Every finding on record at Aristocrat Berea Healthcare and Rehabilitation

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observations, interviews, open and closed medical record review, review of a local police report, review of the facility's investigations, and facility policy review, the facility failed to provide adequate supervision to prevent the elopements of two residents (Resident #44 and Resident #140) without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death when on 05/18/26 at approximately 3:00 P.M., Resident #140, who was moderately cognitively impaired, with diagnoses including borderline intellectual functioning and psychosis, exited the facility's outdoor area during a supervised activity without staff knowledge. Resident #140's whereabouts were unknown to facility staff until the morning of 05/21/26, at which time he was located at a gas station 9.2 miles away from the facility. On 05/21/26, Resident #140 was arrested by the police for a previous outstanding warrant and taken to jail. Furthermore, the Immediate Jeopardy remained ongoing on 07/19/26 at approximately 7:20 A.M. when Resident #44, who was moderately cognitively impaired, with diagnoses including dementia, and traumatic brain injury, and a history of pacing and verbalizing wanting to go home, independently accessed and rode the elevator from the second to the first floor. Resident #44 then followed another resident out the facility's front door without staff knowledge. Upon exiting the facility, Resident #44 proceeded to walk along a busy, four-lane roadway through the center of the municipality in which the facility was located. Resident #44's whereabouts were unknown by staff until he was later located at a local restaurant approximately 1.7 miles from the facility. Resident #44 had attempted to enter the restaurant, fell in the parking lot, and was transported to a local emergency department for evaluation and treatment prior to his return to the facility. This affected two residents (#44 and #140) of three residents reviewed for elopement. The facility identified twelve current residents who were identified as at risk for elopement. The facility census was 135.On 08/10/26 at 12:28 P.M., the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO) #659, and Chief Nursing Officer (CNO) #652 were notified Immediate Jeopardy began on 05/18/26 at 3:00 P.M. when Resident #140 exited the facility through an unsecured courtyard gate while attending an outdoor activity with contracted counselors without staff knowledge. Resident #140's whereabouts were unknown until he was located on 05/21/26 at a gas station 9.2 miles from the facility and was arrested by the police for a previous outstanding warrant. Additionally, the facility was notified that a second situation of Immediate Jeopardy existed on 07/19/26, when Resident #44 was able to exit the facility without staff knowledge and traveled 1.7 miles along a busy roadway to a local restaurant where he fell in the parking lot requiring evaluation and treatment at a local emergency department. The Immediate Jeopardy was removed on 07/19/26 at which time the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on 07/27/26 after the facility implemented the following corrective actions:On 05/18/26 at 3:00 P.M., Contracted Counselor (CC) #657 notified Licensed Independent Social Worker (LISW) #639 that Resident #140, a moderately cognitively impaired resident who was independently ambulatory, could not be located during an outdoor gardening activity in the outside courtyard. LISW #639 notified the DON and Unit Manager (UM) #640. All staff on duty were alerted and the search for Resident #140 began. Resident #140 was located on 05/21/26 at a gas station approximately 9.2 miles from the facility and did not return to the facility. On 05/18/26 at 3:05 P.M., nursing staff on duty completed head-to-toe assessments on all 135 current residents. All other residents, except Resident #140, were accounted for.On 05/18/26 at 4:10 P.M., the DON initiated education with all staff on the facility's missing resident and elopement policy. This education included signs of an elopement, what staff are to do when there are signs of an elopement, and that a magnetic alarm would be installed to secure the outside courtyard gate. On 05/18/26 at 4:15 P.M., Maintenance Director #582 checked the outside courtyard gate and temporarily secured the gate with a lock and key until a magnetic alarm could be installed.On 05/18/26 at 4:15 P.M., the DON implemented 1:1 supervision of residents taken outside into the courtyard by staff until the magnetic alarm was installed.On 05/18/26 at 5:00 P.M., the DON and Regional Clinical Support (RCS) #654 completed elopement assessments on all current residents. The assessments were completed on 05/19/26 at 1:20 P.M. Nine residents (#15, #17, #18, #39, #49, #84, #90, #103, and #145) were identified to be at risk for elopement, and their care plans were reviewed and revised as needed. On 05/19/26, Maintenance Director #582 ordered a magnetic lock to secure the courtyard gate. On 05/19/26 at 11:00 A.M., CNO #652 verified the facility's elopement book was current and up to date. The elopement book was housed at the facility's front desk and contained information sheets, demographics, and a photograph for residents identified with an elopement risk score of four or greater were contained in the book. There were no concerns identified. On 05/19/26 at 12:10 P.M. Chief Operations Officer (COO) #750 and RDO #659 informed the Contracted counseling company's Chief Executive Officer and relayed education topics regarding the facility's Missing Resident/Elopement policy and procedures which needed to be provided to Contracted Counselors #657 and #658 who see facility residents.On 05/19/26 at 1:00 P.M., the DON confirmed proper placement and functioning of wanderguards (a small, wearable device worn by residents at risk for elopement which will cause an exit door to lock and alarm when a resident approaches an unauthorized exit) for all nine current residents (#15, #17, #18, #39, #49, #84, #90, #103, and #145) identified to have orders for wanderguards. There were no negative findings.On 05/19/26 at 1:30 P.M., a root cause analysis (RCA) was completed by the Administrator, DON, RCS #654, and RDO #659. The root cause of Resident #140's elopement was attributed to an unsecured gate in the facility's outside courtyard during a supervised counseling activity with contracted counseling staff.On 05/19/26 at 3:14 P.M., Maintenance Staff #598 checked all facility doors to the outside and secured all doors. All doors were functioning properly with no negative findings. On 05/19/26 at 3:30 P.M., the DON and Maintenance Director #582 completed an elopement drill with all staff present in the facility. The elopement drill encompassed a mock missing resident situation to ensure all staff responded appropriately. There were no concerns or negative findings identified during the drill.On 05/19/26 at 5:00 P.M., the DON completed education with all staff. The education consisted of the Missing Resident/Elopement policy, signs of an elopement, what to do when there are signs of an elopement, elopement prevention, and that a magnetic alarm would be applied to secure the outside courtyard gate. Education was completed with 33 Licensed Practical Nurses (LPN), 11 Registered Nurses (RN), 67 Certified Nursing Assistants (CNA), Human Resources (HR) Manager #549, 14 dietary staff members, 13 housekeeping and laundry staff members, three maintenance staff members, three receptionists, five activity staff members, two social services staff members, two medical record and central supply staff members, five therapy staff members, admission Director #665, Scheduler #626, and Driver #553. On 05/20/26 at 6:00 A.M., the DON completed another elopement drill with night shift staff present. The elopement drill encompassed a mock missing resident situation to ensure all staff responded appropriately. There were no concerns identified during the drill. On 05/21/26, Contracted Counselors #657 and #658 were educated by Contracted counseling company Clinical Director #725 regarding elopement risks and response procedures in nursing facilities, common elopement risk factors, prevention expectations for staff, current temporary safety measures being implemented, the facility's policy and procedure and process for a resident elopement.Beginning on 05/21/26, ongoing audits were initiated to ensure the magnetic alarm was in place to secure the outside courtyard gate. The audit was to be completed five times per week for a duration of four weeks with the results of the audits forwarded to the Quality Assurance Performance Improvement (QAPI) committee for review and recommendations where indicated.On 07/19/26 at 7:30 A.M., LPN #561 attempted to locate Resident #44 for morning medication administration. Resident #44 was unable to be located. LPN #561 initiated a head count and all other facility residents, except Resident #44, were accounted for.On 07/19/26 at 7:45 A.M., LPN #561 was provided verbal education on how to identify a resident at risk for elopement by the DON. On 07/19/26 at 8:00 A.M, the Administrator and DON began educating all staff on the facility's Missing Resident/Elopement policy, signs of wandering, and what to do when signs of wandering are present. On 07/19/26 at 8:15 A.M., an elopement code was initiated and all facility staff assisted in attempting to locate Resident #44. Facility staff searched inside and outside the facility and surrounding areas on foot and in personal vehicles around the vicinity of the facility.On 07/19/26 at 9:05 A.M., Resident #44 was confirmed to be in the emergency department of a local hospital. On 07/19/26 at 9:20 A.M., the DON completed elopement assessments on all current residents and updated care plans as needed. The facility identified 11 residents at risk for elopement (Residents #44, #15, #17, #33, #36, #39, #49, #72, #84, #90, and #103).On 07/19/26 at 9:30 A.M., RCA was completed by the Administrator, DON, RCS #654, and RDO #659. The root cause of Resident #44's elopement was identified to be related to LPN #561 not redirecting Resident #44 after observing him entering the facility's elevator after he had made statements stating he was going home while entering the facility elevator. On 07/19/26 at 9:30 A.M., an ad hoc QAPI meeting was held with the Administrator, DON, Assistant Director of Nursing (ADON) / Infection Preventionist (IP) #669, Dietitian #661, Life Enrichment Director #596, Environmental Services Director #510, Maintenance Director #582, Medical Record Staff #661, HR Manager #549, RCS #649, and Scheduler #626. During the meeting the interdisciplinary team (IDT) reviewed the facility's elopement policy and procedures with the Medical Director, including the missing resident policy and signs of wandering behavior handout. The circumstances surrounding Resident #44's elopement and corrective actions were discussed.On 07/19/26 at 10:00 A.M., the DON updated the elopement book and verified all 11 residents (#44, #15, #17, #33, #36, #39, #49, #72, #84, #90, #103) who were identified to have an elopement score greater than four had the appropriate information sheet and photograph contained in the elopement book. On 07/19/26 at 10:30 A.M., the DON checked all six current residents with wanderguards for proper placement and functioning with no negative findings. The six residents with wanderguards were identified to be Residents #15, #17, #49, #84, #90, and #103. On 07/19/26 at 11:00 A.M., The Administrator, DON, and Maintenance Director #582 completed an elopement drill encompassing a mock missing resident. All staff on duty including four RNs, four LPNs, and eight CNAs were in attendance. There were no concerns identified with the drill. On 07/19/26 at 1:00 P.M., Resident #44 returned to the facility from the local hospital. Upon his return, the DON completed an elopement assessment with a score of four indicating Resident #44 was at risk for elopement. Resident #44 was placed on the secured unit. The DON updated Resident #44's care plan to reflect his elopement risk, and interventions including his placement on the secured unit. On 07/19/26 at 6:30 P.M., the Administrator and DON completed education with all staff regarding the missing resident policy, signs of wandering, and what to do when residents are exhibiting signs of an increased risk for elopement. This included recognition of signs of increased risk for elopement and when to place interventions or precautions in place. All staff interviewed included 31 LPNs, 13 RNs, 67 CNAs, 15 Housekeeping and laundry staff members, 13 dietary staff members, five therapy staff members, two maintenance staff members, two central supply staff members, Medical Record Staff #611, two social service staff members, Driver #553, and HR Manager #549. On 07/19/26 at 7:30 P.M., the Administrator and Maintenance Director #582 completed an elopement drill with night shift staff present. The elopement drill encompassed a missing resident situation to ensure all staff responded appropriately. Night shift staff present at the drill included two RNs, four LPNs, and six CNAs. All staff responded appropriately and no concerns were identified with the drill.Beginning on 07/19/26, any newly hired staff, including contracted staff, will receive education on the facility's missing person policy and procedures prior to working in the facility. This process would be coordinated by the Administrator or designee. On 07/21/26 at 1:00 P.M., Maintenance Director #582 changed the code to the front door. Moving forward, the front door code would be periodically changed at random intervals and as needed. Beginning on 07/21/26, ongoing audits will be completed by the DON or designee by interviewing four to six random staff members to ensure staff understanding of the missing person policy. The interviews will include employees from a combination of various departments and shifts. Staff will be able to identify signs of wandering behavior, can identify appropriate interventions for signs of wandering behavior, immediately respond to door alarms, and report concerns to the nurse, supervisor, and/or DON. The audit will be completed three times weekly for four weeks with the results of the audits forwarded to the QAPI committee for recommendations where indicated.Beginning after the completion of routine scheduled audits, ongoing competency and audits will be monitored by routine monthly staff meetings and elopement drills held /on a monthly basis. This process will be overseen by the Administrator and DON and will be completed at least monthly and as needed. If concerns are identified with ongoing competency or audits, immediate re-education and follow-up competency validation will be provided by the Administrator, DON, or designee. Findings include: 1. Review of Resident #140's closed medical record revealed an admission date of 05/02/26 with medical diagnoses including schizoaffective disorder bipolar type, cannabis use, other stimulant use, psychoactive substance abuse, brief psychotic disorder, depression, and borderline intellectual functioning. Resident #140 discharged from the facility on 05/18/26. Review of a Brief Interview for Mental Status (BIMS) evaluation dated 02/25/26 at 3:08 P.M. revealed Resident #140's score was 11 which indicated the resident had a moderate cognitive impairment. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #140 was moderately cognitively impaired and required supervision for all activities of daily living except eating for which he required set-up assistance. Resident #140 was noted to experience hallucinations and delusions. Resident #140 was on routine antipsychotic medications. Review of the care plan dated 05/29/25 revealed Resident #140 was a long-term resident of the facility. Resident #140 and his family member had determined long-term placement in the facility was in the best interest of Resident #140 as community resources were unable to meet his needs. The care plan focus indicated Resident #140 would not stay put in a group home and Resident #140 ends up consistently homeless and doing illicit street drugs. Listed interventions included staff would assist the resident and family with adjustment in the facility, provide support as needed, and would be aware of significant changes that could result in the need to reassess whether discharge to the community was appropriate. An additional care plan focus dated 05/29/25 revealed Resident #140 required supervision when on a leave of absence (LOA) from the facility related to safety and/or health concerns. Listed interventions included reminding the resident of the sign out book, validating the person who is supervising during LOA, and validating/obtaining a physician order for the LOA. An additional care plan focus dated 05/29/25 revealed Resident #140 demonstrated cognitive impairment due to impaired decision making, poor logic, and poor ability to understand cause and effect. A listed intervention included to simply remind Resident #140 that he was safe and secure in a protected environment. Additionally, Resident #140's care plan indicated he displayed behavior symptoms related substance abuse and severe mental illness, including delusions, hallucinations, anxiousness/restlessness, pacing, wandering, and refusing ordered foot soaks and lotions. Listed interventions were to give psychoactive medications as ordered, record behavioral symptoms, and to remind the resident he was safe and secure in the facility environment. Review of an elopement evaluation dated 05/08/26 at 1:18 P.M. revealed Resident #140 wandered aimlessly or non-goal-oriented. The resident scored a two (2) on the assessment which categorized the resident as at risk for elopement. Review of the counseling and recovery group sign-in sheet for the gardening activity held on 05/18/26 revealed Resident #140 and 15 additional residents attended the activity supervised by Contracted Counselors (CC) #657 and #658. Review of a general note dated 05/18/26 at 5:13 P.M. authored by the DON revealed she and Unit Manager #566 were notified by Licensed Independent Social Worker (LISW) #639 that Resident #140 could not be located after attending an outdoor gardening activity with Counselors #657 and #658 in the enclosed patio. An immediate search pursued, staff were alerted and started searching on foot and via personal vehicles and the surrounding area. The local police department was notified and Resident #140's information was provided. A be on the lookout ([NAME]) alert was initiated. The Rapid Transit Authority (RTA) police were also notified. Resident #140's family was notified and asked if they had signed Resident #140 out of the facility but she had not. The note concluded by indicating the search for Resident #140 was ongoing. Review of a local police report dated 05/18/26 revealed at approximately 3:29 P.M., the police were dispatched to the facility for a missing person report. Prior to arrival, dispatch advised that the missing person was Resident #140. Upon arrival, the police officer spoke with LISW #639 who stated Resident #140 was outside participating in a group activity with a contracted counseling and recovery entity. Resident #140 was to be brought back inside by Contracted Counselors #657 and #658 but somehow disappeared during the activity. LISW #639 stated this occurred around 3:10 P.M. Staff checked the interior of the building and did not locate Resident #140. The officer asked LISW #639 if Resident #140 was a danger to himself outside alone, to which he replied yes, due to the resident's intellectual disability. Resident #140 also had numerous medical conditions and was missing two fingers on his right hand. Resident #140 had no cellular telephone or means of communication. Prior to leaving the facility, the officer spoke with both counselors who stated Resident #140 was hanging around and advised him to come back inside after the activity. The two counselors assumed he returned inside but was later determined he did not. The officer had dispatch send out a [NAME] alert to surrounding cities regarding the missing person. Officers assisted with checking the area but were unable to locate Resident #140. Review of a general note dated 05/21/26 at 9:55 A.M. by the DON revealed she spoke with Resident #140's family to inform her Resident #140 had been arrested after being found standing outside of a gas station (Resident was arrested for a prior-to-admission unrelated issue). The DON informed Resident #140's family that he was transported to the county jail and booked by the sheriff's department. Resident #140's family was informed she could pick up his personal belongings. Review of a written statement dated 05/18/26 authored by Contracted Counselor (CC) #657 revealed CC #657 and CC #658 facilitated a group activity in the courtyard. Some clients wanted to return inside, and CC #658 assisted the clients back inside. When she returned outside, CC #657 assisted another group inside while CC #658 stayed outside with the remainder of the clients. When CC #657 returned to the courtyard and walked the pathway, she observed the client [Resident #140] pacing the wall. She attempted to redirect the client to rejoin the group. CC #657 engaged the other clients outside and joined them at the table. A few minutes later, she noticed the client [Resident #140] had not rejoined the group. CC #657 got up and looked around the courtyard but did not see the client. She alerted CC #658 who stated she had not bring him back inside. CC #657 went inside the building to look for him where he was unable to be located. CC #657 reported LISW #639 was the first staff member she saw and informed him the client was missing. Review of a written statement dated 05/18/26 authored by CC #658 revealed CC #657 and CC #658 facilitated a group outside in the courtyard. Some residents were actively participating, while some wanted to go back inside. CC #658 brought in the first group of clients and CC #657 brought in the second group while CC #658 helped the remaining clients finish their gardening. When CC #657 returned, she asked if CC #658 had taken the client [Resident #140] inside when he did not join the rest of the group. CC #658 stayed with the remainder of the clients outside while CC #657 searched for him inside. When he was nowhere to be found, the two counselors alerted LISW #639 that he was missing. Review of a written statement authored by Licensed Practical Nurse (LPN) #566 dated 05/18/26 revealed she was in the DON's office when one of the social workers came to report Resident #140 was missing. She and the DON got up and went to the last place Resident #140 had been seen and talked to CC #657 and CC #658. LPN #566 then joined in the search for Resident #140. An interview on 08/06/26 at 9:30 A.M. with the DON revealed she was working the day Resident #140 eloped on 05/18/26. Two counselors, CC #657 and CC #658, had taken a group of residents including Resident #140 out into the courtyard for a gardening activity at the time Resident #140 went missing. One of the counselors checked to see if the resident had gone back inside but did not see him. An elopement alert was started immediately, but staff could not locate him within the facility. Notifications to the resident's family, the corporate office, the resident's nurse practitioner, and the police were notified. It was suspected the resident had gotten on the RTA, so they were alerted as well. The DON reported the courtyard gate had been unsecured at the time Resident #140 exited the courtyard. The DON confirmed Resident #140's whereabouts were unknown until 05/21/26 when he was located at a gas station 9.2 miles away from the facility. The police were notified and arrested Resident #140 for a prior outstanding warrant. The DON reported that following the incident, a magnetic, alarming lock had been placed to the courtyard gate. An observation and interview on 08/06/26 at 10:15 A.M. with the DON of the courtyard gate revealed the magnetic, alarming lock was in place and functioning appropriately. The DON verified Resident #140 should have been supervised by one of the two contracted counselors while they had him outside in the courtyard at the 05/18/26 activity. An interview on 08/06/26 at 11:10 A.M. with CC #657 revealed on 05/18/26, her and another counselor took residents from all floors outside for a gardening activity. CC #657 reported Resident #140 was observed pacing back by the wall and gate area of the courtyard and was asked to return to the activity, but he did not. CC #657 had attempted to locate Resident #140 once she realized he was gone but was unable to locate him. She informed the first staff she saw, LISW #639, that Resident #140 was missing and continued to search for him. CC #657 was unaware of Resident #140's care plan which indicated the resident had a history of pacing and wandering behaviors, required close supervision, and had a history of not staying put in prior group home settings. An interview on 08/06/26 at 11:14 A.M. with CC #658 revealed she was with the rest of the residents when CC #657 told her she was unable to find Resident #140. CC #657 had looked inside the facility while CC #658 stayed outside with the rest of the residents. CC #658 reported Resident #140 had been in the courtyard two or three other times without incident. When he was asked to return to the group, he replied ok, ok, ok. When the counselors checked on him approximately a minute later, Resident #140 was gone. CC #658 was unaware of Resident #140's care plan which indicated the resident had a history of pacing and wandering behaviors, required close supervision, and had a history of not staying put in prior group home settings. An interview on 08/12/26 at 12:24 P.M. with LISW #639 revealed CC #657 had reported to him that Resident #140 was missing. He stated Resident #140 was at the side of the building and the two counselors, CC #657 and CC #658, were not paying attention to him. LISW #639 reported on the day Resident #140 eloped [05/18/26] the resident was in a good mood and was not angry or having a behavior. He had previously been moved off of the second-floor secured unit per an interdisciplinary team decision. LISW #140 was unsure how Resident #140 left the premises but thought he maybe saw an opportunity and took it. LISW #639 stated an (unspecified) aide later saw him at a gas station asking for money. An interview on 08/12/26 at 12:35 P.M. with Certified Nursing Assistant (CNA) #605 revealed she did not work the day Resident #140 eloped but had received a group text that an unspecified resident had eloped. She was off work on 05/21/26 and was driving to pick up her children when she saw Resident #140 at a gas station asking people for money. CNA #605 pulled into the gas station and confirmed it was Resident #140. She did not want to put him in her car, but initiated a conversation with the resident while calling to alert the DON. Resident #140 asked CNA #605 for $3.00 so he could get to his mother's house. The DON arrived at the gas station and CNA #605 left. CNA #605 called the DON a short time later to ask if she had gotten Resident #140 in her car. The DON had told her she was unable to as he ran as soon as the DON told him it was unsafe for him to be there. CNA #605 then stated she saw Resident #140 walking down the street. She pulled up to him and carried on a lengthy conversation with him, during which he again specifically asked for $3.00. She told him she was about to get it for him while she called the police and the DON. The police quickly arrived to their location. Resident #140 did not run or fight and was arrested by the police on a prior outstanding warrant. 2. Resident #44 was admitted to the facility on [DATE] with diagnoses that included dementia, traumatic brain injury, schizoaffective disorder, and alcohol abuse. Resident #44 had a legal court-appointed guardian. Review of the care plan dated 03/03/25 revealed Resident #44 had demonstrated cognitive deficits related to impaired decision making and deficits related to memory. An additional care plan focus dated 09/12/25 revealed Resident #44 had behavior problems which included delusions, hallucinations, aggression, and pacing. Review of a Nurse Practitioner (NP) note dated 05/05/26 revealed Resident #44 was oriented with a memory impairment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #44 had a BIMS score of nine indicating moderately impaired cognition. Resident #44 required supervision for completing activities of daily living and was noted to have active delusional thoughts. Review of a progress note dated 07/19/26 at 2:22 P.M. revealed at the start of the shift, Resident #44's nurse observed that Resident #44 was not in his room or restroom. The nurse notified the resident's assigned CNA and instructed them to search the areas of the facility where the resident was frequently known to spend time. After staff confirmed the resident was not located in any of the areas he frequently visited, an elopement code was called to alert staff a resident was missing. Staff were then instructed to conduct a head count on each nursing unit and complete a thorough search of the facility. After staff confirmed all areas of the facility had been searched and Resident #44 remained unaccounted for, staff began searching the areas surrounding the facility. Resident #44's nurse drove an appropriate two-to-three block radius in an attempt to locate the resident. Numerous local hospitals were contacted. Resident #44 was later located at an emergency department approximately 1.5 miles away from the facility. Resident #44 returned to the facility on [DATE] at 12:22 P.M. Review of the facility's investigation dated 07/19/26 revealed Resident #44 exited the facility on 07/19/26 at approximately 7:20 A.M. when he followed another resident out the facility's front door. Upon exiting the facility, Resident #44 turned right onto the main, four-lane roadway running down the center of the municipality in which the facility is located. The road was noted to have a consistent and heavy flow of traffic. Resident #44 proceeded to walk approximately 1.7 miles down the road to a local restaurant. When he attempted to enter the restaurant, Resident #44 fell in the parking lot and suffered lacerations to his knees and forehead. Resident #44 was taken to a local emergency room for evaluation and treatment before he was returned to the facility at which time he was moved to the facility's secured unit. Review of a written statement provided by CNA #523 revealed on 07/19/26 at approximately 6:00 A.M., CNA #523 was in another room cleaning a resident when she heard LPN #561 speaking with Resident #44 during her medication pass. CNA #523 noted Resident #44 sounded more confused than normal. CNA #523 further revealed that when asked where he was going, Resident #44 had stated he was going home. Review of the statement provided by LPN #561, Resident #44's assigned nurse on the morning of 07/19/26, revealed she had last seen Resident #44 on 07/19/26 around 6:20 A.M.

Based on observation and staff interview, the facility failed to maintain resident rooms and common areas in a clean, sanitary, and well-maintained condition. This deficient practice had the potential to affect all 135 residents who resided in the facility.Findings include: Observations conducted on 08/04/26 between 9:30 A.M. and 10:00 A.M. revealed the following:The wood paneling in the bathroom shared by Residents #54, #72, #104, and #105 had a large crack extending down the middle.The bedsheet used by Resident #35 was visibly soiled and contained numerous black stains.The flooring surrounding the toilet in the room occupied by Residents #37 and #132 was stained brown, and a strong odor of urine was present in the area.Privacy curtains were not present in the rooms occupied by Residents #28, #102, and #125.The wedge pillow used by Resident #83 contained a visible red stain.Paint in Resident #19's room was deteriorated and crumbling from the wall.A large hole was present in the wall behind Resident #66's bed.Water-stained ceiling tiles were observed in the rooms occupied by Residents #5, #24, #33, #70, #80, #126, and #130.Visibly stained privacy curtains were observed in the rooms occupied by Residents #16, #24, #47, #88, #91, and #110.The floors in the rooms occupied by Residents #117 and #123 were visibly soiled and contained food particles and other debris.The fall mat used by Resident #46 contained visible accumulations of dust, debris, and other particles.Resident #89 was observed lying on a pillow that contained a large brown stain.Drywall and plaster were deteriorated and crumbling from the walls in the rooms occupied by Residents #69, #85, and #143.Large cracks were present in the floor tiles in the rooms occupied by Residents #31, #70, and #80.The third-floor dining area contained multiple air vents with visible accumulations of dust, numerous water-stained ceiling tiles, and walls with multiple scuff marks.Multiple light fixtures in the second-floor dining area were visibly discolored and stained various shades of brown.Multiple light bulbs in the chandeliers located in the first-floor dining room were not functioning.Hallways throughout the facility contained numerous water-stained ceiling tiles.During an interview on 08/04/26 at 10:05 A.M., Housekeeping Supervisor #901 confirmed and verified the above findings.This deficiency represents non-compliance investigated under Master Complaint Number 3060227.

Based on interview and record review, the facility failed to notify Resident #141's guardian of an outside medical appointment. This affected one (Resident #141) of three residents reviewed for notification. The facility census was 135.Findings include: Review of the medical record for Resident #142 revealed an admission date of [DATE] with diagnoses including malignant neoplasm of liver, hemiplegia and hemiparesis, anxiety disorder, dementia with other behavioral, and other speech and language deficits following cerebral infarction. The resident was discharged to the hospital on [DATE] where he expired.Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #142 had intact cognition. He had behaviors that included hallucinations, delusions, and verbal behavioral symptoms directed at others. The resident was dependent to roll left and right, unable to lay to sit, or sit to stand. He required a mechanical lift and used a manual wheelchair for mobility.Review of the general note dated [DATE] at 9:34 A.M. revealed Resident #142 was escorted to an appointment by a certified nursing assistant (CNA) and transported by an outside transportation service.Review of the Interdisciplinary Team (IDT) note dated [DATE] at 2:56 P.M. revealed the Director of Nursing (DON) received a call from a hospital nurse stating Resident #142 was behavioral and trying to fall out of the chair he was transported to their facility in. She stated she did not feel the wheelchair the resident was sent in was safe for transport back with the outside transportation used to bring the resident to the appointment. Four facility staff members, including the DON, went to the hospital to ensure the resident was transported back to the facility safely.Review of the IDT note dated [DATE] at 3:10 P.M. revealed Resident #142 was transported to an oncology appointment via outside transportation, assisted by a facility staff member. While at the appointment, the physician asked to speak with the guardian, who then instructed the physician to call the DON. The physician informed the DON that the resident was a little behavioral. The physician also informed the DON that the resident's guardian would need to be in attendance for all further appointments scheduled due to the severity of the resident's poor decision-making. The guardian was updated.During an interview on [DATE] at 12:10 P.M., the DON confirmed that no documentation could be found in the medical record indicating the guardian was notified of Resident #142's appointment on [DATE].This deficiency represents non-compliance investigated under Complaint Number 2646256.

Based on record review, staff interview, and facility policy review, the facility failed to ensure routine and comprehensive skin assessments were completed to timely identify a wound for Resident #6 and failed to timely and comprehensively assess a new pressure ulcer/injury for Resident #148. This affected two residents (#6 and #148) of three residents reviewed for wound care. The facility census was 135.Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 02/17/23. Diagnoses included Alzheimer's disease with late onset, adult failure to thrive, dementia with agitation, peripheral vascular disease (PVD) (a blood circulation problem that narrows or blocks vessels outside the heart and brain, mostly affecting the legs and feet), and lymphedema (swelling in the arms or legs caused by a buildup of lymphatic fluid). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had behaviors, required set-up or clean-up assistance for eating, and was dependent on staff for toileting hygiene, showering/bathing, dressing, and transfers. Resident #6 was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries, but had in place a pressure reducing device to the bed. Review of the Braden scale for predicting pressure sore risk dated 11/12/25 revealed Resident #6 was at risk for developing pressure ulcers/injuries due to slightly limited sensory perception and occasional moisture. Resident #6 was identified to be chairfast, had very limited mobility, and was had a potential problem for friction and/or shearing. Review of the care plan revised on 11/12/25 revealed Resident #6 was at risk for impaired skin integrity/pressure ulcers related to chronic incontinence, fragile skin, PVD, immobility, multiple comorbidities, and polypharmacy. Interventions included inspect skin during routine daily care, pad and protect skin as needed, and complete skin assessment as ordered. Review of the weekly skin check assessments revealed no weekly skin assessments were completed between 09/06/25 and 12/18/25, the date of when Resident #6's wound was identified. Review of a progress note dated 12/18/25 at 10:51 P.M. revealed an open area was observed to Resident #6's left heel. The area measured 7 centimeters (cm) in length by 7 cm in width with no mention of the wound's depth. The area was circular in shape. The note indicated there was a moderate amount of serosanguineous (a thin watery body fluid) drainage observed. Resident #6 denied pain to the site. The (unspecified) nurse practitioner (NP) was notified. New orders were received to cleanse the site with normal saline (NS), apply calcium alginate cut to size, cover with an ABD (absorbent dressing) and wrap with kerlix (gauze roll). Change daily and as needed until seen by the in-house wound team. The note indicated a new order was received for Resident #6 to wear heel protectors while in bed. The treatment was performed and Resident #6 tolerated it well. The (unspecified) Unit Manager and Resident #6's representative were notified of the new area. Review of the shower sheets for Resident #6 revealed no shower sheets prior to 01/23/26 were available for review. Interview on 08/06/26 at 8:55 A.M. and at 10:07 A.M. with Regional Registered Nurse (RRN) #649 verified there was a gap between weekly skin checks in the electronic medical record dated between 09/06/25 and after 12/18/25. RRN #649 stated weekly skin should have been completed and verified there were none completed during that time frame. Interview on 08/06/26 at 9:23 A.M. with the Director of Nursing (DON) stated she was unable to find any shower sheets for Resident #6 around the time the pressure injury on the resident's left heel wound was identified on 12/18/26. The DON verified the earliest shower sheets found were from January 2026. 2. Review of the medical record for Resident #148 revealed an admission date of 01/03/19 with diagnoses including senile degeneration of the brain, multiple sclerosis (MS), and cerebrovascular disease. Review of the Braden Scale for Predicting Pressure Score Risk assessment dated [DATE] revealed Resident #148 was identified to be high risk for developing pressure ulcer/injuries. Resident #148 was identified to have slightly limited sensory perception, was constantly moist, was chairfast, and had very limited mobility. Resident #148's nutrition was classified as adequate but Resident #148 required moderate to maximum assistance with moving and was identified to have a problem with friction and shear. Review of the quarterly MDS assessment dated [DATE] revealed Resident #148 had a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. Resident #148 was at risk for pressure ulcer/injury development and was not noted to have any unhealed pressure ulcers/injuries. Review of the weekly skin check for Resident #148 dated 05/04/26 revealed no new areas or skin impairment noted. Review of the physician orders dated 05/07/26 for Resident #148 revealed an order for an air mattress to the bed and an order to cleanse the coccyx wound with normal saline (NS), pat dry, apply Santyl (enzymatic debriding ointment) and calcium alginate (maintains a moist wound environment and enables autolytic debridement) to the wound bed, and cover with bordered foam dressing daily and as needed (PRN), authored and ordered by Nurse Practitioner (NP) #650. There was no corresponding wound assessment recorded until Resident #148 was seen by the facility's wound Nurse Practitioner (NP) six days later on 05/13/26. Review of the Wound Nurse Practitioner (NP) #651 note dated 05/13/26 at 8:15 A.M. for Resident #148 (the first description of the wound to the sacrum which was referenced in the treatment order dated 05/07/26) revealed WNP #651 was being re-consulted for wound care services for multiple areas of skin breakdown including wounds to her sacrum, lumbar region, and posterior thigh right side. The sacral wound was noted to have developed rapidly and resembled a Kennedy terminal ulcer and may be consistent with skin failure associated with end-of-life decline. The note indicated the sacral wound which resembled a Kennedy terminal ulcer was a full-thickness wound and measured 12 centimeters (cm) in length by 7.5 cm in width with a depth that was unable to be determined. The wound contained undermining (indicating the wound was wider than the wound opening appeared) between 12 and 11 o'clock, with deepest point at 11 o'clock at 7.5 cm. The wound contained 30% granulation (the healthy, new tissue that your body builds in a wound as it's healing), 30% necrotic (dead tissue), 10% purple or maroon discoloration, and 30% fascia (thin, web-like layer of connective tissue that wraps around and supports muscles, bones, nerves, and organs throughout your body). The wound contained heavy serosanguinous brown drainage (thin and watery, almost like water, that ranges from light pink to pale red or rosy) and the periwound (the skin surrounding a wound's edge) appeared reddened, fragile, moist, excoriated, and contained signs and symptoms of infection with odor and erythema present. The note indicated this was the wound's initial evaluation and Resident #148 had pain throughout the wound assessment. The note indicated new orders were placed to treat the resident's three wounds and offloading and repositioning were recommended. Review of the assessment titled skin grid pressure for 05/20/26 revealed Resident #148's new area was first observed on 05/08/26 and was an in-house acquired wound. The wound to Resident #148's sacrum was noted to be an unstageable pressure ulcer/injury (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) and measured 13.5 cm in length, 9 cm in width, and had a depth that was unable to be determined. The wound had undermining present between 11 o'clock and 12 o'clock and the wound bed was noted to have granulation tissue, eschar, and purple non-blanchable areas present. The wound had a large amount of serosanguineous drainage present with signs and symptoms of infection. The summary of care and treatment listed the wound type as a Kennedy terminal ulcer. Review of Resident #148's MAR and TAR for May 2026 revealed the TAR was left blank on 05/21/26, indicating the resident's physician-ordered treatments to the sacrum, posterior mid-lumbar region, and right posterior thigh were not completed as ordered. During an interview on 08/06/26 at 7:34 A.M., the DON confirmed when a new skin impairment or wound was identified, nurses were to do a risk management assessment to include the description of the wound with the measurements, notify the physician or NP of the findings, obtain an order for a treatment, and refer the resident to the facility's wound NP. The DON confirmed there was no wound assessment completed on the sacral wound identified on 05/07/26 until 05/13/26 when the Wound NP #651 assessed the area. During a telephone interview on 08/06/26 at 8:56 A.M., Wound NP #651 stated that when a new skin impairment is identified, the nurse was expected to complete a full wound assessment, including measurements, a detailed description, an incident report, documentation of the assessment, notification of the NP/Physician, and obtain treatment orders. Wound NP #651 reported she first assessed Resident #148 on 05/13/26 for a new wound she identified as a Kennedy terminal ulcer on the sacrum, noting it was a very large wound. Wound NP #651 confirmed she had not been aware that the wound was present on 05/07/26 or 05/08/26, and she was unclear regarding the treatment orders written on those dates. She further stated that Resident #148 should have been turned and repositioned every two hours, and that she had included this in her wound care notes. During a follow-up interview on 08/06/26 at 9:24 A.M., the DON confirmed there was no risk management (wound documentation form) done for Resident #148's new wound discovered on 05/07/26. The DON confirmed the MARs and TARs for wound treatment on 05/21/26 to include posterior mid lumbar, right posterior thigh, sacrum were not signed off as completed per physician orders. She reported if the MARs and TARs were left blank, that means the treatment was not done. Reviewed policy Wound Management Program, updated February 2024 revealed the organization is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of facility acquired pressure injuries, unless the individual clinical condition demonstrates they are unavoidable. This deficiency represents non-compliance investigated under Complaint Number 2730041.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure that Resident #77's pain was thoroughly assessed and that pain medication was administered in a timely manner after the resident reported severe pain. This deficiency affected one resident (Resident #77) of three reviewed for pain management. The facility census was 135.Findings include: Review of the medical record for Resident #77 revealed an admission date 03/07/25. Diagnoses pain due to internal orthopedic prosthetic devices, removal of internal fixation device, orthopedic aftercare, cocaine use and nicotine dependence.Review of the care plan dated 05/08/26 revealed Resident #77 was care planned for pain related to immobility, depression, previous orthopedic surgery, muscle weakness, obesity and history of herpes viral infection. Interventions included administering pain medications per order (created 03/10/25), monitoring and documenting pain, monitoring, recording, reporting to nurse complaints of pain or requests for pain treatment (created 03/10/25), and non-pharmacological interventions for pain relief (created 03/10/25).Review of the physician order for April 2026 revealed an order for Tylenol Extra Strength (ES) 500 milligrams (mg) (Acetaminophen) (analgesic) administer two tablets by mouth (PO) three times a day (TID) for pain, dated 10/28/25.Review of the progress note dated 04/13/26 at 11:36 A.M. authored by Registered Nurse (RN) #608 revealed Resident #77's medication prescriptions were faxed to pharmacy, and the resident was medicated with Tylenol as ordered.Review of the physician orders for 04/13/26 at 12:00 P.M. authored by RN #608 revealed an order for Tramadol Hydrochloride (HCI) 50 mg (opioid prescription medication used to treat moderate to severe pain) give one tablet PO every six hours as needed (PRN) for pain until 04/21/26 and an order for Oxycodone (opioid pain medication) 5 mg one tablet PO every six hours PRN for pain until 04/21/26. Review of the progress note dated 04/13/26 at 12:27 P.M., authored by RN #608, revealed Resident #77 repeatedly asked about her pain medication and when she would receive it. RN #609 informed her that it would take time.Review of the progress note dated 04/13/26 at 12:48 P.M., authored by RN #608, revealed Resident #77 had returned from surgery, transported by her family. The dressing to the right hip was intact, pain medication orders were placed in the electronic medical record, and an ice pack was applied to the area for pain.Review of the progress note dated 04/13/26 at 3:30 P.M., authored by RN #608, revealed Resident #77 continued to inquire about her pain medication. RN #608 contacted the pharmacy, which reported it had not received the prescription via fax, and RN #608 re faxed the prescription.Review of the progress note dated 04/13/26 at 7:32 P.M., authored by RN #608, revealed Resident #77 was yelling at the nurse and stated she had called her family because she wanted to go to the hospital due to her pain. RN #608 informed her that was not how the process worked and administered Tylenol.Review of the progress note dated 04/13/26 at 9:35 P.M., authored by RN #608, revealed Resident #77's family came to the facility and requested the pain medication prescriptions so they could take them to a local pharmacy to be filled.Review of the progress note dated 04/13/26 at 10:00 P.M., authored by RN #546, revealed Resident #77's family brought in a prescription bottle of Tramadol. RN #546 and RN #608 counted and verified twenty eight (28) pills in the bottle. Resident #77 was then administered Tramadol 50 mg for pain.Review of the Medication Administration Record (MAR) for April 2026 showed an order for Tramadol HCl 50 mg, one tablet PO every six hours as needed for pain. The MAR for 04/13/26 was blank, with no nurse signature indicating that the medication had been administered. Review of the MAR April 2026 revealed an order for Oxycodone 5 mg, one tablet PO every six hours PRN. The MAR for 04/13/26 was blank, with no nurse signature indicating the medication was administered. The MAR for 04//14/26, showed that Oxycodone 5 mg was administered during the day shift.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had intact cognition with a Brief Interview of Mental Status (BIMS) of 15/15. Resident #77 required set up for eating and dressing and supervision for toileting, showers, and personal hygiene.During an interview on 08/04/26 at 7:10 A.M., Resident #77 reported that on 04/13/26 she had surgery to remove rods from her right hip and returned to the facility approximately at 12:00 P.M. Resident #77's family gave RN #608 two prescriptions for pain, for Tramadol HCI 50 mg and Oxycodone 5 mg. Resident #77 reported her pain was a 12 on a scale from 0-10 with 10 the worst pain. Resident #77 reported finally around 7:00 P.M. she checked with RN #608 regarding her pain medication because she was in so much pain and RN #608 told her she could get the prescription filled herself. Resident #77 reported that her family called her and wanted her sent to hospital for pain management, and RN #608 refused and told her we don't do that. Resident #77 reported her family then came to the facility and took the prescription to a local pharmacy to be filled and returned to the facility with the prescription and gave it to Licensed Practical Nurse (LPN) #456. Resident #77 reported she finally received Tramadol 50 mg at approximately 10:00 P.M. and wasn't able to receive Oxycodone until the next day.During an interview on 08/05/26 at 8:13 A.M., RN #608 initially stated she did not work with Resident #77 on 04/13/26, regarding pain medications, then reported the resident had returned to the facility on 04/13//26, at approximately 4:00-5:00 P.M., and confirmed she documented progress notes earlier that day at 11:36 A.M. RN #608 stated Resident #77 handed her two prescriptions for pain medication and reported she was in pain, and RN #608 administered Tylenol ES until the prescriptions could be filled. She reported faxing the prescriptions to the pharmacy and confirmed the resident continued to complain of pain, stating she told her, Give me a minute. RN #608 stated the pharmacy reported it had not received the fax, prompting her to re fax the prescriptions, which the pharmacy again reported not receiving; RN #608 could not recall specific times. She stated the resident called her family, who came to the facility and took the prescriptions to a local pharmacy to be filled. RN #608 further reported she did not pull medication from the emergency medication starter system (system with medications to include narcotic/pain medications available onsite to pull with authorization) because she did not have access to it.During an interview on 08/05/26 at 10:17 A.M., Regional Nurse #649 confirmed Resident #77's pain medication was not received or administered in a timely manner and stated that RN #608 could have obtained the medications from the emergency medication starter system.During an interview on 08/05/26 at 9:46 A.M., the Director of Nursing (DON) confirmed Resident #77 did not receive her pain medication in a timely manner. She stated the pain medications could have been pulled from the emergency medication starter system and were available. She verified that the MAR for 04/13/26, showed Tramadol 50 mg and Oxycodone 5 mg with blank entries and no nurse signatures indicating administration, and that the MAR for 04/14/26, reflected Oxycodone 5 mg administered on the day shift. The DON confirmed the blank MAR entries on 04/13/26, indicated RN #608 did not administer the medications per physician orders or in a timely manner. She further stated that when Resident #77 wanted to go to the hospital for pain evaluation, RN #608 should have contacted the physician or nurse practitioner (NP)and followed their guidance.During an interview on 08/05/26 at 1:01 P.M., NP #650 confirmed Resident #77's pain medication was not administered in a timely manner. NP #650 stated that timely pain management would have meant administration within three to four hours and confirmed authorization could have been obtained to pull the pain medication from the emergency medication starter system.During a telephone interview on 08/10/26 at 8:26 A.M., Pharmacy Customer Service Manager #656, confirmed that Tramadol and Oxycodone was available in the emergency medication starter system, and the facility could have called to get authorization to pull the medication.During an interview on 08/05/26 at 1:48 P.M., the DON confirmed that Tramadol 50 mg and Oxycodone 5 mg were available in the emergency medication starter system, and that RN #608 should have contacted the pharmacy to obtain authorization to pull the medications and administer them in a timely manner.During an interview on 08/11/26 at 6:31 A.M., RN #625 confirmed Tramadol and Oxycodone were available in the emergency medication starter system to pull with authorization and reported timely pain medication should have been provided within a half an hour.During an interview on 08/11/26 at 6:46 A.M., LPN #546 confirmed Resident #77's family brought in a prescription bottle of Tramadol 50 mg on 04/13/26 at 10:00 P.M. LPN #506 confirmed Resident #77 should have received her pain medication in a timely manner and verified that both Tramadol 50 mg and Oxycodone 5 mg were available in the emergency medication starter system and could have been pulled with authorization from the pharmacy.During a telephone interview on 08/10/26 at 7:01 A.M., LPN #519 confirmed Resident #77's pain medication was not administered timely. LPN #519 stated that waiting over eight hours to administer pain medication was not acceptable. LPN #519 confirmed that Tramadol and Oxycodone were available in the emergency medication starter system at the facility and could have been pulled and administered with authorization.During an interview on 08/11/26 at 6:58 A.M., Night Supervisor RN #575 confirmed Resident #77's pain medication, Tramadol 50 mg and Oxycodone 5 mg, were available in the emergency medication starter system and should have been administered within a half an hour to an hour. Review of the facility policy, Pain Management Guideline, revised 01/2026, revealed it provides direction for staff to maintain the facility's pain management standards and deliver effective pain management. The policy further states that staff should educate the patient and family about pain and appropriate pain management strategies and document this education.This deficiency represents non-compliance investigated under Complaint Numbers 2982878 and 2730041.

Based on observations, staff interviews, and resident interviews, the facility failed to maintain a clean and sanitary living environment. This had the potential to affect all 137 residents in the facility.Findings Include:Observation on 08/29/25 at 8:20 A.M. revealed multiple items of food, dirt, and dust on the first floor dining room. Breakfast was being served at that time, but no residents were in the dining room. Observation during that time revealed an unidentified nursing staff person tell two residents in the hallway that the dining room was closed and they had to eat in their room.Observation on 08/29/25 from 9:05 A.M. to 9:15 A.M. revealed black soot on multiple ceiling tiles in the main laundry room. The black soot was caused by a dryer fire that happened in that room on approximately 05/29/25.Interview with the Housekeeping and Laundry Director #120 on 08/29/25 at 9:22 A.M. and 9:27 A.M. confirmed the black soot on the ceiling tiles. He confirmed the facility is waiting on the insurance claim to be approved prior to replacing all the affected items, including the new dryer, the windows, and the black ceiling tiles.Observation on 08/29/25 at approximately 2:35 P.M. revealed water damage from a water leak to two ceiling tiles above Resident #3 bed.Interview with Resident #3 on 08/29/25 at 2:35 P.M. confirmed she has asked for that ceiling tile to be replaced, but it hasn't been. When asked how long it had been that way, she did not know exactly, but stated, it's been a while.Interview with the Administrator (via e-mail) on 08/29/25 at 3:24 P.M. confirmed they need to replace the ceiling tiles listed above. He confirmed they were waiting for the insurance claim to be approved to replace the ceiling tiles in the laundry room, but then stated they would go ahead and replace them as of this day.Observation of Resident #123 room on 08/29/25 at 4:45 P.M. revealed his room had an strong odor in it. The odor appeared to be of an unkempt person who does not take showers. The odor was so strong the surveyor could not stay in the room for more than 30 seconds. Interview with Licensed Practical Nurse (LPN) #130 and Certified Nursing Aide (CNA) #140 on 08/29/25 at 4:50 P.M. confirmed Resident #123 is able to take showers/baths independently, but needs reminders to do so. But, he is someone that refuses baths/showers constantly, to the point that he has only accepted one shower in the last three months. They confirmed his room has a strong body odor to it, and it's because he refuses to take showers.This deficiency represents non-compliance investigated under Complaint Numbers 2602108, 2599468, 2599445, and 1343060.

Based on medical record review, staff interview, and facility policy review, the facility failed to report an allegation of misappropriation to the State Agency as required. This affected two residents (#13 and #22) of three residents reviewed for misappropriation. The facility census was 137.Findings Include:1.Review of Resident #13's medical record revealed an admission date of 10/20/23. Her diagnoses included cerebral infarction, congestive heart failure, type II diabetes, COPD, multiple sclerosis, dementia, hypertension, factitious disorder, hypertensive heart disorder, anxiety disorder, chronic pain syndrome, psychosis disorder, osteoarthritis, personality disorder, hyperlipidemia, and glaucoma. Review of Resident #13 physician orders, dated 12/12/24 to 06/23/25, revealed an order for oxycodone five (5) milligrams (mg) every six hours as needed for pain.Review of Resident #13 physician orders, dated 06/23/25 to current, revealed an order for oxycodone five (5) mg every 12 hours as needed for pain.Review of Resident #13's Minimum Data Set (MDS) assessment, dated 07/30/25, revealed she was cognitively intact.2. Review of Resident #22's medical record revealed an admission date of 01/24/25. Her diagnoses were antiphospholipid syndrome, insomnia, anxiety disorder, major depressive disorder, diverticulitis, endocarditis, adjustment disorder, lupus anticoagulant syndrome, cognitive communication deficit, hypotension, fibromyalgia, osteoarthritis, anemia, depression, hyperlipidemia, sleep apnea, and convulsions. Review of Resident #22 physician orders, dated 01/25/25 to current, revealed an order for oxycodone five mg every eight hours as needed for pain.Review of Resident #22's MDS assessment, dated 07/14/25, revealed she was cognitively intact.Interview with Licensed Practical Nurse (LPN) #104 on 08/29/25 at 12:45 P.M. confirmed he reported to nursing management that there were reported concerns to him from other nurses, that there were things that didn't look right when it came to Resident #13 and Resident #22's narcotic logs. When asked to explain, he stated it was reported to him by LPN #110 that he felt his signature/initials were being forged by another nurse, when it came to administering oxycodone. He confirmed he reported this to nursing management. He does not know what happened with the rest of the investigation, but he stated all nurses were sent a message from the Director of Nursing (DON) that they were part of a narcotic investigation and would need to report to the facility for a drug test.Interview with DON on 08/29/25 at 1:20 P.M. confirmed they completed an investigation regarding a nurse and the administration of narcotics. DON stated they did not consider this to be an allegation of misappropriation, even though she confirmed the investigation was due to an allegation of this nurse potentially forging LPN #110 signature during administration of oxycodone. When asked why they required all the nurses who worked that area of the facility to take a drug test, if it wasn't an allegation of misappropriation or misuse of narcotics, she stated they were simply trying to collect information to see if they could prove wrongdoing.Review of the facility Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property policy, dated May 2025, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment in accordance with this policy and to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. All incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident property must be reported immediately to the administrator or designee. If any form of of abuse is alleged, or serious bodily injury is identified related to any other reportable incident, the administrator or his/her designee will notify the state department of health immediately, but no later than two hours after the allegation is made.This deficiency represents non-compliance investigated under Complaint Number 2590074.

Based on medical record review, staff interview, facility investigative document review, and facility policy review, the facility failed to fully investigate an allegation of misappropriation as required. This affected two residents (#13 and #22) of three residents reviewed for misappropriation. The facility census was 137.Findings Include:1. Review of Resident #13's medical record revealed an admission date of 10/20/23. Her diagnoses included cerebral infarction, congestive heart failure, type II diabetes, COPD, multiple sclerosis, dementia, hypertension, factitious disorder, hypertensive heart disorder, anxiety disorder, chronic pain syndrome, psychosis disorder, osteoarthritis, personality disorder, hyperlipidemia, and glaucoma. Review of Resident #13 physician orders, dated 12/12/24 to 06/23/25, revealed an order for oxycodone five (5) milligrams (mg) every six hours as needed for pain.Review of Resident #13 physician orders, dated 06/23/25 to current, revealed an order for oxycodone five (5) mg every 12 hours as needed for pain.Review of Resident #13's Minimum Data Set (MDS) assessment, dated 07/30/25, revealed she was cognitively intact.2. Review of Resident #22's medical record revealed an admission date of 01/24/25. Her diagnoses were antiphospholipid syndrome, insomnia, anxiety disorder, major depressive disorder, diverticulitis, endocarditis, adjustment disorder, lupus anticoagulant syndrome, cognitive communication deficit, hypotension, fibromyalgia, osteoarthritis, anemia, depression, hyperlipidemia, sleep apnea, and convulsions. Review of Resident #22 physician orders, dated 01/25/25 to current, revealed an order for oxycodone five mg every eight hours as needed for pain.Review of Resident #22's MDS assessment, dated 07/14/25, revealed she was cognitively intact.Interview with the DON on 08/29/25 at 1:20 P.M. confirmed they completed an investigation regarding a nurse and the administration of narcotics. DON also confirmed she had no written statements from this investigation. When asked why, she stated, we just did face to face interviews with all the nurses involved to help make the determination if wrongdoing happened. She also confirmed they have no interviews/statements completed with any potential residents involved as well.Review of facility Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property policy, dated May 2025, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment in accordance with this policy and to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Investigation protocol includes the person investigating the incident should generally take the following actions: interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident and employees who worked closely with the accused employees and/or alleged victim the day of the incident. Evidence of the investigation should be documented in accordance with quality assurance protocols.This deficiency represents non-compliance investigated under Complaint Number 2590074.

Based on interviews, medical record review, and policy review, the facility failed to report an allegation of abuse as required. This affected one (Resident #63) of of six residents reviewed for abuse. The facility census was 143. Findings Include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, anxiety, depression, and chronic obstructive pulmonary disease. Review of the admission comprehensive Minimum Data Set (MDS) assessment, dated 01/24/25, revealed Resident #63 was cognitively intact, had delusions, verbal outbursts directed towards others, and wandered. Review of a nurse note dated 03/10/25 timed 6:45 A.M. revealed Resident #63 was verbally abusive, intrusive and arguing with staff and residents. Further review of the nurses notes from February 2025 to current revealed no information related to Resident #63 making an allegation of nursing staff twisting her arm. Interview on 04/03/25 at 9:05 A.M. with the Director of Nursing (DON), Regional Registered Nurse (RRN) #601, and the Administrator revealed an allegation was made recently (unable to provide exact date) that staff had twisted the arm of Resident #63 behind her back. Resident #63's statement kept changing about what happened and staff would not provide statements when requested because they did not believe anything had happened. The facility did not report the allegation of abuse made by Resident #63 to the State agency. Interview with the Administrator on 04/03/25 at 12:45 P.M. revealed they did no report the allegation made by Resident #63 because the resident retracted her allegation 10 minutes after making it. However, they did investigate the situation and made a soft file. Resident #63 had a habit of making false allegations. Review of a Root Cause Analysis/soft file investigation dated 03/31/25 revealed Resident #63 initially claimed two aides were taking her to her room and once they were in her room they twisted her arm behind her back. During a second interview, Resident #63 stated Certified Nurse Aide (CNA) #406 threw her walker in the hall then twisted her right arm back refracturing her arm and then walked her down to her room. The incident was reported to staff on 03/31/25 but Resident #63 said it happened on 03/30/25 then changed her mind and said it happened on 03/29/25. An investigation was immediately begun by the Interdisciplinary Team (IDT). The investigation revealed that Resident #63 asked CNA #520 for some hygiene products. CNA #520 asked the resident to give her a minute and she would get them for her. Resident #63 changed her statement several times and and indicated CNA #520 was the one who twisted her arm behind her back and not CNA #406. Resident #63 retracted her allegation while talking to Unit Manager (UM) #474 and apologized to the staff for getting them in trouble. Resident #63 became impatient and accusatory if staff did not meet her needs as soon as she asked. The Root Cause Analysis investigation indicated upon many witness statements, creating a time line, review of past behavioral history, a head to toe assessment and the resident retracting her statement the interdisciplinary team (IDT) determined the allegation was a false statement because she did not receive her requested hygiene products immediately. Interviews with Certified Nursing Assistant (CNA) #415 and CNA #420 on 04/04/25 from 12:00 P.M. through 12:55 P.M. revealed Resident #63 had a long history of making false allegations but always apologized afterwards because she wanted staff to like her. Interview with Licensed Practical Nurse (LPN) #506 on 04/04/25 at 1:07 P.M. revealed false allegations were a daily behavior for Resident #63. Although the allegation was made over the weekend of 03/29/25 and 03/30/25, LPN #506 said she worked that weekend and nothing unusual happened. LPN #506 was unaware the allegation had been made until 04/03/25. LPN #506 said Resident #63 made apologies to the staff for getting them in trouble. Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy, last revised 01/02/25, revealed all allegations of any type of abuse were to be reported to the Administrator and the State agency. If a staff member was accused or suspected of abuse they were to be removed immediately from the facility in order to protect the resident. If abuse was alleged the State agency must be notified immediately, but not later than two hours after the allegation was made. An investigation was to be completed and the results reported to the state agency within five days. Staff training was to be completed with each allegation. This deficiency represents noncompliance investigated under Complaint Numbers OH00164255, OH00163358, and OH00162492.

Based on observation, resident interviews, staff interviews, and facility policy review, the facility failed to ensure dietary preferences were followed. This had the potential to affect all residents, except Resident #68, who the facility identified as receiving no food or drink by mouth (NPO) from the facility kitchen. The facility census was 142. Findings include: Interview on 01/08/25 at 8:47 A.M. with Resident #17 revealed she always received Kool-Aid as her drink for breakfast. Resident #17 revealed Kool-Aid was not considered a breakfast drink, and she was sick of getting it all the time. Interview on 01/08/25 at 8:53 A.M. with Certified Nurse Assistant (CNA) #808 revealed residents received Kool-Aid as a drink with the breakfast meal. CNA #808 revealed residents preferred orange juice, tea, and coffee. Interview on 01/08/25 at 10:09 A.M. with Licensed Practical Nurse (LPN) #820 revealed residents often complained about receiving Kool-Aid with their breakfast meals. Interview on 01/08/25 at 10:27 A.M. with LPN #855 revealed residents often received Kool-Aid with their breakfast meals. Interview on 01/08/25 at 10:44 A.M. with CNA #833 revealed residents were served Kool-Aid for breakfast, lunch, and dinner. CNA #833 revealed sometimes Kool-Aid was the only drink available, and residents would get upset with their lack of options. Interview on 01/08/25 at 10:56 A.M. with LPN #866 revealed residents complained about receiving Kool-Aid with their breakfast. LPN #866 revealed she had never worked at a facility that served Kool-Aid with all of the meals. Interviews on 01/08/25 at 11:05 A.M. with CNA's #826 and #919 revealed residents often complained about receiving Kool-Aid with their breakfast meals. Observation on 01/08/25 at 11:06 A.M. of the third-floor dining room revealed a drink cart with an orange-colored liquid in a clear pitcher. Observation revealed no other drink options. Observation and interview on 01/08/25 at 11:09 A.M. with Dietary Aide (DA) #931 revealed she was pushing a black cart with a clear pitcher of orange-colored liquid and multiple clear-colored cups. Observation revealed no other options. DA #931 identified the orange-colored liquid as orange Kool-Aid. DA #931 revealed she was providing the resident Kool-Aide as their only option of drinks for the lunch meal. Interview on 01/08/25 at 3:41 P.M. with Dietary Manager (DM) #911 revealed he attended food committee meetings every month. DM #911 revealed residents complained about receiving Kool-Aid with their breakfast meals. DM #911 revealed he informed his staff that serving Kool-Aid with the breakfast meal was unacceptable, and residents did not want it. DM #911 revealed there were other options of drinks to be served with the breakfast meal such as orange juice, apple juice, and cranberry juice. DM #911 confirmed and verified the above findings at the time of the interview. Review of the list of current residents and their diets provided by the facility, revealed only one resident (#68) was listed as NPO. Review of the facility document titled Resident's Rights, dated December 2020, revealed the facility had a policy in place that each resident had a right to receive services with reasonable accommodations of their individual needs and references. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents non-compliance investigated under Master Complaint Number OH00161301.

Based on observation, resident interviews, staff interviews, and facility policy review, the facility failed to ensure a clean environment and water temperatures were at a comfortable level. This affected seventeen residents (#10, #20, #26, #30, #34, #41, #56, #70, #76, #78, #92, #101, #109, #118, #127, #130, #134) of seventeen residing on the 2 East Unit located on the second floor and forty-one residents (#1, #2, #5, #6, #7, #8, #15, #16, #19, #23, #27, #28, #31, #32, #35, #36, #46, #50, #51, #52, #53, #59, #71, #73, #75, #80, #88, #89, #96, #99, #100, #102, #112, #113, #114, #116, #121, #122, #131, #135, #137) of forty-one residing on the 3 East and 3 [NAME] Units located on the third floor. The facility census was 142. Findings include: Interview and observation on 01/08/25 at 10:05 A.M. with Resident #58 revealed his room was always dirty. Observation of Resident #58 room, shared with Resident's #49 and #123, revealed Resident #123 bed had multiple areas of food crumbs with brown and yellow substance-stained bed linen. Resident #49's bed linen was stained with brown stains with trash, food crumbs, and various pieces of paper underneath his bed. Resident #49's nightstand had an unmeasurable amount of dust with a white landline phone with red and brown stains (appeared to be blood) covering the receiver end of the phone. Observation also revealed the entire floor was covered in dirt, sticky substances with various red and brown colored stains. Interview and observation on 01/08/25 from 10:09 A.M to 10:18 A.M. with Licensed Practical Nurse (LPN) #820 revealed the housekeepers didn't clean resident's rooms on a daily basis and when the rooms were cleaned, it wasn't a good job. LPN #820 confirmed and verified the appearance of the room belonging to Resident's #49, #58, and #123. Interview on 01/08/25 at 10:40 A.M. with Certified Nurse Assistant (CNA) #888 revealed the temperature of the shower water located on the 2 East Unit was ice cold. Interview on 01/08/25 at 10:43 A.M with CNA #947 revealed the water in the shower room located on the 2 East Unit did not get hot. Observation on 01/08/25 at 10:54 A.M. with CNA #947 of the shower room located on the 2 East Unit revealed the shower water was turned on and was cold to the touch. The shower water ran for approximately three minutes with no changes or fluctuations. Interview and observation on 01/08/25 at 11:02 A.M. with Resident #29 revealed his room floors were dirty and needed cleaned. Resident #29 revealed he needed clean bed linen. Observation of Resident #29 room, shared with Resident #81, revealed both beds linen was stained, and the entire floor was covered in various stains and trash and/or unknown debris. Observation of Resident #81 bed revealed multiple sheets balled up underneath his bed. Interview and observation on 01/08/25 at 11:04 A.M. with LPN #855 revealed housekeepers were seen daily but she did not know the schedule of cleaning. LPN #855 revealed the housekeeping staff would leave garbage bags at the nursing stations for nurses and aides to assist with clean-up, but nursing required a lot of their time. LPN #855 confirmed and verified the observations in the room belonging to Resident's #29 and #81. Interview on 01/08/25 at 11:06 A.M. with CNA's #826 and #919 revealed the shower room located on the third floor, belonging to the 3 East and 3 [NAME] Units of the facility, shower water did not get hot. Interview on 01/08/25 at 11:11 A.M. with Resident #17, who resided on the 1 East Unit, revealed her room did not get cleaned. Interview and observation on 01/08/25 from 11:39 A.M. to 12:00 P.M. with Maintenance Director (MD) #953, during tour of the facility, revealed the water temperatures in the building were checked routinely, and as recently as 01/07/25. MD #953 revealed he was unaware of any concerns related to water temperatures in the facility shower rooms and he kept a log of his water checks. Observation during tour of the facility, with MD #953, revealed the shower room located on the 2 East Unit produced a water temperature reading of 95 degrees Fahrenheit and the shower room located on the third floor, belonging to the 3 East and 3 [NAME] Units of the facility, produced a water temperature reading of 95 degrees Fahrenheit. Follow-up interview on 01/08/25 at 12:15 P.M. with MD #953 revealed he was unable to produce a log of checked water temperatures. MD #953 revealed water temperatures were to reach between a minimum of 105 degrees Fahrenheit and a maximum of 120 degrees Fahrenheit. MD #953 confirmed and verified the above findings during the tour of the facility. Review of the facility document titled Water Temperature Testing, revised March 2023, revealed the facility had a policy in place to test the temperature of the water at least weekly to ensure temperatures were held between 105- and 120-degrees Fahrenheit. Review of the document revealed the facility did not implement the policy. Review of the facility document titled Housekeeping, dated April 2018, revealed the facility had a policy in place that the rooms and common areas were cleaned and maintained. Review of the document revealed the facility did not implement the policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00161301.

Based on record review, observation, resident interview, staff interviews, and facility policy review, the facility failed to ensure facility equipment was maintained to ensure residents received the care pertaining to their needs and preferences. This affected one resident (#17) of one resident, but had the potential to affect five additional residents (#11, #74, #86, #98, #133) residing on the 1 East Unit, who required a mechanical lift. The facility census was 142. Findings include: 1. Review of the medical record for Resident #17 revealed she was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, type two diabetes mellitus, and hypertensive heart disease. Review of the 5-Day, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was alert and oriented with cognitive impairment. Resident #17 was dependent on staff for activities of daily living (ADL). Review of Resident #17's physician orders dated 04/09/24 revealed an order for Hoyer lift (mechanical lift) for all transfers. Review of the weight summary dated 11/06/24 for Resident #17 revealed a weight of 298.4 pounds (Lbs.). Review of the weight summary revealed she was weighed by a Hoyer scale. 2. Review of the medical record for Resident #11 revealed he was admitted to the facility on [DATE] with diagnoses that included morbid obesity, heart failure, and abnormal posture. Review of the physician orders for Resident #11 revealed orders dated 02/04/23 for Hoyer lift for all transfers. 3. Review of the medical record for Resident #74 revealed he was admitted to the facility on [DATE] with diagnoses that included Lennox-Gastaut syndrome intractable without status epilepticus, encephalopathy, and schizoaffective disorder. Review of Resident #74's physician orders dated 04/09/24 revealed an order for Hoyer lift for all transfers. 4. Review of the medical record for Resident #86 revealed he was admitted to the facility on [DATE] with diagnoses that included lymphedema, hypertension, and obesity. Review of Resident #86's physician orders dated 02/08/23 revealed an order for the resident to be transferred via Hoyer lift with two-person assist. 5. Review of the medical record for Resident #98 revealed he was admitted to the facility on [DATE] with diagnoses that included type two diabetes, major depressive disorder, and acquired absence of left leg below knee. Review of Resident #98's physician orders dated 10/14/24 revealed an order for Hoyer lift for all transfers. 6. Review of the medical record for Resident #133 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia and insomnia. Review of Resident #133's physician orders dated 04/09/24 revealed an order stating the resident may use Hoyer lift. Review of the medical records for Resident's #11, #17, #74, #86, #98, #133 revealed they all resided on the 1 East Unit that required the use of the broken Hoyer lift. Interview on 01/08/25 at 10:09 A.M. with Licensed Practical Nurse (LPN) #820 revealed Resident #17 required a Hoyer lift for all transfers. LPN #820 revealed each unit in the facility had a designated Hoyer lift. LPN #820 revealed the 1 East Unit, where Resident #17 resided, had a bariatric Hoyer lift that was broken due to the legs not working properly. LPN #820 revealed Resident #17 was not happy about it due to not being able to get up and being stuck in bed. LPN #820 revealed the Hoyer lift designated for the 1 East Unit had been broken for at least, approximately, one week. LPN #820 revealed Resident #17 preferred to get out of bed, even if it was only for 15 minutes at a time. Observation and interview on 01/08/25 at 11:11 A.M. revealed Resident #17 lying in bed. Resident #17 expressed delight when the state surveyor entered her room. Resident #17 revealed the Hoyer lift was broken, and she had been stuck in bed. Resident #17 revealed the facility would not get the Hoyer lift fixed, and she had been stuck in bed for three weeks. Resident #17 revealed the Hoyer lift being broken was a big issue for her because she did not like being stuck in bed. Resident #17 revealed two staff members had attempted to manually transfer her out of bed, but the attempt was unsuccessful due to her weight. Resident #17 revealed the facility refused to purchase a new Hoyer lift. Interview on 01/08/25 at 2:41 P.M. with Certified Nurse Assistant (CNA) #921 revealed the Hoyer designated for the first-floor unit was broken, and she was unable to get residents up who required a Hoyer lift for transfers. Interview on 01/08/25 at 2:47 P.M. with CNA #808 revealed the first-floor Hoyer lift was broken. Interview on 01/08/25 at 3:24 P.M. with Maintenance Director (MD) #953 revealed he was aware of the broken Hoyer lift designated for the first-floor unit. MD #953 revealed he had a current work order in place due to the legs of the Hoyer not spreading under load. MD #953 revealed each unit had their own designated Hoyer lift. MD #953 revealed the Hoyer lift cost to repair, was unaware how long it had been broken, and was unsure of when it would be repaired. Review of the work order report dated 12/08/24 to 01/09/25, provided by the facility, revealed two work orders regarding a Hoyer lift not working and a Hoyer battery charger broken. Review of the work order report revealed no other work orders related to Hoyer lifts. Review of the undated facility document titled Mechanical Lift Policy revealed the facility had a policy in place to ensure residents received appropriate, high-quality care, and mechanical lifting devices were accessible to staff, maintained regularly, and was kept in proper working order. Review of the documents revealed the facility did not implement the policy. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, resident interviews, staff interviews, and facility policy review, the facility failed to ensure temperatures in the facility were at a comfortable level. This affected nineteen residents (#11, #17, #38, #44, #45, #47, #49, #58, #61, #77, #82, #97, #119, #123, #124, #125, #129, #136, #140) of twenty-nine residing on the 1 East Unit located on the first floor and two residents (#30, #109) of seventeen residing on the 2 East Unit located on the second floor. The facility census was 142. Findings include: Observation on 01/08/25 from 8:00 A.M. to 8:55 A.M., during tour of the 1 East Unit, revealed a cold and chilled breeze circulating throughout the unit. Interview and observation on 01/08/25 at 8:47 A.M. with Resident #82, who resided on the 1 East Unit, revealed it was cold in her room. Resident #82 was observed lying in bed with a sheet and blanket wrapped around her. Interview and observation on 01/08/25 at 8:49 A.M. with Resident #38, who resided on the 1 East Unit, revealed she was always cold. Resident #38 revealed her bed was located up against the wall with a window. Resident #38 revealed it was cold in her room and the facility staff was aware. Resident #38 was observed wearing a robe, heavy coat, and two blankets. Observation on 01/08/25 at 8:52 A.M. located on the 1 East Unit, revealed a vent affixed to the wall outside of Resident's #124 and #129 room. Observation revealed the vent was blowing cold air. Interview on 01/08/25 at 10:05 A.M. with Resident #58, who resided on the 1 East Unit, revealed it was cold in his room. Interview on 01/08/25 at 10:09 A.M. with Licensed Practical Nurse (LPN) #820 revealed residents normally complained about the temperature in the building. LPN #820 revealed the temperature in the building was spotty with certain areas being warmer than other areas. Observation on 01/08/25 at 10:21 A.M., located on the 1 East Unit, revealed a ceiling vent outside of Resident's #49 and #58 room blasting cold air. Interview on 01/08/25 at 10:21 A.M. with LPN #820 confirmed and verified the cold air blowing from the vent affixed to the wall outside of Resident's #124 and #129 room and the ceiling vent outside of Resident's #49 and #58 room. Interviews on 01/08/25 at 10:44 A.M. with Resident's #30 and #109, who shared rooms and resided on the 2 East Unit, revealed they had no heat in their room. Resident's #30 and #109 revealed their room was as cold as it was outside. Interview on 01/08/25 at 10:44 A.M. with Certified Nurse Assistant (CNA) #833 revealed the building was freezing cold. Observation on 01/08/25 at 10:50 A.M. of Resident's #30 and #109 room revealed a cold and chilled breeze circulating throughout the room. Interview on 01/08/25 at 11:11 A.M. with Resident #17, who resided on the 1 East Unit, revealed it was freezing in her room. Interview and observation on 01/08/25 from 11:39 A.M. to 12:00 P.M. with Maintenance Director (MD) #953, during tour of the facility, revealed he routinely checked the temperatures on the different units. MD #953 revealed he attempted to maintain the building temperature with a target temperature of 74 degrees Fahrenheit (F) for the entire facility. Observation during tour of the facility, with MD #953, revealed a temperature reading of 67 degrees F located near the 1 East Nursing station (utilized by residents during medication pass), 68 degrees F located in the 1 East common area, 68 degrees F in Resident's #17 and #61 room, 66 degrees F in Resident's #38 and #82 room, 68 degrees F in Resident's #49 and #58 room, and 68 degrees F in Resident's #45 and #77 room. Observation during tour of the facility with MD #953, of Resident's #30 and #109 room, revealed a temperature reading of 68 degrees F. Interview on 01/08/25 at 12:00 P.M. with MD #953 revealed he was not aware of the concerns in the facility related to temperatures. MD #953 confirmed and verified the above findings at the time of the tour. Follow-up interview on 01/08/25 at 12:15 P.M. with MD #953 revealed the heat on the 1 East Unit was not on. Review of the facility document titled Temperature Extremes, dated March 2019, revealed the facility had a policy in place to provide comfortable and safe temperature levels. Review of the policy revealed the temperature throughout the facility should be maintained between 71 degrees and 81 degrees Fahrenheit. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents non-compliance investigated under Master Complaint Number OH00161301.

Based on record review, observations, staff interviews, and facility policy review, the facility failed to ensure Resident #8 was treated with dignity. This affected one resident (#8) of one reviewed for dignity. The facility census was 142. Findings include: Review of the medical record for Resident #8 revealed she admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, schizoaffective disorder, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ten that indicated Resident #8 had cognitive impairment. Resident #8 required setup or clean-up assistance for eating. Review of Resident #8's physician orders dated 05/29/19 revealed an order for a no added salt diet, pureed texture with thin consistency. Review of the care plan dated 10/13/24 revealed Resident #8 had a nutritional risk related to schizoaffective disorder with interventions that included provide and serve diet as ordered. Observation on 01/09/25 at 12:10 P.M. revealed the third-floor lunch meal tray carts arrived to the unit and were placed in the dining room. Observation revealed Resident's #8, #27, and #137 were seated at the same table. Observation on 01/09/25 at 12:13 P.M. revealed Certified Nurse Assistant (CNA) #817 provided Resident's #27 and #137 their lunch trays. Observation revealed Resident's #27 and #137 begin to eat their lunch meal. Observation revealed Resident #8 was without a lunch meal tray. Observation on 01/09/25 at 12:14 P.M. revealed CNA #817 returned to check the lunch meal tray carts. CNA #817 was unable to located Resident #8's lunch meal tray. Interview on 01/09/25 at 12:14 P.M. with CNA #817 revealed Resident #8 did not have a lunch meal tray and the kitchen forgot to plate her lunch meal. CNA #817 revealed the kitchen was contacted to provide Resident #8 a lunch meal tray. Observation on 01/09/25 at 12:14 P.M. revealed Resident #8 yelling and screaming asking for a lunch tray. Resident #8 was observed pacing the dining room back and forth, visibly upset, crying, and asking for her food. Resident #8 was unable to be redirected. Observation on 01/09/25 at 12:33 P.M., approximately 19 minutes later, revealed Regional Culinary Director (RCD) #956 arrived to the unit with Resident #8's lunch meal tray in hand. Interview on 01/09/25 at 12:33 P.M. with CNA #817 confirmed and verified the above findings at the time of the observation. Review of the facility document titled Resident's Rights, dated December 2020, revealed the facility had a policy in place that each resident had a right to be treated at all times with courtesy, respect, and full dignity and individuality. Review of the document revealed the facility did not implement the policy. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on record review and interview, the facility failed to ensure that Resident #3's privacy was maintained. This affected one resident (#3) of two residents reviewed for personal privacy and confidentiality. The facility census was 145. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included psychosis, impulse disorder, and alcohol dependence with alcohol induced dementia. Resident #3 was discharged to the hospital on 09/09/24, re-entered 09/10 24, was discharged to the hospital on 09/12/24, re-entered 10/01/24, and was discharged to the hospital on 10/09/24. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition. Behaviors included hallucinations, delusions, physical behavioral symptoms, verbal behavioral symptoms, and other behavioral symptoms. Review of the Facility Bulletin Board, on the Electronic Medical Record (EMR) screen revealed on 09/17/24 the administrator posted that Resident #3's daughter/power of attorney (POA) asked the facility not to give out any information regarding the resident to family members except for her. Interview on 10/25/24 at 12:38 P.M. with the Director of Nursing (DON) verified a large group of family members came to see Resident #3 when he was out at the hospital. They were upset and wanted to know what was going on. The family was told Resident #3 had been sent to a hospital in the area. Interview on 10/25/24 at 1:41 P.M. with Resident #3's daughter revealed family members were informed by the facility the resident was admitted to the hospital and the reason why he was admitted . This deficiency represents non-compliance investigated under Master Complaint Number OH00158996.

Based on observation, staff interview and policy review the facility failed to ensure ice machines were maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 140. Findings include: Observation of the facility's ice machine on 08/01/24 at 7:45 A.M. with Dietary Manager (DM) #924 revealed the main ice machine was not working and had been out of service since 06/24/24. DM #924 explained that the facility was awaiting parts to replace the unit and the facility was temporarily using the ice machine on the second floor to meet its needs. Observation of the second floor ice machine on 08/01/24 at 9:11 A.M. with DM #924 revealed the top portion of the ice machine had a large area of slimly brown and green mold. The machine also had a noticeable musty smell when opened. DM #924 verified the condition of the ice machine at the time of observation. Review of the policy clean schedules dated 10/01/21 revealed culinary manager or designee monitors sanitation of department and assigns correction as needed.

Based on interview and observations the facility failed to maintain a safe and sanitary resident environment. This affected 68 residents who used the showers (#1, #4, #5, #13, #17, #22, #23, #29, #31, #32, #35, #41, #46, #48, #52, #55, #56, #70, #71, #73, #75, #87, #88, #89, #93, #96, #97, #100, #102, #104,#112, #113, #114, #129, #132, #134, #135, #10, #14, #19, #26, #34, #37, #43, #44, #45, #47, #60, #61, #63, #67, #72, #77, #79, #80, #82, #85, #98. #107, #116, #119, #122, #123, #124, #128, #130, #131, #133, and #137) and 21 residents who ate in the dining room on the third-floor secured unit (#7, #9, #20, #24, #27, #28, #30, #33, #38, #51, #57, #59, #64, #65, #78, #92, #99, #101, #110, #118, and #126). Facility census was 140. Findings include: Interview on 07/31/24 at 9:17 A.M. with Resident #32 who resided on the third-floor unit revealed the shower was nasty. Resident #32 said a resident with a colostomy bag used the shower room leaving feces all over the toilet and shower floor. Observation on 07/31/24 at 9:30 A.M. of the third-floor dining room revealed staff and residents were present. The residents were finished eating and staff had placed breakfast trays in the tray cart and were cleaning off tables. Approximately 12 gnats were observed flying in the dining room. A three-shelf cart on wheels located on the side of the dining room had an empty tray on it. Further observation of the cart revealed a large amount of milk had spilled between the tray and the cart. Interview on 07/31/24 at 9:35 A.M. with State tested Nurse Assistant (STNA) #200 verified the gnats and empty tray with spilled milk between the tray and the cart. Observation on 07/31/24 at 9:47 A.M. of Resident #129's room located on the third floor revealed the resident was lying in bed. There were at least a dozen gnats crawling on a washcloth that was hanging on the headboard and another dozen lying in a box on the floor next to the resident's bed. Interview with the resident during the observation revealed the resident was not concerned the gnats in his room. Interview on 07/31/24 at 9:53 A.M. with Licensed Practical Nurse (LPN) #211 verified the gnats in Resident #129's room. Observations on 07/31/24 at 10:19 A.M. of the first-floor shower room revealed towels and blankets lying on the floor and a toothbrush on the floor of the shower stall. Interview on 07/31/24 at 10:19 A.M. with STNA #204 and STNA #206 verified the observations and each stated they were unaware of the condition of the shower room until this observation. Observations on 07/31/24 at 4:32 P.M. of the third-floor shower room revealed the shower head and hose were hanging down because the clamp did not secure the shower head to the wall of the shower. The cover to the shower drain (a thin flat round piece of metal) was not properly secured. The screws were missing from the cover and the cover moved when touched. The shower stall had soap scum on the walls and floor. Interview during the observations with STNA #201 and the Housekeeping Manager verified the observations. Observations on 08/01/24 at 9:57 A.M. of the second-floor secured unit shower room revealed broken tile pieces, a blanket, and one shoe lying on the floor. Observation on 08/01/24 at 10:11 A.M. revealed STNA #219 walking a resident into the shower room. Interview with STNA #219 at this time revealed she had just showered another resident prior to walking the current resident into the shower room. STNA #219 verified the broken tile, blanket and shoe lying on the floor. Review of lists provided by the facility revealed Residents #1, #4, #5, #13, #17, #22, #23, #29, #31, #32, #35, #41, #46, #48, #52, #55, #56, #70, #71, #73, #75, #87, #88, #89, #93, #96, #97, #100, #102, #104,#112, #113, #114, #129, #132, #134, #135, #10, #14, #19, #26, #34, #37, #43, #44, #45, #47, #60, #61, #63, #67, #72, #77, #79, #80, #82, #85, #98. #107, #116, #119, #122, #123, #124, #128, #130, #131, #133, and #137 used the shower rooms and Residents #7, #9, #20, #24, #27, #28, #30, #33, #38, #51, #57, #59, #64, #65, #78, #92, #99, #101, #110, #118, and #126 ate their meals in the third floor secured dining room. This deficiency represents non-compliance investigated under Complaint Number OH00156449 and OH00155557.

Based on record review and interview the facility failed to ensure timely assessment of residents and review of the risks and benefits of bed rails with the residents after removing all bed rails that were currently in place and being used by the residents. This affected six (Resident #7, #12, #16, #85, #131, and Resident #133) of 19 residents whose side rails and grab bars were removed. Based on observation, record review and interview the facility also failed to provide timely incontinence care to prevent incontinence dermatitis. This affected one (Resident #66) of three reviewed for incontinence care. Findings include: 1. Interview on 07/31/24 at 9:32 A.M. with Licensed Practical Nurse (LPN) #202 revealed management removed all the bed rails from resident beds leaving residents dependent on staff for mobility and transfers. LPN #202 stated it made it more difficult on staff because the residents were leaning and grabbing on the staff for help. Interview on 07/31/24 at 10:00 A.M. with LPN #211 revealed all the bed rails were removed from resident beds because the state agency told them their use was illegal. Interview on 08/01/24 at 9:31 A.M. with Regional Support Administrator (RSA) #212 revealed the facility had an outside company come in and survey the facility. They were directed to remove all the bed rails. RSA #212 stated all residents would be reassessed by the therapy department for bed mobility and use of bed rails. RSA #212 stated the bed rails were removed in July 2024. Interview on 08/01/24 at 10:12 A.M. with Therapy Director (TD) #213 revealed she was directed by RSA #212 to start assessing the residents for bed mobility on 07/31/24. TD #213 verified the residents were without bed rails for over a month. Interview on 08/01/24 at 10:43 A.M. with Maintenance Director #214 revealed he was told to take the grab bars and side rails off all beds around 06/20/24. 2. Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included unspecified dementia, mild, with anxiety, schizoaffective disorder, unsteadiness on feet, other abnormalities of gait and mobility, and unspecified intellectual disabilities. Review of the plan of care dated 04/14/23 revealed Resident #7 had a activities of daily living (ADL) self-care performance deficit related to schizoaffective disorder, intellectual disabilities, muscle weakness, and anxiety. Interventions included the use of bilateral grab bars to assist with mobility. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/13/24, revealed Resident #7 had intact cognition and was independent with rolling, sitting to standing, and lying to siting while in bed. Review of the facility Functional Abilities and Goals assessment dated [DATE] revealed Resident #7 required moderate assistance to roll left to right while lying in bed, and to move from lying on back to sitting on the side of the bed. Review of the facility Side/Bed Rail Utilization assessment dated [DATE] revealed Resident #7 was observed with bed mobility supine (lying on back) to/from sitting to/from standing at edge of bed safely. Resident #7 stated that she previously had grab bars on her bed that she used because it made her mobility easier. Interview on 07/31/24 at 10:14 A.M. with Resident #7 revealed she did not like it when staff removed the grab bars from her bed. Resident #7 said she felt safe when the grab bars were present and the bars helped her get in and out of bed independently; without the grab bars she was dependent on staff to assist her out of bed. Interview on 07/31/24 at 4:09 P.M. with Certified Occupational Therapy Assistant (COTA) #210 revealed residents could benefit from the use of siderails/grab bars that did not restrain or restrict the residents. COTA #210 stated Resident #7 utilized the grab bars to get in and out of bed independently. 3. Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included altered mental status, unspecified, obesity, difficulty in walking, muscle weakness and a history of falls. Review of the plan of care dated 04/12/23 revealed Resident #12 had a risk for falls due to history of falls, muscle weakness, difficulty walking, and psychotropic medication use. Interventions included the use of bilateral grab bars to enhance bed mobility dated 04/17/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/10/24, revealed Resident #12 had intact cognition and was independent with activities of daily living. Review of the facility Side/Bed Rail Utilization assessment dated [DATE] revealed Resident #12 utilized bed rails to roll, reposition, and perform bed mobility tasks. Resident #12 stated she was unable to use a trapeze because it hurt her back and was very difficult. Resident #12 stated she was able to utilize bed rails with increased independence. Review of the facility Functional Abilities and Goals assessment dated [DATE] revealed Resident #12 was independent with activities of daily living. Interview on 08/05/24 at 9:38 A.M. with Resident #12 revealed staff took the grab bars away and she now had to rely on staff to get out of bed. Resident #12 stated she spent more time in bed now due to not having the bars. 3. Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included vascular dementia, other abnormalities of gait and mobility, unsteadiness on feet, unspecified lack of coordination and a history of falls. Review of the plan of care dated 04/12/23 revealed Resident #16 had a risk for falls related to deconditioning and psychoactive drug use. Interventions included the use of bilateral half siderails to assist with mobility dated 12/01/23 and 04/10/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/07/24, revealed Resident #16 had intact cognition and was independent with activities of daily living. Review of the facility Functional Abilities and Goals assessment dated [DATE] revealed Resident #16 was independent with activities of daily living. Review of the facility Side/Bed Rail Utilization assessment dated [DATE] revealed Resident #16 utilized bilateral bed rails to safely roll, reposition, and perform bed mobility tasks. Resident #16 reported she was spending more time in bed due to increased difficulty performing bed mobility without rails. Interview on 08/05/24 at 9:32 A.M. with Resident #16 revealed staff took her bed bars away and she needed them to pull herself up and get out of bed. Resident #16 stated she now spent more time in her bed due to not having the bars for assistance. 4. Review of the medical record for Resident #85 revealed an admitted [DATE]. Diagnoses included difficulty in walking, bi-polar disorder, unspecified abnormalities of gait and mobility, and obesity. Review of the plan of care dated 04/12/23 revealed Resident #85 had an activities of daily living (ADL) self-care performance deficit related to impaired balance, weakness, rhabdomyolysis, and bi-lateral lower extremity lymphedema. Interventions included the use of bilateral half siderails to assist with mobility dated 04/13/23. Review of the facility Functional Abilities and Goals assessment dated [DATE] revealed Resident #85 required moderate assistance for toilet hygiene, rolling left to right in bed and toilet transfers. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/05/24, revealed Resident #85 had intact cognition and required moderate assist for rolling left to right in bed. Review of the facility Side/Bed Rail Utilization assessment dated [DATE] revealed Resident #85 used bed rails for rolling and repositioning and bed mobility. Interview on 07/31/24 at 11:16 A.M. with Resident #85 revealed he could roll and reposition himself in bed with the siderails, now that the siderails had been removed he was dependent on staff for assistance. 5. Review of the medical record for Resident #131 revealed an admitted [DATE]. Diagnoses included unspecified abnormalities of gait and mobility, vascular dementia, and muscle weakness. Review of the plan of care dated 04/12/23 revealed Resident #131 had an activities of daily living (ADL) self-care performance deficit related to dementia and history of traumatic brain injury. Interventions included the use of bilateral half siderails to assist with mobility dated 07/29/16 and 04/01/18. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/17/24, revealed Resident #131 had intact cognition. Resident #131 required maximum assist for rolling left to right while in bed. Review of the facility Functional Abilities and Goals assessment dated [DATE] revealed Resident #131 was dependent for rolling left to right while in bed. Review of the facility Side/Bed Rail Utilization assessment dated [DATE] revealed Resident #131 displayed use of a grab bar assist bilaterally for rolling and going from supine to sitting. Interview on 08/01/24 at 1:15 P.M. with Resident #131 revealed she used the side rails all the time and since they had been removed she needed help from the staff. Resident #131 stated it was very frustrating that she could no longer roll over in bed independently. 6. Review of the medical record for Resident #133 revealed an admitted [DATE]. Diagnoses included unspecified abnormalities of gait and mobility, schizophrenia, and unsteadiness on feet. Review of the plan of care dated 07/28/22 revealed Resident #133 had an activities of daily living (ADL) self-care performance deficit related to schizophrenia, muscle weakness and use of psychoactive medications. There was no intervention regarding use of side rails or grab bars. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #133 had intact cognition. Resident #133 was independent for rolling left to right while in bed and required touch assistance for sit to stand. Review of the facility Side/Bed Rail Utilization assessment dated [DATE] revealed Resident #133 stated the bilateral bed rails helped her roll to either side and the right rail helped her get in and out of bed. Review of the facility Functional Abilities and Goals assessment dated [DATE] revealed Resident #133 required moderate assist for rolling left to right while in bed and chair/bed-to-chair transfer from bed to wheelchair. Interview on 08/01/24 at 11:53 A.M. with Resident #133 revealed she had a fall because she did not have the rails on her bed. Resident #133 stated she used to be able to get out of bed without staff when the rails were on her bed. Resident #133 stated she was now dependent on staff for assistance Interview on 08/01/24 at 1:29 A.M. with LPN #215 revealed Resident #133 had a fall the day after maintenance removed her bed rails. LPN #215 stated Resident #215 used the bed rails all the time to sit up, roll over in bed and get out of bed. 7. Review of the medical record for Resident #66 revealed an initial admitted [DATE] with readmissions on 04/23/24, 05/13/24, and 07/21/24. Diagnoses included Wernicke's encephalopathy, restlessness and agitation, and anxiety disorder. Review of the plan of care dated 07/26/24 revealed Resident #66 had potential for pressure ulcer development related to limited movement and medical status. Interventions included to provide weekly skin checks and to follow policies/procedures for prevention/treatment of skin breakdown. Review of the admission Minimum Data Set (MDS) assessment, dated 07/28/24, revealed Resident #66 had impaired cognition and was dependent for all activities of daily living. There was no documentation of skin alterations. Review of the facility weekly skin assessments revealed documentation dated 06/06/24, 06/10/24, 06/27/24, 07/09/24 and 08/03/24 which indicated Resident #66 had no skin alterations. Review of shower sheets for Resident #66 dated 07/24/24 through 08/03/24 revealed no documentation indicating the resident had alterations in skin. Review of incontinence care tracking documentation from 07/22/24 through 08/07/24 revealed staff provided incontinence care twice on 07/22/24, once on 07/23/24, twice on 07/24/24, and 07/25/24, once on 07/26/24, once on 07/28/24, twice on 07/30/24, once on 07/31/24, once on 08/02/24, twice on 08/04/24, once on 08/05/24, and twice on 08/06/24 and 08/07/24. Review of the July/August 2024 treatment administration records (TAR) for Resident #66 revealed an order for nystatin external powder, apply to groin and under both breast topically every day for redness dated April 2024 through 07/21/24. Further review of the TAR revealed a order for nystatin external cream 100,000 unit/gram, apply to effected areas topically every 12 hours as needed for irritation. There was no documentation on the TAR indicating staff had applied the nystatin cream since 07/21/24. Review of the plan of care dated 08/07/24 revealed Resident #66 had actual impairment to skin related to redness to perineum and sacrum. Interventions included to encourage medication and treatment regimen. The plan of care also indicated Resident #66 had bowel incontinence related to Wernicke's encephalopathy and disease process. Interventions included to check resident on routine rounds and assist with toileting as needed and provide peri-care after each incontinent episode. Observation on 08/06/24 at 9:00 A.M. revealed State tested Nurse Assistant (STNA) #217, STNA #218 and Unit Manager #221 providing incontinence care for Resident #66. Upon removal of Resident #66's incontinence brief a red rash covering the resident's entire peri area including the buttocks was observed. When asked about the rash, the STNAs stated Oh, she has had that rash forever. Continued observations revealed after the STNAs cleaned the entire peri-area and were getting ready to secure the brief in place the Unit Manager stated, are you going to put cream on her? The STNAs retrieved a tub of thera calazinc body shield from a basket in the resident's room and applied the barrier shield. Interview on 08/07/24 at 8:22 A.M. with the Director of Nursing (DON) revealed she was not aware of Resident #66's rash but she would check into it. The DON verified the documentation in the incontience care tracking indicating staff only provided incontience care one or two times daily from 07/22/24 through 08/07/24. The DON said Resident #66 was also receiving care from hospice services and that the hospice staff came in and completed incontinence care during their visits. Review of hospice documentation revealed hospice services did not visit daily and when they did visit, they stayed an average of 45 minutes to 1.5 hours. Interview on 08/07/24 at 8:52 A.M. with the Wound Nurse verified the information on the TAR and stated she was not made aware of the rash until 08/06/24. The Wound Nurse stated she would put Resident #66 on the list to be assessed by the wound physician. Interview on 08/07/24 at 11:30 A.M. with Nurse Practitioner (NP) #220 revealed she was not aware of Resident #66's rash because hospice rarely communicated with her. NP #220 stated she assessed Resident #66 last week but did not observe the rash because no one informed her of the rash. NP #220 stated she would assess Resident #66 and her share findings. During a follow up interview with NP #220 on 08/07/24 at 11:53 A.M., NP#220 stated Resident #66's rash was dermatitis due to poor incontinence care. Review of the NP note dated 08/07/24 revealed Resident #66 had incontinent dermatitis to peri-area. Review of incontinent dermatitis on www.healthline.com revealed incontinent dermatitis was caused by ineffective or poor condition management which included prolonged exposure to urine and feces and inadequate cleaning of the exposed area. This deficiency represents non-compliance investigated under Complaint Number OH00155631, OH00156449, and OH00155557.

Based on record review and interview the facility failed to develop a comprehensive care plan for Resident #133 related to the use of bed side rails which assisted Resident #133 with bed mobility and getting in and out of bed. This affected one (Resident #133) of six residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #133 revealed an admitted [DATE]. Diagnoses included unspecified abnormalities of gait and mobility, schizophrenia, and unsteadiness on feet. Review of the plan of care dated 07/28/22 revealed Resident #133 had an activities of daily living (ADL) self-care performance deficit related to schizophrenia, muscle weakness and use of psychoactive medications. The interventions listed did not include use of side rails or grab bars to the bed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #133 had intact cognition, was independent for rolling left to right while in bed and required touch assistance for sit to stand. Review of the nurse's progress note dated 06/26/24 timed at 6:44 P.M. revealed Resident #133 was found on the floor in her room yelling for help. Staff completed a full assessment of Resident #133 and no injuries were noted. Resident #133 stated I was reaching for my bars on the bed and could not find them, and that's how I fell . Resident #133 was assisted off the floor by three staff members. Review of the facility Side/Bed Rail Utilization assessment dated [DATE] revealed Resident #133 indicated the bilateral bedrails helped her roll to either side and the right rail helped her get in and out of bed. Review of the facility Functional Abilities and Goals assessment dated [DATE] revealed Resident #133 required moderate assist for rolling left to right while in bed and chair/bed-to-chair transfer from bed to wheelchair. Interview on 08/01/24 at 9:31 A.M., the Regional Support Administrator (RSA) #212 revealed the facility had an outside company come in and survey the facility. After the survey they were directed to remove all the bed side rails and grab bars. RSA #212 stated the bars and side rails were removed July 2024. Interview on 07/31/24 at 1:29 P.M. with Licensed Practical Nurse (LPN) #215 revealed staff had removed the half side rails from Resident #133's bed the day before or on the same day she fell from bed. LPN #215 stated she was upset the side rails had been removed because Resident #133 used the side rails to get in and out of bed. LPN #215 verified Resident #133's care plan did not include information regarding use of side rails. Interview on 08/01/24 at 11:53 A.M. with Resident #133 revealed she had a fall because she did not have the side rails on her bed. Resident #133 stated before the side rails were removed she used to be able to get out of bed without staff, now she was dependent on staff for assistance to get in out of bed.

Based on record review and interview the facility failed to ensure residents were redirected from safety hazards affecting Resident #135 and failed to ensure bed rails were not removed prior to assessing the resident's ability to exit the bed safely without the rails affecting Resident #133. This affected two of six residents reviewed for falls. Findings include: 1. Review of the medical record for Resident #133 revealed an admitted [DATE]. Diagnoses included unspecified abnormalities of gait and mobility, schizophrenia, and unsteadiness on feet. Review of the plan of care dated 07/28/22 revealed Resident #133 had an activities of daily living self-care performance deficit related to schizophrenia, muscle weakness and use of psychoactive medications. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #133 had intact cognition. Resident #133 was independent for rolling left to right while in bed. Review of the facility Side/Bed Rail Utilization assessment dated [DATE] revealed Resident #133 utilized the bilateral bed rails to help her roll to either side and the right bed rail to get in and out of bed. Review of the facility Functional Abilities and Goals assessment dated [DATE] revealed Resident #133 required moderate assist for rolling left to right while in bed and chair/bed-to-chair transfer from bed to wheelchair. Review of the incident log for the past three months revealed Resident #133 had a fall on 06/26/24. Review of the nurse's progress note dated 06/26/24 timed at 6:44 P.M. revealed Resident #133 was found on the floor in her room yelling for help. Staff completed a full assessment and no injuries were reported. Resident #133 stated I was reaching for my bars on the bed and could not find them, and that's how I fell . Resident #133 was assisted off the floor by three staff members. Interview on 07/31/24 at 9:32 A.M. with Licensed Practical Nurse (LPN) #202 revealed management removed all the grab bars and side rails leaving residents dependent on staff for mobility and transfers. Interview on 07/31/24 at 1:29 P.M. with LPN #215 revealed she could not remember if management removed the side rails the day before or on the same day Resident #66 had her fall. LPN #215 was upset because Resident #133 used the rails to get in and out of bed and Resident #133 had no falls prior to this incident. Interview on 08/01/24 at 11:53 A.M. with Resident #133 revealed she had a fall because she did not have the rails on her bed. Resident #133 stated she used to be able to get out of bed without staff using the side rails. Resident #133 stated she was now dependent on staff for assistance. 38091 2. Resident #135 was admitted to the facility on [DATE] with diagnoses that included dementia, restlessness and agitation and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #135 was severely cognitively impaired and required supervision for completing his activities of daily living. Review of the care plan dated 02/12/24 revealed Resident #135 was at risk for falls related to psychoactive drug use. Review of the falls risk assessments from 06/23/24, 05/09/24, and 02/09/24 revealed Resident #135 was at moderate risk for falls. Observation on 08/01/24 at 10:18 A.M. revealed Resident #135 was sprinting laps up and down the hallway. While he was sprinting down the hallway the floor was noted to be wet and Maintenance Technician (MT) # 400 was pushing a large floor scrubbing machine down the hallway. While Resident #135 was running down the hallway he passed State tested Nursing Assistant (STNA) #475 who was engaging in documentation of activities in the hallway on a rolling cart, Licensed Practical Nurse (LPN) #485 documenting inside the nurse's station and Activities Workers (AW) #450 conversing in the hallway, multiple times. After completing approximately two laps up and down the hallway AW #450 began running alongside Resident #135. After running for approximately 15 feet Resident #135 fell to his knees on the floor. Interview with AW #450 on 08/01/24 at 10:24 A.M. verified the events of the observed fall. AW #450 further stated that Resident #135 believed he was part of the Olympics and ran sprints down the hallway all the time. Review of the facility fall policy dated 04/01/21 revealed It is the policy of this facility to assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. This deficiency represents non-compliance investigated under Complaint Number OH00155557 and OH00155631.

Based on observation, record review, review of a facility Self-Reported Incident (SRI) and related facility investigation, review of hospital records, facility policy review and interviews, the facility failed to ensure Resident #143 was free from an incident of resident-to-resident physical abuse. This affected one resident (#143) of three residents reviewed for abuse. The facility census was 145. Actual harm occurred on 06/18/24 when Resident #143, who was cognitively impaired and had been independent with activities of daily living (ADLs) prior to 06/18/24, sustained a fall after being pushed by Resident #109, was sent to the local hospital emergency room for an examination on 06/18/24 and was found to have a left humerus (major upper arm bone) fracture. Although he returned to the facility on [DATE] he was sent out a second time to the hospital on 06/22/24 after complaints of right wrist pain developed at the facility and was diagnosed with a right wrist fracture. The facility investigation confirmed both fractures resulted from the incident on 06/18/24. As a result of the incident related fractures, Resident #143 was no longer independent with his ADLs and required staff to provide assistance to him. Findings include: Review of medical record for Resident #143 revealed an admitted [DATE] with diagnoses including fracture of upper end of left humerus, fracture of the lower end of right radius, and dementia. Review of the 03/24/24 quarterly Minimum Data Set (MDS) assessment for Resident #143 revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15 indicating he was alert and oriented with cognition impairment. The assessment revealed the resident had inattention and disorganized thinking. Further review of the MDS assessment revealed Resident #143 was independent for activities of daily living (ADLs) such as dressing, bathing, eating, toileting, bed mobility and transfers. Review of the care plan, dated 03/24/24, revealed Resident #143 had a history of aggressive behaviors, including but not limited to, throwing things at staff, cursing at others, pacing, hallucinations, delusions and agitation and cognition impairment and dementia. Interventions included to provide assistance as needed, administer medications as ordered, monitor, observe, and report to physician. Review of medical record for Resident #109 revealed an admitted [DATE] with diagnoses including pancytopenia, schizoaffective disorder and cognitive communication deficit. Review of the care plan, dated 08/24/18, revealed Resident #109 had a history of delusions, physically aggressive behaviors, including throwing things at staff, threatening and verbally aggressive, cursing at others, pacing, hallucinations, agitation and cognition impairment and dementia. Interventions included intervening as needed, analyze triggers and circumstances, provide assistance as needed, administering medications as ordered, monitoring, observe, and reporting to physician. Review of the 04/24/24 quarterly MDS assessment for Resident #109 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 that indicated he was alert and oriented to person, place, and time. The assessment revealed the resident had disorganized thinking. Review of the MDS assessment revealed Resident #109 was independent for activities of daily living (ADLs). Further review of the medical record for both Resident #143 and Resident #109 did not reveal any documented incidents of resident-to-resident abuse prior to an incident on 06/18/24. The residents had been roommates for approximately one year. Review of a facility self-reported incident (SRI), dated 06/18/24 revealed an allegation of physical abuse was reported to the State agency involving Resident #143 and Resident #109. Review of the SRI revealed Resident #143 reported, his previous roommate, Resident #109 pushed him from behind causing him to fall and was subsequently sent to the emergency room for evaluation due to also reporting hitting his head. Resident #109 was asked and denied having any physical contact with Resident #143 and subsequently given a room change. Review of the SRI revealed Resident #109 initially denied any physical contact but later admitted to pushing Resident #143 due to him getting in between him and his wife, however, Resident #109 had never been married and was actively having delusional thoughts. Review of the SRI revealed neither resident had a history of resident-to-resident physical altercations, therefore, the facility unsubstantiated the findings. As a result of the resident-to-resident physical altercation, Resident #143 suffered a fracture of the right wrist and left humerus. Review of the facility investigation and witness statement from Licensed Practical Nurse (LPN) #948 revealed Resident #109 stated Resident #143 had fallen on the floor. Upon entry into the shared room, Resident #143 was observed laying at the foot of the bed with blood coming from his nose and left arm out of place. Resident #143 stated the curly head guy (Resident #109) did it to him and broke his arm. Resident #109 denied having physical contact. Resident #143 was sent to the hospital via 911 and Resident #109 received a room change. Review of the progress note dated 06/18/24 at 4:50 A.M. revealed Resident #143 was sent to the hospital via 911 at 4:00 A.M. during the shift with injuries. Review of the progress note dated 06/18/24 at 5:18 A.M. revealed Resident #143 was sent to the emergency room via 911 with visible injuries to the face and upper extremities. Resident #143's guardian and physician were notified. Review of the progress note dated 06/18/24 at 12:57 P.M. revealed Resident #143 stated he was in a tussle with Resident #109 and was pushed down. Resident #143 was resting in bed, verbalized feeling safe, and verbalized no concerns with new roommate. Review of the progress note dated 06/18/24 at 1:10 P.M. revealed Resident #109 admitted to pushing previous roommate (Resident #143) claiming he fell to the ground. Resident #109 was unable to explain how or why the altercation began stating delusions related to previous high school classmates being involved. Resident #109 continued with delusional thoughts throughout conversation but verbalized being apologetic. Resident #109 assessed, emotional support provided, and scheduled to be seen by psych on the next visit. Review of the progress note dated 06/18/24 at 6:02 P.M. revealed Resident #143 returned from the emergency room after multiple tests completed. Resident #143's testing indicated fracture of left humerus with splint and/or sling to remain in place until orthopedic follow-up completed. Review of the hospital After Visit Summary dated 06/18/24 revealed Resident #143 received care instructions for a broken arm, to follow-up with the orthopedic surgeon within three to five days and to keep the arm in a splint or cast to allow it to heal or keep stable. Further review revealed Resident #143 had a displaced comminuted fracture of the left humerus. Review of the physician orders for Resident #143, dated 06/18/24, revealed orders for splint and/or sling to left upper extremity to be always worn and not removed until further instructions per orthopedics and non-weight bearing to lower upper extremity for preventative care. Review of the progress note dated 06/21/24 at 2:42 P.M. revealed Resident #143's right wrist looked a little swollen and red. Resident #143's wrist was assessed, and an order was obtained for a stat x-ray of right wrist. Resident #143 received orders for Tylenol and Norco oral tablets for pain. Review of the physician orders dated 06/21/24 revealed orders for Tylenol oral tablet to be given 500 milligrams by mouth three times a day for pain and Norco 325 milligram oral tablet to be given one tablet by mouth every six hours as needed for pain for 14 days. Review of portable x-ray results dated 06/21/24 revealed Resident #143 had an acute wrist fracture and a closed displaced comminuted fracture of shaft of left humerus with nonunion. Review of the progress note dated 06/21/24 at 10:21 P.M. revealed Resident #143 was to be transported to the hospital emergency room within the next few hours for evaluation due to x-ray result showing right wrist fracture. Review of the hospital After Visit Summary dated 06/22/24 revealed Resident #143 was seen for an arm injury and instructions included to continue immobilizer to left humerus fracture, right wrist fracture was splinted and to continue to use sling for comfort, continue Norco pain medication as prescribed, use wheelchair to prevent further falls, physical and occupation therapy at the facility and follow up with orthopedics as soon as possible. Review of the progress note dated 06/22/24 at 4:37 P.M. revealed Resident #143 returned from the hospital with right wrist fracture with splint applied in emergency room following examination. Resident #143 received pain medication for bilateral upper extremities with extensive assistance of two for transfers. Review of the physician orders dated 06/23/24 revealed an order for sling to right upper extremity for elevation and comfort. Review of the physician orders dated 06/24/24 revealed orders for an orthopedic follow-up as soon as possible and an order to elevate right upper extremity when up in chair and in bed. Further review of the medical record revealed Resident #143 attended the orthopedic follow-up appointment on 06/24/24. Interview on 06/25/24 at 1:35 P.M. with Regional Clinical Support (RCS) #957 revealed Resident #109 and #143 had been roommates when Resident #109 pushed Resident #143 he fell on his hand, but it was initially reported as a tussle between the two. RCS #957 revealed Resident #109 denied it at first but after being investigated, he admitted he pushed Resident #143 due to him getting in between him and his wife, despite Resident #109 never being married. RCS #957 revealed Resident #143 was assessed and sent to the emergency room due to reporting arm pain and hitting his head. RCS #957 revealed Resident #143 sustained a broken arm and wrist and Resident #109 received a room change. RCS #957 revealed both residents had cognition impairment and had diagnoses of schizophrenia but with no known history of resident-to-resident physical altercations. Interviews were attempted on 06/25/24 at 4:11 P.M. and 07/02/24 at 2:19 P.M. and 4:23 P.M. with LPN #884 and LPN #948 who were on duty at the time of the incident, however, neither LPN returned the calls. Interview on 07/01/24 at 2:00 P.M. with the Administrator confirmed and verified the above findings and that Resident #143 had sustained fractures because of falling after being pushed (an incident of physical abuse) by Resident #109 who was responding to delusions. Interview on 07/02/24 at 10:34 A.M. with LPN #935 and at 10:46 A.M. with LPN #830 revealed they both were familiar with Resident #109 and Resident #143, and stated they were not aware of any recent incidents of physical aggression with either resident. LPN #830 said Resident #109 was known to be pleasant but did have delusions and was to be monitored for behaviors due to a history of physical aggression towards staff. Interview conducted on 07/02/24 at 2:15 P.M. with Resident #143 revealing he was alert with confusion. An observation at the time of the interview revealed Resident #143 was sitting in the dining room with his left arm in a sling and his right wrist in a splint. Resident #143 removed the splint from his right wrist and a reddish-purple looking bruise was located on the forearm. Resident #143 revealed Resident #109 tussled and grabbed him while in the room and he now had pain. At that time, Resident #143 then declined to continue to the interview. Interview on 07/02/24 at 2:30 P.M. with Resident #109 revealed he was alert sitting in his room. Observation at the time of the interview revealed Resident #109 appeared free from injury and his room was located on another floor away from Resident #143. Resident #109 revealed he did not recall the incident in question regarding Resident #143. Review of the facility document titled Abuse, Neglect, and Exploitation Policy revised June 2021, revealed the facility defined physical abuse as hitting, slapping, pinching, kicking, flicking with fingers or striking in any manner that was demeaning. It also included controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Master Complaint Number #OH00155125.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID- 19 line list, review of facility infection control policies, interviews with staff, observations, interview with the local health department (LHD) and medical record review, the facility failed to timely and appropriately exclude COVID-19 positive staff from working in the facility with COVID-19 negative residents. The facility failed to implement appropriate infection control practices including appropriate use of personal protective equipment (PPE) and cohorting exposed negative COVID-19 residents with non-exposed COVID-19 negative residents. This resulted in Immediate Jeopardy on 12/21/21 when three residents (Resident's #2, #19 and #30) tested positive for COVID-19 exposing Resident's #20 and #134. The facility cohorted exposed COVID-19 negative residents (Resident's #20 and #134) with non-exposed residents (Resident's #11, #56 and #128). In addition, on 12/29/21 exposed COVID-19 negative Resident #68 was moved to a room with a non-exposed unvaccinated resident (Resident #85). Resident's #68 and #85 tested positive for COVID-19 on 01/05/22. On 01/03/22 Licensed Practical Nurse (LPN) #308 tested positive for COVID-19 via rapid test. LPN #308 worked 7:00 P.M. to 7:00 A.M. on 01/04/22 wearing only a surgical mask and goggles unless going into a COVID-19 positive resident room. LPN #308 took care of COVID-19 negative and positive residents. On 01/06/22 LPN #308's polymerase chain reaction (PCR) test was positive for COVID-19. LPN #308 continued to work with COVID-19 positive residents on 01/08/22 and 01/09/22. On 01/08/21 State tested Nurses Assistant (STNA) #316 was observed wearing two surgical masks (no N95 masks) going into a COVID-19 positive resident isolation room of Resident's #27 and #33. On 01/10/22 Resident's #35 and #64 on isolation precautions for COVID-19 were sharing a bathroom with Resident's #27 and #33 in the adjoining room who were negative for COVID-19. On 01/10/22 Housekeeper (HK) #311 was cleaning a COVID-19 positive isolation room without appropriate PPE; there was no sign or PPE cart outside of the door. The lack of effective infection control practice affected 61 residents (Resident's #2, #4, #6, #8, #11, #14, #18, #19, #22, #23, #24, #28, #30, #31, #33, #34, #35, #36, #42, #51, #52, #54, #55, #56, #57, #58, #60, #63, #64, #67, #68, #72, #74, #75, #79, #80, #81, #82, #85, #87, #93, #94, #95, #99, #102, #106, #107, #109, #110, #111, #115, #117, #119, #124, #127, #130, #131, #132, #134, #135 and #136) now positive for COVID-19 and placed all residents at risk for serious life-threatening harm, complications and/or death. The facility census was 135. On 01/10/22 at 3:35 P.M. the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #307 and Infection Control Preventionist/LPN #309 were notified that Immediate Jeopardy began on 12/21/21 when the facility cohorted COVID-19 exposed negative residents with non-exposed residents, and the facility did not implement CDC guidance with their COVID-19 policy and procedure including appropriate use of PPE, isolation of COVID-19 positive residents and COVID-19 exposed residents and return to work guidance for COVID-19 positive staff. The Immediate Jeopardy was removed on 01/12/22 when the facility implemented the following corrective actions: · On 01/06/22 at 5:00 P.M. the DON placed all staff in N95 masks versus surgical masks. On 01/07/22 at 7:00 A.M. the DON made rounds to ensure that all staff were in N95 masks. · Facility Infection Preventionist Staff Development Coordinator (SDC) #309 initiated education on 01/7/22 and was completed by 01/11/22 at 3:00 P.M to all staff regarding proper use and procedure for wearing N95 masks. Staff will obtain a N95 mask upon signing in each morning; all staff were educated on wearing blue surgical mask over N95 mask upon entrance to isolation rooms and disposing prior to exiting. Staff were educated on cleansing goggles with provided cleaning solution and maintaining good hand hygiene. · The DON initiated room moves for residents and ensured that all residents were placed in appropriate COVID-19 status isolation by the end of day on 01/10/22. · The Administrator, DON, Assistant Director of Nursing (ADON) LPN #307 and SDC #309 who are responsible for room assignments based on resident COVID-19 status/isolation were educated by Regional Clinical Support/RN (RCS) #317 on proper placement of residents on 01/11/22 at 1:00 P.M. utilizing COVID-19 Infection Control Practices and 01/11/22 Addendum written outlining appropriate placement of COVID-19 status for isolation. · 1. COVID-19 Infection Control Isolation Addendum: When isolation residents during COVID-19 outbreak: · 2. Positive COVID-19 Residents: If unable to isolate in a private room due to many considerations, PositiveCOVID-19 residents may be cohorted with each other if testing dates are similar. · 3. High Risk Exposure Residents: If a resident that has been exposed to another person that is COVID-19 positive, resident must be placed in isolation for 14 days, preferred method is private room. If you have more than one resident who is high exposure and there is need to cohort, both residents must be vaccinated. Unvaccinated residents must isolate in a private room. · 4. Negative Residents: Can only be cohorted with other negative residents. · The Administrator, DON, ADON #307, SDC #309 and Scheduler #318 who are responsible for staffing the facility were educated by the RCS #317 on 01/11/22 and completed by 1:00 P.M. on the CDC handout: Work Restrictions for HCP with SARCS-CoV-2 Infection and Exposures dated 12/23/21 5:27 P.M. and Testing for COVID-19 facility policy, staff who are positive for COVID-19 asymptomatic or symptomatic with resolving symptoms and return to work in crisis staffing will only work with COVID-19 positive residents only. The facility will reach out to the Local Health Department to assist with determination of Crisis staffing capacity. · All Nurses and STNA'S will be educated by the DON, ADON/LPN #307 and SDC #309 by 01/12/22 by 2:00 P.M. on proper isolation with like COVID-19 status (COVID-19 positive, COVID-19 high exposure vaccinated, unvaccinated & COVID-19 negative) are cohorted appropriately with consideration of shared space/equipment/bathrooms and/or measures to ensure/prevent cross contamination from shared multi-use resident equipment/space, residents who are negative will receive the commode unless otherwise contraindicated due to cognitive abilities or safety concerns, at which time the other residents would have commode. The DON and/or ADON/LPN #307 need to be contacted for directive when this situation arrives. · All Nurses and STNA'S will be educated by DON, ADON/LPN #307 and SDC #309 by 01/12/22 by 2:00 P.M. on proper PPE signage for isolation and appropriate PPE to be worn in isolation rooms. · SDC #309, DON and other leadership/designee will conduct rounds daily three to five days a week auditing total 10-15 employees random throughout facility, and departments to ensure proper usage of N95 masks and goggles. Ad hoc education will be provided by to persons who are not correctly implementing the above infection prevention and control procedures. · SDC #309, DON and other leadership/designee will conduct rounds daily, three to five days a week for four weeks alternating shifts, on each unit throughout the facility to ensure residents with like COVID-19 status are cohorted appropriately to ensure infection prevention measures are implemented appropriately. Ad hoc education will be provided to persons who are not correctly implementing the above infection prevention and control procedures. · Results of all audits will be reported to and reviewed by Quality Assurance Performance Improvement (QAPI) for tracking and trending purposes to determine if current interventions are adequate or additional action will need to be completed to ensure infection prevention and control procedures are implemented appropriately. Although the Immediate Jeopardy was removed on 01/12/22, the facility remained out of compliance at Severity Level 2 (no actual harm with harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1. Interview on 01/05/22 at 2:00 P.M. with the DON revealed the facility was currently in outbreak status as Therapist #313 and Maintenance #314 tested positive for COVID-19 on 12/14/21. Observation upon entrance revealed staff were wearing surgical masks and eye protection and no N95 masks were noted. On 01/05/22 from 2:30 P.M. to 3:00 P.M. tour revealed residents were observed on quarantine or isolation precautions. Staff observed during the tour only had surgical masks and eye protection on with no N95 masks noted. Residents were observed without masks and were not being encouraged to wear a mask if they were outside of their rooms. Interview on 01/05/22 at 3:23 P.M. with LPN #301 and State tested Nurses Assistant (STNA) #302 revealed they were told they only needed to wear surgical masks and goggles even if there were positive COVID-19 residents in the facility. LPN #301 and STNA #302 revealed the facility did not have a COVID-19 unit, and residents were kept in their rooms or cohorted with like residents. Interview on 01/05/22 at 5:00 P.M. with the DON revealed the facility staff were wearing surgical masks unless going into a COVID-19 positive isolation room. The DON verified the facility was in an outbreak status for COVID-19. Phone Interview on 01/08/22 at 9:37 A.M. with Local Health Department (LHD) Coordinator Investigator Supervisor (CIS) #315 revealed the facility had not reached out to the health department related to recommendations on what PPE needed to be worn by staff in resident areas. CIS #315 stated since the facility was in an outbreak status for COVID-19 staff should be wearing N95 masks and eye protection in resident areas, and if they are having a PPE shortage a KN95 mask could be worn or a surgical mask as a last resort. It was not appropriate for staff to only wear a surgical mask and eye protection if the facility was in outbreak status. 2. Interview on 01/05/22 at 5:00 P.M. with ADON/LPN #307 and the DON revealed the facility was in outbreak status for COVID-19. On 12/21/21 three residents (Resident's #2, #19 and #30) tested positive for COVID-19. Residents #134 and #20 (roommates of Resident's #2, #19, and #30) were moved to other rooms. Resident #134 was moved to a private room and later tested positive for COVID-19. Resident #20 (exposed and negative) was moved to a room with Residents #11, #56 and #128. Residents #11, #56 and #128 were not exposed to COVID-19 at that time. On 01/10/22 Residents #11 and #56 tested positive for COVID-19. The DON stated when cohorting, like residents were put together. The DON verified Residents #11, #56 and #128 had not been exposed until Resident #20 was put in the room with them. Review of the line list from 12/14/21 to 01/05/22 revealed on 12/29/21 Resident #115 tested positive for COVID-19 and his roommate (Resident #68) was moved to Resident 85's room. Resident #85 was not exposed or vaccinated for COVID-19. On 01/05/22 Resident's #68 and #85 tested positive for COVID-19. Interview on 01/06/22 at 2:00 P.M. with the DON verified Resident #68 was moved into a room with a non-exposed, unvaccinated resident (Resident #85) and both Resident's #68 and #85 tested positive for COVID-19 on 01/05/22. 3. Observation on 01/05/22 at 3:55 P.M. with LPN #303 revealed STNA #304 going into a COVID-19 positive isolation room. STNA #304 was wearing two surgical masks and goggles when she walked into the resident room. STNA #304 then donned gloves and a gown continuing to wear goggles and two surgical masks when she entered the isolation room. Upon exiting the isolation room, STNA #304 removed the gloves and gown and used hand sanitizer. STNA #304 did not remove the two surgical masks or clean the goggles. Interview on 01/05/22 at 4:00 P.M. with STNA #304 verified she was to wear full PPE, including an N95 mask when going into a COVID-19 positive isolation room. STNA #304 stated she did not wear full PPE because she was only going into the room to answer the call light, not providing care. LPN #303 verified STNA #304 did not change her surgical masks to a N95 mask when entering a COVID-19 positive room and did not change her surgical mask or clean her goggles when she exited the room. Observation on 01/08/22 at 9:05 A.M. revealed STNA #316 entering the room of Residents #6 and #111, who were on COVID-19 positive isolation precautions. STNA #316 was wearing two surgical masks and goggles (no N95 mask). STNA #316 exited the room did not change the two surgical masks and did not clean the goggles. Interview on 01/08/22 at 9:10 A.M. with STNA #316 verified she wore two surgical masks into the COVID-19 positive isolation room and did not change masks or clean her goggles after exiting the room. STNA #316 stated there were no N95 masks on the unit, and the nurse was not on the unit at that time. Interview on 01/10/22 at 9:23 A.M. with LPN #309 stated the N95 masks were put down at the main entrance, so every staff could put one on for their shift. LPN #309 stated there were adequate amount of supply available down at the front desk and in supply room. Observation on 01/10/22 at 9:23 A.M. with LPN #309 revealed Residents #27 and #33, who were negative for COVID-19, and Residents #35 and #64, who tested positive for COVID-19 on 01/07/22, were sharing the same bathroom. LPN #309 verified Resident's #35 and #64 tested positive for COVID-19 and were sharing a bathroom with Resident's #27 and #33 until 01/10/22. All residents used the bathroom independently. On 01/10/22 Resident #33 tested positive for COVID-19 4. Observation on 01/10/22 at 10:02 A.M. revealed Housekeeper (HK) #311 entered the room of Residents #8, #18, and #28, a COVID-19 positive room, with only an N95 mask, goggles, and gloves and no gown. HK #311 stated he did not know the room was on COVID-19 positive isolation precautions because there were no signs or PPE cart outside of the room. HK #311 stated if he had known Resident's #8, #18 and #28 was on isolation precautions, he would have put full PPE on before entering the room. Interview on 01/10/22 at 10:03 A.M. with STNA #310 verified Residents #8, #18 and #28 were on COVID-19 positive isolation precautions and did not have an isolation sign on the door or a PPE cart outside of the room. Interview on 01/10/22 at 10:45 A.M. with the DON verified staff were to be wearing N95 masks when entering COVID-19 positive isolation rooms and all isolation rooms were to have a sign on the door stating what PPE was needed and have a PPE cart outside of the room. 5. On 01/05/22 review of the facility COVID-19 positive line list that was sent to the LHD on 01/03/22 revealed LPN #308 was positive for COVID-19 on 01/03/22 and asymptomatic. Interview on 01/05/22 at 5:00 P.M. with the DON revealed the facility was in emergency staffing on 01/04/22 due to staff being sick and that is what put them in staffing crisis. The DON stated they tried to get agency but did not get a response. No other staffing information was provided. On 01/03/22 LPN #308 tested positive for COVID-19 using a rapid test and a PCR test was done, and LPN #308 was sent home. On 01/04/22 LPN #308 worked from 7:00 P.M. to 7:00 A.M. on Two-East-Hall with COVID-19 negative residents. The DON verified the PCR test results had not been received when LPN #308 worked on 01/05/22. Interview on 01/06/22 at 11:32 A.M. with LNHA revealed the facility was not in crisis mode on 01/04/22 and had not been in crisis mode. The LNHA verified he did not know that a COVID-19 positive nurse had worked on the floor with COVID-19 positive and negative residents. Phone Interview on 01/06/22 at 3:09 P.M. with LPN #308 revealed she tested positive for COVID-19 with a rapid test on 01/03/22 and was sent home after submitting a PCR test. Her next shift was 01/04/22 from 7:00 P.M. to 7:00 A.M., and she worked with COVID-19 positive and negative residents, while wearing a surgical mask and eye protection taking care of COVID-19 negative residents. LPN #308 verified her PCR test was positive on 01/06/22. Observation on 01/10/22 at 9:00 A.M. revealed LPN #308 in the Two-East-Hall nurses station wearing a N95 mask and a face shield. LPN #308 stated she worked night shift on 01/08/22 and 01/09/22 and that she only worked with COVID-19 positive residents. LPN #308 stated she started wearing an N95 mask on 01/08/22. Review of the time sheet from 01/03/22 through 01/09/22 for LPN #308 revealed LPN #308 worked on 01/03/22 from 7:00 P.M. to 2:30 A.M. (LPN #308 went home after testing positive for COVID-19 with a rapid test. She did not finish shift.), on 01/04/22 7:00 P.M. to 8:00 A.M., on 01/08/22 7:00 P.M. to 7:30 A.M. and on 01/09/22 7:00 P.M. to 9:30 A.M. Review of vaccination verification for LPN #308 revealed a second dose of the COVID-19 vaccine was administered on 03/02/21. Interview on 01/10/22 at 10:45 A.M. with the DON revealed LPN #308 worked on 01/08/22 and 01/09/22 after testing positive for COVID-19 on 01/03/22 with a rapid test, and COVID-19 positive PCR results on 01/06/22. The DON stated LPN #308 went home after she had tested positive on 01/03/22. She also worked 7:00 P.M. on 01/04/22 to 7:00 A.M. on 01/05/22. Review of the census dated 01/05/22 revealed 17 residents (Resident #3, #7, #9, #13, #15, #25, #47, #62, #66, #69, #83, #89, #92, #96, #119, #122 and #131) resided on Two-East-Hall ([NAME]) when LPN #308 worked on from 7:00 P.M. on 01/04/22 to 7:00 A.M. on 01/05/21. She went home after a positive COVID-19 rapid test on 01/03/22 around 1:30 A.M. LPN #308 was swabbed by another nurse that was doing the testing. LPN #308 did not know she had covid prior to that time. Review of the Facility COVID-19 positive line list sent to the LHD dated 01/10/22 revealed 61 residents (Resident's #2, #4, #6, #8, #11, #14, #18, #19, #22, #23, #24, #28, #30, #31, #33, #34, #35, #36, #42, #51, #52, #54, #55, #56, #57, #58, #60, #63, #64, #67, #68, #72, #74, #75, #79, #80, #81, #82, #85, #87, #93, #94, #95, #99, #102, #106, #107, #109, #110, #111, #115, #117, #119, #124, #127, #130, #131, #132, #134, #135 and #136) were positive for COVID-19. Review of the facility policy titled COVID-19: Recommended Infection Control Practices, revised 12/2021, revealed if COVID-19 is present, the resident will be placed in transmission-based precautions isolation for at least 10 days. The facility will have signage posted outside each isolation resident room identifying the type of precautions and ample required PPE to enter room. Use of an N95 respirator (or facemask if a respirator is not available), glove, and gown should be worn during care of residents under transmission-based precautions. Avoid cross contamination in the situation with shared bathrooms. Resident with COVID-19 will not share a bathroom with another resident. Center will follow CDC guidelines. Ample supply for recommended PPE (facemasks, respirator, gown, gloves, eye protection) will be available to staff in isolation areas and on each unit. Exposed residents may be permitted to room share with other exposed residents in space is not available for them to remain in a single room. Review of CMS memorandum QSO-20-38-NH, revised 09/10/21, revealed staff with symptoms or signs of COVID-19, vaccinated or not vaccinated, must be tested immediately and are expected to be restricted from the facility pending the results of testing. Review of the CDC's Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated 12/23/21, revealed allowing healthcare personnel (HCP) with [CONDITION(S)]-CoV-2 infection who are well enough and willing to work to return to work as follows: HCP with mild to moderate illness who are not moderately to severely immunocompromised: at least five days have passed since symptoms first appeared (day 0), and; at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. Healthcare facilities may choose to confirm resolution of infection with a negative [MEDICATION(S)] test or NAAT*. HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: at least 5 days have passed since the date of their first positive [CONDITION(S)] test (day 0). This deficiency substantiates Complaint NumberOH 844.

Based on interview, record review, and policy review, the facility failed to monitor the nutritional status for one resident (Resident #59). This resulted in actual harm when Resident #59, who was congnitively impaired and required extensive assistance with eating, sustained an unplanned 15.9 percent (%) significant weight loss within a 180 day (six month) time period. This affected one (Resident #59) of seven residents reviewed for nutrition. The facility census was 141 residents. Findings include: Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual comprehensive Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #59 was rarely understood and was severely cognitively impaired. The resident required extensive assistance with one staff member for eating and had sustained weight loss and was not on a prescribed weight loss regimen. Review of Resident #59's weight history revealed on 09/21/20 she weighed 136 pounds and on 03/03/21 she weighed 115 pounds indicating a 15.44 percent (%) weight loss. There was no evidence the facility obtained the resident's weights from November 2020 until February 2021. There was no evidence of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nutrition note dated 02/03/21 at 1:37 P.M. revealed Resident #59 received a controlled carbohydrate diet, pureed texture with nectar thick liquids. The resident's intake of meals on average was documented in this note as 25%-50%. Resident #59's current body weight was 115 pounds, which was significantly shifted down from the previous weight of 134.2 pounds (11/24/20). This note indicated the resident had a significant weight change of 15.9% over 180 days (dates were not indicated in the note). The nutrition note documented a re-weigh was necessary to verify the accuracy of the weight loss. The dietitian recommended to re-weigh the resident and increase the nutritional supplement order, monitor intake, and complete weekly weights for four weeks. There was no evidence in the clinical record that Resident #59 was re-weighed or weighed weekly for four weeks as recommended by the dietitian on 02/03/21. Resident #59 was observed at the lunch meal on 05/10/21 at 12:30 P.M. She was set up to feed herself and only took a couple of bites despite staff occasionally cueing her to eat. Resident #59 was observed at the lunch meal on 05/11/21 at 12:15 P.M. completely asleep. Interview with Registered Dietitian (RD) #800 on 05/19/21 at 12:44 P.M. revealed if there was a gap or lack of weights the resident may have refused but this would have been captured in the care plan. Review of the care plan revealed there was no indication the resident had refused being weighed. On 05/20/21 at 9:15 A.M. the administrator was informed of Resident #59's weight loss with no re-weigh or monitoring. Interview with RD #800 on 05/20/21 at 9:35 A.M. revealed the resident's weights were not obtained due to COVID-19. Resident #59 was droplet isolation beginning in 12/07/20 for 14 days. Resident #59 was always on the list for the dietitian to review due to her variable intake. RD #800 said the last dietary note by the dietetic technician was on 12/09/20, however, there was no evidence of any notes written by the dietary technician in the electronic medical record. Review of the weight policy (revised May 2021) indicated the facility would attempt to attain/maintain a resident's weight within the recommended range as appropriate in relation to their medical and physical status. Weights were to be obtained in a timely and accurate manner, documented, and responded to in an appropriate manner. Weights would be obtained by staff each month. Re-weighs should occur within a reasonable amount of time after the monthly weight for weights varying 5% or more from the previous month with the weights available for review by the dietitian/diet tech and clinical team each month. The dietitian would review and establish a re-weigh list to be completed by the next interdisciplinary team visit. The dietitian/diet tech would be notified of routine weights, significant changes in weights, insidious weight loss and other concerns related to diet an intake. Acute or chronic weight changes would be documented and recommendations will be provided the dietitian/diet tech as appropriate. The physician and resident/representative will be made aware of significant changes in weight or intake of the resident. Residents with weight loss and overall facility weight loss trends or concerns will be discussed at the routine quality of life meetings and appropriate interventions or action plans put in place and brought to he facility QA committee for further review and follow up if trends were identified.

Based on observation, review of the medical record, facility policy and procedure, and interviews with staff, Physician #397 and Psychiatrist #398, the facility failed to ensure one resident (Resident #152) who was diagnosed with [REDACTED]. This resulted in Immediate Jeopardy that was actual harm when Resident #152, who was known to inflict personal injury, opened a previously self-inflicted wound with an electrical cord, made multiple self-harming body cuts, threatened to harm others and had suicidal ideation without appropriate action by the facility. On 11/21/19 at 5:30 P.M. the Administrator, Director of Nursing (DON), and Quality Assurance Nurse #396 were notified the Immediate Jeopardy began on 11/03/19 at 6:24 P.M. when the facility was notified Resident #152 was found in her room bleeding from a previous self-cutting wrist wound that she had re- opened with an electrical cord. Resident #152 voiced multiple desires to commit suicide and harm self or others and had multiple incidents of self-cutting and aggressive behaviors and was not provided appropriate supervision, psychological services or interventions to guard against and treat the behavior. The Immediate Jeopardy was removed on 11/25/19 when the facility implemented the following corrective action: · On 11/21/19 Resident #152 was assessed by Licensed Practical Nurse (LPN) #294 at 2:30 P.M.; one on one was immediately initiated with escalation of the resident's behavior. The physician was notified of the behaviors at 2:30 P.M. and Resident #152 was sent to the emergency room for a behavioral assessment at 3:29 P.M. · On 11/21/19, a pink slip (emergent discharge) was obtained at 6:07 P.M. Resident #152 was transferred to a behavioral health facility at 10:45 P.M. upon return from the emergency room . · On 11/21/19, all residents with [DIAGNOSES REDACTED]. · On 11/21/19, a list of residents with a history of [MEDICAL CONDITION] and self-harm was placed at all nurse's stations. The lists will be reviewed and updated with all new admissions or changes of condition. Placement of list will be monitored daily by DON/or their designee. · On 11/21/19, all residents with indications or signs and symptoms of behavior escalation or who exhibit spontaneous self-harm or [MEDICAL CONDITION] will be immediately placed on some form of one on one monitoring including distant one on one due to various anxiety disorders to prevent further escalation or behavior. · On 11/21/19 by 9:30 P.M., all staff were educated by phone or in person on [MEDICAL CONDITION] and self-harm guidance by DON/or their designee. · The Executive Director will conduct an audit of all referrals with [MEDICAL CONDITION] or self-harm behaviors. Results of the audit will be reviewed in monthly during the quality assessment and assurance meetings for trends and further guidance beginning 11/21/19. · Beginning 11/21/19 the DON/designee will conduct staff questionnaires on what to do if residents exhibit [MEDICAL CONDITION] and self-harm. Questionnaires will be completed daily for two weeks, then five times a week for two weeks, then three times a week for two weeks. Results of the questionnaire will be reviewed in quality assessment and assurance meetings. · On 11/25/19, by 11:00 [NAME]M. all staff were educated Licensed Practical Nurse (LPN) #357, Human Resources #360 and Staff Development Coordinator #372 on the procedure when a resident exhibits self-harming behavior. · On 11/25/19, observations from 3:50 to 4:02 P.M. confirmed the list of residents with a history of [MEDICAL CONDITION] and self-harm was posted at the nurse stations. · Interviews on 11/25/19 at 11:55 [NAME]M. with LPN #288 and at 12:03 P.M. with State tested Nurse Aide (STNA) #237 verified education was completed. Although the Immediate Jeopardy was removed on 11/25/19, the facility remained out of compliance at Severity Level 2 (No actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing behavior interventions/suicide precautions for Resident #152 and other residents at risk, implementing new policies and procedures for recognizing suicidal or self-harm behaviors, completing audits on all referrals with [MEDICAL CONDITION] and completing staff questionnaires on recognizing resident with self-harming or [MEDICAL CONDITION]. Findings include: Resident #152 was initially admitted on [DATE] and readmitted on [DATE] following a hospital admission for self-harm and suicidal ideation. [DIAGNOSES REDACTED]. Resident #152's five day Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed cognitive skills for daily decision making was moderately impaired; little interest or pleasure in doing things; felt or appeared down, depressed, or hopeless; felt tired or had little energy; had a poor appetite; felt bad about self, was a failure, or has let self or family down. Resident #152 was short tempered and easily annoyed, and stated that life was not worth living, had wishes for death or attempted to harm self. Review of Resident #152's general progress note dated 11/03/19 at 6:24 P.M., authored by LPN #294 revealed the receptionist stated a friend of Resident #152 called to say Resident #152 had cut herself again. LPN #294 and two other nurses entered the room and observed the resident lying on her side in bed using the cell phone. Resident #152 was asked to let them see her arm and she refused. After 15 to 20 minutes, she showed the nurses her arm, and the bandage was not on a previous self-inflicted wound. The area had been re-opened and bleeding was observed. The nurses cleansed the resident's arm and applied a bandage. Resident #152 stated she used an electrical cord to open the wound. The progress note indicated staff remained in the room offering emotional support and would continue to monitor. Resident #152's medical record contained no evidence of monitoring measures related to Resident #152's self-harming behavior. Review of Resident #152's general progress note dated 11/05/19 at 1:38 [NAME]M. revealed the resident remained in her room, refusing meals, refusing medications, and assistance with activities of daily living. Resident #152 was verbally aggressive with staff and accused staff of wrong doings. All attempts to get the resident to be compliant failed and the staff reassured Resident #152 of her safety and their willingness to assist her. Per the progress note Resident #152 was in her room at this time and the staff would continue to monitor. Review of Resident #152's general progress note dated 11/05/19 at 6:28 [NAME]M., authored by Registered Nurse (RN) #309 revealed the facility received a call from a local crisis hotline indicating Resident #152 had slit her wrist. RN #309 went to assess the resident and noted dried blood on her right inner wrist. Resident #152 refused to show the nurse and denied calling the hotline but was observed with the phone in her hand. The progress note indicated the wound appeared old, measured 1 centimeter (cm) by 0.5 cm, and was wrapped with Kerlix. The nurse manager and physician were notified. Resident #152's general progress note dated 11/05/19 at 7:15 [NAME]M., authored by RN #308, revealed the resident was calling the suicide hotline all night long, and peeled off an old scar on the ventral right wrist, measuring 4.0 cm long, 1.0 cm wide, and 0.1 cm deep. The wound had some fluid drainage. The progress note indicated staff wound continue to monitor. The medical record contained no evidence of monitoring the resident to ensure safety or providing additional psychosocial support related to self-harming behavior. Resident #152's general progress note dated 11/05/19 at 12:14 P.M., authored by LPN #285 revealed staff went in the resident's room to assist her when she turned her call light on. Resident #152 started yelling that she wanted to leave and to leave her alone. The resident threw herself on the floor, started banging her head on the floor, punching the dresser, kicked the wheelchair over and attempted to pull the television down on herself. Resident #152 stated she was cutting herself because she wants to kill herself. Resident #152 had a piece of plastic that she was attempting to cut herself with. LPN #285 and the DON went in the room to speak to the resident, calm her down, and redirect her, and were unable to do so at the time. Emergency Medical Services (EMS) was called, and the resident was sent to the hospital. Resident #152's general progress note dated 11/05/19 at 10:50 P.M. revealed the resident returned to the facility with two new orders, an antibiotic for [MEDICAL CONDITION] and potassium for low potassium. The resident seemed calm and pleasant. The note indicated the facility would continue to monitor. Resident #152's medical record contained no evidence of additional safety measures or psychosocial services related to [MEDICAL CONDITION] and self-harming behavior. Review of Resident #152's general progress note dated 11/08/19 at 10:39 [NAME]M. by LPN #293 revealed the resident came towards the nurses' station and began to yell at staff. The nurses attempted to calm the resident down and while wheeling herself back to her room she yelled at another resident. Resident #152 then attempted to hit the other resident and staff were able to move the resident out of the way before physical contact was made. LPN #293 then went to calm Resident #152 down and the resident began to punch a window. The nurse pulled back the resident's wheelchair form the window and the resident attempted to hit the nurse. The nurse explained to the resident that she could hurt herself, and it was not acceptable behavior. The DON and Administrator were able to calm Resident #152 down and she was provided with education on appropriate behavior and ways to deal with emotions in a healthy manner. Review of Resident #152's general progress note dated 11/08/19 revealed the resident was seen by the physician with no new orders. Review of Resident #152's general progress note dated 11/10/19 at 5:33 P.M., authored by LPN #285 revealed STNA #221 went into the resident's room to check on her and notified the nurse that she saw blood on the resident's sheets. LPN #285 went in to see the resident. The resident hid her arms on the side of the bed and started screaming for the nurse to get out. The supervisor was called to the floor, and upon assessment the resident had scraped off the scabs on her wrists from her previous wounds. The wrists were cleaned and wrapped by the nurses. Fifteen minutes later, staff went to check on the resident and she had taken the bandages off and she had the clip from the call light in her hand. The clip was taken, and she was brought to the television area where she could be observed by staff on a one on one bases. Resident #152's medical record contained no evidence of how long she remained one on one supervision or that she was assessed to determine the risk of harming herself further. Interview on 11/21/19 at 12:38 P.M. with the DON confirmed there was no evidence of the duration of her one on one observation or additional safety measures put into place on 11/10/19. The DON revealed the facility started seeking alternative placements for the resident on 11/08/19. Review of Resident #152's general progress note dated 11/14/19 at 10:13 [NAME]M., authored by LPN #285 revealed the resident was in the dining room for breakfast in the morning. Staff walked into the dining room and the resident started screaming at staff to get the (expletive) away from her and stop talking about her and calling her names. Resident #152 started yelling that she was going to kill a staff member. Other residents told Resident #152 to be quiet, and she yelled at them to shut the (expletive) up or she would kill them too. Resident #57 and Resident #7 went to the nurse stating Resident #152 should not be around them and they did not feel safe. At this time, therapy went to get Resident #152 and took several minutes to calm the resident down to go to therapy. When therapy brought Resident #152 back, the therapist reported that the resident kept saying she was going to hurt someone or herself. Resident #152 stated she wanted to kill someone, and the nurse attempted to talk to the resident and the resident would not listen. Resident #152 requested to speak to the administrator and said that she wanted to leave. Resident #152's general progress note dated 11/14/19 at 5:33 P.M., authored by RN #302 revealed the resident was totally out of control. Resident #152 threw a tray in the dining room at another resident, was yelling foul language at residents, and showing her fist to other residents. Resident #152 threw a chair on the floor, punched a computer, and was not redirectable. A call was placed to the psychiatrist regarding transfer out of the facility to another facility, but the facility they wanted to transfer her to declined the resident's admission. Resident #152's general progress note dated 11/14/19 at 11:00 P.M., authored by LPN #286, revealed the resident believed she was leaving the facility on this day, and stated if she was not allowed to leave, she would find a way to commit suicide. Resident #152 became more agitated and was screaming. Resident #152 was sent to the hospital emergency department at 10:23 P.M. Resident #152's general progress note dated 11/15/19 at 11:18 [NAME]M. revealed she returned to the facility and the facility would continue to monitor her. The medical record contained no evidence the resident was monitored more closely or was provided psychosocial services related to self-harming behavior. Review of Resident #152's general progress note dated 11/17/19 at 1:12 [NAME]M. revealed the nurse was called to the resident's room by STNA #240 at 1:00 [NAME]M. STNA #240 stated it appeared the resident was attempting to harm herself. The nurse entered the room and the resident was sitting in a wheelchair hiding her left arm behind her. Droplets of blood were noted on floor beneath the wheelchair, and the skin to her left wrist was observed to be open. Resident #152 refused to identify the object used to cause the injury and no objects were visible for staff to identify. Staff remained one on one with the resident and she was sent to the emergency room for evaluation. Resident #152's general progress note dated 11/17/19 at 10:57 [NAME]M., authored by LPN #294 revealed the resident returned to the facility. Staff reported she did not want to return to the facility and would continue to cut herself. The medical record contained no evidence the resident was monitored more closely upon her return or was provided psychosocial services related to wanting to harm self. Resident #152's general progress note dated 11/17/19 at 6:31 P.M., authored by LPN #294 revealed the resident was lying in bed, refused meals, and stated she cut herself again, and asked the nurse not to tell anyone. The previous arm wound was reopened, and dried blood was observed around wound. The resident refused to have the wound cleaned and wrapped and stated, I'm not done yet. Resident #152 was re-educated regarding keeping the wound clean and wrapped. The progress note indicated the staff would continue to monitor. The medical record contained no evidence of what monitoring measures were in place or that the physician was notified. Review of Resident #152's general progress note dated 11/18/19 at 2:17 [NAME]M., authored by RN #308 revealed at 1:00 [NAME]M. the resident was assisted to her wheelchair and stated she would like to be discharged . When told she would not be discharged at this time, she stated she was going to kill herself. The progress note stated Non-emergency police were invited to help calm her down, which was ineffective. Resident #152 was sent to the hospital. Resident #152's general progress note dated 11/18/19 at 2:47 [NAME]M., revealed the resident returned from the hospital with no new orders and they would continue to monitor her. The medical record contained no evidence of what monitoring measures were in place or additional psychosocial services provided. Interview on 11/21/19 at 11:23 [NAME]M. with Resident #152 revealed she tried to kill herself and she pointed to a bandage on her right wrist. Resident #152 stated State tested Nursing Assistant (STNA) #200 was evil when she was first admitted , by stating get you're (expletive) up and you can walk. Resident #152 revealed Licensed Practical Nurse (LPN) #281 agreed with STNA #200 so it got worse. Resident #152 revealed when STNA #200 worked the next time the STNA stated get you're (expletive) up and I do not give a (expletive) what you think or care who knows. Resident #152 revealed she started crying and she has post-traumatic stress disorder ([MEDICAL CONDITION]) and depression. Resident #152 stated when STNA #200 left, that is when she tried to commit suicide because everyone has abused her in her past. Resident #152 revealed she asked the facility for counseling and they said no, and the staff say they do not have time. Resident #152 revealed she tried calling the crisis hotline to talk to someone at one point, so she would not try and hurt herself, and the hotline called the facility. In addition to the right wrist bandage, Resident #152 was observed with scars on her neck and left wrist from previous wounds. Interview on 11/21/19 at 12:38 P.M. with the DON revealed Resident #152 was accepted at a behavioral health facility on 11/20/19, but the resident declined to go, and started to come out of her room more around this time. Quality Assurance Nurse #396 revealed the staff on the floor were trained on how to respond to the resident's behavior. The DON indicated Resident #152 needed a behavior modification plan, but it was difficult if she did not agree. Quality Assurance Nurse #396 revealed when Resident #152 comes back to the facility from the hospital, her behaviors are subdued, and the facility continues to monitor her. Interviews on 11/21/19 between 12:28 P.M. and 5:15P.M. were completed with the DON and Quality Assurance Nurse #396. At 12:28 P.M. the interview revealed after Resident #152 harmed herself on 11/03/19 they took the electrical cords away, and she was checked on every two hours. Additional information from the interview, at 12:28 P.M. revealed after Resident #152 opened a previous wound on 11/05/19 at 6:28 [NAME]M. The nurses tried to calm the resident down and divert her attention. The DON revealed they did not increase supervision for the resident because she did not like someone constantly with her; they were able to walk past her room and observe what she was doing. The DON indicated the resident did not disclose what she used to cut herself, but her room was searched without finding anything. The DON revealed the resident eventually disclosed using a plastic piece from the cap of a needle to cut herself. The DON revealed the resident was supposed to see the psychiatrist on 11/05/19, but because she was hospitalized , she was not seen. The DON stated the psychiatrist did not see Resident #152 until 11/11/19. The interview confirmed the unit manager and nurse practitioner were notified of Resident #152's self- harming behavior on 11/17/19 although it was not documented. Interview on 11/21/19 at 2:53 P.M. with the DON revealed Resident #152 was not offered counseling services, as counseling services were stopped on the resident's floor. Interview on 11/21/19 at 4:54 P.M. with Physician #397 revealed Resident #152 has been sent to the emergency room multiple times and they keep sending her back. Physician #397 revealed when a resident cuts themselves they are usually always sent out. Physician #397 revealed the hospital gives the facility the clear that they can come back, as the resident does not have any psychiatric issue that needed to be addressed. Interview on 11/21/19 at 5:15 P.M. with Psychiatrist #398 revealed the expectation when a resident exhibits self-harming behavior is to make medication adjustments if needed and observe the resident for safety. Review of the undated facility policy, titled Suicide Threats revealed staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. The nurse supervisor/charge nurse shall immediately assess the situation and notify the charge nurse/supervisor and/or DON of such threats. A staff member shall remain within view of the resident until the nurse supervisor/charge nurse arrives to evaluate the resident. After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party and shall seek further direction from the physician. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update physician accordingly, until a physician has determined that a risk of suicide does not appear to be present. Staff should monitor the resident frequently as not to increase further agitation, if the resident allows sit with the resident and provide distraction, comfort, and ensure safety. Staff shall document details of the situation objectively in the resident's medical record.