06/04/25 indicated discussing the schedule and call-offs with RN #302 who was upset about it at the time. It was near smoke break for residents, so they were told it had to wait while the nurses were trying to call the DON to discuss the schedule. Then quacking was heard, and ducks were seen in the therapy area where the door had been propped open, so the residents were told to close the doors and not use them, but the residents replied they were just waiting for their smoke break. The nurses then informed them it may be some time before there was a smoke break. Resident #3 became upset yelling at them and called RN #302 a [expletive]. RN #302 was stern with Resident #3 telling the resident to leave the area. After the ducks got out of the facility, RN #302 went to the medication cart at the nurses' station when Resident #3 approached her and called her a lesbian [expletive]. RN #302 did not take it well and responded to Resident #3, I'm [expletive] married and have seven [expletive] kids. I bend over for every [expletive] in here, and you have the nerve to call me names. Resident #3 responded to RN #302, yep, yep. RN #302 then called the DON and reported Resident #3 was calling her names. The DON tried to talk to Resident #3 but the resident threw the phone down when LPN #243 handed it to her. RN #302 was crying and very upset. Review of the written telephone interview between RDCS #303 and witness LPN #257 dated 06/04/25 indicated RN #302 was trying to get two residents (#3 and #56) to exit the therapy area, shut the doors and redirect ducks out of the building. Resident #3 was calling RN #302 names then called the DON to discuss it and get assistance with getting residents to comply. While RN #302 was on the phone with the DON she called Resident #3 hillbilly [expletive]. Review of the written telephone interview between RDCS #303 and alleged perpetrator RN #302 dated 06/04/25 indicated Residents #3 and #56 were exiting the facility through the therapy doors which allowed ducks into the building. RN #302 asked them to close the doors to let the ducks exit, but Resident #3 started calling her names, calling her a [expletive] and telling her to kiss her [expletive] [expletive] all while attempting to get residents to come in. RN #302 denied calling Resident #3 any names only that the resident called her names. RN #302 reported working on the day after the incident and received report from other staff that Resident #3 had continued to talk about her, calling her names, so RN #302 approached the resident and asked her to stop speaking of the incident and calling her inappropriate names, but there were no further interactions. Review of the written telephone interview between RDCS #303 and witness LPN #301 (undated) indicated not being present during the incident on 05/31/25 but on 06/01/25 while working with RN #302 at the nurses' station, RN #302 informed her, and the other staff present there what had occurred the previous evening with Resident #3. RN #302 told them the resident had called her names, so she reciprocated. It was also relayed that the DON was on the phone at the time of the event, so LPN #301 called the compliance hotline (on 06/04/25).Review of a performance improvement form dated 06/06/25 for RN #302 indicated the nurse was discharged from employment due to being observed by staff being disrespectful to Resident #3 which was confirmed by review of video showing RN #302 pointing at the resident appearing to be aggressive. Review of the state nursing board complaint filed by the Administrator dated on 06/11/25 revealed a complaint made against RN #302 who was witnessed calling Resident #3 a [expletive], saying I'm [expletive] married and have seven [expletive] kids, was seen on video pointing at the resident while approaching her repeatedly shaking her arms, and was reported to the state agency for verbal abuse against Resident #3. Interview on 07/22/25 at 1:03 P.M. with the Administrator verified the above incident findings and confirmed the abuse investigation, SRI #261204, was substantiated. Interview on 07/22/25 at 3:00 P.M. with RDCS #303 confirmed the above findings of the incident and described the video findings as the nurses had come in at the start of the shift. RN #302 was there and probably was discussing the schedule. Another staff member saw ducks in the therapy gym, so everyone migrated over to them and then returned. RN #302 and LPN #248 were at the medication cart with Resident #3 at the other side of the nurses' station. The resident walked up to RN #302, said some things, supposedly calling the nurse a [expletive] and walked away. The altercation then occurred with RN #302 making a statement to the resident, pointing hands going toward her before returning to the medication cart to call the DON. Another nurse directed Resident #3 away from RN #302 back to her room. Review of the written interview between Social Services Designee (SSD) #275 and Resident #3 dated 06/04/25 indicated the resident got upset with a nurse, called her a [expletive] and then the staff member called the resident a [expletive]. Review of the facility policy, Abuse, Neglect and Exploitation, revised 01/10/24, revealed the facility implemented written policies and procedures to prohibit and prevent abuse, neglect and exploitation of residents. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after an investigation. All alleged violations were to be reported to the Administrator. The deficient practice was corrected on 06/06/25 when the facility implemented the following corrective actions:The DON and RN #302 were suspended on 06/04/25 immediately when the incident was reported via the company compliance hotline on 06/04/25 by LPN #301.Staff statements from those involved were obtained by RDCS #303 on 06/04/25.Resident #3 refused a skin assessment on 06/06/25 and then reattempted and allowed with no skin alterations noted.Resident #3 was observed via camera footage by RDCS #303 as being removed from the situation by LPN #257 on 05/31/25 and redirect to her room.Resident #3's responsible party and nurse practitioner were notified on 06/04/25 by RDCS #303.SSD #275 completed psychosocial visits with Resident #3 daily for 72 hours with no changes from baseline.The DON and RN #302 were suspended by RDCS #303 on 06/04/25 and after the investigation identified the DON was not on the phone at the time of the incident, and RN #302 displayed inappropriate behavior and cursing at Resident #3 which resulted in termination of employment on 06/06/25.A root cause analysis was completed on 06/05/25 by the interdisciplinary team (IDT).RN #302 was reported to the state board of nursing by the Administrator at the conclusion of the investigation.A PHQ9 assessment (measures depressive symptoms) was completed for Resident #3 and the resident was referred to psychiatric/psychological services on 06/06/25 by SSD #275.Police were notified by RDCS #303 on 06/05/25, and a report was completed.All residents were interviewed and those who could not be interviewed received comprehensive skin assessments by licensed nurses by 06/04/25 with no variances noted.All staff were educated by RDCS #303 or designee by 06/06/25 regarding facility abuse policy, including timely reporting, the abuse coordinator and removing residents immediately when abuse identified; resident rights; and caring for residents with behaviors.Beginning on 06/05/25, online education was assigned entitled, Abuse Prevention, Dealing with Difficult Behaviors, which all staff members completed by 06/06/25.All facility staff completed questionnaires on 06/06/25 to validate learning of abuse reporting and prevention with immediate education provided by DON or designee if incorrect answers were submitted.Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held on 06/06/25 with the interdisciplinary team to ensure compliance with facility abuse policy, timely reporting and resident rights.Beginning 06/06/25, the DON or designee audited two staff members daily on various shifts using visual audit to validate resident rights were honored, correct actions in response to resident refusals of care, and residents were free from abuse for four weeks.Beginning 06/06/25, the DON or designee interviewed two staff members daily on various shifts on response to resident abuse or denial of rights, and when to notify the abuse coordinator of suspected abuse with immediate education if incorrect responses received for four weeks.Beginning 06/06/25, the DON or designee interviewed 15 residents weekly for four weeks regarding abuse and resident rights being followed.Results of audits were reviewed in a one-month follow-up QAPI Committee meeting with revisions to the plan or changes made in monitoring as deemed by the QAPI committee.This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, photographs of meals & tray ticket review, and interview, the facility failed to follow Resident #90's meal preferences. This affected one resident (Resident #90) of four residents reviewed for preferences. The census was 68. Findings include: Review of the closed medical record for Resident #90 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #90's diagnoses included diabetes, end stage renal disease and major depression disorder. Review of the 5-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was cognitively intact. She required set up assistance with meals. Review of the Nutrition Data Collection/Evaluation dated 04/23/25 revealed Resident #90 had carrots listed as one of her dislikes. Review of the undated Meal Tracker printout, revealed carrots were listed as a dislike among several other dislikes for Resident #90. The printout stated her diet was updated on 04/23/25. Review of photographs provided by Resident #90's family revealed four photographs of meals with tray tickets with the plated meal. On 04/28/25 the lunch ticket listed brussel sprouts selected as the vegetable to be served and the photograph showed carrots were served. On 4/28/25 the dinner ticket listed whole kernel corn to be served as the vegetable and the photograph showed carrots were served. On 04/30/25 the lunch ticket listed brussel sprouts as the selected vegetable and the photograph revealed the selection was not served. On 05/02/25 the lunch ticket listed broccoli florets selected as the vegetable and the photograph showed carrots were served. Interview on 05/13/25 at 7:30 P.M. with Resident #90's family member revealed Resident #90 was not provided meals according to her preference and the photos supported this. Interview on 05/14/25 at 12:00 P.M. with the District Director of Dietary and at 3:15 P.M. with the Director of Nursing revealed they reviewed the photographs of meals with tray tickets and verified Resident #90 received food items listed on her dislike list for three of the meals. Review of the facility policy titled Dining and Food Preferences, revised 10/2022 revealed individual dining, food, and beverage preferences are identified for all residents. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies & intolerances, and preferences. The photographs were viewed and verified on 05/14/25 by both the Regional Director of Dietary at 12:00 P.M. and the Director of Nursing on 3:15 P.M. This deficiency represents non-compliance investigated under Complaint Number OH00165632.

Based on record reviews and interview the facility failed to ensure the Facility Assessment was completed accurately and thoroughly. This had the potential to affect all 67 residents. Findings Include: Review of the Facility Assessment revealed it was dated 01/2024 through 12/2024. The assessment did not have the names of the Administrator, Director of Nursing or Medical Director in the lines indicated nor was it marked as being reviewed. There was no indication of the type and number of staff needed to provide care and services. Interview on 02/05/25 at 12:30 P.M. with Administrator confirmed the Facility Assessment was not thorough and accurate.

Based on observation, interview and policy review, the facility failed to secure sharp objects were disposed of properly. This had the potential to affect six residents (#17, #32, #53, #119, #121 and #122) identified as being ambulatory and residing on the 600 unit. The facility census was 67. Findings include: On 02/04/25 at 11:25 A.M. an observation of a treatment cart on the 600 unit revealed an open compartment for sharp objects. The open compartment did not contain a second receptacle for securing sharp objects. The open compartment contained nine used syringes, three lancets (a sharp object used to pierce fingers to test blood sugars) and one used needle for an insulin injector pen. Licensed Practical Nurse (LPN) #361 verified the exposed syringes, lancets and needle at the time of the observation. A review of the policy titled; Safe and Homelike Environment dated 01/01/2022 revealed the facility will provide a safe, clean, comfortable and home like environment. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of facility video surveillance, review of a local police report, facility policy review and interview, the facility failed to provide adequate supervision for Resident #03, who was assessed to be high risk for elopement, had a history of exit seeking behavior, resided on the secured memory care unit and had a wander guard (wearable device to help keep residents at risk of wandering safe) to prevent elopement. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death on [DATE] at 12:44 P.M. when Resident #03 followed dietary staff through the secured memory care door, traveled through the facility and eloped through the front door without staff knowledge. Furthermore, Resident #03's wander guard alarmed (as designed) at the front door when he exited; however, staff failed to timely respond and further failed to adequately investigate the source of the alarm upon response. Resident #03 walked approximately 0.7 miles away from the facility, through a neighborhood with two large ponds of water along the route traveled. Resident #03 was found by the local police after a concerned neighborhood resident saw Resident #03 fall and called 911. Upon police arrival, Resident #03 was found on his hands and knees on the sidewalk. Facility staff were unaware Resident #03 was missing until notified by the local police department (LPD) he had been found, approximately two hours after he was last seen in the facility by staff. In addition, a concern that did not rise to an Immediate Jeopardy occurred when the facility failed to provide adequate supervision for Resident #18 resulting in the resident eloping from the facility without staff knowledge. The resident was found by a facility staff member who was traveling to the facility for their scheduled shift. This affected two residents (#03 and #18) of three residents identified by the facility as being assessed as high risk for elopement. The facility census was 71. On [DATE] at 1:49 P.M. the Regional Director of Operations (RDO) #245, Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #160, RDCS #161 and Licensed Practical Nurse/Unit Manager (LPN/UM) #248 were notified Immediate Jeopardy began on [DATE] at 12:44 P.M. when Resident #03 followed Dietary Aide (DA) #157 off the secured memory care unit, unnoticed. Resident #03 eloped through the front door of the facility and staff failed to respond timely to the wander guard alarm at the front door. When staff did respond, approximately 20 minutes after the alarm sounded, staff did not fully investigate the source of the alarm, turned the alarm off and failed to conduct a resident head count to ensure all residents were accounted for. The facility was unaware the resident was missing until returned to the facility by the LPD, nearly two hours after he eloped. The Immediate Jeopardy was removed, and the deficient practice corrected on [DATE] when the facility implemented the following corrective actions: On [DATE], upon discovery Resident #18 had eloped from the facility, a head count was initiated by Licensed Practical Nurses (LPNs) #136 and #137 and all additional residents were accounted for. On [DATE] at [DATE], LPN #249 completed a head-to-toe assessment on Resident #18. On [DATE], Resident #18 was placed on one-on-one staff supervision, which would continue pending the outcome of a guardianship hearing on [DATE]. On [DATE] at 2:10 P.M., LPN #144 was notified by the LPD Resident #03 had been located off facility grounds. On [DATE] at 2:11 P.M., LPN #144 initiated a resident head count to ensure all other residents were accounted for. On [DATE] at approximately 2:30 P.M., the LPD and Emergency Medical Services (EMS) arrived at the facility with Resident #03. EMS and LPN #144 assessed the resident, and the resident was returned to the secured memory care unit. On [DATE], Resident #03 was placed on one-on-one supervision. This would continue while the facility worked with the resident's guardian to determine any additional interventions or alternative placement. On [DATE] at 5:30 P.M., the DON and LPN/UM #248 reviewed the facility cameras and completed a root cause analysis. It was determined Resident #03 was able to elope when staff exited the secured memory care unit without ensuring no residents were following, lack of timely staff response when the wander guard set off the front door alarm and lack of adequate staff response upon investigating the front door alarm. On [DATE] at 5:45 P.M., the DON completed a wander guard audit for all residents (#03, #53 and #54) with wander guards to ensure the intervention was appropriate, orders were in place and care plans were updated with no discrepancies identified. On [DATE] at 6:00 P.M., the DON and LPN/UM #248 reviewed and updated the resident elopement binder to ensure accuracy of information. On [DATE] at 7:30 P.M., the DON completed a second audit of the facility elopement binder with no discrepancies identified. On [DATE] at 8:00 P.M., the DON and LPN/UM #248 completed a reassessment of all facility residents for elopement risk. Care plans for residents at risk for elopement (#03, #18, #53 and #54) were reviewed and updated as appropriate. On [DATE], an elopement drill was completed by the DON and LPN/UM #248. On [DATE] by 11:59 P.M., the DON educated all facility staff in-person and by phone on ensuring residents do not follow them through the locked door of the secured memory care unit, the facility policy for elopement, responding to door alarms and missing resident with 100% of staff receiving the education. On [DATE] by 11:59 P.M., the DON educated all Certified Nursing Assistants (CNA) in-person and by phone on resident supervision, to include checking on residents every two hours, and if unable to locate a resident, to immediately notify the nurse so a headcount of facility residents can be initiated and search conducted per facility policy with 100% of the CNAs receiving the education. On [DATE] at 11:00 A.M., LPN #249 and LPN #139 completed a whole facility audit of windows and doors to validate all security measures were in place with no concerns identified. On [DATE], Dietary Manager (DM) #156 completed one-on-one education with Dietary Aide (DA) #157 to ensure no residents were following when exiting the secured memory care unit. Beginning on [DATE], the DON/designee would review all risk for elopement assessments and nursing quarterly assessments for four weeks to ensure accuracy and appropriate interventions are in place. Beginning on [DATE], the DON/designee would observe food carts going off the secured memory care unit five times per week for eight weeks to ensure staff are following procedures to prevent residents from following behind them when exiting the unit. Beginning on [DATE], the DON/designee would randomly observe staff entering and exiting the secured memory care unit for eight weeks to ensure procedures are followed to prevent residents from exiting the unit. Beginning on [DATE], the Administrator/designee would complete daily elopement drills on random shifts for two weeks then monthly elopement drills (one on each shift per quarter). Beginning on [DATE], the DON would review progress notes for all residents daily, Monday through Friday, for any documentation of exit seeking behaviors for four weeks to ensure appropriate interventions are implemented and care plans revised. The Interdisciplinary Team (IDT) would continue to identify residents at risk for elopement upon admission/re-admission and change in condition to ensure appropriate interventions are implemented and care planned to address elopement risk. DOM #246 would continue to monitor and validate door alarms and function per facility policy and procedures. On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held, which included the Administrator, DON, Medical Director (MD) #247, Activities Director (AD) #255 and LPN/UM #248 to review the root cause analysis, policies and procedures and corrective action plan. On [DATE], the QAPI Committee met to review the first week audit findings with no concerns identified. Review of five (#08, #41, #42, #46, #54) additional open resident records revealed elopement risk assessments and elopement care plans were updated and accurately reflected resident needs to prevent elopement. No concerns were identified. Interviews on [DATE] with DA #157, LPN #144, Certified Nursing Assistant (CNA) #123, Hospitality Aide (HA) #110, Medication Technician (MT) #102 and CNA #124 verified the facility provided education on the elopement policy and procedure, missing residents, response to door alarms and resident supervision. Findings include: 1. Review of the medical record for the Resident #03 revealed an admitted [DATE] with diagnoses including dementia, mild with agitation; mild intellectual disabilities; impulse disorder; Alzheimer's disease with late onset; wandering in diseases classified elsewhere; and unspecified psychosis not due to a substance or known physiological condition. Further review revealed Resident #03 had a legal guardian and resided on the secured memory care unit of the facility. Review of the current physician orders revealed the resident's orders included may reside on the secure unit due to need for a smaller, more structured environment related to dementia diagnosis, nurse to check function and battery life of wander guard and may go on leave of absence (LOA) with escort and medications. Review of the Risk of Elopement/Wandering Review assessment, dated [DATE], revealed Resident #03 was moderately cognitively impaired with poor decision-making skills (for example, intermittent confusion, cognitive deficits or disoriented). Resident #03 ambulated independently. The resident verbalized the desire to go home, packed belongings to go home or stayed near exit doors. The assessment indicated Resident #03 wandered aimlessly/non-goal directed and this was not a new behavior. Further review of the assessment revealed Resident #03 was at risk for elopement/wandering as evidenced by pushing on the secured unit doors and verbalizing the desire to leave. Resident #03 had a history of leaving the secured unit, but not the facility. Review of the plan of care dated [DATE] revealed Resident #03 was at risk for elopement/wandering behavior related to exit seeking behavior, high risk for elopement and exiting unit. Interventions included every 15-minute checks per nursing judgment, placement of wander guard to lower extremity and check placement and battery life, calmly redirect and divert the resident's attention, distract when wandering/insisting on leaving the facility by offering pleasant diversions and promptly check when alarm system goes off to ensure the resident is safe and remains in the facility. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #03 had a Brief Interview for Mental Status (BIMS) score of 09, indicating he had moderate cognitive impairment. The assessment identified the resident to have behaviors of wandering and was independent for ambulation. Review of a nursing note dated [DATE] at 3:58 P.M., and completed by LPN #144, revealed a call was received from the police department at 2:10 P.M. stating a resident (identified to be Resident #03) was on a street 0.7 miles away from the facility. The resident was crying and lost, taken to the police station and then brought back to the facility around 2:30 P.M. Further review of the note revealed the last time the resident was seen by the nurse was around 12:00 P.M. when the resident was eating pizza at a dining room table. Once Resident #03 was brought back to the facility by the police, a full head-to-toe assessment was completed. Vitals and assessment were normal and at baseline and the resident denied any pain. Resident #03 was wearing plaid pajama pants, a grey shirt and black slippers. Resident #03 stated he waited until the food tray cart was being collected to sneak behind the cart as the door was opened by staff. Resident #03 stated he went out the front door to go home with his sister. The resident denied being hurt or in any pain. Facility staff were asked if anyone noticed Resident #03 elope and all staff denied seeing the resident. Education was provided to staff on elopement risk and wander guard function check. Resident #03 was placed on one-on-one staff supervision and the responsible party was notified. Full head count was completed, and all residents were accounted for. Review of a local police report revealed on [DATE] at 1:43 P.M., a call was received from a neighborhood resident who reported seeing an elderly male walking, who was stumbling and fell to the ground. Further review revealed the responding officer arrived on the scene at 1:50 P.M. and found Resident #03 on his hands and knees and appeared disoriented. The officer called EMS, who responded and cleared the resident. EMS transported the resident back to the facility. The police response was cleared at 2:42 P.M. Review of the current physician orders revealed an order dated [DATE] (following the incident) for Resident #03 to remain on one-on-one with staff (supervision). Interview on [DATE] at 8:35 A.M. with the DON and LPN/UM #248 revealed on [DATE], DA #157 went to the secured memory care unit to collect the meal cart. When DA #157 exited the unit at 12:44 P.M., Resident #03 caught the door just before it closed. The resident then walked up the 600-hall, around the corner, down the 300-hall and out the front door. The administrative staff revealed there was no receptionist that day and the resident did not pass any staff member. The DON verified Resident #03 had a wander guard and the front door alarmed when he exited but stated staff did not respond timely or thoroughly investigate the alarms. The DON further confirmed Resident #03 was found 0.7 miles away by the police after someone in the neighborhood called 911 stating an elderly person was walking around. The DON stated EMS assessed Resident #03 and the resident had no visible injuries and did not require further evaluation at the hospital. Additionally, the DON verified Resident #03 had a history of eloping off the secured memory care unit, but not the facility, and staff were unaware the resident was gone until contacted by the police. Following the incident, the DON stated all facility staff received education on facility policies and procedures. Interview on [DATE] at 10:56 A.M. with Medication Technician (MT) #102 revealed she worked on the secured memory care unit early in the day on [DATE]. MT #102 stated staff were busy caring for other residents and did not see Resident #03 elope from the unit. MT #102 stated (prior to the incident) Resident #03 always tried to run off the unit by following staff through the secured memory care unit door and DA #157 did not look to ensure the resident was not following him when he left the unit with the meal cart. Observation on [DATE] at 4:00 P.M. of the facility video surveillance from [DATE], with the DON, verified Resident #03 eloped from the secured memory care unit by following dietary staff off the unit. Resident #03 proceeded to walk down two halls and exited the facility through the front door. Interview on [DATE] at 10:33 A.M. with DA #157 verified Resident #03 was able to elope on [DATE] when he did not check behind him when exiting the secured memory care unit. Interview on [DATE] at 12:06 P.M. with Hospitality Aide (HA) #110 revealed on [DATE], she heard the front door alarm. HA #110 stated she responded, turned the alarm off and walked the perimeter of the parking lot. HA #110 stated she did not see anything and returned to the building without notifying anyone of the alarm. A telephone interview on [DATE] at 12:22 P.M. with LPN #144 revealed he was Resident #03's assigned nurse on [DATE]. LPN #144 stated he last saw Resident #03 on that date around 12:00 P.M. when he was eating pizza brought in by his sister. LPN #144 stated he was caught up in his tasks and took a break from 12:25 P.M. to 1:05 P.M. LPN #144 verified he was unaware Resident #03 was missing until the police called around 2:10 P.M. Upon Resident #03's return to the facility around 2:30 P.M., LPN #144 assessed the resident, and no injuries or other concerns were identified. A telephone interview on [DATE] at 12:27 P.M. with RN #148 revealed she worked the 100 and 400-halls on [DATE]. RN #148 stated she was unaware Resident #03 was missing from the facility until she saw the police and EMS arrive to the facility with the resident. Interview on [DATE] at 12:31 P.M. with CNA #123 revealed she worked on the 300-hall on [DATE]. CNA #123 stated she was unaware Resident #03 had eloped from the facility until she saw the police bringing the resident back to the facility. Review of the facility policy titled Unsafe Wandering & Elopement Prevention, revised [DATE], revealed every effort would be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Nursing personnel must report and investigate all reports of missing residents. Additionally, it was the responsibility of all personnel to report any resident attempting to leave the premises, or suspected to be missing, to the licensed nurse. 2. Review of Resident #18's medical record revealed an admitted [DATE] with diagnoses including unspecified dementia with psychotic disturbance, hallucinations, mild cognitive impairment and diabetes mellitus type II. Further review revealed Resident #18 was her own responsible person. Review of a nursing note dated [DATE] at 7:30 P.M. revealed Resident #18 was seen by oncoming shift staff in the church parking lot approximately 1.1 miles from the facility. Staff informed the writer of her location and staff were able to get the resident safely back to the facility. Once returned, a wander guard was placed on the resident and one-on-one with staff (supervision) was initiated. Resident #18 was assessed with no negative findings and the resident denied pain. She also denied any mental anguish and stated she was just going to get fresh air and grab something from the store, but then found herself lost and did not know how to get back. The Nurse Practitioner (NP), interim DON and Administrator were notified. Review of a Social Services (SS) progress note dated [DATE] at 7:59 P.M. revealed Resident #18 was wearing maroon plaid pajama pants, maroon crewneck sweatshirt, grey shoes, a black/tan ball cap and was carrying a red bag. Review of the Risk of Elopement/Wandering Review assessment, dated [DATE], revealed Resident #18 was cognitively impaired with poor decision-making skills (for example, intermittent confusion, cognitive deficits or disoriented), ambulated independently and wandered aimlessly or non-goal directed. This was a new behavior, and, for the first time, Resident #18 left the facility without supervision, when supervision was required. Review of care plan revised [DATE] revealed Resident #18 was at risk for elopement related to exit seeking behavior/elopement. Interventions included, but not limited to, one-on-one with staff (supervision), evaluate for need of wander guard use and distraction when wandering/insistent on leaving the facility by offering pleasant diversions. Further review revealed Resident #18 refused the use of a wander guard. Review of a Social Services (SS) progress note dated [DATE] at 10:08 A.M. revealed Resident #18 stated she went outdoors on the evening of [DATE] but was unable to recall the time. The resident stated she went to get fresh air and asked someone in passing, once off the facility property, if they could tell her where a store was. Resident #18 went to the store and purchased snacks. Resident #18 stated she was on her way back to the facility when she was contacted by staff. The resident stated she did not recall being lost. She was upset regarding a wander guard and refused a room change despite concerns regarding her safety being voiced to her. Resident #18 continued to state she was going home one minute, but the next minute voiced she no longer had her apartment as she told the manager she was ending her lease. Nursing also spoke with her regarding a possible psychiatric evaluation and the resident refused to go to the emergency room (ER) for evaluation. Resident #18's sister was aware and attempted to speak with her on the phone; however, Resident #18 became agitated and stated, I am not speaking to my sister or any other family! Review of a written statement, dated [DATE] at 9:05 A.M. and completed by former CNA #177, revealed she was driving to work (on [DATE]), arriving around 7:02 P.M. CNA #177 was on Cleveland-East Liverpool Road when she looked to her right and witnessed an older black female dressed in flannel pajama pants, a long sleeve shirt, shoes, a tan baseball cap, carrying a tote bag and a box and she was wearing a surgical mask. She was standing on the sidewalk in front of the entrance of the driveway of a church. The woman looked familiar to one of the facility residents. Upon arrival at work, CNA #177 approached the nurses' station and stated she believed she saw one of the residents outside, in front of a church. CNA #177 asked if anyone had signed out and other staff indicated they were unaware of any residents outside and gone from the facility. CNA #177 was told to follow a nurse in her car to look for the resident where she was last seen, in front of the church. The resident was not there. CNA #177 pulled into the church parking lot and asked a man and a woman who were leaving the church if they had seen the resident. They said they had not seen her and gave CNA #177 permission to enter the church to look for her. Resident #18 was not located in the church. CNA #177 called the facility and was informed the nurse had searched the building and the resident had not returned. Review of the facility timeline of events, as observed via facility camera footage, revealed on [DATE] at 5:49 P.M., Resident #18 was observed in the facility around the nurses' station, heading in the direction of the front door. At 5:49 P.M. she was observed exiting he front door. From 5:49 P.M. through 6:01 P.M., Resident #18 remained on the facility grounds. At 6:01 P.M., Resident #18 left the property and started walking down the sidewalk. At 7:12 P.M., CNA, nurses and Resident #18 returned to the facility. Resident #18 was immediately assessed, a wander guard placed, and Resident #18 became one-on-one with staff (supervision). Review of the quarterly MDS assessment, dated [DATE], revealed Resident #18 had a BIMS score of 11, indicating she had moderate cognitive impairment. The resident was independent for ambulation. Interview on [DATE] at 9:22 A.M. with the DON, the Administrator, RDCS #160 and RDCS #161 revealed on [DATE] Resident #18 was seen in an area church parking lot, approximately 1.1 miles from the facility. CNA #177 informed LPN #137 she thought she saw the resident when she was driving into work. LPN #137, CNA #177 and LPN #136 got in the car and went to the church to bring Resident #18 back. While Resident #18 had never signed out of the facility previously, CNA #177 did not stop when she initially saw her because she was unsure if the resident had signed out. Resident #18 was her own responsible person, but the facility considered this incident an elopement because the resident did not inform staff she was leaving, and staff were unaware the resident left. Since the incident, Resident #18 had remained on one-on-one staff supervision pending the outcome of a guardianship hearing, which the resident appealed. Resident #18 refused the use of a wander guard and placement on the secured memory care unit. Interview on [DATE] at 11:50 A.M. with Resident #18 revealed she recalled the incident on [DATE]. Resident #18 stated she wanted snacks, asked people where the store was located and went. Resident #18 stated she was not lost and knew what she was doing. Resident #18 confirmed she did not tell anyone she was leaving. On her way back to the facility, Resident #18 stated a girl (unable to recall who) stopped her, told her staff were looking for her and took her back to the facility. Review of the facility policy titled Unsafe Wandering & Elopement Prevention, revised [DATE], revealed every effort would be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Nursing personnel must report and investigate all reports of missing residents. Additionally, it was the responsibility of all personnel to report any resident attempting to leave the premises, or suspected to be missing, to the licensed nurse. This deficiency represents non-compliance investigated under Complaint Number OH00159626.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interviews with staff, review of the facility's fall investigation and facility policy and procedure the facility failed to prevent Resident #53's fall. This affected one out of three residents reviewed for falls. The facility census was 67. Actual Harm occurred on 06/25/23 when Hospitality Aide (HA) #75 was pushing Resident #53, who was dependent on staff for transfer, had impairment on one side of the upper body and impairment on both sides of the lower extremities and used a wheelchair for mobility outside in her wheelchair while talking on her phone. Resident #63's wheelchair slipped off the sidewalk, tipping the wheelchair and Resident #53 fell to the ground. Resident #53 sustained a fractured left humerus because of the fall. Findings include: Resident #53 was admitted on [DATE] with diagnoses including nontraumatic subarachnoid hemorrhage, Alzheimer's dementia, fractured left humerus, bone density disorder, osteoarthritis, intervertebral disc degeneration, spondylosis, presbyopia, peripheral vascular disease, obesity, atrial fibrillation, cerebral vascular disease, high blood pressure, right and left ankle contracture, right and left knee contracture, anemia, depression, and a history of venous thrombosis. Resident #53 had medical conditions including muscle weakness, need for assistance with personal care, and dependence on a wheelchair for mobility. Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #53 was dependent on staff for transfer, impairment on one side of the upper body and impairment on both sides of the lower extremities and used a wheelchair for mobility. The MDS assessment indicated she had a risk for falls and a plan of care was initiated to prevent falls. Review of Resident #53's plan of care revised on 08/18/23 indicated a risk for falls related to cerebral vascular accident, agitation, bladder incontinence, decrease strength and endurance, functional problems, opioid/antipsychotic medication use, recent fracture of the humerus. Resident #53 was dependent on staff for all transfers using a mechanical lift. Interventions in the plan of care included applying anti-tippers to the back of the wheelchair. Review of Resident #53's nursing progress note dated 06/25/23 indicated staff assisted Resident #23 in her wheelchair to go outside for a smoking break. While staff was pushing Resident #53 in her wheelchair the front wheel of the wheelchair slipped off the sidewalk causing the wheelchair to tip and Resident #53 fell out of the wheelchair onto her stomach. Resident #53 was assessed and found abrasions on both knees and Resident #53 complained of left shoulder pain and had redness noted on the right side of her forehead. Resident #53 was sent to the hospital for an evaluation. Staff were educated to stay towards the center of the sidewalk when assisting a resident outdoors in a wheelchair. Resident #53 returned to the facility from the emergency roiagnom on [DATE] with her left arm mobilized in a sling. Review of the fall investigation dated 06/25/23 indicated while HA #75 was pushing Resident #53 in her wheelchair the front wheel slid off the sidewalk, tipped and Resident #53 fell to the ground on her stomach. The staff used a mechanical lift pad to lift Resident #53 back to the wheelchair. An interview with Resident #53 on 11/15/23 at 9:40 A.M. revealed she was assisted by an aide (unnamed) in her wheelchair to go outside for her smoking break. Resident #53 stated the aide was talking on her phone and was distracted. Resident #53 stated the aide was pushing her outside on the sidewalk and the front wheel of the wheelchair slipped off the edge of sidewalk causing the wheelchair to tip, and she fell to the ground. Resident #53 stated she was transported to the hospital and an x-ray was performed on her left shoulder. Resident #53 stated the x-ray results revealed she had fractured her left arm. The hospital staff applied a sling to immobilize her shoulder and she returned to the facility the next day. Interviews with Resident #3 and Resident #5 on 11/15/23 at 9:47 A.M revealed they witnessed Resident #53's fall on 06/25/34. Both residents stated HA #75 was talking on her phone while pushing Resident #53 in her wheelchair outside the facility on the sidewalk and the front wheel of the wheelchair slipped off the sidewalk causing the wheelchair to tip and Resident #53 to fall out of the wheelchair to the ground. Both residents stated they reported they had witnessed the fall to staff (unnamed). An interview with HA #76 on 11/15/23 at 2:52 P.M. revealed she was pushing a resident in a wheelchair following behind Resident #53 and HA #75 on 06/25/23 for the residents' smoking break. HA #76 stated she witnessed the fall and stated HA #75 was talking on her phone and was distracted when Resident #53's wheelchair went off the sidewalk and Resident #53 fell to the ground. HA #76 stated HA #75 was not paying attention and had one hand on Resident #53's wheelchair while pushing Resident #53's wheelchair to guide the wheelchair down the sidewalk when the fall occurred. An interview with the Director of Nursing on 11/15/23 at 3:00 P.M. verified the above information. The facility policy and procedure titled Fall Prevention Program revised on 10/25/23 indicated each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. The policy and compliance guidelines included: 1. The facility utilized a standardized risk assessment for determining a resident's fall risk. 2. Upon admission, the nurse would complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse would indicate the resident's fall risk and initiate interventions on the resident's care plan, in accordance with the resident's level of risk. 4. When a resident who did not have a history of falling experienced a fall, the resident would be placed on the facility's Fall Prevention Program. 5. Each resident's risk factors, and environmental hazards would be evaluated when developing the comprehensive plan of care. The deficient practice was corrected on 06/30/23 when the facility implemented the following corrective actions: On 06/26/23 all staff responsible for assisting with smoking breaks were provided education by the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #82 to ensure residents who needed assistance with mobility were kept in the middle of the pathway. On 06/26/23 the facility conducted an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the findings of the investigation. On 06/28/23 all staff and cognitively intact residents were educated regarding wheelchairs having the right of way on the sidewalk by the DON. On 06/30/23 the edges of the facility sidewalk were highlighted by the Maintenance Director to clearly identify the sidewalk edge parameters. On 06/30/23 a new smoking area was identified by Maintenance Director in the dementia courtyard for residents residing in the dementia unit. Residents residing on the secured dementia unit would start their smoking break after the non-secured nursing unit residents until the dementia smoking area was completed. All newly admitted residents who smoke will be educated on the smoking break times and residents in wheelchairs have the right of way while using the sidewalk. The DON to audit smoking breaks five times a week for four weeks of using both hands to maneuver the wheelchair while assisting residents for their smoking break, residents moving in and out of the facility using the sidewalk in single file, and the ensure the sidewalk was clearly marked. Results of the audits would be reviewed in the QAPI Committee meeting after one month with revision to the plan and changes in monitoring as deemed by the QAPI committee. On 07/06/23 and 07/13/23 the facility conducted additional ad hoc QAPI meeting and reviewed the occurrence. This deficiency represents non-compliance investigated under Complaint Number OH00147691.

Based on record review, self-reported incident (SRI) review, policy review and interview, the facility failed to ensure Residents #40 and #43 were free from physical abuse by Residents #18 and #2. This resulted in Actual Harm when Resident #43 was pushed to the ground by Resident #18 and sustained a [MEDICAL CONDITION] requiring surgical intervention during a resident to resident altercation. This affected two residents (Resident #40 and Resident #43) of six residents reviewed for abuse. The facility census was 74. Findings include: 1. Review of Resident #18's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment, and revealed Resident #18 required supervision for most activities of daily living except for dressing and hygiene which he required extensive assistance of one person. A care plan for Resident #18 revealed he exhibited physical aggression towards another resident when another resident was going through his belongings. On 08/24/19 there was an incident of resident-resident aggression due to another resident entering his room. Listed interventions included a stop sign placed on the door to deter other residents from entering (08/26/19). Review of Resident #43's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a discharge-return anticipated MDS 3.0 assessment dated [DATE] revealed Resident #43 was moderately cognitively impaired, required supervision for walking in the corridor, supervision with locomotion on the unit and required extensive assistance with toileting and eating. Review of a facility SRI dated 08/23/19 revealed a resident to resident altercation between Resident #18 and Resident #43. Resident #18 stated he had pushed Resident #43 because he wandered into his room. Facility staff found Resident #43 on the floor, assisted him to bed and conducted a skin and pain assessment. Resident #43 showed non-verbal signs of pain to his right hip and was sent to the emergency room . Resident #18 was placed on 15-minute checks and a fabric stop sign was placed on his door as an intervention. Family and physician notifications were made. The facility found the allegation of physical abuse to be unsubstantiated. Review of the facility's corresponding SRI investigation revealed an incident report written by Licensed Practical Nurse (LPN) #200. The report revealed Resident #18 notified staff on 08/23/19 at 4:20 P.M. that Resident #43 was on the ground because he had wandered into his room and Resident #18 had pushed him. Facility staff found Resident #43 on the floor and assisted him to bed. At that time a pain and skin assessment was conducted by the facility nurse. Neurological checks were completed, an x-ray was obtained and Resident #43 was sent to the emergency room due to x-ray results. A written statement with no name or date was included with the investigation. The note stated Resident #18 informed nursing staff that Resident #43 was on the floor due to Resident #18 pushing Resident #43. This nurse observed Resident #43 on the floor. The nurse assessed the resident, initiated neuro checks, and transferred the resident to bed. Notifications were made to the Director of Nursing (DON), physician and family members. A written statement dated 08/23/19 from State tested Nursing Assistant (STNA) #205 revealed she and STNA #206 were dancing with residents in the dining room as part of an activity when Resident #18 came to them and said Resident #43 was on the floor, and he had pushed him. STNA #205 and STNA #206 went to Resident #43, who seemed ok but tried to stand him up and realized he wouldn't put pressure on his right leg and complained of pain when he tried. STNA #205 and STNA #206 carried him to the nearest bed and called the nurse, LPN #203. STNA #205 and STNA #206 did not see the incident. A written statement dated 08/23/19 from STNA #206 revealed she and another aide (STNA #205) were dancing with residents as an activity when another resident (Resident #18) came to let them know Resident #43 was lying on the ground because he had pushed him. When we went to see what had happened, Resident #43 seemed fine. STNA #206 stated they tried to get him off of the floor when he realized he wouldn't put pressure on his right leg and complained of pain. We carried him over to the nearest bed and called the nurse. STNA #206 did not see the incident. Review of nurses' notes from Resident #18's medical record revealed a note dated 08/23/19 at 4:03 P.M. when Resident #18 approached nursing staff and stated Resident #43 was on the floor because I pushed him. Nursing staff immediately went to Resident #43 and performed an assessment then transferred to bed. Resident #18 was placed on one-to-one supervision and was asked why he pushed Resident #43 to which he replied, I pushed him because I was tired of him coming in my room. The nurse re-educated Resident #18 on asking nursing staff for assistance with co-residents when or if co-resident entered his room; Resident #18 declined having the door closed as an intervention. The nurse re-iterated to Resident #18 it was not appropriate behavior to engage aggressive actions towards residents or staff which the resident stated he understood. The nurses' note continued, Resident #18 did not voice or display sympathy towards the results of co-resident Resident #43 falling. A nurses' note dated 08/23/19 at 5:44 P.M. revealed Resident #18 was placed on 15-minute checks. An interdisciplinary note dated 09/06/19 revealed the team met to review the resident-resident altercation and a stop sign was placed on Resident #18's door as a result to keep other residents from entering his room. Review of nurses' notes from Resident #43's medical record revealed a noted dated 08/23/19 at 4:40 P.M. which revealed the nurse was notified of Resident #43 being on the floor due to another resident pushing him, causing him to fall. The nurse assessed Resident #43 and two staff assisted him into bed. No injuries were noted, but Resident #43 was unable to bear weight on right lower extremity during the transfer. Notifications were made and an order was received for an x-ray to the right lower extremity. Review of a nurses' note dated 08/23/19 at 9:45 P.M. revealed Resident #43's x-rays indicated a acute right intertrochanteric fracture with lesser trochanteric avulsion. Resident #43 was sent to the emergency room . Review of a hip x-ray report dated 08/23/19 revealed Resident #43 acute right intertrochanteric fracture with lesser trochanteric avulsion. Review of an Situation Background Assessment and Recommendation (SBAR) communication and progress note for Resident #43 dated 08/24/19 revealed the resident had a fall on 08/23/19 and was transferred to the hospital. Resident #43's family was notified. Review of a nurses' note dated 08/26/19 at 4:22 P.M. revealed Resident #43 returned to the facility status [REDACTED]. A phone interview was attempted with STNA #205 on 11/13/19 at 1:51 P.M. No return call was received. A phone interview was conducted on 11/13/19 at 1:56 P.M. with STNA #206. STNA #206 verified she had worked on 08/23/19 and verified her written statement. STNA #206 recalled Resident #18 had come over to her and stated Resident #43 was on the floor because he pushed him. Resident #43 had been rubbing his leg and holding his hip. STNA #206 stated she and the other aide tried to get Resident #43 in bed and got a nurse to come over. STNA #206 verified when a resident fell , residents were not to be moved until completely assessed. An interview was conducted on 11/13/19 at 2:17 P.M. with LPN #203. LPN #203 identified the unsigned and undated statement as hers and stated Resident #18 came to the nurses station to tell her Resident #43 was on the floor. When asked if the resident to resident altercation was abuse, LPN #203 stated the way she was educated it was not abuse, but because while wandering a resident did harm another resident, she had to call Resident #43's spouse to see if she wanted to press charges. LPN #203 stated Resident #43 wandered and entered Resident #18's room and he did not like that. Interview on 11/13/19 at 2:33 P.M. with the Administrator and DON revealed they did not feel the resident to resident altercation with Resident #18 and Resident #43 was abuse due to residents being on the secured unit and their cognitive status. When asked about the STNAs attempting to move Resident #43 before he was assessed by the nurse, the DON confirmed a nurse should assess a resident before they were moved. An interview was conducted on 11/13/19 at 2:39 P.M. with LPN #200. LPN #200 verified she was not present during the altercation between Resident #18 and Resident #43 but did the investigation report. LPN #200 stated Resident #18 had pushed Resident #43 because the resident was in his room. LPN #200 described the incident as an altercation, not abuse. LPN #200 stated if a resident was on the floor they were to be assessed before moved off of the floor. A follow up interview with the Administrator and DON on 11/13/19 at 2:58 P.M. revealed there were discrepancies between Resident #43's medical record and the SRI investigation. The nurses' note dated 08/23/19 at 4:40 P.M. revealed LPN #203 stated the resident was assessed prior to being moved, while the written statements from STNA #205 and STNA #206 stated they moved Resident #43 before he was assessed by a nurse. A follow-up interview was conducted on 11/13/19 at 3:18 P.M. with LPN #203. LPN #203 verified she also wrote the nurses' note dated 08/23/19 at 4:40 P.M. in which it was documented she assessed Resident #43, then he was transferred into bed. When asked about the statements written by STNA #205 and STNA #206 which indicated Resident #43 had been moved into bed before assessed by a nurse, LPN #203 verified STNA #205 and STNA #206 had attempted to transfer the resident before she could assess him. A follow-up interview with the Administrator and the DON on 11/13/19 at 3:46 P.M. regarding the inconsistencies in the STNA's written statements and Resident #43's medical record revealed the DON took the nurses' note at face value as the nurse was more qualified, and she had assumed what was written was how the events played out. Review of the facility policy, Accidents and Incidents- Investigating and Reporting revised 12/01/17 revealed staff were not to move the victim until he/she had been examined for possible injuries. Review of the facility policy, Abuse Prevention Program revised 02/22/18 defined abuse at the willful infliction of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition cause physical harm, pain or mental anguish. Upon reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident and findings of the examination must be recorded in the medical record. The policy did not address how to investigate or prevent resident to resident incidents. 2. Review of Resident #2's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A quarterly MDS 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact, and no behaviors were noted. A care plan revised 08/19/19 revealed Resident #2 had potential to be physically aggressive or agitated due to [MEDICAL CONDITION], and indicated the resident had a resident to resident altercation with another resident on 08/16/19. An intervention dated 08/16/19 revealed the resident was to be moved to a different hallway. Review of Resident #40's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A quarterly MDS 3.0 assessment dated [DATE] revealed Resident #40 was cognitively intact, and no behaviors were coded. Review of a care plan revised 04/26/19 revealed the resident made accusations about staff during personal care. A care plan revised 04/26/19 revealed Resident #40 had attention seeking behaviors due to personality disorder including being accusatory towards staff with money; a lock box had been offered and declined. Review of a facility SRI dated 08/16/19 revealed an allegation of physical abuse between Resident #2 and Resident #40. Resident #40 stated Resident #2 had struck her. Review of the corresponding internal investigation revealed Resident #40 stated Resident #2 had punched her in the stomach yesterday (08/15/19) and in the face today (08/16/19); her left eye was noted to be red. Resident #40 requested to have the police notified. Resident #2 stated a female resident (Resident #40) had stolen money from him and he hit her in the stomach yesterday (08/15/19) and hit her in the face today (08/16/19). Resident #2 stated the money was stolen a month ago. The investigation results stated Resident #2 admitted to hitting Resident #40 in the stomach and punching her in the face. The facility found the allegation of abuse to be unsubstantiated. A witness statement dated 08/16/19 written by the DON revealed Resident #40 reported to the DON and the Administrator Resident #2 had punched her in the stomach yesterday (08/15/19) in the hallway in the face and today (08/16/19) in the hallway. A witness statement dated 08/16/19 written by the DON on behalf of Resident #2 revealed he was questioned regarding Resident #40's allegation. Resident #2 admitted to punching Resident #40 in the stomach yesterday (08/15/19) evening and in the face today (08/16/19), and stated he hit Resident #40 because he felt she took money from him last month. Review of a police report dated 08/28/19 revealed police came to the facility due to a reported assault between Resident #2 and Resident #40. Resident #2 stated he struck Resident #40 in the face because she took his money. A statement was collected from Resident #40. There were no witnesses to the incident. Review of Resident #2's medical record revealed a nurses' note dated 08/16/19 indicating Resident #2 admitted to hitting another resident in the stomach last evening (08/15/19) and in the face today (08/16/19). Resident #2 stated he hit her because he thought she took ten dollars from him over a month ago. Resident #2 was placed on one to one care, labs were completed, and notifications were made. A behavior progress note dated 08/19/19 revealed a resident reported to staff Resident #2 was physically aggressive towards her, and Resident #2 admitted this to be true. Review of Resident #40's medical record revealed a nurses' note dated 08/16/19 at 5:15 P.M. where Resident #40 reported to staff on 08/16/19 at 3:45 P.M. that another resident punched her in the stomach yesterday (08/15/19) and in the face today (08/16/19). Skin and neurological checks were completed, and the required notifications were made. The police were contacted and made a report of Resident #40's allegation. An interview was conducted on 11/13/19 at 6:17 P.M. with the DON and the Administrator. The facility did not substantiate the allegation of abuse due to the cognitive defects of Resident #2 and Resident #40. When asked how an incident involving two residents with BIMS scores of 15 (indicative of being cognitively intact) would not constitute abuse, the Administrator stated the surveyor needed to interview both Resident #2 and Resident #40 to see why the facility did not substantiate the allegation. An interview was conducted with Resident #40 on 11/13/19 at 6:29 P.M. and 6:39 P.M. with the Administrator and DON present. Resident #40 was seated in her wheelchair and noted to be dressed appropriately. Resident #40 was questioned regarding the resident-to-resident altercation on 08/16/19 and verified Resident had #2 hit her because he felt she took ten dollars from him. An interview was conducted with Resident #2 on 11/13/19 at 6:35 P.M. with the Administrator and the DON present. Resident #2 ambulated into the room and sat down in a chair; the resident was noted to be dressed appropriately. Resident #2 was questioned regarding the resident-to-resident altercation on 08/16/19 and, smiling, verified he had hit Resident #40 in the head because she got ten dollars off of me. Resident #2 stated he had a different room with no roommate since the incident. Review of the facility policy, Abuse Prevention Program revised 02/22/18 defined abuse at the willful infliction of injury with resulting physical harm, pain or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition cause physical harm, pain or mental anguish. The policy did not address how to investigate or prevent resident to resident incidents.

Based on observations, record review and interviews, the facility failed to identify a right heel pressure ulcer for Resident #73 until it progressed to unstageable. The facility also failed to ensure effective pressure reduction measures and new wound treatments were implemented after discovery of the wound. This resulted in harm when Resident #73's right heel unstageable pressure ulcer increased in size and a left heel stage one pressure ulcer deteriorated to unstageable. This affected one of three residents reviewed for pressure ulcers. Findings include: Resident #73 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. physician's orders [REDACTED].#73 had a pressure reduction mattress to his bed and a pressure reduction cushion to his wheelchair. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed a brief interview of mental status was not conducted and the staff deemed Resident #73 with modified independence for cognition. The MDS assessment indicated Resident #73 required extensive assistance for bed mobility for all activities of daily living, except for eating. The assessment revealed Resident #73 was at risk for the development of pressure ulcers. The assessment did not identify facility acquired right and left heel pressure ulcers. Review of a progress note dated 04/12/17 and signed by Certified Nurse Practitioner (CNP) #53, revealed Resident #73's chief complaint for the visit was foot wounds. The progress note revealed Resident #73 had mild pain to both feet and revealed bilateral, unstageable foot wounds. CNP #53 wrote that Resident #73's right medial heel and left heel had approximately two inch wounds, with skin intact and no [DIAGNOSES REDACTED] or warmth. The CNP's plan was for heel protectors to both feet. An addendum was added to the note dated 05/09/17 to correct the approximate measurements. CNP #53 noted that the right medial heel wound was approximately 2.0 centimeters (cm). A physician's orders [REDACTED]. A physician's orders [REDACTED].#73 every two hours. Review of the Nursing Evaluation Data V-6 dated 04/13/17 revealed Resident #73 had a right heel pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissues) that measured 2.0 cm by 2.75 cm with no depth. The wound was staged as unstageable, however no description of the wound bed was included in the assessment. A wound is rendered unstageable when the wound bed is covered with slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist or stringy) or eschar (thick, leathery, frequently black or brown in color, dead or devitalized tissue that has lost its usual properties and biological activity). The Nursing Evaluation Data V-6 dated 04/13/17 also indicated Resident #73 had a Stage One (an observable, pressure-related alteration of intact skin, whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined persistent redness) left heel pressure ulcer that measured 1.0 cm by 1.0 cm with no depth. There was no description of the wound included in the assessment. Resident #73 had no care plan in place related to pressure ulcers. An impairment to bilateral lower extremity care plan, related to [DIAGNOSES REDACTED]. There were no pressure reduction interventions included in the plan of care until 04/13/17, post discovery of the heel wounds. The new interventions were for bilateral lower extremity dressings per treatment plan daily and as needed and to float Resident #73's heels, at all times, while in bed. Wound documentation dated 04/19/17 indicated Resident #73's right heel pressure wound was unstageable, with no odor or exudate. The printed assessment included printed zeros which were crossed out and measurements of 2 x 2.75 x 0, were hand written. Wound documentation dated 04/19/17 indicated Resident #73's left heel wound had progressed to Stage Two (a partial thickness skin loss presenting as a shallow open ulcer with a red/pink wound bed). The wound was measured at 1.0 cm by 1.0 cm with no depth measurement documented. The note revealed serous (clear, thin and watery) exudate with [MEDICATION NAME] tissue on the wound bed. The wound treatment remained the same. Wound documentation dated 04/26/17 revealed Resident #73's unstageable right heel pressure wound had increased in size to 2.0 cm by 4.0 cm. The wound bed was described as necrotic (dead). Wound documentation dated 04/26/17 revealed Resident #73's Stage Two left heel pressure wound increased in size to 2.0 cm by 3.0 cm with no depth documented. The assessment indicated serous drainage and granulation (new) tissue as the wound bed. No treatment changes were made. Wound documentation dated 05/02/17 indicated Resident #73's right heel unstageable pressure ulcer measured 2.0 cm by 3.8 cm with a necrotic wound bed. Wound documentation dated 05/02/17 indicated Resident #73's left heel Stage Two pressure ulcer measured 2.0 cm by 3.0 cm with no depth measurement. The assessment documented serous exudate with [MEDICATION NAME] tissue to the wound bed. No changes in treatments were made. During observation of wound care on 05/08/17 beginning at 3:15 P.M., Registered Nurses (RN) #57 and RN #58 provided wound care for Resident #73's heel wounds. The dressings had been removed prior to the observation. RN #58 cleaned Resident #73's right heel and revealed a large black necrotic unstageable pressure ulcer. RN #58 applied the wound treatment, per order. When the left heel was raised, an area of yellow slough with a pinpoint area of black in the center, was noted within the red open area. RN #57 measured the unstageable area of the wound at 0.75 cm by 1.0 cm and verified the unstageable area was new. RN #58 cleaned the wound and applied skin prep over the entire wound. Resident #73 yelled loudly when the skin prep was applied to the open wound. During an interview on 05/08/17 at 4:42 P.M., RN #57 verified Resident #73's right heel pressure ulcer was not discovered until 04/12/17, when it was an unstageable wound. RN #57 verified a stage one left heel pressure ulcer was also found on that date. RN #57 acknowledged wound documentation from 04/13/17 indicated Resident #73's right heel wound was unstageable, but included no description of the wound bed. RN #57 recalled the wound bed presented as black, necrotic tissue on that date. RN # 57 confirmed the wound documentation from 04/19/17 included no measurements of Resident #73's right heel wound and the copy of the documentation provided had hand written measurements crossed over the zeros. RN #57 reported she was using a new computer system for documentation, and accidentally zeroed out the measurements. RN #57 indicated that she recalled the wound measured 2.0 cm by 2.75 cm on that date, and explained she had an excellent memory and remembered the measurements of all of her wounds. On 05/09/17 at 7:07 A.M., Resident #73 was observed lying in his bed with heel protectors in place to both feet. However, his heels were not floated and were in direct contact with the surface of the mattress. At 7:35 A.M., the Director of Nursing (DON) and RN #57 verified Resident #73's heels were not floated and were resting on the mattress. RN #57 explained it was difficult to keep Resident #73's heels floated and the situation had to be monitored frequently by staff. RN #57 acknowledged no new intervention to off load pressure to the heels had been attempted such as use of Prevalon (heel protection boots that deliver continuous heel pressure relief) type boots and a low air loss mattress, even though the facility had identified the difficulty of keeping Resident #73's heel floated off the mattress. During an observation of wound care at 1:41 P.M. on 05/09/17, RN #57 was assisted by the DON during the weekly skin assessment/measurement of Resident #73's wounds. Resident #73's right heel unstageable pressure ulcer had increased in size measuring 4.5 cm by 2.2 cm, with black eschar covering the wound bed. Resident #73's left heel wound was measured with a 0.75 cm by 0.4 cm unstageable area with yellow slough and a dark black center. Surrounding the unstageable portion of the wound, was a deep red open area that measured 3.0 cm. by 3.0 cm by less than 0.1 cm deep, which had increased in size since the previous week. During an interview on 05/09/17 at 2:48 P.M., the DON and RN #57 revealed the right and left pressure ulcers were discovered by Resident #73's insurance company nurse practitioner (NP) when she visited the facility on 04/12/17. However, there was no documentation available from the insurance company's NP. The nurses verified the ordered wound treatment for [REDACTED]. The DON acknowledged the same wound treatment remained in place and had not been changed, despite both wounds progressive deterioration. The DON verified skin prep was not meant to be applied to open wounds. This deficiency substantiates Complaint Number OH 090.

Based on observation, record review and interview the facility failed to ensure Resident #87 was free from physical abuse. Harm occurred when Resident #87 was physically held down by two State tested nursing assistants (STNAs) after the resident refused to allow care to be provided resulted in bruising to her bilateral arm/wrist areas. This affected one resident (Resident #87) of three residents reviewed for incidents involving abuse, misappropriation and injury of unknown origin. Findings Include: This deficiency is based on past non-compliance. Record review revealed Resident #87 was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/08/16 revealed the resident was alert and oriented with a Brief Interview for Mental Status score of 15 (cognitively intact). The resident required assistance from staff for activities of daily living including bed mobility, toileting and transfers per the assessment and current plan of care. The assessment also revealed the resident had a history of [REDACTED]. Review of a self reported incident submitted on 08/14/16 revealed Resident #87 told a day shift State tested Nursing Assistant (STNA) that she was abused on the previous night shift by two STNAs. The resident stated on the early morning of 08/14/16, two STNAs entered her room to check and change her. She stated she told the STNAs that she did not need to be changed but they proceeded to change her anyway. She further stated she then started screaming, kicking, and hitting the STNAs. The male STNA, STNA #11 held down her wrists and the female STNA, STNA #10 held her legs and they proceeded to change her. Further investigation revealed the resident sustained [REDACTED]. She also had a round circular bruise on the outside of her left hand. Review of the facility investigation revealed a written statement, obtained from STNA #11 verified the STNAs were changing the resident while she did not want to be changed. STNA #10, who assisted in changing this resident stated in her statement that the resident was kicking and screaming and calling them names. On 08/22/16 at 9:15 A.M. during an interview with Resident #87 the resident discussed the incident that had occurred on 08/14/16 during the early morning hours which was consistent with the above facility investigation. Observation of the resident's left arm revealed bruising was noted. When asked about the bruise on her left palm she stated that it was from the male STNA. This bruise was observed to be more a purplish yellow in color at this time. A bruise on her right wrist was also a darkish purple on the inner aspect of the right arm and appeared to be healing. The resident indicated neither of the STNAs involved had been back to provide care to her since the incident and she currently felt safe in the facility. The resident also denied she was currently having any pain to the areas that were bruised. Interview with the Director of Nursing (DON) on 08/22/16 at 11:15 A.M. verified the facility substantiated an allegation of abuse involving Resident #87 when the resident was held down and provided care against her will. The resident sustained [REDACTED]. As a result of the investigation, both STNAs were terminated. This deficiency substantiates Complaint Number OH 357.

Based on staff interview, record review and policy and procedure review, the facility failed to provide restorative services to maintain or improve bladder continence. Harm occurred to Resident #29 when the resident declined from continent of bladder function to frequently incontinent and no restorative program was initiated. This affected one of three residents reviewed for urinary incontinence. The facility census was 95. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ssessment ((MDS) dated [DATE] indicated the resident was independent with daily decision making and had no behavioral symptoms. Resident #29 was identified as always continent of bladder. The MDS 3.0 dated 11/02/15 indicated the resident was occasionally incontinent of bladder identifying a decline in urinary continence. The MDS 3.0 dated 12/07/15 indicated the resident was now frequently incontinent of bladder identifying a further decline in urinary continence. None of the assessments identified any bladder programs. Review of the bladder reports capturing bladder activity since Resident #29's admission on 08/02/15 revealed she was continent of bladder through 08/31/15. She was documented to have an incontinence episode on 09/01/15 and 10/16/15. At that time the documentation showed a decline in continence with another four episodes in October 2015. In November 2015 she had 28 episodes of bladder incontinence and had 14 episode so far for December 2015. Review of the plan of care revealed no evidence of a plan related to bladder function. Review of the nurse aide care plan dated October 2015 indicated she was independent and continent of bladder. Interview with Resident #29 on 12/15/15 at 9:38 A.M. indicated she was independent with activities of daily living. Interview with Licensed Practical Nurse (LPN) #21 on 12/15/15 at 2:53 P.M. indicated she was only aware that Resident #29 had been incontinent one time. Interview with State tested Nurse Aide (STNA) #22 on 12/15/15 at 3:03 P.M. indicated Resident #29 would ring her call bell at night to have her incontinent brief changed. She indicated the brief would be wet. STNA #22 indicated Resident #29 had the awareness to go to the bathroom and verified Resident #29 was mostly independent with her care. Interview with the director of nursing on 12/17/15 at 8:10 A.M. verified the facility lacked any initial bladder assessment and no subsequent bladder assessment when Resident #29 was identified to have a decline in bladder function. Interview with STNA #23 on 12/17/15 at 10:00 A.M. indicated Resident #29 had occasional urinary incontinence. She stated she cued her upon waking in the morning, around lunch time and prior to going off shift but the resident still had occasional accidents. Review of the revised restorative nursing program policy and procedure dated September 2014 indicated the goal of the program was to maintain independence in activities of daily living and mobility which was critically important to most people. Further, a functional decline could lead to depression, withdrawal, social isolation and complications of immobility such as incontinence and pressure ulcers. Based on the assessment and goals a program could enable a resident to attain or maintain their highest practicable level of physical, mental and psychosocial function increase independence, foster self-esteem and promote a positive quality of life. A referral to restorative services would be warranted for bladder retraining or management to maintain or prevent decline in bladder function.

Based on observation, interview and record review, the facility failed to ensure interventions recommended by the registered dietitian were implemented to address the significant weight loss of Resident #53. Harm resulted when the resident sustained [REDACTED]. The facility also failed to address fluctuating weight changes for Resident #1. This affected two of three residents reviewed for nutrition. The facility census was 119 residents. Findings include: 1. Review of the record revealed that Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nutritional care plan dated 04/29/13, and updated through 07/29/13, revealed the resident was at risk for weight loss and weights would be monitored. Review of the nutrition admission assessment dated [DATE] revealed the resident weighed 127 pounds on admission and her usual body weight was 130 pounds. The resident was on a Regular diet with a snack in the evening. A nutritional supplement was ordered on [DATE] to be given once a day. Review of the record revealed that the resident weighed 118 pounds on 05/14/13. A nutrition note dated 05/17/13 verified the weight loss of 7.1%. The note revealed a recommendation to increase the nutritional supplement to three times a day and start the resident on [MEDICATION NAME], an anti-depressant medication that can increase appetite. Review of the record revealed the nutritional supplement was not increased to three times a day until an order was written on 05/30/13 and the [MEDICATION NAME] was not ordered until 06/06/13, when the resident was found to weigh 112 pounds. Review of the nutrition note dated 06/07/13 revealed the resident weighed 112 pounds, which was an 11.81% (significant) weight loss in 30 days. The note indicated the resident was agreeable to increasing her supplement to four times a day. On 06/26/13, review of the treatment record for June 2013 revealed the resident was still receiving the supplement only three times a day. The resident had not been weighed since 06/07/13 when her weight was recorded as 112 pounds. The resident was observed in her room on 06/27/13 at 8:45 A.M. Her breakfast tray was on her bedside table, but the resident stated she was not hungry. She had eaten about half of a pancake. She was also observed in her room in bed around 11:45 A.M. on 06/27/13, with her lunch untouched on her bedside table. She was holding an emesis basin and stated that she did not feel hungry. Interview with the dietitian on 06/27/13 at 8:30 A.M. verified that the resident had continued to lose weight since her admission to the facility. She verified that despite a recommendation in her nutrition note, dated 05/17/13, to an increase in the supplement and to begin an appetite stimulant medication on that date, orders were not written until 05/30/13 for the increase in supplements, and 06/06/13 for the medication. The dietitian also verified that the nutrition note dated 06/07/13 recommended another increase in the supplements, which had not been implemented as of 06/27/13. She further verified the resident had not been weighed since 06/07/13. The resident's weight was then obtained on 06/27/13, which was 111 pounds. The dietitian verified that recommended interventions had not been put in place and that the resident's weight continued to decline. 2. Review of the record revealed Resident #1 was originally admitted to the facility in 2004, and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's nutritional care plan, originally dated 08/10/12 and updated through 08/31/13, revealed interventions including a Regular diet with large portions, and to monitor the resident's weights. On 12/01/12 the resident had a documented weight of 299 pounds. A re-weigh of 249 pounds was obtained on 12/03/12. On 12/07/12 a weight of 290 pounds was obtained. There was no documentation of the resident being re-weighed. A weight of 247 pounds was obtained on 01/10/13. The record did not contain any documented evidence that the dietitian or the physician were notified of the resident's weight changes. An interview was conducted with the dietitian on 06/27/13 at 10:20 A.M. The dietitian verified that Resident #1 had large weight fluctuations. She further verified that reweighs were not consistently obtained after a significant weight loss or gain was found with this resident, and that the resident's significant weight changes were not promptly addressed in the record.