Every finding on record at Astoria Place of Cincinnati

Based on record review, review of hospital records, review of emergency medical services (EMS) record, staff interviews, written staff statement reviews, observations, and policy reviews, the facility failed to ensure adequate supervision was in place to prevent a resident from climbing out a window on the second floor. This resulted in Immediate Jeopardy and serious physical harm and injuries on 07/22/26 when Resident #100 was found hanging from a windowpane and fell to the ground outside of the facility. Resident #100 had opened the window in room [ROOM NUMBER] and dropped two stories to the pavement below. The resident sustained a right temporal bone fracture, subdural and subarachnoid hemorrhage, epidural hematoma, sacral fracture and right clavicle fracture. Resident #100 underwent an emergent craniectomy on 07/23/26. This affected one (Resident #100) of three residents reviewed for elopement risk. The facility census was 94. On 08/04/26 at 3:41 P.M., the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO) #220, Regional Clinical Nurse (RCN) #210 and Director of Clinical Operations (DCO) #200 were notified that Immediate Jeopardy began on 07/22/26 at 7:15 P.M. when Resident #100 was seen by two dietary staff attempting to exit a window from the second floor. Resident #100 had climbed out a second-floor window and was holding onto the windowsill with one arm and then fell approximately 20 feet hitting a railing and landing on concrete. Resident #100 was hospitalized with a right temporal bone fracture and subdural and subarachnoid hemorrhages, which required emergency surgery. On 07/22/26 at 6:55 P.M., Resident #100 had a verbal encounter with Registered Nurse (RN) #124 when the nurse discovered Resident #100 had medication in his dresser drawer and removed the medications. Resident #100 became agitated, crying and repeatedly yelling why?. At approximately 7:05 P.M. the resident continued with the agitation and began wandering in and out of resident rooms on the male behavior unit yelling why?. On 07/22/26 at 7:15 P.M., kitchen staff reported to nursing staff they saw Resident #100 hanging from the windowsill in room [ROOM NUMBER] and then fell to the concrete ramp near the dietary department outside entrance. Nursing staff sent Resident #100 to the hospital via emergency transport after Resident #100 was assessed. The initial facility investigation revealed that Resident #100 had raised the window in room [ROOM NUMBER] lower to exit the facility. The Immediate Jeopardy was removed on 07/23/26 when the facility implemented the following corrective actions: On 07/22/26 at approximately 7:30 P.M., The DON arrived at the facility and immediately secured the window that Resident #100 had jumped from. On 07/22/26 at approximately 7:32 P.M. the ADON completed a head count to ensure that all residents were accounted for. On 07/22/26 at approximately 7:35 P.M., Certified Nursing Assistant (CNA) #110 and Registered Nurse (RN) #124 completed rounds to verify window security and all residents on the second floor were redirected from their rooms to dining areas and activities area for supervision while windows were inspected. On 07/22/26 at approximately 7:35 P.M., Scheduler Staff #97 initiated continuous rounds on the second floor to ensure resident safety. On 07/22/26 at approximately 7:40 P.M., the Administrator arrived at the facility and immediately started the investigation including interviews with staff that worked the prior shift and the shift the incident occurred on. On 07/22/26 at approximately 7:40 P.M. Assistant Director of Nursing (ADON) #4, RN #124, and Scheduler Staff #97 conducted interviews of residents on the male secured unit for the investigation. On 07/22/26 at approximately 8:00 P.M. Maintenance Director (MD) #86 arrived at the facility and completed auditing of all windows and ensured that windows were secured to open no less than 6 inches. On 07/22/26 and 07/23/26, the Intra disciplinary team (IDT) that consists of the DON, ADON #4, RN #124, Unit Manager #127, Administrator, Dietary Manager #48, Housekeeping/Laundry Supervisor #70, and the Business Office Manager (BOM) #5 in serviced all staff on elopement risk identification and interventions, emergency response procedures, environmental safety inspections including window security, wandering, managing difficult behaviors, trauma informed care, behavioral health services, and safety and supervision. All nurses were also educated related to proper storage of medications, administration, and ensuring that medications are taken prior to leaving room and not leaving medications at bedside. On 07/22/26 and 07/23/26, all windows were secured with different tamper resistant window hardware by the MD #86 and multiple contractors. On 07/23/26, DON, ADON #4, RN #124, and Unit Manager #127 completed wander/elope risk assessments on all residents in the facility. On 07/23/26, DON, ADON #4, RN #124, and Unit Manager #127 completed behavior risk assessments on all residents in the facility. On 07/23/26, all windows that had window air conditioner units had plywood placed and secured to window frame by the MD #86 and multiple contractors. On 07/23/26, Minimum Data Set (MDS) Nurse #86, RCN #210 reviewed all plans of cares for all residents to ensure that exit seeking behaviors were captured with appropriate interventions. On 07/23/26, Receptionist #122 reviewed the elopement resident binder to ensure that all residents that were at risk for elopement had information sheets present. On 07/23/26, a Quality Assurance and Performance Improvement (QAPI) meeting was held with the IDT team in attendance including the Administrator, DON, ADON #4, BOM #5, DCO #200, Human Resource (HR) Staff #19, RCN #210, MDS Nurse #86, and Social Service Designee (SSD) #96, to review the incident that occurred on 07/22/26 with Resident #100 jumping from the second-floor window. On 07/23/26, an audit was completed of all residents' rooms to ensure that there were no medications in room per DON, ADON #4, and Unit Manager #127. On 07/27/26, a follow up IDT meeting was held to evaluate the current interventions, and random audits were initiated related to window securement, behaviors, and medications at bedside. Participants in the IDT meeting included Administrator, DON, ADON #4, BOM #5, HR #19, MDS Nurse #86, MD #86, RCN #210, Housekeeping Supervisor #70, SSD #96, and DCO #200. Secondary Inservice was held for all staff reviewing prior education subjects listed per DON and ADON #4. Starting 07/27/26, the MD #86 and/or designee will conduct audits three times a week for four weeks, then monthly for two months of window integrity and safety checks to include a minimum of four windows on each unit. Any noncompliance will be immediately addressed. This will be added to the TELS system (a digital building-operations and asset management system designed for senior living and healthcare facilities) for monthly audits ongoing. Starting 07/27/26, the DON/designee will conduct audits three times a week for four weeks, then monthly for two months, related to wandering and escalated behaviors and medications at bedside, to include a minimum of four residents for each audit. Any noncompliance will be immediately addressed. On 08/03/27, screws that were used to secure plywood to windows with the air conditioner units were drilled to prevent tampering by multiple contractors. This was verified by DCO #200 and RDO #220. Although the Immediate Jeopardy was removed on 07/23/26, the facility remains out of compliance at a Severity Level 2, (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy), as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses included encephalopathy, depressive disorder, extrapyramidal and movement disorders, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affecting left side, opioid dependence, contracture of right upper arm and aphasia. The resident resided on an all-male behavior unit on the second story of the facility. Review of Wandering assessment dated [DATE] revealed it was incomplete and only had the first question answered that Resident #100 had not wandered before. The rest of the questions on the assessment were not filled out. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #100 had severely impaired cognition and required partial assistance with activities of daily living (ADL) skills. The resident received supervision assistance with rolling in bed, walking up to 50 feet and using a wheelchair for mobility. Review of undated care plans for Resident #100 revealed he had a potential for inflict self-harm related to mild cognitive impairment, cerebral infarction, encephalopathy, vascular dementia and mood disorder. Resident #100 will hit himself and will punch walls and other hard objects when he gets angry or frustrated which has resulted in physical harm to self. Interventions included administering medications, assessing and anticipating needs, psych consult, engage calmly in conversation, and intervene before agitation escalates. Resident #100 admitted to secured unit due to cognitive impairment and mood disorder with interventions including to monitor location and secure safety. Review of a physician note dated 07/19/26 revealed Resident #100 was seen for vascular dementia with behavioral disturbance. The physician documented to monitor for cognition, judgement, behavior and to notify of any acute changes in mental status or worsening behavior and to maintain fall and safety precautions. Review of nursing note dated 07/20/26 revealed Resident #100 was in hallway asking nurse please pointing to the elevator. The nurse stated he was not going downstairs at this time. Resident yelled please repeatedly. Resident #100 was redirected back to his room. Resident #100 was stomping his feet, and the nurse called nurse practitioner and gave new orders for Clonazepam three times a day as needed for anxiety for 14 days and Hydroxyzine every six hours as needed for anxiety for 14 days. Review of the progress note dated 07/21/26 by Psychiatric Nurse Practitioner (PNP) #230 revealed Resident #100 was alert and oriented to self only and had an episode on the afternoon of 07/21/26 of exit seeking behaviors and demanded to go off the unit downstairs. Resident #100 could not be easily redirected and became aggressive. Review of nursing notes dated 07/22/26 at 6:59 P.M documented by the DON as a late entry revealed Resident #100 became visibly agitated while speaking with the nursing staff during the medication count. The resident was yelling at the nurse and was unable to be redirected despite verbal attempts to calm situation. Resident #100 went away and back into the hallway. A message was sent to the psychiatry nurse practitioner. Review of nursing notes dated 07/22/26 at 7:20 P.M documented by DON as a late entry revealed an acute medical emergency occurred requiring an immediate emergency response. Nursing staff initiated emergency procedures and the emergency response was called. Review of Receptionist #101's witness statement dated 07/22/26 revealed Resident #100 was outside smoking at 6:30 P.M. When it was time to come back inside, he kept saying no as the resident returned up to the second floor to his unit. Review of CNA #75's witness statement revealed on 07/22/26 at 7:00 P.M., Resident #100 was agitated, going up and down hallway and going in and out of rooms crying and asking why. Resident #100 was in a fit of rage and did not want to sit in wheelchair. She was passing snacks; he refused a snack when offered and he wandered off. Shortly after that she had heard he fell out the window. Review of Dietary Aide (DA) #28 and #30's witness statements revealed on 07/22/26 at approximately 7:15 P.M., Resident #100 was seen attempting to exit a window from second floor. Resident #100 had climbed out a second-floor window and was holding onto windowsill with one arm and ultimately fell hitting a railing and landing on concrete. Resident #100 stood up with an apparent head injury and the emergency response transported him to the hospital. Review of the EMS report dated 07/22/26 at 8:10 P. M. revealed the emergency call was received at 7:22 P.M. Resident #100 jumped out of a second story window of approximately 20 feet. The fall appeared to be three stories and landed on a subdivision leading to a basement. Resident #100 had blood coming from his right eye, blood around left kneecap and several injuries and cuts all over his body, including an injury to the head. Review of hospital records revealed Resident #100 presented to the emergency department on 07/22/26 and transferred to intensive care unit as a trauma consultation after a fall from the second story of his nursing facility. Initial work-up revealed subdural hematoma, subarachnoid hematoma, epidural hematoma, squamous temporal bone fracture on right, minimal displaced sacral S5 fracture, nondisplaced fracture of right distal clavicle and right coracoid process. On 07/23/26 Resident #100 underwent emergent craniectomy for evacuation of epidural hematoma. Review of hospital psychiatric evaluation dated 08/01/26 revealed Resident #100 had a complex medical history with Traumatic Brain Injury (TBI) from mycotic brain aneurysm and now had episodic agitation and depression. Treatment recommendation included one on one observation related to moderate risk for agitation. During an interview on 08/03/26 at 11:50 A.M. Maintenance Director (MD) #85 stated he understood the windows had stoppers to not permit the resident room windows to be raised above six inches throughout the facility. MD #85 stated on 07/22/26 at approximately 7:30 P.M. he received a call from the Administrator and was directed to review room [ROOM NUMBER] window. MD #85 stated when he arrived at the room [ROOM NUMBER], the window was opened to six inches, but the screw drilled into the window slide was bent upwards. MD #85 said he thought the Resident #100 had altered the screw upward to permit the window to be raised greater than six inches. He thought Resident #100 was able to get out a greater than six-inch window opening. The screen was out on the ground below and not attached to the frame completely. MD #85 stated the left side of the double hung window was not altered and had the screw still in place in the frame, preventing the left side windowpane from raising more than six inches. During an observation on 08/03/26 at 12:10 P.M., the exterior of the facility under room [ROOM NUMBER] had a concrete delivery ramp directly beneath the window. There was a railing along the concrete ramp leading to the dietary department entrance. The screen on the right side of the right pane of the double hung window was halfway detached from the window and torn. During an interview on 08/03/26 at 5:42 P.M., Dietary aide (DA) #28 stated she witnessed Resident #100 hanging feet first and hanging by one arm on the windowsill on 07/22/26 at about 7:00 P.M. She stated the resident appeared to be trying to get up into the window, yelling for help. She called the emergency squad who arrived within minutes. He was unable to pull himself up and he fell hitting the railing of the delivery ramp onto the concrete, falling approximately 20 feet with his face down. He stood up and had blood around his face and other body areas. During an interview on 08/03/26 at 6:00 P.M., Licensed Practical Nurse (LPN) # 11 stated he arrived at 7:00 P.M. and heard Reisdent#100 yelling at the RN #124 and asking why. LPN #11 stated he had not seen the resident so agitated. LPN #11 saw CNA # 75 in the hallway attempting to redirect the resident from yelling and pacing behavior with snacks. Resident #100 could not to be easily redirected as usual when his behaviors were escalated. LPN #11 stated he left the 200 unit to the 100 unit to get nursing report at about 7:05 P.M. CNA #75 was the only staff person on the unit when he left for unit 100. LPN #11 was notified that Resident #100 fell from the room [ROOM NUMBER] window at approximately 7:15 P.M. LPN #11 verified he saw the window immediately after the fall and the window was raised above six inches where the resident could have squeezed out of the window. During an interview on 08/04/26 at 7:52 A.M., with MD #85 he had not checked the functionally or the six-inch raised window limit of any windows in the facility. He stated he thought the previous company who left in January of 2026 had secured the windows with a screw in the window frames. During an interview on 08/04/26 at 11:15 A.M., CNA # 79 revealed she had noticed room [ROOM NUMBER] window was raised above six inches, approximately ten inches about one week prior to 07/22/26, when it was raining on first shift. CNA #79 stated she reported the window being raised higher than six inches to MD #85 on that day, and she had no knowledge if MD #85 had secured the window to raise no more than six inches. During an interview on 08/04/26 at 11:30 A.M., Resident #40 stated he had his window open more than six inches a few weeks ago when it was raining because he was hot and wanted fresh air. He demonstrated by showing with his hands, he raised the window approximately 10 inches. During an interview on 08/04/26 at12:55 P.M., the DON verified the PNP #230 progress note of 07/21/26 documented that Resident #100 was exit seeking. The DON verified that Resident #100 was very upset on 07/22/26 at 6:50 P.M. when RN #124 removed medications in Resident #100's drawer and was unable to be redirected. The DON verified on 07/22/26 at 6:55 P.M. that documentation revealed the PNP #230 was notified of Resident #100 condition change. The DON stated behavior change procedure would be to start one on one supervision or send the resident out to hospital for escalated behaviors. During an interview on 08/04/26 at 2:40 P.M., MD #85 stated he had been directed by the Administrator on 07/20/26 to give a count of windows needing screen replacement. MD #85 stated a month ago, a staff reported room [ROOM NUMBER] had no nail or screw in the window frame to prevent the window opening more than six inches. MD #85 stated he secured the room [ROOM NUMBER] window with a nail in the frame to prevent a six inch opening. MD #85 did not audit or check any other windows in the facility for six-inch security or functionality. MD #85 stated windows are normally checked at least monthly. During an interview on 08/05/26 at 11:23 A.M., the Administrator stated there was no policy for window monitoring for functionality or six-inch opening limit, but usually windows would be checked during monthly maintenance checks. The Administrator did not know the window in room [ROOM NUMBER] had been open during a rainy day a few weeks ago more than six inches or that room [ROOM NUMBER] had no window stopper approximately one month ago. During an interview on 08/05/26 at 1:48 P.M. CNA #75, who worked on Resident #100's unit on 07/22/26, stated when she came onto the unit at 7:00 P.M. that Resident #100 was already irate. He was crying, yelling why, and walking around up and down the hallway going in and out of other residents' rooms. He usually is calm and in his wheelchair. CNA #75 stated she decided to pass snacks to Resident #100 and other residents in the hallway, as she was the only staff person on the unit. She stated LPN # 11 had left the unit to go to the 100 unit. CNA #75 stated she attempted to calm Resident #100 by offering him a snack at the snack cart in the hallway. He did not want to talk, and pushed past her, at about 7:05 P.M. She looked up from assisting other residents with their snacks and the Resident #100 had disappeared into other resident's rooms on the short hallway, the hallway of room [ROOM NUMBER]. He did not go past her to his room [ROOM NUMBER]. CNA #75 denied hearing or seeing Resident #100 go into room [ROOM NUMBER]. Less than five minutes later, staff arrived at the unit and notified her that Resident #100 had dropped from the room [ROOM NUMBER] window. CNA #75 stated she went to room [ROOM NUMBER] and observed the left side windowpane had no window screen and the windowpane was opened approximately nine inches, nearly halfway up and stated she did know the window could go that high. CNA #75 stated Resident #100 could raise a window and capable of maneuvering his body through an open window. Review of the facility policy titled Accident and Incidents - Investigation and Reporting, not dated, revealed all incidents involving residents shall be investigated and reported to the Administrator. Incidents and Accident Reports will be reviewed by the Safety Committee for trends related to safety hazards and to analyze any individual resident vulnerabilities. Review of the facility policy titled Wandering, Unsafe Resident, not dated, revealed staff identified residents who were at risk for harm for unsafe wandering and elopement and complete and file an incident report. This deficiency represents noncompliance investigated under Complaint Number 3122574.

Based on observation, staff interview, and review of the facility policy, the facility failed to store and prepare food in a sanitary manner to prevent foodborne illness. This had the potential to affect all residents residing in the facility. The facility census was 84 residents.Findings include: 1.Observation of the kitchen on 02/17/26 at 9:27 A.M. revealed the soda gun nozzle was dirty and had a build-up of a red substance. Interview on 02/17/26 at 9:27 A.M. with Dietary Manager (DM) #605 confirmed the soda gun nozzle was dirty. Review of the facility policy titled Sanitization dated October 2008 revealed all kitchen equipment should be kept clean. 2.Observation on 02/17/26 at 9:29 A.M. revealed that the white cutting block attached to the front of the steam table was dirty with black residue on the top surface. Interview on 02/17/26 at 9:29 A.M. with DM #605 confirmed the white cutting block attached to the front of the steam table was dirty. Review of the facility policy titled Sanitization dated October 2008 revealed all counters and utensils should be kept clean. 3. Observation of the walk-in cooler on 02/17/26 at 9:33 A.M. revealed it contained the following undated items: vanilla pudding, white American cheese, Swiss cheese, provolone cheese, bologna. A container of unpasteurized raw eggs were stored on the top shelf above potatoes. Interview on 02/17/26 at 9:33 A.M. with DM #605 verified that the foods items should have been dated when they were prepared or opened and raw eggs should be stored on the bottom shelf. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed food will be dated. 4. Observation of the walk-in freezer on 02/17/26 at 9:40 A.M. revealed the temperature was 25 degrees Fahrenheit (F) food was soft to the touch. Interview on 02/17/26 at 9:40 A.M. with DM #605 confirmed the freezer was put into defrost mode the day prior and verified that the food should have been frozen solid. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed frozen food should be frozen to a solid state. 5.Observation of the dry storage room on 02/17/26 at 9:42 A.M. revealed it contained the following opened and undated items: a bag of spaghetti noodles, three bags of egg noodles. Interview on 02/17/26 at 9:42 A.M with DM #605 verified opened bags of pasta were undated. Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed food will be dated. 6. Observation in the food prep area on 02/17/26 at 9:50 A.M. revealed there were five dirty knives stored in the clean knife storage case. Interview on 02/17/26 at 9:50 A.M with DM #605 verified the five knives stored in the clean knife case were dirty. Review of the facility policy titled Sanitization dated October 2008 revealed all counters and utensils should be kept clean. 7.Observation of the walk-in freezer on 02/18/26 at 10:20 A.M. revealed there was an icicle coming from the condenser and there was an open box of peas stored underneath it. Interview on 02/18/26 at 10:20 A.M. with DM #605 verified the peas were open and should not be stored under the leaking condenser. 8.Observation on 02/18/26 at 12:20 P.M. revealed the ice machine in the kitchen was leaking. Interview on 02/18/26 at 12:20 P.M with DM #605 confirmed the ice machine did not stop making ice once it was full. The ice machine would then be overfilled with water and would leak down the side. 9.Observation of the lunch service on 02/18/26 at 12:35 P.M. revealed the broccoli on the steam table was being held at 123 degrees F. Interview on 02/18/26 at 12:35 P.M. with DM #605 confirmed half of the steam table was not working, and all hot food should be held above 135 degrees F. Review of the facility policy titled Food Preparation and Service dated October 2017 revealed hot food should be stored above 135 degrees F. This deficiency represents noncompliance investigated under Complaint Number 2727645.

Based on record review, staff interview, review of the facility policy, and review of online resources from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure a comprehensive water management plan was implemented to minimize the risk of waterborne pathogens including Legionella. This had the potential to affect all residents living in the facility. The facility census was 84 residents. Findings include:Review of the facility documents revealed the facility did not have a water management plan to prevent the growth of Legionella. Interview on 02/18/26 at 3:18 P.M. with Director of Clinical Operations (DCO)#900 verified the facility did not have a water management plan in place to prevent the growth of Legionella. Review of facility policy titled Legionella Water Management Program undated revealed the facility as part of the infection prevention and control program would have a water management program in place. Review of online resources from the CDC at https://www.cdc.gov/control-legionella/php/wmp/wmp-steps.html titled Steps to Develop a Water Management Program revealed development of a water management program was a multi-step process that required continuous review. An approved plan consisted of the following teps to building an effective Legionella water management program: establish a water management program team, describe the building water systems, identify areas where Legionella could grow and spread, decide where to apply and how to monitor control measures, establish interventions when control limits aren't met, make sure the program runs as designed and is effective, document and communicate all the activities.

Based on observation, interview, and policy review the facility failed to ensure food served was palatable and at an appetizing temperature. This had the potential to affect all 84 residents as the facility identified all residents received food from the kitchen. The facility census was 84. Findings include:Review of the lunch menu for 02/18/26 revealed the residents would be served lemon zest broccoli, chocolate cake with icing, chicken patty on bun, and rice. Observations of puree diets being prepared on 02/18/26 at 11:21 A.M., revealed Dietary Manager (DM) #65 initially added chicken patties, lettuce, tomatoes, mayonnaise, and slices of bread to a blender. After blending, hot water was added to thin the consistency to the desired texture. During an interview on 02/18/26 at 11:28 A.M., DM #605 verified that the mixture was too thick, and he added hot water to create a pudding like consistency. DM #605 verified that the facility had recipe cards for all meals; however, he knows the consistency that he is looking for and does not use the recipe. Observation on 02/18/26 at 11:32 A.M., revealed DM #605 added oil to a pan that was heated on the stove. DM #605 added flour to the oil to create a roux and then mixed in hot water to thin the consistency. Interview with DM #605 verified that he was making gravy for the puree and mechanical soft diets. DM #605 verified that the only ingredients used for the gravy were oil, flour, and water. Observation on 02/18/26 at 11:47 A.M., revealed DM #605 add six scoops of rice and two glasses of hot water to a blender. The consistency of the mixture was thick and sticky. Observation of the test tray on 02/18/26 at 1:03 P.M. with DM #605, revealed the chicken sandwich was 106 degrees Fahrenheit (F), broccoli was 139 degrees F, rice was 120 degrees F and the chocolate pudding was 58 degrees F. The surveyor tasted the items and the broccoli tasted bland and the chicken sandwich was cold. Interview with DM #605 at the same verified the chicken sandwich was cold and that lemon seasoning was supposed to be added to the broccoli. Review of the spreadsheet for lunch on 02/18/26 revealed the cream of rice should have been substituted for rice for the residents with a puree diet. During an interview on 02/19/26 at 1:04 P.M., Registered Dietician (RD) #600 stated the kitchen staff should be following recipe cards and spreadsheets. RD #600 also verified that gravy made with only oil, water, and flour would not taste very good and he would expect something like a chicken or beef base to be used for flavoring. Review of the recipe card Chicken Patty on Bun revealed the meat, mayonnaise and bread should be pureed together. The gravy should be added a little at a time to achieve smooth consistency. Review of the recipe card Gravy revealed that gravy should be made with flour, fat (meat drippings), black pepper, chicken or beef base, and water. Review of the facility policy titled, Food and Nutrition Services dated October 2017 revealed each resident is provided a nourishing, palatable well-balanced diet that meets his or her daily nutritional and special dietary needs. This deficiency represents non-compliance investigated under Complaint Number 2742960.

Based on observations, record review, staff interviews and policy review, the facility failed to ensure foods were made to the correct consistency for residents with a puree and mechanical soft diet order. This affected seventeen Residents (#08, #34, #75, #05, #06, #17, #25, #27, #32, #46, #53, #54, #56, #73, #79, #81, and #95) who the facility identified as receiving a puree or mechanical soft diet order. The facility census was 84. Review of the medical records revealed three Residents (#08, #34, and #75) had physician orders for a puree diet. Further review revealed fourteen Residents (#05, #06, #17, #25, #27, #32, #46, #53, #54, #56, #73, #79, #81, and #95) had physician orders for a mechanical soft diet. Review of the lunch menu for 02/18/26 revealed the residents would be served lemon zest broccoli, chocolate cake with icing, chicken patty on bun, and rice. Review of the lunch spreadsheet for 02/18/26 revealed the residents with a mechanical soft diet should receive chopped bite size broccoli and the residents with a puree diet should receive cream of rice. Observation of the lunch service on 02/18/26 at 11:57 A.M., revealed the residents ordered a mechanical soft diet were served the same broccoli as the regular diets and the residents ordered a puree diet, were served rice pureed with water. During an interview on 02/19/26 at 1:04 P.M., Registered Dietician (RD) #600 stated he would expect the kitchen staff to follow the items listed on the spread sheets. During an interview on 02/19/26 at 2:43 P.M., Dietary Manager (DM) #605 verified the spreadsheet for 02/18/25 indicated the residents with a mechanical soft diet should have received cut broccoli and the residents ordered a puree diet should have been served cream of rice. DM #605 verified the residents were not served cut broccoli and cream of rice. Review of the facility policy titled, Food and Nutrition Services dated October 2017 revealed each resident is provided a nourishing, palatable well-balanced diet that meets his or her daily nutritional and special dietary needs.

Based on review of the survey results notebook in the main receptionist area, review of the Certification and Licensure System (CALS), review of facility policy, and staff interview, the facility failed to ensure the most recent survey of the facility conducted by Federal or State surveyors and any plan of corrections was maintained in a readily accessible. This affected all 84 residents in the facility. Review of the survey results notebook in the main receptionist area revealed the last facility survey results were dated 08/16/23. Review of the CALS survey history for the facility revealed the facility had surveys on 08/31/23, 09/21/23, 10/24/23, 11/08/23, 12/26/23, 01/23/24, 02/22/24, 03/13/24, 04/09/24, 04/18/24, 06/12/24, 08/12/24, 09/19/24, 10/02/24, 10/22/24, 12/24/24, 05/19/25, 07/10/25, 07/18/25, 08/12/25, 10/22/25, 12/09/25, and 01/22/26. None of these survey results were in the Survey Results notebook located in the main receptionist area. During an interview on 02/18/26 at 1:28 P.M. the Administrator verified the facility survey results notebook had not been updated since 08/16/23. Review of the policy titled, Resident Rights, not dated, revealed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to examine survey results.

Based on review of facility documents, staff interview, and review of the facility policy, the facility failed to complete the facility assessment. This affected all residents in the facility. The facility census was 84 residents. Findings include: Review of facility Quality Assurance and Performance Improvement (QAPI) documents revealed the facility did not have a completed facility assessment document on file. Interview on 02/10/26 at 5:48 P.M. with the Director of Nursing (DON) verified the facility had not completed a facility assessment. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan dated 2001 revealed the facility should develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems.

Based on record review, staff interview, and review of the facility policy, the facility failed to develop, implement, and maintain an effective Quality Assurance Performance Improvement (QAPI) program that identified and addressed systemic noncompliance. This affected all residents in the facility. The facility census was 84 residents. Findings include: Review of the facility documents revealed the facility could not provide any documentation of any facility QAPI activities for the entirety of 2025. Interview on 02/10/26 at 5:48 P.M. with the Director of Nursing (DON) verified the facility did not have any QAPI activities for the entirety of 2025, including a QAPI Plan, facility assessment, or proof that QAPI meetings were held monthly and/ or quarterly for the entirety of 2025. Review of the policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 2001 revealed the facility should develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems.

Based on record review, staff interview, and review of the facility policy, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to perform any QAPI activities for the entirety of 2025. This affected all residents in the facility. The facility census was 84 residents. Findings include: Review of the facility documents revealed there was no documentation of a QAPI Plan, a facility assessment, performance improvement projects, or QAPI meeting minutes for the entirety of 2025. Interview on 02/10/26 at 5:48 P.M. with the Director of Nursing (DON) verified the facility did not have documentation the facility QAPI Plan, a facility assessment, performance improvement projects, or QAPI meetings minutes for the entirety of 2025. Review of the policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 2001,revealed the facility should develop, implement, and maintain an ongoing facility-wide QAPI Plan to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) meetings were conducted on a quarterly basis. This affected all residents in the facility. The facility census was 84 residents. Findings include: Review of the facility documents revealed the facility had no documentation of QAPI meetings conducted monthly and/or quarterly for the entirety of 2025. Interview on 02/10/26 at 5:48 P.M. with the Director of Nursing (DON) verified the facility did not conduct monthly and/or quarterly QAPI meetings for the entirety of 2025. Review of the policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 2001 revealed the QAPI committee should meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees.

Based on observation, staff interviews, record review and policy review, the facility failed to ensure meals delivered to the residents matched the residents ' meal tickets and the daily menu. This affected all residents in the facility as the facility identified all 84 residents received food from the kitchen. The facility census was 84.1) Review of medical record of Resident #37 revealed an admission date of 12/10/25. Diagnoses included chronic obstructive pulmonary disease (COPD), unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, left bundle-branch block, unspecified, unspecified mood disorder, acute kidney failure, unspecified, other toxic encephalopathy, and cocaine abuse. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37's cognitive status was not assessed. The resident was independent for eating, oral hygiene, and ambulation, supervision assistance for toileting, bathing, dressing, personal hygiene, and transfers. Observation on 02/18/26 at 9:10 A.M. revealed Resident #37 had a breakfast tray delivered to her room which contained milk, grape juice, hot oatmeal, breakfast ham, and scrambled eggs. The breakfast ticket on Resident #37's tray indicated the tray should include cold or hot cereal, juice of choice, waffles, breakfast ham, milk, and coffee or hot tea. During an interview on 02/18/26 at 9:10 A.M. with Resident #37, she reported that tray tickets and menus often do not match the meal that is served. Resident #37 stated that the tray ticket and menu did not match the meal she was provided on 02/18/26. During an interview on 02/18/26 at 9:24 A.M., Certified Nursing Assistant (CNA) #526 confirmed Resident #37's meal tray included milk, grape juice, hot oatmeal, breakfast ham, and scrambled eggs. CNA#526 confirmed the tray ticket indicated the tray should include cold or hot cereal, juice of choice, waffles, breakfast ham, milk, and coffee or hot tea, which did not match the meal served. During an interview on 02/18/26 10:18 A.M., Dietary Manager (DM) #605 confirmed the document titled Maple Grove, Regular diet Week at a glance, included the following menu items for breakfast on 02/18/26 cold cereal or hot cereal, juice of choice, waffles, breakfast ham slice, milk of choice, coffee or hot tea. DM #605 stated the cook on staff for breakfast on 02/18/26 forgot to make and serve the waffles listed on the document Maple Grove, Regular diet Week at a glance on 02/18/26. Review of a document titled Maple Grove, Regular diet Week at a glance, which included breakfast meal items listed for date 02/18/26 listed the following items to be served for breakfast on 02/18/26 cold cereal or hot cereal, juice of choice, waffles, breakfast ham slice, milk of choice, coffee or hot tea. 2) Review of the lunch menu for 02/18/26 revealed the residents would be served lemon zest broccoli, chocolate cake with icing, chicken patty on bun, and rice. Observation of the lunch service on 02/18/26 at 11:57 A.M. with Dietary Manager (DM) #605 revealed the residents' trays included lettuce and tomatoes on their chicken patties. Continued observation of the lunch service on 02/18/26 at 12:28 P.M., revealed the kitchen ran out of lettuce for the chicken sandwiches. Interview with DM #605 at the same time verified the facility did not have enough lettuce and tomatoes and 17 residents did not receive the two items on their chicken sandwich. Continued observation of the lunch service on 02/18/26 at 1:03 P.M. revealed all residents received chocolate pudding instead of chocolate cake. Interview with DM #605 at the same time verified the facility had chocolate cake; however, a cook followed the incorrect menu and served chocolate pudding instead. Review of the facility policy titled, Menus dated October 2017, revealed menus are developed and prepared in advance to meet needs of the residents. This deficiency represents non-compliance investigated under Complaint Number 2742960.

Based on observation, staff interview, and review of the facility policy, the facility failed to maintain the building in a safe and sanitary manner for residents, staff, and the public. This had the potential to affect all residents in the facility. The facility census was 84 residents. Findings include: 1. Observation on 02/19/26 at 10:47 A.M. of the facility's laundry area revealed there was a pool of water on the floor directly inside the entrance to the dirty linens area of the laundry area which was approximately three feet wide by six feet long and approximately one-eighth inch deep. Further observation revealed water was being released from a pipe located under a sink next to the pool of water. The wall adjacent to the pool of water on the floor was missing drywall from the bottom two inches of the wall which was in contact with the pooled water. The metal studs inside the wall appeared to be rusted. Interview on 02/19/26 at 10:47 A.M. with Laundry Aides (LAs) #710 and #712 confirmed there was pool of water on the floor just inside the entrance to the dirty linens side of the laundry area. LA's #710 and #712 further confirmed dirty linens were brought into the laundry area through the entrance impacted by the pool of water. Interview on 02/19/26 at 10:56 A.M. with Maintenance Director (MD) #200 confirmed the existence of a pool of water on the floor directly inside the entrance to the dirty linens area of the laundry area. Further interview with MD #200 verified the pool of water was approximately three feet wide by six feet long and approximately one-eighth of an inch deep. MD #200 further confirmed water was actively being released from a pipe located under a sink, which was located to the right of the pool of water. MD #200 reported the water being released from the pipe under the sink was the source of the water pooled on the floor. MD #200 also confirmed that approximately two inches of drywall was missing from the bottom of the wall adjacent to the pool of water and the studs in the wall appeared to be degraded by rust. MD #200 he reported awareness of the pipe leaking under the sink in the dirty linens area of the laundry room since his first day of employment as Maintenance Director with the facility. Interview on 02/19/26 at 11:35 A.M. with Human Resources (HR) #125 confirmed MD #200's hire date was 12/08/25. 2. Observation on 02/17/26 at 12:16 PM during lunch service in the 400-hall dining area revealed the heating unit was uncovered with a wire sticking out from left of the unit. The cover to the heating unit was sitting on the floor. Interview on 02/17/26 at 12:17 P.M. with the Scheduler and Certified Nursing Assistant (CNA) #185 confirmed the heating unit in the 400-hall dining area was uncovered with a wire sticking out from the left side of the unit, and the cover to the unit was on the floor. The Scheduler further confirmed this was a safety hazard for the residents and she would report it to the maintenance department. Observation on 02/19/26 at 10:00 A.M. of the 400-hall dining area revealed the heating unit was covered, but there was still a wire sticking out of the left side of the unit. Interview on 02/19/26 at 10:00 A.M. with the Director of Nursing (DON) confirmed the heating unit in the dining area was covered but there was a wire coming out of the left side of the unit and it was a safety hazard for all the residents in the 400 hall since they were all mobile and ate their meals in the dining area. 3. Observation on 02/19/26 at 11:08 A.M. with Registered Nurse (RN) #305 of Resident #7's room revealed there was a square floor fan in the room which was approximately 24 inches by 24 inches with a white grate that was covered with black dust particles some of which were approximately two inches long. The fan was pointed towards Resident #7 who was in bed. Interview on 02/19/26 at 11:08 A.M. with RN #305 verified Resident #7's fan grate was covered with black dust/lint and the fan was on and pointed directly at the resident. Review of the facility policy titled Quality of Life – Homelike Environment revealed the facility staff and management would maintain a clean, sanitary and orderly environment.

Based on observation, staff interview, and review of the facility policy, the facility failed to provide privacy curtains in resident rooms. This affected five (Residents #30, #96, #10, #80 and #18) of five residents reviewed for privacy. The facility census was 84 residents. Findings include: 1.Observation on 02/17/26 at 11:21 A.M. revealed the room of Residents #96 and #30 only had one privacy curtain which was not adequate to provide visual privacy to either resident. Interview on 02/17/26 at 11:21 A.M. with Certified Nursing Assistant #505 verified the one privacy curtain that was in place was not adequate to provide either Resident #96 or Resident #30 privacy during care. 2.Observations on 02/18/26 at 10:34 A.M. and on 02/19/26 at 8:08 A.M. revealed the room of Residents #96 and #30 continued to have only one privacy curtain in place. Observation on 02/18/26 at 12:15 P.M. with Registered Nurse (RN) #309 revealed there were no privacy curtains in Resident #18's room. Interview on 02/18/26 at 12:16 P.M. with RN #309 confirmed there were no privacy curtains in Resident #18's room and she was unsure how long the curtains had been missing. 3.Observation on 02/17/26 at 12:39 P.M. revealed no privacy curtains were present in Resident #10's room and the resident had a roommate. Interview on 02/17/26 at 12:39 P.M. with Resident #10 confirmed privacy curtains were not present in the resident's room. Interview on 02/17/26 at 3:20 P.M. with Human Resources (HR) #125 confirmed privacy curtains were not present in Resident #10's room. 4.Observation on 02/17/26 at 12:41 P.M. revealed privacy curtains were not present in Resident #80's room. Interview on 02/17/26 at 12:42 P.M. with Resident #80 confirmed privacy curtains were not present in the resident's room and the resident had a roommate. Resident #80 confirmed there had been no privacy curtains in the room since his admission on [DATE]. Interview on 02/17/26 at 3:20 P.M. with Human Resources (HR) #125 confirmed privacy curtains were not present in Resident #80's room. HR #125 was unable to confirm how long privacy curtains had not been present in Resident #80's room. Review of the facility policy titled Resident Rights undated revealed residents had a right to privacy.

Based on record reviews, interviews, and policy review, the facility failed to conduct quarterly care conferences. This affected five Residents (#03, #06, #07, #61 and #49) of five residents reviewed for care conferences. The facility census was 84. 1) Review of the medical record revealed Resident #03 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, hypertension, atrial fibrillation, bipolar disorder and anxiety disorder. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #03 had intact cognition. Review of care conferences for Resident #03, as provided by the facility, revealed the only documented care conference for Resident #03 was in the third quarter of 2025. There were no documented care conferences at admission and fourth quarter of 2025. During an interview on 02/19/26 at 11:50 A.M. the Director of Nursing (DON) verified Resident #03 was not provided with an admission care conference or a care conference in the fourth quarter of 2025. 2) Review of the medical record revealed Resident #06 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident with left (non-dominant) side hemiplegia and hemiparesis, dysphagia, congestive heart failure and depression. Review of the MDS admission assessment dated [DATE] revealed Resident #06 had moderate cognitive impairment. Review of care conferences for Resident #06, as provided by the facility, revealed there was no documented admission care conference. During an interview on 02/17/26 at 11:11 A.M. Resident #06's representative stated there had been no communication about Resident #06's plan of care. Resident #06's representative stated the facility had not conducted an admission care conference for the resident. During an interview on 02/19/26 at 11:50 A.M., the DON verified Resident #06 was not provided with an admission care conference. 3) Review of the medical record revealed Resident #07 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia, tracheostomy, mechanical ventilation, dysphagia, enteral feeding tube, diabetes mellitus type II, atrial fibrillation and depression. Review of the MDS Quarterly assessment dated [DATE] revealed Resident #07 had intact cognition. Review of care conferences for Resident #07, as provided by the facility, revealed there were no documented care conferences provided to Resident #07 in the first, second, third and fourth quarters of 2025. During an interview on 02/19/26 at 11:50 A.M., the DON verified Resident #07 was not provided care conferences in the first, second, third and fourth quarters of 2025. 4) Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses of schizophrenia, chronic obstructive pulmonary disease, Alzheimer's disease, peripheral vascular disease, bipolar disorder and anxiety disorder. Review of the MDS Quarterly assessment dated [DATE] revealed Resident #61 had moderate cognitive impairment. Review of care conferences for Resident #61, as provided by the facility, revealed a conference was conducted with Resident #61 and Resident #61's Representative in the third quarter of 2025. There were no documented care conferences for the first, second and fourth quarters of 2025. During an interview on 02/19/26 at 11:50 A.M., the DON verified Resident #61 was not provided with a care conference in the first, second, third and fourth quarters of 2025. 5) Review of medical record of Resident #49 revealed an admission date of 12/20/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type II diabetes mellitus without complications, anxiety disorder, polyneuropathy, muscle weakness, major depressive disorder, and alcohol use with alcohol induced persisting dementia. Review of most recent annual MDS assessment dated [DATE] revealed Resident #49 had severe problems with thinking and memory. The resident was maximal assistance for eating and oral hygiene, dependent for toileting, bathing, dressing, personal hygiene, transfers, and mobility with a manual wheelchair. Review of care conferences for Resident #49 revealed a care conference was conducted on 06/19/25 with the resident's legal guardian. There was no documented evidence of any additional care conferences being completed. Interview on 02/18/2026 at 2:46 P.M. with Social Services Worker (SSW) #150 confirmed documentation of a care conference on 06/19/25 which included Resident #49's legal guardian. SSW #150 confirmed there was no additional documentation of care conferences for Resident #49. Review of the Care Planning Conferences policy revealed the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The facility staff supports and encourages resident/representative participation in the care planning process by holding care planning meetings at times of day when the resident, representative and family members can attend and are functioning at their best. A seven day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone.

Based on observation, staff interview, record review and policy review, the facility failed to dispose of expired vaccines. This had the potential to affect the forty-six Residents (#01,#02, #03, #06, #07, #09, #10, #11, #15, #16, #20, #22, #25, #28, #29, #30, #33, #34, #35, #37, #38, #39, #40, #41,#47, #49, #50, #52, #54, #57, #58, #59, #61, #62, #64, #69, #71, #73, #74, #77, #78, #80, #85, #94, #95, and #96) housed in the 100 and 300 halls who the facility identified as receiving vaccines. The census was 84.During a medication storage observation on [DATE] at 4:01 P.M., three 0.5 milliliter (mL) single dose Influenza Vaccine Afluria were found to be expired (expiration date [DATE]). Four boxes each containing ten Pneumococcal Vaccine Polyvalent Pneumovax – 23, single dose 0.5 mL syringes were found to be expired (expiration date [DATE]). During an interview on [DATE] at 4:30 P.M., The Director of Nursing ([NAME]) confirmed all the products in the medication storage room on the first floor are intended for the Residents in the 100 and 300 halls, and staff were required to remove and properly dispose of all expired vaccines. The DON verified expired vaccines were in the medication storage room. Review of facility policy titled, Storage of Medications), revised [DATE], revealed discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observations, staff interviews, record reviews and policy review, the facility failed to provide residents with regular utensils during meals. This directly affected three Residents (#37, #03 and #61) but had the potential to all affect all 84 residents as the facility identified all residents received Meals from the kitchen. The facility census was 84. Findings include: 1) Review of medical record of Resident #37 revealed an admission date of 12/10/25. Diagnoses included chronic obstructive pulmonary disease (COPD), unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, left bundle-branch block, unspecified, unspecified mood disorder, acute kidney failure, unspecified, other toxic encephalopathy, and cocaine abuse. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a cognitive status was not assessed. The resident was independent for eating, oral hygiene, and ambulation, supervision assistance for toileting, bathing, dressing, personal hygiene, and transfers. Observation on 02/18/26 at 9:10 A.M. revealed Resident #37 was utilizing plastic utensils to feed herself breakfast in her room. During an interview on 02/18/26 at 9:10 A.M. Resident #37 stated she was displeased with being provided plastic utensils for meals and would prefer regular utensils. Resident #37 further reported that often residents are provided with plastic utensils instead of metal utensils with their meals. During an interview on 02/18/26 at 9:24 A.M., Certified Nursing Assistant (CNA) #526 verified Resident #37 was provided with plastic utensils to eat breakfast. CNA #526 stated the residents were periodically provided with plastic utensils for meals when the kitchen ran out of regular utensils. CNA #256 stated the regular utensils were not often returned to the kitchen in a timely manner causing the kitchen to run out of regular utensils. 2) Review of the medical record revealed Resident #03 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, hypertension, atrial fibrillation, bipolar disorder and anxiety disorder. Review of the MDS Quarterly assessment dated [DATE] revealed Resident #03 had intact cognition and required set up assistance for eating. Observation of Resident #03's room on 02/19/26 at 12:10 P.M. revealed the breakfast tray was delivered with plastic utensils instead of traditional metal utensils. Resident #03 stated he disliked plastic utensils and preferred regular utensils. 3) Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses of schizophrenia, chronic obstructive pulmonary disease, Alzheimer's disease, peripheral vascular disease, bipolar disorder and anxiety disorder. Review of the MDS Quarterly assessment dated [DATE] revealed Resident #61 had moderate cognitive impairment. The resident was independent for eating. Observation of Resident #61's room on 02/19/26 at 12:21 P.M. revealed the breakfast tray was delivered with plastic utensils instead of traditional metal utensils. Resident #03 stated he disliked plastic utensils and preferred regular utensils. Resident #61 stated he disliked plastic utensils and preferred regular utensils. Review of a facility document titled Quality of Life – Homelike Environment which indicated version 1.2 stated, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. This deficiency represents non-compliance investigated under Complaint Number 2747574.

Based on observation, staff interview and policy review, the facility failed to ensure a safe, functional and homelike environment for the residents. This affected three Residents (#10, #49 and #80) of four resident rooms reviewed for a safe, functional and homelike environment. The facility census was 84. 1) Review of the medical record of Resident #10 revealed an admission date of 12/28/25. Diagnoses included acute kidney failure with tubular necrosis, rhabdomyolysis, encephalopathy, abnormal levels of other serum enzymes, and cocaine abuse. Review of the admission Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #10 was cognitively intact. Observation of Resident #10's room on 02/17/26 at 12:39 P.M. revealed the door to the resident's bathroom did not close completely, thus not providing privacy for the resident while using the bathroom adjacent to his sleeping quarters. This was a semi-private room shared with Resident #80. Interview with Resident #10 at the same time expressed concerns that the door to the bathroom would not close completely and thus did not provide enough privacy for him or his roommate. During an interview on 02/17/26 at 3:20 P.M. with Human Resources (HR) #125 confirmed the bathroom door adjacent to Resident #10's sleeping quarters would not close completely. 2) Review of the medical record of Resident #80 revealed an admission date of 12/22/25. Diagnoses included radiculopathy, lumbar region, human immunodeficiency virus, post-traumatic stress disorder, major depressive disorder, chronic viral hepatitis C, and other psychoactive substance dependence. Review of the admission MDS assessment dated 12/28 /25 revealed Resident #80 was cognitively intact. Observation of Resident #80's room on 02/17/26 at 12:39 P.M. revealed the door to the resident's bathroom did not close completely, thus not providing privacy for the resident while using the bathroom. Interview with Resident #80 at the same time, expressed concerns that the door to the bathroom did not close completely, and thus did not provide privacy for he or his roommate when using the bathroom. During an interview on 02/17/26 at 3:20 P.M. Human Resources (HR) #125 verified the bathroom for Resident #80 and Resident #`10's door adjacent to Resident #80's sleeping quarters did not close completely thus providing privacy. Review of a facility document titled Resident Rights which contained no date or version number revealed the Federal and State laws guarantee certain basic rights to all residents of this facility which included the rights to privacy. 3) Review of medical record of Resident #49 revealed an admission date of 12/20/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type II diabetes mellitus without complications, anxiety disorder, polyneuropathy, muscle weakness, major depressive disorder, and alcohol use, unspecified with alcohol induced persisting dementia. Review of most recent annual MDS assessment dated [DATE] revealed Resident #49 had severe problems with thinking and memory. Observation oof Resident #49's room on 02/17/26 at 10:31 A.M. revealed an unmonitored space heater which was plugged in, running and was located on the floor in the resident's room with the resident's door standing open. During an interview on 02/17/26 at 11:03 A.M. Certified Nursing Assistant (CNA) #508 verified Resident #49's room had a space heater running. During an interview on 02/19/26 at 10:37 A.M. the Director of Nursing (DON) #300 stated the heat was not working properly in Resident #49's room and a space heater was being used in the resident's room. Review of a facility document titled Electrical Safety for Residents with a revised date of January 2011 stated, Portable space heaters are not permitted in the facility. Review of the policy titled, Quality of Life-Homelike Environment, dated 2001, revealed residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include a clean, sanitary and orderly environment. This deficiency represents non-compliance investigated under Complaint Number 2747574.

Based on review of Minimum Data Set (MDS) assessments, review of medical record, and staff interview, the facility failed to ensure a significant change assessment was completed for one (Resident #02) of one resident reviewed for significant change assessments. The facility census was 84.Findings include: Review of the medical record revealed Resident #02 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident with aphasia, diabetes mellitus type II, post-traumatic stress disorder, hypertension and epilepsy. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #02 had severe cognitive impairment and was frequently incontinent of bowel and occasionally incontinent of bladder. The resident required supervision for eating, toileting, bed mobility and transfers, and moderate assistance for bathing and dressing, and was independent for oral and personal hygiene. Review of Hospice progress note dated 01/14/26 at 5:27 P.M. revealed Resident #02 was admitted to Hospice services for a diagnosis of cerebral vascular accident. Review of physician orders for Resident #02 revealed an order dated 01/14/26 authored by Medical Director (MD) #900 for Resident #02 to be admitted to Hospice services. Review of the MDS assessments for Resident #02 revealed a Significant Change assessment was not completed when Resident #02 transitioned to Hospice services. During an interview on 02/18/26 at 3:25 P.M. the Director of Nursing (DON) verified Resident #02 did not have a Significant Change assessment completed when the resident transitioned to Hospice services.

Based on observation, staff interviews, and facility policy review, the facility failed to provide a discreet cover for a resident's catheter bag and ensure appropriate placement of catheter bag. This affected one (Resident #94) of two residents reviewed for catheter care. The facility census was 84. Review of the medical record of Resident #94 revealed an admission date of 02/16/26. Diagnoses included acute hematogenous osteomyelitis, left ankle and foot, complete lesion at T1 level of thoracic spinal cord, neuromuscular dysfunction of bladder, borderline personality disorder, antisocial personality disorder, paraplegia, schizoaffective disorder, and acquired absence of right leg above knee. The admission Minimum Data Set (MDS) assessment for Resident #94 was still in progress. A Brief Interview for Mental Status (BIMS) revealed Resident #94 was cognitively intact. Observation on 02/18/26 at 10:44 A.M. revealed Resident #94 was present in the main lobby with his catheter bag sitting on his lap and not covered. During an interview on 02/18/26 at 10:44 A.M., Resident #94 acknowledged his catheter bag was lying on his lap uncovered. Resident #94 reported he would like to have cover for his catheter bag. During an interview on 02/18/26 at 10:52 A.M. Director of Clinical Operations (DCO) #915 , confirmed Resident #94's catheter bag was lying on the resident's lap and was not covered while the resident was present in the main lobby. Review of the policy titled, Resident Rights, not dated, revealed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence. Review of policy titled Catheter Care, Urinary revealed the urinary drainage bag must be held or positioned lower than the bladder at all times.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to implement nutritional recommendations made by the Registered Dietitian (RD) for a resident with weight loss. This affected one (Resident #03) of three residents reviewed for nutrition. The facility census was 84.Findings include:Review of the medical record revealed Resident #03 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, hypertension, atrial fibrillation, bipolar disorder and anxiety disorder.Review of weights for Resident #03 revealed on 08/03/25 Resident #03 had a documented weight of 221 pounds and on 02/01/26 Resident #03 had a documented weight of 189.8 pounds. This represented a 14.12 percent (%) weight loss in six months.Review of RD progress note for Resident #03 dated 10/15/25 authored by RD #600 revealed Resident #03 was ordered to receive double portions for all meals.Review of weights for Resident #03 revealed on 11/04/25 Resident #03 had a documented weight of 209.8 pounds and on 02/01/26 Resident #03 had a documented weight of 189.8 pounds. This represented a 9.53 percent (%) weight loss in three months.Review of RD progress note for Resident #03 dated 12/11/25 authored by RD #600 revealed Resident #03 triggered for a significant weight loss over the past 90 days. Meal acceptance noted was at 75% to 100% most days and there were no chewing or swallowing issues reported. RD #600 ordered to recheck the resident's weights to confirm and to liberalize the resident's diet to regular from No Added Salt (NAS) to promote palatability and intakes for the resident. RD #600 recommended to monitor weekly weights if weight loss is confirmed.Review of the physician order for Resident #03 revealed an order dated 12/12/25 for Resident #03 to receive a regular diet, regular texture, regular (thin) consistency.Review of weights for Resident #03 revealed Resident #03 had a documented weight on 12/24/25 and was not weight again until 02/01/26. During this period Resident #03's experienced continued weight loss from 194 pounds to 189.8 pounds.Review of RD progress note for Resident #03 dated 01/15/26 authored by RD #600 revealed Resident #03 was noted with significant weight loss of 11.4% over the past 180 days. The resident previously received additional portions with meals, but an order was no longer in place since the resident's hospitalization. RD #600 noted given the history of weight loss, RD #600 recommended resuming large portions with meals to support intake and nutritional adequacy. And obtaining January 2026 weight and to start weekly weights.Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #03 had intact cognition and was frequently incontinent of bowel, and always continent of bladder. The resident required set-up assistance for eating, supervision for oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfers. Interview on 02/19/26 at 11:32 A.M. with Resident #03 revealed he was not trying to lose weight. The resident revealed he was not receiving double portions of food.Review of the menu tray card for Resident #03 dated 02/19/26 revealed Resident #03 was not indicated to receive large portions and/or double portions.Observation of breakfast tray for Resident #03 on 02/19/26 revealed Resident #03 was provided with three pieces of dry white toast and two bowls of frosted flakes cereal with no milk (resident does not drink milk). The breakfast menu for 02/19/26 revealed pancakes were to be served and Resident #03 said he wanted pancakes. During an interview on 02/19/26 at 1:48 P.M., Dietary Manager #605 verified Resident #03's menu tray card did not indicate Resident #03 was to receive large portions and/or double portions for all meals.During an interview via phone on 02/19/26 at 1:13 P.M., RD #600 verified since 01/15/26, Resident #03 should have received double portions and verified Resident #03 should have been weighed weekly. RD #600 verified neither recommendation had been implemented for Resident #03.Review of list of residents to receive large portions and/or double portions on 02/19/26 at 5:00 P.M., as provided by the facility, revealed Resident #03 was not on the list to receive large portions and/or double portions.During an interview on 02/19/26 at 5:48 P.M., the Director of Nursing (DON) verified Resident #03 had experienced a significant weight loss and that RD #600's recommended interventions of large/double portions and weekly weights had not been implemented. The DON also verified Resident #03 had no documented weights from 12/24/25 to 02/01/26. Review of the February 2026 active plan of care for Resident #03 revealed Resident #03 was at moderate nutrition/hydration risk related to being on medication which may impact nutritional status with a goal to experience no significant unplanned weight change. Interventions included to monitor for difficulties chewing/swallowing. monitor laboratory findings (labs), weights, intakes and skin assessments, observe for sign and symptoms of dehydration, provide and serve diet and supplements as ordered, provide dietary education as needed, and update dietary preferences as needed. Review of the policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, not dated, revealed the nursing staff would monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria:a. 1 month - 5 % weight loss is significant; greater than 5 % is severe.b. 3 months - 7.5 % weight loss is significant; greater than 7.5 % is severe.c. 6 months - 10 % weight loss is significant; greater than 10 % is severe.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of staff witness statements, review of hospital records, staff interview, resident interview, and review of the facility policy, the facility failed to ensure residents were free from resident-to-resident abuse. This resulted in Actual Harm on 07/01/25 to Resident #38 when Resident #43, a resident with a known history of aggressive behaviors towards other residents, struck Resident #38 in the face causing a nasal fracture. This affected one (Resident #38) of three residents reviewed for abuse. The facility census was 71 residents.Findings include: 1. 1.Review of the medical record for Resident #38 revealed an admission date of 05/13/25 with diagnoses including dementia without behavioral disturbance, hepatitis C, and atrioventricular heart block. Review of the Minimum Data Set (MDS) assessment for Resident #38, dated 05/22/25, revealed the resident had intact cognition and ambulated with a cane. Review of the census profile for Resident #38 revealed the resident was moved into a room with Resident #43 on 06/25/25 because Resident #38 was not getting along with his roommate. Review of the progress note for Resident #38, dated 07/01/25 at 6:06 P.M., revealed Resident #38 had been punched in the face by Resident #43. Upon entering the room, Resident #38 was sitting on his bed with blood and blood clots gushing out of his right nostril. The nose appeared to be injured. Emergency medical services (EMS) were called, and Resident #38 was sent to the hospital for evaluation. Review of the witness statement from Certified Nursing Assistant (CNA) #530 revealed the aide was coming back from a break and was passing Resident #38 and Resident #43's room when the aide noticed blood on the sheets. CNA #530 entered the room and Resident #38 told the aide that Resident #43 had hit him. CNA #530 then notified the nurse. Review of the Self-Reported Incident (SRI) regarding Resident #38 dated 07/01/25 revealed on 07/01/25 at 6:00 P.M., Resident #43 struck Resident #38 in the nose resulting in a bloody nose and a nasal fracture for Resident #38. The facility substantiated abuse had occurred by Resident #43 towards Resident #38. Review of the hospital note for Resident #38, dated 07/01/25 at 6:35 P.M., revealed the resident presented at the hospital due to blunt force trauma to the head and was diagnosed with a closed fracture of nasal bone, which was confirmed by a computerized tomography (CT) scans of the maxillofacial area and the head. Review of the hospital discharge instructions for Resident #38, dated 07/01/25 at 7:42 P.M., revealed the resident had a nasal bone fracture and should follow up with an ear, nose, and throat (ENT) physician for further examination and recommendation. Review of the progress note for Resident #38, dated 07/02/25 at 3:03 A.M., revealed the resident returned from the hospital with a fractured nasal bone. A report from the hospital nurse revealed the resident received tranexamic acid (a medication to help control bleeding) due to the resident's bloody nose. Resident #38 was to follow up with an ENT physician as soon as possible. Resident #38 was moved to a new room and was monitored frequently by staff. Review of the progress note for Resident #38, dated 07/03/25 at 2:43 P.M., revealed the resident returned to the facility after his ENT physician follow up visit with new orders for Amoxicillin 500 milligrams (mg), give one tablet by mouth two times a day for ten days for nasal swelling. The ENT physician's note indicated surgical repair of the nasal fracture was not indicated and staff should monitor the swelling to the resident's nose. 2. Review of the medical record for Resident #43 revealed an admission date of 04/23/25 with diagnoses including schizoaffective disorder (bipolar type), anxiety disorder, unspecified dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), and hypertension. Review of the MDS assessment for Resident #43 dated 05/06/25 revealed the resident had severe cognitive impairment and was independently mobile. Review of Resident #38's medical record revealed preadmission progress notes from the nursing home where Resident #43 had previously resided. The progress note dated 03/01/25 at 9:02 A.M., revealed the resident was involved in a physical altercation with another resident after Resident #43 had wandered into the other resident's room. Review of a preadmission progress note dated 03/18/25 at 6:20 P.M., revealed Resident #43 told the nurse he had gotten into a fight with his roommate. Resident #43's roommate had mistakenly laid down in the wrong bed and Resident #43 struck the roommate in the face with a closed fist. The other resident sustained a bruise and an abrasion to his forehead. Review of a preadmission progress note, dated 03/25/25 at 10:27 A.M., revealed Resident #43 was propelling himself in his wheelchair through the common area when he stopped behind another resident who was eating breakfast and punched the other resident twice in the back. Review of a preadmission progress note, dated 03/27/25 at 11:37 A.M., revealed social services spoke with Resident #43's guardian regarding finding alternate placement of the resident due to physically aggressive behaviors. Resident #43's guardian said he was agreeable to alternate placement to any facility able to accept Resident #43. Review of the note revealed Resident #43 had three physical altercations with other residents since his admission to the facility on [DATE]. Resident #43 was physically aggressive to other residents without provocation. Staff noted Resident #43 was cooperative with care and did not exhibit aggression towards staff members but was only physically aggressive with other residents. Review of the one to one observation form for Resident #43 form initiated on 06/25/25 revealed the resident was placed on one-on-one monitoring from 06/25/25 at 7:00 P.M. to 06/27/25 at 7:00 P.M. The one-on-one observation was discontinued for Resident #43 as the resident remained calm and did not appear to want to harm self or others. Review of a progress note for Resident #43, dated 06/25/25 at 5:05 A.M., revealed Resident #43 was observed engaged in a physical altercation with Resident #41. Resident #43 had no injuries and Resident #41 sustained scratches on his face. The staff moved Resident #41 to another room and placed Resident #43 on one to one supervision. Review of the facility SRI dated 06/25/25 revealed Resident #43 was involved in a physical altercation with Resident #41, in which Resident #41 received facial abrasions. The facility did not substantiate abuse, because the investigation revealed Resident #41 was in Resident #43's face and there was no intent to cause harm, just an effort for the residents to be clear of each other. Review of the care plan for Resident #43, initiated on 06/25/25 after the incident involving Resident #41, revealed the resident had the potential to be physically aggressive related to dementia and poor impulse control. Interventions included the following: administer medications as ordered, assess and address contributing sensory deficits, assess and anticipate resident's needs, assess resident's understanding of the situation and allow time for the resident to express self and feelings toward the situation, monitor/document/report as needed any signs/symptoms of resident posing danger to self and others, psychiatric/psychogeriatric consultation as indicated, review for triggers and patterns at scheduled behavior meeting, when physical aggression occurs, remove individuals to a controlled environment, when the resident becomes agitated, intervene before agitation escalates and guide away from source of distress, engage calmly in conversation, if resident is aggressive, staff to walk calmly away and approach later. Review of the census profile for Resident #43 revealed the resident was moved to a private room on 07/01/25 before being sent to the hospital for a psychiatric evaluation. Review of a hospital note for Resident #43 dated 07/01/25 at 6:30 P.M. revealed the resident should be admitted as he represented a substantial risk of physical harm to others as manifested by evidence of recent homicidal or other violent behavior, evidence of recent threats that place another in reasonable fear of violent behavior and serious physical harm, or other evidence of present dangerousness. Resident #43 had exhibited worsening agitation and aggression and had been hitting other residents. Resident #43 was admitted to the psychiatric unit of the hospital on [DATE] and was readmitted to the facility on [DATE]. Review of the progress note for Resident #43, dated 07/02/25 at 8:35 P.M., revealed it was reported to the nurse on 07/01/25 that Resident #43 had punched Resident #38 in the nose. When the nurse asked Resident #43 why he had punched Resident #38, Resident #43 shrugged his shoulders and did not otherwise respond to the nurse. The nurse notified Resident #43's physician who gave orders to send the resident to the hospital for a psychiatric evaluation. Review of the progress note for Resident #43 dated 07/03/25 at 6:41 A.M. revealed the resident was admitted to the hospital's geriatric psych unit. Review of the progress note for Resident #43 dated 07/11/25 at 12:42 P.M. revealed the resident returned from the hospital with no new orders. During an interview on 07/16/25 at 8:13 A.M., CNA #530 stated he was the first person to respond to the incident on 07/01/25 between Residents #43 and #38. CNA #530 stated on 07/01/25 at approximately 6:00 P.M. he returned to the unit after supervising the 5:30 P.M. smoking session when he saw bloody sheets on Resident #38's nightstand. CNA #530 entered Resident #38's room and saw the resident in bed in a fetal position and there was blood everywhere. Resident #38 told the aide he had been resting in bed when Resident #43 wheeled over in his wheelchair and hit him in the face. Resident #43 was sitting in the room in his wheelchair while Resident #38 spoke to the aide regarding the incident. CNA #530 left the room and notified Licensed Practical Nurse (LPN) #401 of the incident. During an interview on 07/16/25 at 8:20 A.M., Resident #38 stated he was lying in bed on 07/01/25 when Resident #43 wheeled up in his wheelchair next to the bed and hit the resident in the face. Resident #38 said his nose hurt after he got hit but it felt better now. An interview with Resident #43 was attempted on 07/16/25 at 8:35 A.M. but was unsuccessful as Resident #43's responses to questions were unintelligible. During an interview on 07/16/25 at 8:42 A.M., LPN# 401 stated on 07/01/25 at approximately 6:00 P.M. she was in the nursing station when CNA #530 notified her Resident #43 had hit Resident #38. LPN #401 said she immediately went to Resident 38's room and observed the resident sitting on the side of the bed with blood gushing out of his nose. LPN #410 stated there was blood on the resident, on the sheets, and on the floor, and Resident #38's nose was crooked. LPN #401 notified the physician who gave orders to send Resident #38 to the hospital emergency room for evaluation and treatment and to send Resident #43 to the hospital for a psychiatric evaluation. During an interview on 07/16/25 at 9:32 A.M., the Director of Nursing (DON) stated Resident #38 was moved into the room with Resident #43 on 06/25/25, which was the same day of the incident between Residents #41 and #43. The DON stated she had heard the previous DON and Administrator had been reluctant to admit Resident #43 to the facility due to the resident's history of aggression towards other residents at his previous nursing home. The DON stated she believed Resident #43 should have been placed in a private room due to the resident's known history of physical aggression towards other residents. During an interview on 07/16/25 at 10:05 A.M., the Administrator stated he was not employed at the facility when Resident #43 was accepted for admission in April 2025. The Administrator stated the DON had the responsibility to screen residents and determine appropriateness for admission, but the Administrator had the final say regarding admissions. The Administrator stated he was unaware the previous Administrator and DON had not wanted to admit Resident #43. The Administrator verified Resident #43 had not had any altercations since being placed in a private room upon return from the hospital. The Administrator could not explain why Resident #38 was moved into a room with Resident #43 on 06/25/25. Review of the facility policy titled Abuse and Neglect Protocol, revised 06/13/21, revealed residents have the right to be free from abuse, neglect, misappropriation or resident property, exploitation, corporal punishment, physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, and involuntary seclusion. This deficiency represents noncompliance investigated under Complaint Number OH00166548 (1313528) and Complaint Number OH00166287 (1313527).

Based on resident interviews, staff interviews, an Ombudsman interview, police interviews, medical record review, and policy review, the facility failed to provide a safe discharge for Resident #19. This resulted in Immediate Jeopardy on 04/10/25 when Resident #19 was placed at risk for potential serious life-threatening harm, injuries, negative health outcomes and/or death when the facility discharged Resident #19 without providing a safe discharge location or provisions for a wound treatment. This affected one (Resident #19) of three residents reviewed for discharge. The facility census was 69. On 04/23/25 at 1:07 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Operations (RDO) #200 were notified that Immediate Jeopardy began on 04/10/25 at 3:00 P.M. when Resident #19 was refused access to the facility and the facility issued an emergency discharge based on allegations from two other residents on 04/09/25 that Resident #19 was in possession of a firearm. On 04/09/24, the resident left the facility at approximately 9:00 A.M. and the facility packed Resident #19's belongings in trash bags while Resident #19 was on leave of absence, and did not locate a firearm. Upon Resident #19's return to the building on 04/10/25 at 3:00 P.M., the resident was not allowed in, and the police were called. Police arrived, were on-site at the facility, and searched Resident #19 for a weapon and did not find one. Police escorted Resident #19 off the property and staff placed Resident #19's personal items by the garbage dumpster. The nurse who discharged the resident gave him his face sheet, his medication list and all his routine medications, except the narcotics. Resident #19 was not provided with a safe discharge destination. The Immediate Jeopardy was removed on 04/23/25 when the facility implemented the following corrective actions: • On 04/16/25 and 04/23/25, the DON/Designee reviewed all facility-initiated discharges in the last 90 days for safe discharge criteria. The Administrator/Designee will conduct weekly audits for four weeks, monthly for one quarter, and periodically thereafter to ensure all facility-initiated discharges are completed in a safe, orderly manner. All findings will be reviewed through the Quality Assurance and Performance Improvement (QAPI) committee, and any negative findings will be corrected immediately. • On 04/16/25, the Administrator reviewed the facility's discharge policy for compliance with safe, orderly discharge criteria, with no revisions made. • On 04/23/25, RDO #200 in-serviced the Administrator about completing a safe and orderly discharge. The education included obtaining orders for discharge, obtaining orders for appropriate services and equipment when transferring to a location in the community, preparing a discharge summary and/or assessment, preparing medications to be discharged with the resident as permitted by law, assisting with transportation as applicable, and communicating with resident and/or representative regarding the discharge plan and appropriate documents. • On 04/23/25, the Administrator in-serviced members of the interdisciplinary team, including the DON, Assistant Director of Nursing (ADON) #127, Minimum Data Set (MDS) Nurse #124, Social Worker #135, and Business Office Manager (BOM) #166, and all nurses about completing a safe and orderly discharge. The education included obtaining orders for discharge, obtaining orders for appropriate services and equipment when transferring to a location in the community, preparing a discharge summary and/or assessment, preparing medications to be discharged with the resident as permitted by law, assisting with transportation as applicable, and communicating with resident and/or representative regarding the discharge plan and appropriate documents. Any nurse that was not educated was not allowed back to the floor until they were in-serviced. Although the Immediate Jeopardy was removed on 04/23/25, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] and was discharged on 04/10/25. Diagnoses included unspecified paraplegia, stage III pressure ulcer to the left heel, chronic pain syndrome, unspecified protein calorie malnutrition, morbid obesity, unspecified bipolar disorder, and neuromuscular dysfunction of the bladder. Review of the care plan dated 01/28/25 revealed Resident #19 wanted to discharge to home or community. Interventions included encouraging the resident to discuss feelings/concerns about discharge, evaluating the resident's ability to safely discharge to the community, and providing community referrals to determine/address gaps in the resident's strengths and abilities that could affect a safe discharge. Review of the most recent Minimum Data Set (MDS) assessment, dated 02/04/25, revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of progress notes revealed on 04/09/25 at approximately 7:30 A.M. a male resident on 300 unit asked Licensed Practical Nurse (LPN) #109 to keep Resident #19 out of his room. Resident #19 shouted for the male resident to shut up, and Resident #19 returned to his room. At approximately 9:00 A.M., Resident #19 could not be located in the building and staff stated Resident #19 had left without signing out. The facility notified the Ombudsman who recommended Resident #19 be given an emergency discharge. The facility notified the physician. Review of a progress note dated 04/09/25 at 11:18 A.M. revealed the DON and Administrator were notified that Resident #19 allegedly had a firearm and threatened two male residents earlier that morning. Review of a progress noted dated 04/09/25 at 1:29 P.M. revealed Resident #19 was placed in Emergency Discharge status. Social Worker (SW) #135 attempted to locate emergency placement for Resident #19 with four long-term care facilities, but each denied admission. SW #135 attempted to schedule a follow-up appointment for Resident #19 at University of Cincinnati Health but was unsuccessful. SW #135 reached out to community housing programs for emergency housing but was unsuccessful. Resident #19 was unavailable for participation in the discharge process. Review of a progress note dated 04/09/25 at 6:35 P.M. revealed the facility checked Resident #19's room for safety hazards and found none. The administration directed staff to notify authorities if Resident #19 returned to the facility. Review of the Discharge summary dated [DATE] revealed Resident #19 had a planned, emergency discharge recommended by the Ombudsman related to threats with a firearm. Social Services attempted to locate emergency placement with several long-term care facilities, but the resident was not accepted for admission. The resident was away from the building and was unable to be reached to discuss his plans for discharge location. Resident #19 received a copy of his discharge instructions. Review of the document titled Emergency Notice of Discharge, dated 04/10/25, documented Resident #19 was discharged from the facility because the safety of other residents was endangered. Specific allegations in support of the reason included residents had alleged Resident #19 had threatened them with a gun. The resident had been offered services to assist with placement, and discharge was made to Mountain Crest Health Care. The discharge notice listed the resident's right to appeal the discharge and the right to remain in the facility until the appeal was heard by a Hearing Official. Contact information was listed for the Ohio Office of Legal Services and State Long-Term Care Ombudsman. The document was signed by the Administrator with LPN #88 signing as a witness. Review of the Social Service Recapitulation note, dated 04/10/25 at 5:21 P.M., documented that the social worker was unable to discuss discharge plans with Resident #19 due to him having to exit the building because of an emergency discharge. The physician was notified and gave orders that directed Resident #19 could not have narcotic medications. Staff gave Resident #19 his face sheet, orders, and medications. Review of a progress note dated 04/10/25 at 5:53 P.M. revealed Resident #19 arrived on facility property and police were called. Resident #19 spoke with the Administrator regarding an emergency discharge and Resident #19 refused to accept the discharge notice. Review of progress note dated 04/10/25 at 6:49 P.M. revealed Resident #19 was discharged with all his possessions and a nurse provided discharge instructions. During the entrance conference on 04/16/25 at 9:25 A.M., the Administrator stated on 04/09/25 Residents #42 and #43 reported Resident #19 had threatened each of them on separate occasions with a gun. Each resident stated he had seen Resident #19 with a gun. Resident #19 left the facility without signing himself out. The facility placed the building in lockdown status and vetted anyone who entered the facility. The facility called the police right away. Upon police suggestion, the facility searched Resident #19's room and did not find a weapon. Police instructed the facility not to let Resident #19 back into the building until the police questioned him. Resident #19 returned to the building the next day. The facility told Resident #19 he could not come into the building, but he entered anyway and went towards his room. The police arrived. The facility gave Resident #19 his medications, medical records, and an emergency discharge notice. After making the initial police report the facility contacted the Ombudsman who told them due to the threat, they had to issue an emergency discharge to keep the other residents safe. Resident #19 refused to take the discharge paperwork. Resident #19 took all of his things with him. The police ensured all of his things were out of the building. The Administrator stated Resident #19's sister came and picked him up in the parking lot and took all his items. During a telephone interview on 04/16/25 at 10:18 A.M., Ombudsman #71 stated the facility called her on 04/09/25 for guidance. They stated that Resident #19 had allegedly threatened someone with a gun. They never found a gun. Ombudsman #71 stated she advised the facility they could discharge Resident #19, but it had to be a safe discharge, which they had to provide for both him and his representative in writing. Ombudsman #71 stated Resident #19 returned to the facility on [DATE], and staff alerted her they were putting Resident #19 on the street. Resident #19 slept in a car for two days and was hospitalized at Christ Hospital. During concurrent interviews on 04/16/25 at 10:55 A.M., Residents #42 and #43 each stated they had seen Resident #19 with a nine-millimeter pistol, and he had threatened each of them. During a telephone interview on 04/16/25 at 12:33 P.M., Certified Nursing Assistant (CNA) #172 stated she was working on 04/10/25 from 7:00 A.M. to 7:00 P.M. Resident #19's possessions were in plastic trash liners and lined up by the back door. Resident #19 arrived at the facility around 3:00 P.M. accompanied by another young male. CNA #172 stated she took a 15-minute break and as she went outside, Resident #19 zoomed past her into the building. CNA #172 stated the police pulled up while she was on break, and a task force entered the building through the back. When she went back into the building, the police and Administrator were talking to Resident #19. An officer asked her if she had ever seen Resident #19 with a gun, and she said no. CNA #172 stated per police request, she carried bags of Resident #19's personal items out of the facility and placed them near the garbage dumpster. During an interview on 04/17/25 at 8:30 A.M., SW #135 stated Resident #19 met her at the time clock when she came into work on 04/09/25. He asked her to search him. Resident #19 explained other residents had made accusations that he had threatened them with a gun. Resident #19 went to his room. ADON #127 was there. Resident #19 asked her to search him. Resident #19 said he had an appointment, and he left the building. SW #135 stated she went to the morning meeting, but the meeting was canceled when the police arrived. The management team held an emergency meeting with all staff to discuss the active shooter policy. Staff were instructed to inform the Administrator if Resident #19 returned to the building, to not let him inside until the police arrived. The building was placed on lockdown. Staff could come and go but residents had to stay inside. While he was gone, the social worker attempted to get Resident #19 placement at four long term care facilities. Each rejected him. She tried to set up an appointment with a primary care provider at UC Health and was told to call back the next day. Resident #19 returned to the facility on [DATE] between 2:00 to 3:00 P.M. SW #135 stated she went outside. Resident #19 called the police since the Administrator was not at the building. Human Resources (HR) Staff #176 came out too. They waited together for the police, but no one came. The police called Resident #19 back, and SW #135 talked to them. The officer was confused as to why a police presence was needed and stated the police were not coming. The police advised calling on Friday and talking to Officer #32 in District 4 because he was handling the case. SW #135 stated she looked and saw the Administrator in the building. Resident #19 asked him to come out, but the Administrator refused. SW #135 stated she went back into the building. Later, Resident #19 followed staff into the building. He went towards his room to get his clothes. The Administrator told him he could not be in the building and told him to leave. Police entered the building wearing body [NAME] with guns drawn and were shouting Where is the gun? repeatedly. Resident #19 said they could search him and denied having a weapon. Resident #19 was very upset because he did not have anywhere to go. There was no family there to get him. Management assumed Resident #19 had a sister who worked in housekeeping at the facility, but she was not his sister and of no blood relation. She had no vehicle and had stairs in front of her house that Resident #19 would not have been able to access while in his wheelchair. Police asked staff to move Resident #19's possessions off the property so police would not later be called back to arrest him for trespassing. Resident #19 left and rolled up the hill in his wheelchair. SW #135 stated she stopped her car after exiting out of the parking lot so Resident #19 could cross the street in his wheelchair. SW #135 stated no one knew where Resident #19 went after he left the facility. During an interview on 04/17/25 at 9:09 A.M., HR Staff #176 stated when Resident #19 was accused of having a gun, ADON #127 was right there. Resident #19 asked ADON #127 to search him and his things. She did not search him, told him not to worry about it, and said he could leave. On 04/10/25, Resident #19 called HR Staff #176 and said he was coming to the facility to talk to the Administrator about the situation. HR Staff #176 stated she informed the Administrator. Around 3:00 P.M., HR Staff #176 saw Resident #19 approaching the front door. She went out to speak to him. Resident #19 said he had already called the police. HR Staff #176 waited outside with him for about 30 minutes. The police never came. Resident #19 tried to call the police again and put the call on speaker phone. The officer was confused why a police presence was necessary for Resident #19 to enter the building. HR Staff #176 explained the events to the officer who said he would check and call back. When the officer called back, the officer spoke with the social worker. He was still confused and gave her the name of someone to call the next day. The Administrator returned to the facility and entered through the ambulance entrance. HR Staff #176 stated she explained to the Administrator that the police were confused about why they needed to come to the building. Somehow Resident #19 followed someone into the building and started going towards his room. The Administrator told him he had to leave. Resident #19 said they could not just put him out on the streets, stated he did not have a gun, and stated he called the police, and they weren ' t coming. HR Staff #176 stated around 5:00 P.M., she was driving out of the parking lot when multiple police vehicles approached the facility. She pulled back into the parking lot and entered the building. A male officer was shouting for the DON. He stated the DON called police and reported Resident #19 had a gun. Police started questioning staff if they had seen a gun. All staff denied seeing a gun. HR Staff #176 stated she had gone to her car. An officer approached her and asked her to carry Resident #19's items to the curb so he would not have to be trespassed off the property. Resident #19 was heard saying, How can you put me out? I have no gun. No one saw a gun. The police did not see a gun. Now you got the DON calling in saying I got a gun? HR Staff #176 stated when she finally left the facility, she saw Resident #19 wheeling himself up the street. Staff were still setting his stuff on the curb. He did not take any of his items with him and she did not know what happened to his items. During an interview on 04/17/25 at 10:54 A.M., Housekeeper #97 stated she was not related to Resident #19, and he was not discharged into her care. During a telephone interview on 04/17/25 at 2:21 P.M., Police Supervisor #25 stated he advised the facility that police could not search Resident #19's property without a search warrant and advised the facility to follow their policy. The officer stated the police would respond if the facility called again with additional concerns once Resident #19 returned. During a telephone interview on 04/22/25 Resident #19 denied having a weapon or threatening other residents with a weapon at the facility. Resident #19 stated he asked multiple staff to search himself and his property prior to leaving on 04/09/25. Resident #19 stated that ADON #127 assured him he did not need to be searched before he left. Resident #19 stated he called the facility on 04/10/25 prior to going to the facility and spoke with two staff members who advised him to call the detectives before returning to the facility. Resident #19 stated when he spoke to police, they said they would meet him at the facility. Resident #19 stated he waited outside the facility for approximately two hours before entering the building. Police never came. When he called back, the officers seemed confused as to why they were needed. Resident #19 stated he had put the call on speaker phone so staff waiting outside with him could hear them say they were not coming before he entered the building. After he entered the building, the Administrator yelled at him, told him he could not be there, and said he was calling the police. The police came charging in asking him where his gun was. Resident #19 denied having a weapon. The Administrator stated Resident #19 needed to leave the premises and handed Resident #19 a face sheet. Resident #19 stated they had to send him somewhere. The Administrator stated it was an emergency discharge, and they did not have to do anything but get him out of the building. The administrator had police and staff set his things out by the dumpster. Resident #19 stated he did not carry anything with him in his wheelchair. The police said he had to leave his things and get off the lot so they would not have to arrest him for trespassing. Resident #19 stated he propelled down the street in his wheelchair. Two staff members stopped their cars so he could cross the street. It started raining and Resident #19 stated he began checking cars because he was cold. When he found an unlocked vehicle, Resident #19 pulled himself and his wheelchair inside. Resident #19 stated he stayed in the car for two days until it stopped raining. Resident #19 stated he propelled himself to his cousin's house, within five miles of the facility, and called for an ambulance. Resident #19 stated he was admitted to the hospital on [DATE] for a stomach infection and was to be discharged to another nursing facility on 04/22/25 because he was homeless. During an interview on 04/22/25 at 10:31 A.M., the Administrator verified the discharge notice signed on 04/10/25 had an inaccurate discharge destination. The Administrator stated he was trying to change it, but Resident #19 would not let him. The Administrator stated he did not see Resident #19 leave the building and was told by staff he discharged with his sister. During an interview on 04/22/25 at 12:54 P.M., Scheduler #98 stated she was sitting at the reception desk from 04/09/25 at 9:00 P.M. until 04/10/25 at 7:00 A.M. She had a white envelope with discharge papers inside. She was instructed that if Resident #19 came to the building, she was to notify the Administrator and police. Staff were not allowed to let Resident #19 in the building. During an interview on 04/22/25 at 1:08 P.M., Maintenance Staff #164 stated he covered the front desk on 04/09/25 from 4:00 P.M. until 9:00 P.M. He was instructed that if Resident #19 returned to the building, he was to have Resident #19 sign his discharge papers and to call the police if he refused to sign. During a telephone interview on 04/22/25 at 2:26 P.M., LPN #122 stated she and ADON #127 searched Resident #19's room on 04/09/25 and did not find a weapon. During a telephone interview on 04/22/25 at 2:35 P.M., LPN #88 stated she was working upstairs on 04/10/25 when Resident #19 returned to the facility. LPN #88 stated the Administrator asked her to assist with Resident #19's discharge. LPN #88 stated she prepared Resident #19's medications, reviewed the orders, and read the discharge notice to him. The paper said he was discharged to another nursing facility. Resident #19 refused to sign the paper. The Administrator had LPN #88 sign the discharge notice, and she returned to her assignment upstairs. LPN #88 stated she did not see Resident #19 leave the building. During an interview on 04/22/25 at 3:35 P.M., Receptionist #163 stated on 04/10/25 around 4:30 P.M., Resident #19 wheeled himself into the building. She told him he was not allowed to be in the building. Resident #19 continued to propel towards his room while the receptionist notified the Administrator. Shortly after, the police entered the building from both entrances. They searched the building and did not find a weapon. The Administrator asked the police to get Resident #19 off the property. Resident #19 asked the police where he was supposed to go, and they said they could not help him. An unidentified nurse gave Resident #19 a plastic bag with medications and papers. The receptionist watched Resident #19 propel himself down the sidewalk away from the building, and the police left. The receptionist stated Resident #19 appeared to be wearing a long-sleeved t-shirt and pants. He was not wearing a coat. During a telephone interview on 04/24/25 at 10:30 A.M., Medical Director (MD) #35 stated the facility notified him on 04/09/25 that Resident #19 had left the building, and they did not know where he had gone. The DON called the police on 04/10/25 because Resident #10 brandished a weapon at the facility. He was being given an emergency discharge. MD #35 approved for the facility to discharge Resident #19 with routine medications. MD #35 stated Resident #19 had active unspecified wounds to his heel, great toe, and ankle. MD #35 verified staff did not ask about treatments and he did not give orders for wound care. During a telephone interview on 04/28/25 at 3:09 P.M., Police Officer #40 stated he was among several officers who responded on 04/10/25 when the DON alerted police that a resident was in the building with a firearm. Other officers were already on scene when Officer #40 and his partner arrived. The Administrator was speaking with Resident #19 and another officer. The Administrator had signed discharge papers and stated that Resident #19 needed to leave because he was no longer a patient. Officer #40 stated he told Resident #19 to stay off the property. Staff carried Resident #19's personal items out of the building in bags. Officer #40 stated Resident #19 was in the parking lot speaking to staff when the officers left. Review of the facility policy titled Preparing a Resident for Transfer or Discharge, dated 12/2016, revealed residents were prepared in advance for discharge. Nursing services included obtaining orders for discharge, preparing a discharge summary and post-discharge plan, preparing medications for discharge, providing discharge summary and plan to the resident/family, packing resident belongings, assisting with transportation, and escorting the resident to transportation. This deficiency represents non-compliance investigated under Complaint Numbers OH00165501, OH00164746, and OH00164671.

Based on record review, review of hospital records, staff interviews, and policy review, the facility failed to ensure adequate supervision was in place to prevent one resident, identified as an elopement risk and who was assessed with purposeful exit seeking behaviors, from eloping from the facility unknown to staff. This resulted in Immediate Jeopardy and serious physical harm and injuries on 04/26/25 when Resident #75 was removed from one-on-one supervision and was subsequently found on the ground outside of the facility after removing a windowpane from the window in his room and dropping two stories to the pavement below, sustaining bilateral ankle fractures which required surgery. This affected one (Resident #75) of three residents reviewed for elopement risk. The facility census was 69. On 05/02/25, the Administrator was notified that Immediate Jeopardy began on 04/26/25 at 7:50 A.M. when the facility removed Resident #75 from one-on-one supervision. At 8:10 A.M., staff found Resident #75 on the ground outside of the facility. He was unable to stand or walk. On 04/25/25 around 11:00 A.M., Resident #75 stated to Licensed Practical Nurse (LPN) #106 if the facility did not let him leave to go to the bank, he would jump out the window. LPN #106 educated Resident #75 to the risks of his actions. Resident #75 stated he would rather be homeless than stay at the facility. Staff pursued having Resident #75 sent to the hospital for involuntary psychiatric treatment for suicidal ideations. Resident #75 was sent to the hospital on [DATE] around 4:00 P.M. The hospital sent Resident #75 back to the facility on [DATE] around 8:00 P.M. with documentation stating Resident #75 was assessed and did not have suicidal ideations; Resident #75 wanted to leave the facility and go to the bank. The facility continued with one-on-one supervision from 04/25/25 at 9:00 P.M. to 04/26/25 at 7:50 A.M. On 04/26/25 at 8:10 AM, kitchen staff reported to nursing staff they found Resident #75 on the sidewalk near the outside entrance after responding to a loud thud noise. Nursing staff sent Resident #75 to the hospital via emergency transport after Resident #75 was assessed and unable to bear weight or ambulate. The initial facility investigation revealed that Resident #75 had removed the lower pane from his window to exit the facility. The hospital reported on 04/26/25 that Resident #75 was admitted with bilateral ankle fractures and required surgery. Immediate Jeopardy was removed on 05/02/25 when the facility implemented the following corrective actions: • On 04/26/25, Resident #75 was found outside, the nurse immediately assessed the resident and called 911, and he was sent to the hospital for evaluation and treatment. • On 04/26/25, the facility immediately notified Resident #75 ' s responsible party and doctor. • On 04/26/25, Maintenance Director (MD) #164 or/designee completed immediate audits on all windows that were accessible to residents on the second floor to ensure they were secure. All windows that were found unsecure were immediately addressed to ensure they could not be pulled out of the frame. • On 04/26/25, the Administrator/designee held an in-service for staff to provide education and expectations as it relates to monitoring suicidal ideation. The Administrator/designee held an in-service for maintenance staff as it relates to window maintenance. • On 05/02/25, the Administrator/designee commenced an in-service for staff to provide education on policies and procedures as it relates supervision to prevent elopement. No staff will be allowed to start their shift until they have completed said education. • On 05/02/25, Assistant Director of Nursing (ADON) #127/designee completed elopement assessments for all residents to assess risk for elopement and ensure there is proper supervision in place. Although the Immediate Jeopardy was removed on 05/02/25, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] and remains in active status. Diagnoses included schizoaffective disorder bipolar type, suicidal ideations, other uncomplicated psychoactive substance abuse, antisocial personality disorder, uncomplicated nicotine dependence, uncomplicated alcohol dependence, mild neurocognitive disorder with behavioral disturbance, and mild cognitive condition with behavioral disturbance. Review of elopement assessment dated [DATE] revealed Resident #75 was at risk for elopement based on medical diagnoses, independent mobility, purposeful exit-seeking, and recent admission. Interventions included placement on a locked (secured) unit in the facility. Review of the care plan dated 04/23/25 revealed Resident #75 had no care plan related to placement on a secured unit for increased risk for elopement. Review of the document titled Statement of Expert Evaluation dated 04/22/25 revealed a University of Cincinnati Physician evaluated Resident #75 and determined him to be mentally impaired with a low level of fundamental knowledge and incapable of managing personal finances, personal property, incapable of caring for activities of daily living, and incapable of making decisions concerning medical treatments, living arrangements, and diet. Resident #75 had a poor prognosis, especially if he became noncompliant and began using drugs or alcohol again. The physician indicated Resident #75 was incompetent and guardianship should be granted. The evaluation had a disclaimer stating the evaluation did not declare the prospective ward to be incompetent but was evidence to be considered by the Court. Review of progress notes documented on 04/24/25 at 11:08 A.M., an unidentified therapy staff noticed Resident #75 pulling on doors, exit-seeking, and requesting to leave. Therapy staff notified management (specific person unidentified) and Social Worker (SW) #135. On 04/24/25, SW #135 spoke with Resident #75 ' s responsible party to inquire about guardianship. The responsible party stated he was working on it. On 04/25/25 at 10:54 A.M., Resident #75 was agitated and pacing. He told the staff he wanted to leave immediately and threatened to jump out the window if he was not allowed to sign out immediately. LPN #106 educated Resident #75 of the risks of jumping out the window. Resident #75 stated he did not care, he just wanted to leave. LPN #106 notified the Director of Nursing (DON), Psychiatric Nurse Practitioner (PNP) #45 and SW #135. On 04/25/25 at 11:08 A.M., the DON placed Resident #75 on one-on-one supervision and called PNP #45 after LPN #106 reported Resident #75 threatened to kill himself by jumping out the second-floor window. PNP #45 authorized a pink slip for suicidal ideation. The DON notified Resident #75 ' s responsible party. On 04/25/25 at 2:51 P.M., SW #135 went to the men ' s locked unit and spoke to Resident #75. Resident #75 stated he wanted to leave Against Medical Advice (AMA). He did not like being around others and stated he felt confined/closed in. Resident #75 stated he did not want to be in a room with a person who required professionals to clean him and stated this was a trigger for him. Resident #75 stated he was a lander and chose to be homeless, living outside or in a shelter. Resident #75 verbalized knowledge of community resources. Resident #75 stated when he went to the bank, his ATM (Automated Teller Machine) card got stuck in the ATM machine. The bank was closing and staff told him to come back the next day. He did not want to sleep outside, so he took himself to the hospital. Resident #75 stated he wanted to go to the bank to get money for cigarettes and stated if they let him leave, he would return to the facility. Review of a late entry progress note created on 04/26/25 at 8:45 P.M. for 04/25/25 at 8:55 P.M. revealed Resident #75 returned from the hospital via stretcher and was placed back on one-on-one supervision while he was re-acclimated to the facility. The hospital reported Resident #75 did not have suicidal ideation. Resident #75 was calm and cooperative. He stated all he wanted to do was smoke. Resident #75 slept through the night with no signs of suicidal ideation. Review of the late entry progress note created 04/26/25 at 8:46 P.M. for 04/26/25 at 7:30 A.M. documented provider was notified of discontinuation of one-on-one supervision. Resident #75 was stable with no signs of suicidal ideation. Review of progress notes dated 04/26/25 at 9:48 A.M. revealed at 8:10 A.M. staff reported Resident #75 was outside on the ground after jumping out of a second-floor window on the 200 Unit. Prior to this incident, Resident #75 had asked LPN #42 to call 911 and tell them to get him out of there. Upon investigation, LPN #42 noted the windowpane was on the floor leaning against the wall. At 10:08 A.M., LPN #42 notified Resident #75 ' s responsible party who questioned why there were no additional safety measures placed after Resident #75 had first threatened to jump out the window and voiced concerns for safety moving forward. At 7:41 P.M., LPN #42 called the hospital and learned Resident #75 was admitted for bilateral ankle fractures. During concurrent interviews with the Administrator, ADON #127 and Scheduler #98 on 04/30/25 at 9:54 A.M., ADON #127 stated after the original admission, the former DON decided to place Resident #75 in the secured unit due to his history of admission from the hospital on a psychiatric hold. ADON #127 was unaware of any assessment required for the secured unit placement. ADON #127 stated on the elopement risk assessment, if a patient was identified at risk, the nurse would add the intervention on the assessment to place in a secured unit. ADON #127 stated when Resident #75 returned from the hospital on [DATE], he was placed back on one-on-one supervision for 12 hours out of an abundance of caution for safety. When Resident #75 had remained calm during those 12 hours and made no further statements of wanting to leave, the one-on-one supervision was removed at change of shift on 04/26/25 after 7:00 A.M. During an interview on 04/30/25 at 11:28 A.M., Regional Director of Operations (RDO) #200 stated Resident #75 came from a psychiatric hospital and had paranoid delusions. His responsible party was going to retain guardianship. He was placed on a secured unit for safety after he was discharged from the psychiatric unit. He was focused on getting out of the facility and going to the bank. While the Ohio Department of Health was present in the building for a survey, the facility could not spare staff to go downtown. Staff had planned to take Resident #75 to the bank next week. Resident #75 had stated, If you don ' t let me go, I ' m going to jump out the window. RDO #200 stated he did not know if staff specifically asked Resident #75 if he wanted to hurt himself, but the facility had him sent out for suicidal ideation. The hospital sent him back. They said he wanted to go to the bank, and he did not have suicidal ideations. Out of caution, staff continued one-on-one supervision for 12 hours after his return. He seemed calm and pleasant, so staff removed the one-on-one supervision after night shift ended. The doctor was notified immediately after the incident. The facility decided on 04/29/25 to begin auditing all resident records to ensure admission paperwork was completed and all residents upstairs had assessments for placement on the secured unit. Resident #75 was a skinny 140-pound man, and staff were not sure how he did it. On 04/26/25, the maintenance department secured all windows with washers and screws so the windows could not be opened. During a telephone interview on 04/30/25 at 2:27 P.M., Resident #75 ' s responsible party stated he was trying to obtain guardianship for his responsible party. He stated he had three or four separate phone calls with female staff on 04/25/25 but did not remember all their names. One said Resident #75 stated he was being held against his will, and he was leaving. If they did not let him leave, he was going to jump out the window. The responsible party stated he was not there to determine Resident #75 ' s state of mind but based on prior history that statement could have easily been interpreted as both ways. Resident #75 was very labile and would swing easily from desperation to suicidal ideation. The responsible party described Resident #75 as having the mind and emotional control of an 8-year-old. He could be very cooperative and sweet one minute and become aggressive and temperamental the next with little warning. He said he recommended staff not let Resident #75 leave the facility unsupervised. The responsible party stated Resident #75 was an alcoholic, and if they had let him go, he would have been drunk by 5:00 P.M. The responsible party stated he almost told them to just let him go based on how upset Resident #75 was, but he thought it would be a shame to waste all the hard work the hospital staff had completed to make him stable. During an interview on 04/30/25 at 3:02 P.M. Activity Aide (AA) #108 stated on 04/25/25 around 10:45 A.M. she noticed Resident #75 pacing near the door between the men and women ' s locked units repeatedly punching his fisted hand into his palm. AA #108 stated she reported it to the activities director that he seemed agitated, and she was afraid he was going to hit somebody. Staff assigned AA #108 to one-on-one supervision with Resident #75 around 11:00 A.M. until about 4:00 P.M., and SW #135 came to the unit and there was a meeting in the activity room with Resident #75, SW #135, Activities Director #75 and MDS nurse #124. They spoke about the resident wanting to leave AMA to go to the bank, about his lifestyle as a lander, and about his knowledge of community resources. Resident #75 stated he had enough money in the bank to get a car or apartment. SW #135 said she could help him with that if he gave her the time. He was calm during the meeting and made no remarks about wanting to hurt himself or anyone else. He said he had to get to the bank downtown and get his ATM card from the machine. The facility bus was not there, or staff could have taken him to the bank that day. Staff took Resident #75 downstairs to ask the DON about signing him out to go to the bank. She told him he could not leave, and they returned to the locked unit. AA #108 stated she was with Resident #75 until he left with EMS personnel, and stated Resident #75 never made any comments to her about self-harm or jumping out the window. During an interview on 04/30/25 at 3:23 P.M., LPN #106 stated she was assigned to the men ' s locked unit on 04/25/25. It was before 11:00 A.M. when Resident #75 approached the nurse ' s station and stated he wanted to leave the facility. He said, I want to get out of this place. I don ' t want to be here. If I don ' t get out of here, I will jump out the window. LPN #106 stated she educated Resident #75 about the potential harm his actions could cause. He stated he did not care, and he would rather be homeless than stay there. LPN #106 stated she did not believe Resident #75 was suicidal at the time; he was just desperate to leave. LPN #106 reported the incident to the DON, and they placed Resident #75 on one-on-one supervision. She called PNP #45 and got a pink slip to send him out to the hospital for suicidal ideations. During an interview on 04/30/25 at 3:41 P.M., LPN #42 stated she met Resident #75 when he admitted to the facility on [DATE] but she was not his admitting nurse. LPN #42 stated Resident #75 repeatedly and obsessively spoke about going to the bank and getting his ATM card. LPN #42 stated Resident #75 needed to speak to the social worker about getting assistance to go to the bank. LPN #42 stated she had no knowledge Resident #75 was on one-on-one supervision on 04/26/25 when she reported to work. It was not communicated to her in nurse-to-nurse report that Resident #75 had been on one-on-one supervision overnight, or that the one-on-one supervision had been removed. LPN #42 stated she had been downstairs for approximately five minutes on 04/26/25 when kitchen staff reported Resident #75 was outside on the ground. He was sitting on the concrete at the top of the steps near the entrance to the kitchen, smiling, and asking for a cigarette. He had attempted to walk but could not and stated his ankles hurt. Staff called 911, and he was sent to the hospital. LPN #42 stated she called the hospital later and was informed that Resident #75 was admitted for bilateral ankle fractures and had no head injuries. LPN #42 stated her investigation revealed Resident #75 had removed the lower windowpane and placed it against the wall before eloping by climbing out the window. During an interview on 05/01/25 at 10:18 A.M., Medical Director (MD) #35 stated the admissions team made the decision of where to place residents on admission based on the resident ' s past medical history, mental health history, behaviors, and mental status at the time of admission. MD #35 stated he was aware of the incident with Resident #75 but had not reviewed his chart. MD #35 stated he was in the building on 04/24/25 but did not see Resident #75 because he was not on his schedule to be seen that day. Review of the facility policy titled Wandering, Unsafe Resident, not dated, revealed staff identified residents who were at risk for harm for unsafe wandering and elopement and developed a detailed monitoring plan to maintain safety as indicated. Review of the facility policy titled Safety and Supervision of Residents, dated July 2017, revealed the care team implemented resident-centered interventions to reduce individual risks related to hazards in the environments, including adequate supervision and assistive devices. Monitoring included evaluating the effectiveness of interventions and modifying or replacing interventions as needed. This deficiency represents non-compliance investigated under Complaint Numbers OH00165190, OH00163006 and OH00165734.

Based on closed record review, hospital record review, review of a facility timeline and investigation, physical therapy notes, review of a facility self-reported incident (SRI), review of facility policy, and staff interview, the facility failed to ensure adequate monitoring/assessment and timely medical intervention following a change in condition. Actual harm occurred on 06/21/23 when Resident #25 was transferred to the hospital and admitted with a diagnosis of left femoral neck fracture requiring surgical intervention to repair the femoral fracture. Resident #25 sustained a fall on 06/09/23, complained of pain to Physician Assistant (PA) #120 on 06/14/23 and was refusing to get out of bed. The resident was not further assessed or provided treatment at that time. On 06/21/23 the resident continued to complain of pain and therapy staff identified the resident's left leg was shortened. An x-ray, on 06/21/23 identified the fracture. This affected one Resident (#25) of three residents reviewed for quality of care. The in-house facility census was 71. Findings include: Review of Resident #25's closed medical record revealed the resident was admitted to the facility on [DATE] with a re-assessment date of 04/17/17. Resident #25 had diagnoses including delusional disorders, cataracts, polyosteoarthritis, anxiety, vascular dementia, schizoaffective bipolar disorder, and muscle weakness. Resident #25 was discharged to the hospital on 06/21/23 and did not return to the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #25, revealed the resident was severely cognitively impaired and required supervision with all activities of daily living (ADLs). Review of the fall risk scoring tool dated 05/05/23 revealed the resident scored a 12, indicating she was at high risk for falls. Review of Resident #25's care plan, dated 05/31/23 revealed the resident was at risk for falls related to unsteady gait, psychoactive medication use, incontinent episodes, impaired mobility, and anxiety. Resident #25 would occasionally place herself on the floor, lay on the floor, or crawl around on the floor. Interventions included assist resident with ambulating, encourage resident to ask for assistance, fall mats in place, place resident in common area for increased supervision, and have commonly used items within easy reach. Review of an incident report dated 06/09/23 at 7:25 A.M., authored by Licensed Practical Nurse (LPN) #80, revealed Resident #25 was observed laying on her left side, in her room and an assessment revealed the resident's range motion (ROM) was at baseline for the bilateral upper extremities, the left lower extremity was at baseline, and the right lower extremity at baseline with minimal contraction. Resident #25 denied pain, had no outward rotation to bilateral lower extremities, had no hip pain, the neuro checks were within normal limits, resident was resistant to straighten right lower extremity at times and the resident's vital signs were at baseline. Resident #25 was assisted to her bed with assistance of two staff. The incident report revealed there were no injuries observed at the time of the incident. New interventions to be determined and MD #141 was notified on 06/09/23 at 7:58 A.M. Review of a nurse's progress note dated 06/09/23 at 8:07 A.M., revealed Resident #25 had a history of transferring herself onto the floor. The resident's lower left extremity was at baseline and the resident was observed to straighten right lower extremity on command and at other times, the resident was observed to keep right leg bent. Resident #25 denied pain/discomfort, and MD #141 was notified for possible therapy evaluation. Review of a nurse's progress note dated 06/11/23 at 6:38 P.M., for Resident #25, revealed the resident was at baseline, and when ADLs were provided by staff, the resident was resistant to turn, repositioning and participate with any ROM. The resident denied pain, no distress was assessed, and medications were administered as ordered. The note did not further elaborate why the resident was resistant to turn, reposition or participate with ROM. Review of Physician Assistant (PA) #120's progress note dated 06/14/23 at 12:00 A.M. for Resident #25, revealed the resident was seen for follow-up and a possible fall, but staff and the resident denied a recent fall. Resident #25 was complaining of pain to left leg and PA #120 gave reassurance and ordered Tylenol 500 milligrams every six hours as needed for left leg pain. There was no evidence the resident's left leg was further assessed or follow up testing/medical intervention/x-ray being considered or completed at this time. Review of a nursing progress note dated 06/19/23 at 6:19 P.M. for Resident #25, revealed the resident was in bed, was fed by staff, ADL care was provided by staff and the resident had limited ROM to bilateral lower extremities and therapy was notified. Resident #25 had a blistered area to outer left ankle and the resident was repositioned as tolerated. Record review revealed no evidence the limited range of motion was further investigated or assessed or that the physician was notified at this time. Review of a nurse's progress note dated 06/20/23 at 7:21 P.M. for Resident #25, revealed the resident transferred to her wheelchair with assistance of two staff. The note documented the resident was up in her wheelchair propelling self in common areas with no pain. Review of a physical therapy assessment note dated 06/20/23 for Resident #25 and authored by Physical Therapist (PT) #121, revealed the resident was referred to therapy due to a decrease in functional mobility and decreased lower extremity ROM. Resident #25 exhibited new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance and decrease in ROM. Therapy was ordered to increase lower extremity ROM and minimize falls. Resident #25 was noted to be bed bound with total dependence on staff for transfers. The therapy assessment note did not include any information or indication the resident had been out of bed or related to the resident's ability to self-proper herself at this time. Review of a nurse's progress note dated 06/21/23 at 3:20 P.M. for Resident #25, revealed the resident was in therapy when the therapy staff noted a shortening of the resident's left leg and the resident complained pain. The resident was given Tylenol. The nurse received an order for a stat Xray for left hip and pelvis. Review of a nurse's progress note dated 06/21/23 at 8:11 P.M. for Resident #25, revealed the resident's x-ray was completed and the x-ray technologist made the nurse aware of a left hip fracture. MD #141 and Nurse Practitioner (NP) #142 were made aware. The guardian was made aware and wanted an update on the plan of care. Review of a nurse's progress note dated 06/21/23 at 10:00 P.M. for Resident #25, revealed the nurse received a call from the Director of Nursing (DON) and ordered resident to be transported to the hospital via 911 per a physician's order due to a fractured left hip. The resident's guardian was made aware. Review of a PT progress note dated 06/21/23 for Resident #25 authored by Physical Therapy Assistant (PTA) #140, revealed the resident was positioned in extension with a pillow under the resident's calves as tolerated with resident's left lower extremity shorter than the right and the resident complained of hip pain. Nursing was informed of concerns with hip positioning and nursing to check on previous fall. Concerns were reported to the Director of Rehabilitation (rehab) due to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) not being in the building. Review of a facility timeline, revealed Resident #25 had a fall on 06/09/23 when she was found on the floor in front of her bed. Resident #25 did not show any signs/symptoms of a fracture or pain and the resident was to be monitored. The next entry on the timeline, dated 06/19/23 revealed Resident #25 was up in chair, propelling herself in a wheelchair, enjoying her peers, with no complaints of pain. On 06/20/23, Resident #25 was prescribed Tylenol (over the counter pain medication) as needed (PRN) for pain to the left leg. On 06/21/23, Resident #25 was evaluated by therapy, and when the therapy staff were unable to extend the resident's left leg, an x-ray was suggested. The x-ray results showed a fracture. On 06/21/23, MD #141 was made aware of the injury and ordered for Resident #25 be sent to the hospital and the family agreed. Review of a hospital note dated 06/21/23, revealed Resident #25 was presented to the emergency department due to concerns for repeated falls. The resident complained of diffuse tenderness throughout the entire left lower extremity. Resident #25 was diagnosed with an impacted superolaterally displaced, and varus angulated left femoral subcapital neck fracture with soft tissue swelling along the lateral left hip from an unknown date of injury. The resident was referred to an orthopedic surgeon and required an operative intervention for the left femoral neck fracture. Review of a facility SRI tracking number 236341, created 06/23/23 revealed the facility reported an injury of unknown origin/source to the State agency. The SRI noted Resident #25 fell from bed on 06/09/23, landed on her left side, and was discovered as having a fractured left hip on 06/21/23. The SRI was marked as completed on 06/29/23 and the allegations were unsubstantiated as the evidence was inconclusive. The facility implemented a new fall intervention and resident was being treated at the hospital at the time the SRI was created. Review the facility investigation dated 06/28/23, revealed Resident #25 had an unwitnessed fall on 06/09/23 and when staff asked resident what she was doing, the resident stated she was taking a walk. Resident #25 had no psychosocial changes due to the fall. Resident #25 was a frequent faller and known to place herself on the floor at times. The nurses stated Resident #25 did not show any other signs and symptoms of discomfort outside of her normal. Staff thought the resident was slowly starting to contract possibly in her lower extremities because she could be resistant and fights with care. The resident had diagnoses of polyosteoarthritis, bipolar disorder and schizoaffective disorder. The resident had a history of refusing care, being combative and placing self on the floor. The investigation findings were not verified, and the injury was linked to a prior fall. A full fall investigation was completed, and intervention of fall mats was placed on 06/09/23. The investigation revealed the Interdisciplinary Team (IDT) would continue to remind staff to check the resident for three days after the fall and to notify the physician right now if they notice something strange with the resident. Interview on 07/13/23 at 10:30 A.M. with LPN #80, reported Resident #25 was not getting out of bed like she normally did after the 06/09/23 fall but the LPN stated she did not think anything about it due to the resident's previous behaviors. An attempted interview on 07/13/23 at 11:00 A.M. with the DON, revealed the DON refused to participate in an interview with the surveyor regarding Resident #25. The DON would only state, LPN #80 put in a fall note for Resident #25. Review of a nurse's progress note dated 07/13/23 at 11:43 A.M. as a late entry for 06/09/23 at 7:20 A.M. and authored by Licensed Practical Nurse (LPN) #80, revealed Resident #25 was observed laying on her left side on the floor in her room. Resident #25's mental status was noted to be at baseline and resident stated she was taking a walk. Resident #25 was bending and straightening right leg randomly and with directions, denied any pain, had no outward rotation, neurological (neuro) checks were normal, vital signs assessed to be normal, and Medical Director (MD) #141 and guardian were notified of a gravitational incident. Interviews on 07/13/23 at 2:51 P.M. with three State tested Nursing Assistants (STNA), STNA #44, #58, and #88, who regularly cared for Resident #25, revealed the resident was not very active after the fall on 06/09/23 but stated they did not report this to anyone because they thought it was just the resident's behaviors. An attempted interview with MD #141 on 07/17/23 at 3:42 P.M., revealed the MD's voice mail was full and a voice message could not left. There was a text message sent to call the surveyor back and no contact was made. A telephone interview on 07/18/23 at 10:26 A.M. with PT #121, revealed he does telehealth sessions, and his assistant PTA #140 does the physical work with the residents. PT #121 stated during Resident #25's evaluation on 06/20/23, the resident did not do any initiation and was totally dependent on staff to stand or transfer. PT #121 reported since Resident #25 would not initiate or participate in evaluation, they ended up putting the resident back in bed. PT #121 was not aware Resident #25 was admitted to the hospital with a fractured femur. A telephone interview on 07/18/23 at 3:09 P.M. with PA #120 reported a staff nurse (identified as LPN #59) was on duty and told her that Resident #25 did not have a fall. Interview on 07/19/23 at 8:30 A.M. with LPN #59, indicated she was caring for Resident #25 when PA #120 saw the resident on 06/14/23. LPN #59 stated she was not aware Resident #25 had fallen when PA #120 was making rounds. Review of e-mail correspondence from the DON dated 07/24/23 at 3:58 P.M. revealed there were no specific IDT meeting notes for this incident. The DON stated the facility reviewed notes and orders daily in the morning meetings. The DON indicated the team consisted of Assistant Director of Nursing (ADON) #41, MDS Nurse #105 and occasionally therapy. The DON stated the team discussed Resident #25's fall and interventions at that time. Review of the Fall Policy, dated 01/11/21 revealed all residents would receive adequate supervision, assistance, and assistive devices to prevent falls. Each resident would be evaluated for safety risks, including falls and accidents. Care plans would be created and implemented based on the individual risk factors to aid in preventing falls. All falls were to be investigated and monitored. This deficiency represents non-compliance investigated under Complaint Number OH00144228.

Based on observation, record review, review of the Cincinnati Fire Department (CFD) first responders report, review of an Emergency Medical Services (EMS) report, review of the facility policy regarding elopement and interviews, the facility failed to provide adequate supervision to prevent Resident #10, who resided on and had physician orders (dated [DATE]) for placement on the facility's secured behavioral unit due to poor judgment and insight and safety concerns from eloping. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/death on [DATE] at approximately 9:50 P.M. when Resident #10 exited the secured behavioral unit through an alarmed basement door without staff's knowledge. After exiting the facility, Resident #10 wheeled herself up an exterior wheelchair ramp, across the facility's parking lot and into a dimly lit, busy, curvy two-way street where Resident #10 had fallen out of her wheelchair and on to the street when a motorist discovered the resident. Upon CFD first responders and EMS arrival to the scene, they recognized Resident #10 and knew she resided on the facility's secured behavioral unit. EMS took the resident back to the facility on [DATE] at approximately 10:25 P.M.; however, staff were not aware Resident #10 had eloped or how she exited the facility without staff knowledge. Consequently, Resident #10 was transported to the local emergency department (ED) where she was treated for possible injuries from being found in the street and for a psychiatric evaluation. This affected one resident (#10) of the seven residents reviewed for being at risk for elopement. The facility identified 10 residents (#1, #2, #3, #4, #5, #8, #10, #11, #12, and #13) currently residing in the facility at risk for elopement. The facility census was 63. On [DATE] at 2:57 P.M., the Administrator and Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on [DATE] at approximately 9:50 P.M. when Resident #10 exited the secured behavioral unit through an alarmed basement door without staff's knowledge. The resident was subsequently found on the ground in the road in a dimly lit, busy, curvy two-way street area by a motorist. The resident was returned to the facility by EMS at approximately 10:25 P.M. and staff were not aware Resident #10 had eloped or how. Consequently, Resident #10 was transported to the local emergency department (ED) where she was treated for possible injuries. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Maintenance Director #151 changed all doors, elevator, and stairwell codes and no numbers were the same. In addition, the facility indicated door codes would be changed, per the elopement policy. Then updated door codes were at each secured nurse's station and given to the nursing staff by Maintenance Director #151 each time they would be changed. Maintenance Director #151 would give copies of the door code to the department heads each time the codes were changed. On [DATE] at 2:00 P.M., Assistant Director or Nursing (ADON) #120 reviewed the care plan, the elopement risk assessments, and the physician orders for Resident #10. No changes were made. On [DATE] at 4:00 P.M., the elopement policy was reviewed by Medical Director #400, the Administrator, ADON #120, and Maintenance Director #151. No changes were made. On [DATE] at 5:04 P.M., Regional Registered Nurse (RN) #410 educated the Administrator on the elopement policy, door codes, (including ensuring when employees entered the door codes, it was discreet/confidential and the residents were not around), and not to give codes to residents and/or family members. On [DATE] and [DATE] Human Resources Director #148 and/or the Administrator educated all staff regarding elopement. Topics included ensuring when employees entered the door codes, it was discreet/confidential and the residents were not around, and not to give codes to residents and/or family members. Staff educated included: ADON #120, 17 licensed nurses, 15 State tested Nursing Assistants (STNAs), Business Office Manager (BOM) #128, Admissions Director #119, Activities Director #180 and two activities aids, Social Service Designee (SSD) #108, Dietary Manager #109 and eight dietary staff, Minimum Data Set (MDS) /Care Plan Coordinator #124, Medical Records Clerk #113, Receptionist #163, Housekeeping Manager #159 and eight housekeepers, Maintenance Director #151 and two maintenance workers. The facility also planned additional mandatory staff education on [DATE] at 7:00 A.M., 2:00 P.M. and 4:00 P.M. for topics including the facility elopement policy, active shooter, facility key code usage, and resident safety. Those staff who were not able to attend would be in serviced prior to their next shift being worked. To monitor ongoing compliance, beginning on [DATE], head counts on all residents would be completed by ADON #120 or designee every 15 minutes for 48 hours, then beginning on [DATE] head counts for all residents would be conducted three times a week for four weeks. The findings will be reviewed by Quality Assurance Performance Improvement (QAPI) weekly. On [DATE] at 4:18 A.M. and 10:27 A.M., elopement drills were completed by Maintenance Director #151 and the staff participated with no issues discovered. The missing resident identified in the drill was found within minutes after the drill began. On [DATE] at 1:38 P.M., the Administrator spoke with the staffing agency supervisor and did education with her via telephone regarding the facility elopement policy and to ensure when employees entered the door codes, it was discreet/confidential, residents were not around, and not to give codes to residents and/or family members. The Staffing Agency Supervisor informed the Administrator this education would be reviewed and acknowledged by all agency staff before they could pick up a shift at the facility. On [DATE] between 8:30 A.M. and 9:00 A.M., interviews with SSD #108, STNAs (#142 and #129) Housekeeping #127, Receptionist #163, Licensed Practical Nurse (LPN) #171, verified they were educated on resident elopements and wandering as well as responding to resident alarms.? All staff members interviewed were knowledgeable of the content of each education provided by the facility. On [DATE], a staffing agency orientation binder was created by the Administrator and left at each nurse's station with helpful facility information, including the above in-services and any future in-services. This information was also communicated to the Staffing Agency Supervisor on [DATE] and she would communicate this with her agency staff immediately. On [DATE], ADON #120 reviewed the care plans, the elopement risk assessments, and the physician's order for all facility residents. The facility also identified the Immediate Jeopardy action plan would be a Quality Assessment and Performance Improvement (QAPI) plan and would be followed-up with facility QAPI team members. On [DATE], Resident #10 had an expert evaluation by Physician #181 and the resident was deemed to be incompetent. Resident #10's father would pursue guardianship. On [DATE], Resident #10 was placed on 1:1 observation until a wanderguard device (elopement monitoring device) could be placed on the resident. The wanderguard was ordered on [DATE] and was scheduled to be delivered and implemented on [DATE]. To monitor on-going compliance, beginning on [DATE], the interim Director of Nursing (DON) will complete audits on exit seeking residents three times a week for four weeks. Findings to be reviewed in QAPI weekly for four weeks. On [DATE], ADON #120 updated the elopement risk evaluations for residents (#01, #02, #03, #04, #05, #08, #11, #12, and #13). On [DATE] review of the medical records for Resident # #4, #5, #6, #7, #8, #9, and #10, identified by the facility as elopement risks revealed no additional concerns related to actual elopements from the facility. The elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of the medical record for Resident #10 revealed an admitted [DATE]. The resident had a diagnosis including schizophrenia, cerebral infarction (disrupted blood flow to the brain) with hemiplegia/hemiparesis, epilepsy, and anxiety. Review of Resident #10's plan of care, dated [DATE] revealed the resident was at risk for elopement related to impaired safety awareness with interventions to distract the resident from wandering, staff to identify patterns of wandering and to monitor exit seeking behavior. Review of a psychiatry progress note dated [DATE] revealed Resident #10 was seen per the facility request for a psychiatric evaluation and medication management. The evaluation indicated resident's cognitive status was forgetful but functional, she had mild impairment related to judgment and insight and she had ongoing episodes of drug seeking behaviors that led to dangerous behaviors. Furthermore, the note revealed the resident attempted to jump out of a window and would call strangers to pick her up. During the evaluation, the resident presented with symptoms of anxiety, exit seeking, and substance usage. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #10, revealed the resident had no cognitive deficits and required supervision to limited assistance with activities of daily living (ADLs). Review of a progress note, dated [DATE] revealed Resident #10 left the secured unit at approximately 11:45 A.M. When staff searched the building, the resident was found on the lower level (basement) in the employee break room. STNA #116 brought Resident #10 back to the secured unit. When the on-duty nurse questioned Resident #10 on how she got down to the basement, the resident replied that she knew the codes to the door and the elevator. Resident #10 was placed on every 15-minute checks throughout the night. Review of an elopement risk evaluation, dated [DATE] completed by ADON #120, revealed Resident #10 was assessed as being an elopement risk. Further review of Resident #10's elopement/wandering assessment indicated the resident had impaired decision-making skills. Review of the progress note dated [DATE] at 10:48 P.M. completed by LPN #117, revealed the nurse was coming out of another resident's room when STNA #116 alerted her that the fire department was outside with Resident #10. Resident #10 had been outside the building trying to cross the street when she was seen by a pedestrian who called 911 out of concern. The note revealed Resident #10 was last seen in the dining area by STNA #107 who was assigned to the secured unit. Resident #10 stated she was going to bed since she had already received her night-time medications, and LPN #117 did not see Resident #10 again until she was returned by the fire department. Review of the Cincinnati Fire Department (CFD) report, dated [DATE], revealed the first responder (Engine #32) was dispatched to the area of [NAME] Avenue at 10:17 P.M. for a person who was found in the street. The CFD first responders arrived on the scene at 10:21 P.M. and found a person (later identified as Resident #10) in a wheelchair, seated on the sidewalk with bystanders stating they found the person in the middle of the street.? Resident #10 had no medical complaints, she was a resident at Astoria Place Nursing Home, under the care of a behavioral psychiatrist locked down unit on the second floor. Resident #10 was wheeled back to the nursing home when the resident began acting to be unresponsive. However, the resident was responsive to painful stimuli of a sternal rub. The nursing home staff stated they did not know how Resident #10 got out of the facility. Resident #10 was transported to the ER for an evaluation due to patients' known history of street drug usage and prior medical history of a stroke from drug usage. Review of the EMS report dated [DATE], revealed EMS was dispatched to the area of [NAME] Avenue at 10:27 P.M. EMS arrived on scene at 10:31 P.M. and found Resident #10 acting erratic, outside her rehabilitation facility and refused to go back in Resident #10 stated she wanted to go see her boyfriend. Resident #10 faked sleeping when questioned by the police.?Resident #10 stated she got out of the facility and wanted someone to drive her to her boyfriend's home. Resident #10 was noted to be in the middle of the street as she had deficits from a previous stroke and a broken hip. Resident #10 vital signs were normal, she had no complaints, and was transported to a local emergency room for evaluation. The resident returned to the facility after being evaluated in the emergency room . Review of a witness statement from STNA #107, dated [DATE], revealed STNA #107 was in the women's secured unit's dining room with other residents including Resident #10 going through and giving out clothes that a staff member had brought in for the residents. STNA #107 was talking to Resident #10 between 9:30 P.M. and 10:00 P.M. STNA #107 reported she did not hear any alarms go off on the units. Review of a progress note dated [DATE] at approximately 10:00 A.M. and authored by LPN #132 revealed this nurse was notified by the on-call manager that Resident #10 had an elopement attempt and questioned if Resident #10 was on 1:1 observation. LPN #132 informed the on-call manager, Resident #10 was on every 15-minute checks and the unit was staffed with two STNAs and one nurse. One aide was giving a shower, the nurse was performing medication administration, and the other aide was on the floor providing resident care. The on-call manager informed LPN #132 that Resident #10 was to be always in sight of staff. When LPN #132 went to inform the unit staff about Resident #10's 1:1 observation, the unit staff went to get Resident #10 for continued close observation. After a unit sweep, Resident #10 was found hiding in another resident's closet with the door closed. Resident #10 was immediately assigned to have a 1:1 aide and the on-call manager was called and made aware of events. The activities aid was pulled to the unit to be 1:1 with Resident #10 for the remainder of the shift. Interview on [DATE] at 7:03 A.M. with SSD #108, revealed the door pass codes were not hidden when staff entered the numbers and often times the staff would just say the codes aloud and in front of the residents. Interview [DATE] at 12:22 P.M. with LPN #117, revealed Resident #10 was in the dining room on [DATE] at unknown time going through clothes that were brought in for residents when the resident stated she was going to bed and the next thing she knew, the fire department was at the door bringing Resident #10 back into facility. LPN #117 stated she was not aware Resident #10 was out of the facility. LPN #117 stated she was not sure of the time frame when Resident #10 was in the dining room, but stated it was after 9:00 P.M. because she had given the resident her nighttime medications. Interview on [DATE] at approximately 1:00 P.M. with Maintenance Director #151, revealed every time there was an elopement, he was required to immediately change all the key codes on the doors, stairwells, and the elevators. Maintenance Director #151 stated he was in the facility after Resident #10's elopement on [DATE] for most of the night changing the codes to all the doors, stairwells, and elevator. Maintenance Director #151 stated when he changed the codes, he had to send out an all-staff alert as to what the codes were, so they were able to get in and around the building. Maintenance Director #151 stated he was not aware Resident #10 had gotten off the secured unit on [DATE]. On [DATE] at 2:30 P.M. observation of the facility's video footage from [DATE] with Maintenance Director #151, revealed Resident #10 was seen propelling into the parking lot from an exterior ramp on the north side of the parking lot. Resident #10 wheeled through the parking lot and onto the sidewalk where the resident went south and visual was lost when she went around the facility's van parked in the lot. The ambulance entrance video footage at 9:50 P.M. revealed EMS were at the door with Resident #10. Interview on [DATE] at 4:07 PM with Resident #10's power-of-attorney (father) revealed the resident was supposed to be on a locked unit because she had brain damage to the frontal lobe from a stroke she suffered, and she made bad judgments and bad decisions. He stated the resident had been in multiple other nursing homes because of her behaviors and none of them wanted to keep her. He was unaware the resident had eloped on [DATE] but stated he does not always get his calls when he has no service. Interview on [DATE] at 7:40 AM with Interim Nurse Practitioner (NP #400), revealed she was unable to comment on Resident #10's competency since she had only seen the resident a couple of times. Observation of the active camera times on [DATE] at 8:15 A.M. with Maintenance Director #151 revealed the camera times were showing 7:49 AM and the real time was 8:15 AM. Maintenance Director #151 confirmed that the camera times were off by 35 minutes. Interview on [DATE] at 9:48 A.M. with Resident #10, revealed someone gave her the pass codes, but she was not going to say who it was. Resident #10 stated on [DATE], she was trying to get a ride to Colerain and when she was crossing the street, a bra that she had on her lap got caught in the front wheel of her wheelchair which led her to getting stuck in the middle of the road. Resident #10 stated she fell out of the wheelchair and almost got hit by two cars when a third car noticed her, stopped, and the guy got out and called 911. Resident #10 could not focus on the interview and kept looking at the ground and yelling expletives. Interview on [DATE] at 3:35 P.M. with Medical Director (MD) #410 reported Resident #10 makes very bad choices which were dangerous for her safety due to her brain injuries. MD #410 indicated Resident #10 should be on a secured unit. On [DATE] at approximately 3:30 P.M., an interview with the Administrator revealed she did not do a thorough assessment of Resident #10's cognitive status, so she was going to have an expert evaluation completed on Resident #10. Review of the Statement of Expert Evaluation dated [DATE] by Physician #181, revealed Resident #10 was incompetent due to poor judgement and insight and guardianship should be granted. Review of the Elopement Prevention and Missing Resident Policy dated [DATE] revealed the policy indicated to create an environment that was as safe as possible for residents at risk for elopement. The policy also included to develop a plan of action that would ensure a prompt, effective, and coordinated response when a resident was reported missing. This deficiency represents non-compliance investigated under Complaint Number OH000142443. This deficiency represents ongoing non-compliance from the surveys dated [DATE] and [DATE].

Based on medical record review, review of hospital medical records, staff interview, and facility policy and procedure review, the facility failed to ensure a dependent resident (Resident #57) received adequate nail care. This resulted in Immediate Jeopardy on 03/08/23 when Resident #57 was found to have his fingernails grown into his palm, forming an abscess. Resident #57 was subsequently sent to the hospital and found to be severely septic (severe infection) and diagnosed with tenosynovitis (inflammation of a tendon) of the right middle finger and gas gangrene (highly lethal infection)/necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death) of the right middle finger. Resident #57 required emergency amputation of his right third finger and partial amputation of his right fifth finger. Additionally, the facility failed to provide adequate nail care for dependent residents (#50 and #56) which did not rise to the level of Immediate Jeopardy. This affected three (#57, #50, and #56) of five residents reviewed for dependent residents receiving appropriate Activity of Daily Living (ADL) care. The facility reported all residents residing in the facility required some sort of assistance with nail care. The facility's census was 64. On 04/06/23 at 4:28 P.M., the Administrator, Director of Nursing (DON) #301, Registered Nurse (RN) #560, Licensed Practical Nurse (LPN) #360, and LPN #550 were notified Immediate Jeopardy began on 03/08/23 when Resident #57 was discovered to have his fingernails growing into his palm, forming an abscess, due to the lack of nail care. Resident #57 was subsequently sent to the hospital and found to be severely septic and diagnosed with tenosynovitis of the right middle finger and gas gangrene/necrotizing fasciitis of the right middle finger. Resident #57 required emergency amputation of his right third finger and partial amputation of his right fifth finger. The Immediate Jeopardy was removed on 04/10/23 when the facility implemented the following corrective actions: On 03/09/23, Resident #57 was assessed by the facility Nurse Practitioner (NP) and was immediately sent to the Emergency Department (ED) for care. Resident #57 returned to the facility on [DATE]. On 03/10/23, the Administrator filed a Self-Reported Incident (SRI) regarding the incident involving Resident #57. On 03/10/23, former DON #710, RN #700, and RN #705 assessed the fingernails and hands of all residents on Resident #57's unit (100 unit) to ensure proper length and hygiene. On 03/10/23, two residents (#47 and #52) were identified with fingernails that needed trimmed, however both residents refused to have their fingernails cut and neither resident had any skin issues noted. On 03/28/23 and 04/07/23, current DON #301 and LPN #555 completed skin assessments on all residents on all units. On 03/28/23, LPN #555 identified three additional residents with pressure ulcers (#50, #41, and #57). Treatments were put into place immediately on 03/28/23. On 04/07/23, no additional skin concerns were identified. On 03/28/23 and 04/10/23, all residents on all units were assessed for proper nail care by DON #301 and LPN #555. There were no areas of further concern noted. On 03/31/23, a new wound care provider began providing services in the facility. The previous provider was removed due to incorrect documentation regarding Resident #57's skin assessments. The program consists of wound rounds with the physician and LPN #555 every Friday. The purpose of the program is to identify new wounds and treat new/existing wounds. Residents identified by LPN #555 as needing the wound care program will be referred. This program will be ongoing. On 04/03/23, LPN #550 reviewed all resident care plans to ensure bathing, nail care, and skin needs were updated and correct. Any care plans requiring corrections were corrected by 04/03/23. On 04/07/23, all resident shower schedules were reviewed by DON #301 and updated as needed to ensure resident preferences were being met and all residents were scheduled for showers/nail care twice a week. On 04/07/23, the Administrator reviewed the facility's bathing policy, and no changes were needed. DON #301 and the Administrator re-educated all nursing staff on the bathing policy by 04/10/23. On 04/09/23, DON #301 and LPN #555 updated all residents' Treatment Administration Records (TAR) to include showers and nail care to ensure proper care is being provided. Shower/nail care days were added to the TAR on the days they are scheduled, and the nurse must sign off once they are completed. On 04/10/23, DON #301 created binders, containing the bathing policy, nail care policy, and skin assessment procedures. The binders are for agency staff who pick up shifts at the facility. The agency staff must sign off on these policies on the included sign-off sheet in the front of the binder before starting to work on the floor. Beginning 04/10/23, DON #301 and/or designee will conduct audits on nail care, shower sheets, and skin assessments on five residents, twice weekly for four weeks, three residents, once a week for four weeks, and then one resident once a week for four weeks. The results of these audits will be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting and the QAPI committee will determine when 100% compliance is achieved or if ongoing monitoring is required. Although the Immediate Jeopardy was removed on 04/10/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #57 revealed an admitted [DATE]. Resident #57 transferred to the hospital on 03/09/23 and returned to the facility on [DATE]. Diagnoses included type II diabetes mellitus, anemia, bipolar disorder, acquired absence of left leg below knee, peripheral vascular disease, acquired absence of right leg above knee, paranoid schizophrenia, cognitive communication deficit, and hypertensive heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had moderately impaired cognition. Resident #57 was assessed as not exhibiting any behaviors during the assessment period, including rejection of care. Resident #57 was dependent on staff for bed mobility, transfers, dressing, and maintaining personal hygiene, and required limited assistance for eating. Resident #57 had impaired range of motion on all extremities. Review of Resident #57's current care plans revealed refusals of skin care were not incorporated into the care plan until 03/10/23. Review of Occupational Therapy (OT) progress notes dated from 11/18/22 to 12/15/22 revealed Resident #57 worked with OT on tolerance of Bilateral Upper Extremity (BUE) splints for the resident's hands, including application and wear. Resident #57 was noted to be cooperative with treatment and was tolerating the splints for approximately two hours at a time upon discharge from therapy. The resident required maximum assistance to don (put on) and doff (take off) the right-hand splint. At the time of discharge, OT recommended to continue bilateral hand splints as tolerated. Review of physician orders revealed an order dated 12/15/22 and discontinued 01/16/23 to discontinue OT as maximum potential had been reached. Continue Wrist Hand Orthotics as tolerated to improve hand Range of Motion (ROM) and function and prevent further contractures. No documentation was required with the order. Review of the Skin Observation Tool dated 03/01/23 revealed Resident #57's skin was intact. Review of the ADL charting from 03/01/23 to 03/08/23 revealed no refusals of care were documented for Resident #57 in the State Testing Nurse Aide (STNA) charting. Review of behavior charting from 03/05/23 to 04/03/23 revealed no behaviors noted. Resident #57 did not refuse care. Review of progress notes dated 01/01/23 through 03/09/23 revealed Resident #57 frequently refused ordered medications; however, there was no documentation related to Resident #57's right hand, nor his fingernails. Additional review revealed no refusal for nail care documented. Review of the progress note dated 03/08/23 at 6:56 P.M. revealed Resident #57 was noted with a skin infection to the right third finger. The Nurse Practitioner was notified and ordered antibiotics and indicated Resident #57 would be evaluated the following day. Observation on 04/03/23 at 2:05 P.M. revealed Resident #57 was in the facility following a recent hospital stay. Resident #57 was resting in bed with his right hand wrapped. Resident #57 was unable to provide any meaningful information and mostly mumbled when asked questions. Interview on 04/03/23 at 3:35 P.M. with LPN #310 she stated she found the abscessed area on Resident #57's hand. LPN #310 stated she had not worked on Resident #57's unit in a while and, on 03/08/23, she noticed a foul odor in his room. LPN #310 stated, before dinner on 03/08/23, she went to check Resident #57's blood sugar. LPN #310 reported Resident #57 typically utilized a freestyle libre (device used to detect blood sugar levels without having to do a fingerstick), however the device was not working, so she went to conduct a finger stick when she noticed the resident's right hand was wrapped in the bed sheets and the resident was guarding it. LPN #310 stated Resident #57 used to wear a palm protector and was unsure of the last time she saw the resident with it. LPN #310 stated she unwrapped the resident's hand and found the nailbed was infected. LPN #310 stated Resident #57 fought with her and two other aids to get the hand open and, once they got the hand open, they found his fingernail had dug into his palm and formed an abscess. LPN #310 stated she thought the podiatrist cut his fingernails and described the nail as thick, overgrown, and calloused and described it as looking like a toenail. LPN #310 stated the nurses in the facility could not have done anything with his fingernails and further stated, for someone like Resident #57, who was a brittle diabetic, she wouldn't have touched his fingernails anyway. Interview on 04/04/23 at 3:09 P.M., RN #430 stated he did not recall ever seeing anything in Resident #57's hand to protect his palm prior to the abscessed area being identified. Interview on 04/05/23 at 10:45 A.M., LPN #440 stated sometimes Resident #57 would allow staff to apply a splint or put something in his hand to protect against pressure, however on occasion, he would refuse. LPN #440 stated, if the resident refused, it should be charted in the progress notes. Interview on 04/06/23 at 9:32 A.M., Podiatrist #505 stated, by law, he cannot provide care to any body parts above the ankle and denied ever cutting Resident #57's fingernails. Interview on 04/06/23 at 12:34 P.M., LPN #435 stated the last time he provided care to Resident #57 was prior to going out for the amputation and his hand was not wrapped. LPN #435 stated he did not know the area was there and did not recall seeing any type of barrier in place to the right palm prior to then. Interview on 04/06/23 at 12:52 P.M., LPN #520 stated the last time she provided care to Resident #57 was prior to him going out for the amputation, and his hand was not wrapped, nor was she aware of any conditions to the resident's hand. LPN #520 stated Resident #57 could get aggressive, so she didn't get too close to him. LPN #520 stated, sometimes she would notice a rag in Resident #57's hand and stated sometimes he would allow her to put something in it. LPN #520 stated she would document the resident's refusals in the medical record. LPN #520 stated she was unsure of the last time she tried to cut the resident's fingernails, however estimated it to be approximately two weeks prior to the area in the palm being identified and she recalled the resident was aggressive that day and she did not get far in cutting his fingernails. Interview on 04/06/23 at 12:41 P.M., LPN #460 stated she was unsure of the last time she saw a washcloth or splint in Resident #57's right hand. LPN #460 stated she did not perform Passive Range of Motion (PROM) services at any point for Resident #57's right hand. LPN #460 stated she had probably tried to cut the resident's fingernails in the past, and was probably not successful, and stated she probably would not have documented that. Interview on 04/06/23 at 12:46 P.M., Nurse Practitioner (NP) #515 stated the area and condition of Resident #57's palm definitely did not form overnight. NP #515 stated, upon visiting Resident #57 during the morning of 03/09/23, there was nothing in his right hand and, during prior visits, she did not recall seeing anything in his right hand. NP #515 denied being aware of any problems with staff cutting the resident's fingernails. She stated staff informed her of refusing medications and sometimes, personal care, however they did not say anything specific relating to his fingernails. Review of the Emergency Department (ED) Physician note dated 03/09/23 at 3:13 P.M. revealed Resident #57 presented to the ED via EMS (emergency medical services) from a local nursing home with reports of a tender, swollen right middle finger, which Resident #57 refused to allow staff to cut his fingernail on. Resident #57's other fingernails were noted to be cut. Resident #57 stated he did not want his fingernail touched, which was noted to be curled around the end of his fingertip and pierced the skin over the volar aspect of the distal phalanx (fingertip). There were reports the NP at the nursing home had hoped Resident #57 could be sedated in the ED to cut the fingernail. Resident #57's White Blood Cell Count (WBC) was 19.38 (high) in the ED. Resident #57 was determined to be severely septic and was diagnosed with tenosynovitis of the right middle finger and gas gangrene/necrotizing fasciitis of the right middle finger. Review of the Orthopedic Surgery Consultation dated 03/09/23 at 6:29 P.M. revealed Resident #57 had little use of his right hand and maintained it in a clenched fashion. As a result, his fingernails had grown back into his fingertips and his right middle finger had become severely infected. Orthopedics was consulted for management of an acute and severe infection. Resident #57 was noted to be seen for a limb threatening condition and a life-threatening condition. Review of the Orthopedic Op-Note dated 03/09/23 at 8:41 P.M. revealed a post-op diagnosis of osteomyelitis of entire third finger, full necrosis (dead tissue) and death of distal fifth digit as a result of the fingernail growing into the finger, flexor tenosynovitis (infection) of the third flexor sheath, mild flexor tenosynovitis of the fifth flexor sheath, and palmar abscess (a hand abscess is an accumulation of pus affecting the hand, usually caused by a bacterial infection). The procedure included amputation of the right third finger through the MCP joint (metacarpophalangeal joint), amputation of the right fifth finger through the PIP joint (the middle joint of each of your fingers). Incision and Drainage (I and D) of flexor sheath right finger, I and D of flexor sheath of right fifth finger, I and D of palmar abscess, and I and D of volar distal forearm. Review of the facility policy titled, Bathing Policy, dated 03/01/21 revealed care of fingers is part of the bath. Be sure nails are clean and notify the nurse if the nails are challenging. 2. Review of the medical record of Resident #50 revealed an admitted [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, gastro-esophageal reflux disease, history of covid-19, type II diabetes mellitus, adult failure to thrive, and chronic pain syndrome. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 had moderately impaired cognition. Resident #50 was dependent on one staff for personal hygiene and bathing. Resident #50 required limited assistance with eating. Resident #50 was assessed as having impairment on one side of his upper extremities. Review of the plan of care dated 07/28/20 revealed Resident #50 had an ADL self-care performance deficit. Interventions included to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of task documentation dated 03/13/23 through 04/10/23 revealed Resident #50 did not refuse personal hygiene/grooming, Observation on 04/10/23 at 9:56 A.M. revealed Resident #50 lying in his bed. Resident #50's fingernails were observed to extend approximately 1/4 inch beyond the fingertip and an unidentified brown substance was observed beneath all fingernails. Interview on 04/10/23 at 9:57 A.M., LPN #555 verified Resident #50's fingernails were long and had a brown substance underneath. 3. Review of the medical record of Resident #56 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, major depressive disorder, schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #56 had intact cognition. The resident did not exhibit behaviors during the assessment period. The resident was dependent on staff for personal hygiene. Review of the plan of care dated 05/14/22 revealed Resident #56 had an ADL self-care performance deficit related to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. Interventions included to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of task documentation dated 03/13/23 through 04/10/23 revealed the resident did not refuse personal hygiene/grooming. Review of progress notes from 03/01/23 to 04/10/23 revealed no documentation of refusals of nail care Observation and interview on 04/10/23 at 10:00 A.M. revealed Resident #56's fingernails of his left (contracted) hand extended approximately 1/4 inch beyond the fingertip and an unidentified brown substance was observed beneath some of the fingernails. Resident #56 stated it had been awhile since someone cut his fingernails. Interview on 04/10/23 at 10:01 A.M., Activity Aid (AA) #410 verified Resident #56's fingernails were long and had an unidentified brown substance underneath. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, resident interview, staff interview, review of the facility's timeline, review of staff statements, review of the facility's incident log, review of information from MapQuest, review of a weather report, review of facility investigative files, and review of a facility policy, the facility failed to complete thorough investigations following resident elopements to potentially prevent additional elopements. Additionally, the facility failed to update residents' elopement assessments and care plans following elopements. Lastly, the facility failed to identify like-residents at risk for elopement to ensure appropriate interventions were in place to potentially prevent future elopements. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death on [DATE] at approximately 10:45 P.M. when Resident #59 exited the facility's secured, all-female unit on the second floor via an alarmed door which led to a stairwell and exited the building through an exterior door. Resident #59 was found by staff the following morning sitting on a bench approximately 4.7 miles away from the facility. The Immediate Jeopardy continued when Resident #41 exited the secured, all-male unit on the second floor of the facility, without staff knowledge, on [DATE] at approximately 12:01 A.M. and was returned to the facility by police on [DATE] at approximately 1:45 A.M. Resident #41 left the faciity on [DATE] and walked approximately 1.8 miles from the facility and was found by police wandering near a local hospital. The facility failed to follow their elopement policy and did not review and update Resident #41's elopement risk assessment and care plan to prevent recurrence. This affected two (Residents #41 and #59) of three residents reviewed for elopements. The facility census was 69. On [DATE] at 4:30 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] at 10:45 P.M. when Resident #59 eloped from the facility and was not found until the following morning. Resident #59 was found by the Director of Nursing (DON) sitting on a bench at a busy intersection 4.7 miles away from the facility. Resident #59 complained she was cold but refused to have her body temperature taken and refused evaluation at the hospital. Temperature in the area in which the facility was situated for [DATE] in the late-night hours was approximately 28 degrees Fahrenheit (F) with a wind chill of 25 degrees F. Upon Resident #59's return to the facility, the facility did not conduct a re-assessment of her elopement risk nor did they update her elopement risk care plan to prevent recurrence. Additionally, the facility did not identify like-residents to ensure appropriate interventions were in place to potentially prevent future elopements. The Immediate Jeopardy continued when Resident #41 left the facility without staff knowledge and was found wandering outside a hospital 1.8 miles away from the facility. Temperature in the area in which the facility was situated for [DATE] in the late-night hours was approximately 39 degrees F with a wind chill of 34 degrees F. The facility did not conduct a physical assessment of Resident #59 when he was returned to the facility by the police. Upon Resident #41's return to the facility, the facility did not conduct a reassessment of his elopement risk, nor did they update his elopement risk care plan to prevent recurrence. Additionally, the facility did not identify like-residents to ensure appropriate interventions were in place to potentially prevent future elopements. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the DON identified nine residents in the facility at risk for elopement and completed updated elopement risk assessments. On [DATE], Minimum Data Set Nurse (MDSN) #295 updated all care plans for residents at risk for elopement. On [DATE], Maintenance Director (MD) #515 did a physical audit of all alarmed and coded doors and ensured they were functioning properly. MD #515 also changed the elevator code. On [DATE] at 6:15 P.M., all department heads were assigned continuous 4-hour supervisory shifts over the weekend, including the night shift. The supervising staff observed to ensure staff responded to alarms appropriately and were conducting 15-minute checks on all units throughout the weekend until [DATE]. On [DATE] at 6:30 P.M., the DON and Administrator began conducting in-person in-servicing of dayshift and nightshift staff addressing the elopement policy, specifically how to respond to elopement situations. Staff education concluded on [DATE]. On [DATE] at 7:00 P.M., clinical staff completed rounding and 15-minute checks on all residents with all residents present in the facility. The clinical staff will continue every 15-minute checks on all residents until [DATE]. On [DATE], elopement drills were completed by the Administrator on all three shifts. Elopement drills are to continue once per month for four months. Staff interviews on [DATE] at 11:53 A.M. with Floor Tech (FT) #520, at 11:55 A.M. with State tested Nurse Aide (STNA) #400 and at 11:57 A.M. with Human Resources Director (HRD) #525 confirmed they received education and were knowledgeable regarding the importance of responding immediately to door alarms and the importance of following the facility elopement policy. Medical record review on [DATE] for Residents #59, #41, #44, #58, and #62 identified as elopement risk revealed their care plans and elopement risk assessments were updated. On [DATE], the DON and/or Administrator will complete audits to determine staff knowledge of the facility's elopement procedures to continue twice per week for four weeks. On [DATE], the facility's Quality Assurance and Performance Improvement (QAPI) committee will meet to review the elopements and the facility's abatement plan to determine the need for further monitoring. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses including schizoaffective disorder bipolar type, psychosis, paranoid schizophrenia, major depressive disorder, anxiety disorder, and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively impaired and required supervision and physical assistance of one staff with activities of daily living (ADLs). Review of the most recent elopement risk assessment dated [DATE] revealed Resident #59 was at risk for elopement. Further review of the medical record revealed no additional elopement assessments were completed. Review of the elopement care plan for Resident #59, last updated [DATE], revealed the resident had a behavior problem which included repeated attempts to elope from the facility, laughs repeatedly without cause or reason, makes up fictitious stories about her children, asks repeatedly about her upcoming discharge, and will say she needs to leave immediately to go home and get her kids. Interventions included the following: 15 minute checks for 24 hours ([DATE]), administer medications as ordered and monitor for effectiveness, anticipate and meet the resident's needs, caregivers to provide positive interaction, stop and talk with the resident when passing by, medication review ([DATE]), monitor behavior episodes and attempt to determine the underlying cause, and provide a program of activities that is of interest and accommodates resident's status. Review of the nurse progress note dated [DATE] at 9:30 A.M. revealed Resident #59 returned to the facility escorted by staff. Medications were administered as ordered and the resident was observed to have random verbal outbursts. Resident #59 denied pain but complained of being cold and was offered blankets. Vital signs were within normal limits, but the resident refused to have her temperature taken. The resident was to be transferred to the hospital for an evaluation. Further review of the progress note revealed no details about how the resident eloped from the facility. Review of the nurse progress note dated [DATE] revealed Resident #59 was evaluated by Nurse Practitioner (NP) #600 due to her elopement from the facility during the night of [DATE] and not returning until the morning on [DATE]. The resident denied pain and was receiving one-on-one (1:1) supervision at the time of the visit. Review of a timeline provided by the facility revealed on [DATE] at 10:30 P.M., Resident #59 was observed in the hallway of the secured all-female behavioral unit on the second floor of the facility, and Licensed Practical Nurse (LPN) #465 directed the resident to go to her room to get some rest. At 10:45 P.M., the coded and alarmed door adjacent to Resident #59's room was noted to alarm. Resident #59's room was immediately searched without success. Staff searched all rooms on the unit and a resident headcount was completed noting Resident #59 was not present. At 10:50 P.M., all units were alerted that Resident #59 was not on the unit and the DON was notified via telephone that Resident #59 could not be located. Police were contacted by LPN #245. Direct care staff conducted a search of the facility and a resident headcount of all residents. At 11:00 P.M., LPN #465 was instructed to participate in an outside facility grounds search including the rear of the building and parking lot without success. At 11:05 P.M., Resident #59's physician and responsible party were contacted and notified of the resident's elopement. Management staff arrived at the facility along with emergency services personnel. At 11:10 P.M., management staff were instructed to drive their vehicles within the closely connected neighborhoods to look for Resident #59. On [DATE] at 8:30 A.M., management personnel arrived at the facility and the search recommenced. At 10:00 A.M., the resident was located. Resident #59 declined to go the hospital for an evaluation. Review of the in-service provided to staff dated [DATE] revealed, 'should an exit alarm sound, staff shall immediately respond and determine the cause of the alarm. If no reason can be found, the Supervisor shall be notified, and an account of all residents identified to be at risk for elopement shall be performed.' Review of agency STNA #545's statement dated [DATE] revealed the aide was in the hallway when an alarm went off, and she checked the door by the nurses' station and the television room. STNA #545 then asked where it was coming from and was told it was the back door by the elevator. STNA #545 went to turn off the alarm and while doing so, noticed Resident #59 was not on the unit. Review of STNA #225's statement dated [DATE] revealed she was notified Resident #59 was missing. She and LPN #240 went looking in all the rooms for Resident #59 and did not find her. Review of agency STNA #545's added statement dated [DATE] revealed on the night of Resident #59's elopement, she, and another (undisclosed) aide went to the door at the back of the hallway (where the resident had left from). The aide turned off the alarm and they checked the stairways and hallway rooms, and another aide went outside. Observations on [DATE] during initial tour of the facility with MD #515 revealed the facility's secured doors were in working order and alarmed appropriately, including the door Resident #59 exited through. Observation on [DATE] at 1:19 P.M. of Resident #59 revealed the resident was ambulating in the hallway on the women's secured unit on the second floor of the facility. Interview on [DATE] at 1:19 P.M. with Resident #59 revealed the resident was confused but stated, I want to get out of here. Interview on [DATE] at 1:30 P.M. with the Administrator and the DON confirmed Resident #59 eloped from the facility on [DATE] at approximately 10:45 P.M. Interview confirmed the resident's record did not include a description of the elopement. STNA #545 heard a door alarm on the women's secured behavioral unit located on the second floor. Interview confirmed the staff statements did not say how long it took STNA #545 to respond to the alarm, nor did the statements or facility timeline indicate the area outside the facility was searched until [DATE] at 11:00 P.M., approximately fifteen minutes after the alarm had sounded. Interview further confirmed STNA #545 checked the stairwell, and no one saw Resident #59 leave the facility. Staff did a headcount and determined Resident #59 was missing. The Police, DON, and Administrator were notified of the missing resident, and other management staff came in to assist with the search. Staff searched nearby neighborhoods in their vehicles but did not find the resident. Staff notified the resident's family the resident was missing. On [DATE] at 8:30 A.M. staff resumed the search. The DON found Resident #59 at approximately 9:30 A.M. downtown sitting on a bench at a busy intersection approximately 4.5 miles away from the facility. Interview confirmed the facility had not updated Resident #59's elopement risk assessment or care plan following the elopement. Additionally, the facility did not review other residents in the facility who were at risk for elopement. Interview on [DATE] at 10:33 A.M. with the Administrator and DON confirmed they had no other statements regarding Resident #59's elopement besides the ones provided. The Administrator confirmed STNA #545 was employed with an agency at the time of Resident #59's elopement. They learned she is no longer employed with the agency, but they were able to reach her again on [DATE] to question her. A phone interview with STNA #545 was attempted on [DATE] at 11:34 A.M. STNA #545 answered the phone and confirmed her identity but when the surveyor explained the reason for the call, STNA #545 hung up the phone. A second attempt was made to interview STNA #545 on [DATE] at 11:35 A.M. but was unsuccessful. A phone interview with STNA #225 was attempted on [DATE] at 11:46 A.M. and 5:16 P.M. but was unsuccessful. Phone interview on [DATE] at 3:47 P.M. with STNA #545 revealed she worked the night Resident #59 eloped. STNA #545 reported she was in another resident's room when she heard an alarm. STNA #545 stated she responded to the alarm, and herself and an unidentified aide looked up and down the floor and had not seen anyone leave. STNA #545 went down the stairs and did not see anyone. STNA #545 verified she did not go outside. When asked how staff figured out which resident was missing, STNA #545 reported a headcount was completed, and once it was discovered Resident #59 was missing, then staff went outside to look. Phone interview on [DATE] at 4:09 P.M. with LPN #245 revealed he helped search for Resident #59, but he was not working on her floor. LPN #245 reported he did not see the resident leave, but he did call the police to report the missing resident. Review of an online map per the website MapQuest, revealed the intersection where Resident #59 was located on [DATE] was 4.7 miles from the facility. Review of the online weather resource at https://world-weather.info/forecast/usa/cincinnati/08-january/ revealed the air temperature was 28 degrees F, and the wind chill was 25 degrees F for the night of [DATE] for the city in which the facility was situated. 2) Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including schizoaffective disorder bipolar type, dementia with behavioral disturbance, DM, and hypertension (HTN). Review of the MDS assessment dated [DATE] revealed Resident #41 was cognitively impaired and required supervision with ADLs. Review of the most recent elopement risk assessment completed for Resident #41, prior to this survey, was dated [DATE] and revealed the resident was at risk for elopement. Review of the elopement care plan for Resident #41, last updated [DATE], revealed the resident was at risk for elopement. Interventions included: apply Wanderguard (bracelet device used to alert staff if a resident exits an alarmed door to prevent elopement); monitor function and placement, monitor exit seeking behavior, provide structured activities, toileting, walking inside and outside, and re-orientation strategies including signs, pictures and memory boxes. Review of the facility incident log dated [DATE] to [DATE] revealed Resident #41 had an elopement on [DATE]. Review of nurse's progress notes dated [DATE] at 6:48 P.M. revealed the nurse questioned Resident #41 about his elopement from the facility, and the resident indicated he had learned the elevator code and exited the facility via the coded and alarmed elevator on the all-male secured behavioral unit on the second floor of the facility. Further review of progress notes revealed no additional documentation regarding the resident's elopement or the resident's condition following the elopement. Review of a timeline provided by the facility dated [DATE] revealed at 12:00 A.M., Resident #41 was noted to be sitting in his doorway in his wheelchair by the aide. At 1:45 A.M., the resident was returned to the facility by the police. The resident was placed on 1:1 supervision for 72 hours. Review of agency STNA #550's statement dated [DATE] revealed the aide observed Resident #41 lying in bed on [DATE] at approximately 12:00 A.M. Review of LPN #240's statement dated [DATE] revealed the nurse last observed Resident #41 up in his wheelchair on [DATE] at approximately 12:00 A.M. Further review of the statement revealed the police brought the resident back to the facility at 1:45 A.M. Observations on [DATE] during initial tour of the facility with Maintenance Director #515 revealed the facility's secured doors were in working order and alarmed appropriately. Observation on [DATE] at 1:05 P.M. of Resident #41 revealed the resident was seated in his wheelchair on the first floor (off the secured unit) and was getting ready to go outside with staff for a supervised smoke break. Interview on [DATE] at 1:05 P.M. with Resident #41 revealed he wanted to go home. Interview on [DATE] at 1:30 P.M. with the Administrator and the DON confirmed Resident #41 eloped from the facility without staff knowledge on [DATE] and was brought back to the facility by local police. Interview confirmed STNA #550, and LPN #240 were the staff on the all-male secured behavioral unit on the second floor of the facility. Police said resident was found at a nearby hospital about 1.5 miles away from the facility. Interview confirmed there was no documentation in the resident's medical record regarding the elopement. Additionally, there was no assessment of the resident following his return by the police regarding possible injuries. Resident #41's elopement risk assessment and elopement risk care plan were not updated following the elopement, and the facility did not review other residents at risk for elopement. The Administrator confirmed Resident #41's care plan listed placement of a Wanderguard bracelet as an intervention, but the facility did not have a Wanderguard system. Interview on [DATE] at 10:03 A.M. with the Administrator and the DON confirmed they interviewed LPN #240 again on [DATE] and he confirmed when Resident #41 was brought back to the facility by police, the resident was on foot and had not taken his wheelchair. A phone interview with LPN #240 was attempted on [DATE] at 11:36 A.M. and 5:17 P.M. but was unsuccessful. Phone interview on [DATE] at 4:09 P.M. with LPN #245 revealed he was Resident #41's nurse the night of the elopement. LPN #245 reported Resident #41 was sitting in a regular chair outside of his room the last time he saw the resident (not a wheelchair as described in the facility's timeline). LPN #245 reported Resident #41 did not use a wheelchair. LPN #245 further verified he had no idea Resident #41 was gone. LPN #245 suspects the resident learned the code for the elevator and eloped through the smoking area because the smoke door did not shut all the way. LPN #245 reported 'everyone' was aware the smoke patio door did not shut all the time and it could just be pushed open sometimes. Review of an online map per the website MapQuest, revealed the hospital where Resident #41 was found by police on [DATE] was 1.8 miles from the facility. Review of the online weather resource at https://world-weather.info/forecast/usa/cincinnati/10-february/ revealed the air temperature was 39 degrees F and the wind chill was 34 degrees F for the night of [DATE] for the city in which the facility was situated. Review of the facility policy titled, Elopement Prevention and Missing Resident, dated [DATE] revealed the facility will ensure the environment is as safe as possible for residents at risk for elopement and develop a plan of action that will ensure a prompt, effective, and coordinated response when a resident is reported missing. Upon admission, re-admission, or the development of elopement behaviors, all residents will be assessed for elopement risk. A comprehensive elopement prevention plan of care will be developed for each resident identified as at risk for elopement. Should an exit alarm sound, staff shall immediately respond and determine the cause of the alarm. Should an elopement occur, the facility's QAPI Committee should review the facility's systems, policies, procedures, and responses to elopements to evaluate all systems. Should a resident attempt to elope, a review of the resident's care plan shall be conducted for possible adjustments in care practices or safety precautions. This deficiency represents non-compliance investigated under Complaint Number OH00140432.

Based on record review, review of hospital records, review of facility Self-Reported Incidents (SRI's), staff interview, and review of facility policy, the facility failed to ensure residents were free from abuse. This resulted in Actual harm when Resident #83 was physically assaulted by another resident (Resident #22) in the facility and Resident #83 was transported to the hospital immediately following the assault and was admitted with a fracture to his rib and bruising to both eyes and right side of his face. This affected one (#83) out of three residents reviewed for abuse. The census was 82. Findings include: Review of the medical record for Resident #83 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #83 dated 09/21/22 revealed the resident was severely cognitively impaired. Activities of daily living (ADL's) were not assessed. Review of the care plan for Resident #83 dated 09/15/22 revealed the resident was weight bearing and ambulatory. Review of the admission note for Resident #83 dated 09/15/22 revealed the resident was admitted to the secured men's behavioral unit and exhibited increased anxiety. Resident #83 was a wanderer, was non-cooperative, and walks into other rooms in the unit and refused care sometimes. Review of the nurse's progress note for Resident #83 dated 10/17/22 revealed the resident was in bed most of the shift but was noted going in and out of rooms on the unit during the meal hour. Review of the next nurse's progress note for Resident #83 dated 10/19/22 timed at 11:09 P.M. revealed per report the resident was sent to the emergency room due to being assaulted by another resident (Resident #22). Review of the hospital note for Resident #83 dated 10/20/22 revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83 had dried blood covering his face, bruising to both eyes, and swelling to the right eye and right side of face. X-ray revealed an acute right rib fracture. Review of the medical record for Resident #22 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MDS assessment for Resident #22 dated 10/17/22 revealed the resident was cognitively intact and required supervision and set up with ADL's. Review of the nurse's progress note for Resident #22 dated 10/19/22 revealed the resident assaulted another resident (Resident #83) who had to be sent to the hospital for evaluation of injuries. Resident #22 was sent to the hospital via nine-one-one (911) for a psychological evaluation due to his behavior. Review of the hospital note for Resident #22 dated 10/20/22 revealed the resident reported to hospital staff that he got into an altercation last night at the facility after another resident touched his arm several times before he acted. Review of the facility SRI dated 10/19/22 revealed the facility conducted an investigation of alleged physical abuse between Resident #83 and Resident #22. The Administrator interviewed Resident #22 who stated that Resident #83 got about an inch from his face and was antagonizing him. He asked him to step back and leave him alone. Resident #22 stated that Resident #83 then hit him in the arm and then he hit Resident #83 back. The altercation was unwitnessed, but staff heard commotion in the activity area, and separated both residents. Resident #83 was sent to the hospital for assessment of his injuries and was not able to be interviewed. Resident #22 was assessed and had no injuries and was sent to the hospital for a psychological evaluation due to his behavior. The facility did not substantiate abuse. Review of the witness statement from agency State tested Nursing Assistant (STNA) #475 dated 10/19/22 revealed the aide called her into the room and said, He's beating him. Review of the statement revealed STNA #475 saw Resident #83 on the floor in the dining room with blood dripping down his face and he was unable to verbalize what happened. The statement revealed the aide felt Resident #83's injuries were serious, so they called 911. Resident #22 said Resident #83 had hit him, so he hit him back. Review of the witness statement from Licensed Practical Nurse (LPN) #155 revealed she was called to the unit and saw Resident #83 walking with blood coming from his face and eyes and she assisted with getting the resident sent to the hospital via 911 for an evaluation of his injuries. Resident #83 was nonverbal and unable to give an account of what happened. Resident #22 had no injuries and said he beat Resident #83 because he kept going into his room. Interview on 11/01/22 at 3:33 P.M. with the Administrator confirmed Resident #22 sustained no injuries in the altercation with Resident #83 on 10/19/22. Administrator confirmed when she interviewed Resident #22, he admitted he hit Resident #83 and that he did so in response to Resident #83 hitting him on the arm. Administrator confirmed she was not aware of the severity of Resident #83's injuries (rib fracture, black eyes, facial contusion) because she had not reviewed the hospital notes at the time of the SRI investigation. Review of the facility policy titled Resident Rights dated December 2016 revealed residents had the right to be free from abuse. Review of the facility policy titled Abuse and Neglect - Clinical Protocol dated March 2018 revealed Abuse was defined as the willful infliction of injury. The word willful as used in the definition of abuse meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect. This deficiency represents non-compliance investigated under Complaint Number OH 846.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure the dietician was notified of a significant weight loss, failed to ensure meal intakes were monitored on a regular basis and failed to ensure new interventions were attempted. Actual harm occurred to Resident #86 when the resident experienced an avoidable 14.6 percent (%) severe weight loss in one month and a severe weight loss of 21.7 % over five months. This affected two (#66 and #86) of three residents reviewed for severe weight loss. The facility identified five residents with significant weight loss over the past 90 days. Findings include: 1. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., [MEDICAL CONDITION] disorder, anxiety, depression, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment for decision making skills. She was dependent on one staff for eating. The resident was dependent on staff for bed mobility, transfers, toilet use and personal hygiene. Review of the nutrition care plan revealed the resident was at risk for a decline in nutrition and hydration secondary to [MEDICAL CONDITIONS] disorder, delusional behavior, poor oral intake, gastrostomy tube and a history of impaired skin. One of the goals documented the resident would maintain weight without significant change. Pertinent interventions included weights as ordered and monitor laboratory results. Review of the weights revealed on 09/04/18 the resident weighed 138 pounds, on 11/01/18 the resident weighed 134.2 pounds, on 12/03/18 the resident weighed 112.6. There was a re-weigh on 12/04/18 of 114.6 pounds. The next documented weight was 02/16/19 at 105.8 pounds, and on 02/26/19 she weighed 108 pounds. The residents' height was 62 inches. Review of physician order [REDACTED]. The resident was on a regular diet, pureed texture and honey consistency. During an interview with Registered Dietician Licensed Dietician (RDLD) #73 on 02/26/19 at 2:02 P.M., she stated the resident varied as to what she wanted to eat. She was on a bolus feeding four times a day as a supplement. The resident had never complained of any nausea, diarrhea or stomach problems. She stated if a resident sustained [REDACTED]. RDLD #73 verified she was not notified of Resident #86's weight loss on 11/01/18 or on 02/16/19. Follow up interview on 02/26/19 at 3:08 P.M., RDLD#73 stated she had written an order for [REDACTED].>During an observation on 02/26/19 at 5:15 P.M. the resident was lying in her bed and was non verbal. When asked if she was hungry, the resident shook her head no. During a follow up interview with RDLD #73 on 02/26/19 at 5:25 P.M., she verified there was no evidence the resident had refused weights. She further verified there was no evidence of weekly weights being implemented and there were no other interventions added after the resident sustained [REDACTED]. Review of a dietary note dated 02/26/19 at 6:49 P.M. documented a diet change of [MEDICATION NAME] 237 milliliters (ml) four times a day and nocturnal continuous feed of [MEDICATION NAME] 1.8 at a rate of 60 ml over 12 hours (running between 8:00 P.M. to 8:00 A.M.). Change the flush order from 200 ml four times a day to 200 ml twice a day. Further review revealed the resident remained on pureed texture diet with honey thick liquids. However the resident would only take a few bites or would refuse the meal completely. Current body weight on 02/26/19 of 108 pounds showed a 21.7 % weight loss within five months. Will start weekly weights and will monitor acceptance to new rate of tube feed for any nausea or vomiting. Physician aware and left voice message for the guardian. During an interview with RDLD #73 on 02/27/19 at 12:05 P.M., she verified she was not informed of the weight loss on 02/16/19 until 02/26/19. She verified the resident's weight loss was unplanned and significant. She verified the facility did not follow their weight policy and reweigh the resident on 02/16/19. RDLD #73 stated if she had been notified of the weight loss she would have notified the physician and the guardian, started the resident on weekly weights and changed the tube feed rate. She verified she had not notified the physician or the guardian of the weight loss until 02/26/19. On 02/27/19 at 4:07 P.M., RDLD #73 verified Resident #86 had a weight loss documented on 12/03/18 and the facility did not notify her of the weight loss. On 02/28/19 at 8:30 A.M. the resident was observed laying in bed with her tube feed of [MEDICATION NAME] running at 60 ml per hour. Review of the facility's Weight Assessment and Intervention policy dated 2001 and revised 09/2008 revealed the multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. Any weight change of five percent or more since the last assessment will be retaken for confirmation. If the weight is verified, nursing will immediately notify the Dietitian. The Dietitian will respond within 24 hours of receipt of written notification. The Dietitian will review the unit Weight Record each month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. one month - five percent weight loss is significant and greater than five percent is severe. Three months - 7.5 percent weight loss is significant; greater than 7.5 percent is severe. Six months - 10 percent weight loss is significant; greater than 10 percent is severe. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. 2. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed Resident #66 was rarely/never understood, had moderately impaired cognitive skills for daily decision making, and was totally dependent upon staff for activities of daily living (ADL's). Review of a physician order [REDACTED].#66 was on a regular diet, mechanical soft texture with thin liquids. Review of dietary progress note dated 01/24/19 at 2:20 P.M. revealed the residents's diet was downgraded to mechanical soft with thin liquids. Resident complained of difficulties chewing regular texture meals as resident was without teeth. Will monitor acceptance and make recommendations as needed. Review of physician order [REDACTED].#66 was admitted to hospice services for end stage [MEDICAL CONDITION] Review of the care plan dated 01/31/19 revealed altered nutrition and/or hydration status related to therapeutic diet; [MEDICAL CONDITION], anxiety, dementia, [MEDICAL CONDITIONS], acute [MEDICAL CONDITION], and hypertension. Interventions included mechanical soft diet with thin liquids, monitor diet tolerance, monitor meal and fluid intake, monitor weight and notify medical doctor (MD) of significant changes, offer alternate for foods/beverages refused, and provide diet and fluids as ordered. Review of nutritional risk assessment dated [DATE] revealed Resident #66 was 70 inches tall and weighed 363 pounds, obtained per mechanical lift upon admission on 01/18/19, with a body mass index (BMI) of 52.1. Review of hospital records revealed the closest recorded weight prior to Resident #66's admission to the facility was 332 pounds on 01/07/19. Review of dietary progress note dated 01/31/19 at 3:45 P.M. revealed Resident #66 was prescribed a mechanical soft, thin liquid diet with a current intake of 75 to 100 %. Resident #66 was alert, able to make needs known, and was fed meals. There weren't any chewing or swallowing complications and estimated needs were met through oral intakes. Estimated needs were calculated using ideal body weight (IBW) due to BMI status and indicated 1886-2263 kilocalories (kcal), 60-75 kilograms (kg) of protein, and 2264-2641 milliliters (ml) of fluids. Weight obtained on 01/18/19 was 363 pounds with a BMI of 52.1 which was morbidly obese. No other weight history was available. Resident #66 was at low risk for skin breakdown and there weren't any labs to review. Will continue to monitor and make recommendations as needed. No other dietary progress notes or assessments were in the medical record. Review of next weight dated 02/08/19 revealed Resident #66 weighed 309 pounds, a loss of 54 pounds, a significant weight loss of 10% since admission to the facility. Review of Resident #66's nutrition - amount eaten record revealed an intake of 76-100% on 02/01/19 at both 8:00 A.M. and 12:30 P.M., 51-75% on 02/04/19 at 10:59 A.M., and 0% on 02/25/19 at 8:00 A.M. and 12:30 P.M. No other meal intakes were recorded. Observation on 02/25/19 at 3:44 P.M. revealed Resident #66 was awake in bed with the television on. Interview with Resident #66 at the time of the observation revealed inability to answer simple questions due to a confused mental status. Observation on 02/27/19 at 8:19 A.M. revealed Resident #66 was awake in bed with only a disposable brief on and complained of being cold. Resident #66's breakfast tray was located untouched, still covered, on a tray table near the wardrobe, out of reach of the resident. The tray ticket revealed a mechanical soft regular diet and included an egg and cheese omelet, cereal, milk, and juice. Two state tested nursing assistants (STNA's) entered the residents bedroom at 8:30 A.M. and closed the door to the bedroom. At 8:36 A.M. Resident #66 could be heard through the closed door, screaming don't put that in my mouth. I have to take a shower today. Leave me alone. I'm sick. I don't want anything to eat. Interview with STNA's #2 and #189 upon exiting Resident #66's room reported Resident #66 refused to eat. Observation of Resident #66's breakfast tray revealed it was untouched. They reported sometimes Resident #66 would eat but when he/she didn't want to eat, the resident would spit food out or reach into the mouth and grab the food out as if he/she didn't understand how to eat. Other times, the resident would complain the food caused abdominal pain and would refuse to eat anymore. During the interview, Resident #66 continued to scream about being cold, wanting out of bed, and needing to have his back scratched. Observation on 02/27/19 at 8:51 A.M., 9:07 A.M., and 9:11 A.M. revealed Resident #66 remained agitated and continued to scream and curse. Interview on 02/27/19 at 1:27 P.M. with RDLD #73 reported weight sheets were provided to nursing staff at the first of the month to obtain weights on the residents. Every Tuesday an electronic report was generated and reviewed for significant weight loss. Resident #66 had only been weighed twice since admission which indicated a 54 pound weight loss in three weeks on 02/08/19, from 363 pounds to 309 pounds for a significant unplanned weight loss of 10 %. Resident #66's diet was downgraded following admission, as recommended by nursing, as Resident #66 was having difficulty chewing. Resident #66 didn't have any complications related to the downgrade. The STNA's document after each meal how much the resident consumed in the electronic medical record which was reviewed to develop nutrition plan. RDLD #73 reported he/she found out about Resident #66's weight loss on 02/12/19 but felt the initial weight was inaccurate. RDLD #73 reported he/she was unaware of the residents weight prior to admission but it may be in the admission packet which RDLD #73 reported was unavailable to him/her. Upon request, RDLD #73 agreed to obtain a current weight on Resident #66. Interview on 02/27/19 at 4:25 P.M. with RDLD #73 and Assistant Director of Nursing Licensed Practical Nurse (LPN) #24 reported Resident #66 was weighed with a mechanical lift and the weight was 290.8 pounds for a significant unplanned weight loss of 20% since admission. RDLD #73 reported being unaware of weights prior to admission to the facility. LPN #24 reported Resident #66 just showed up one day with limited information. During a risk meeting on 02/12/19, Resident #66's weight loss was discussed but the initial weight was felt to be inaccurate as LPN #24 reported remembering the residents weight at the hospital was closer to the weight obtained on 02/08/19. LPN #24 denied verifying weight in the hospital records and reported now was unable to find a weight in the hospital records. LPN #24 then reported Resident #66 must have been weighed in a wheelchair and staff forgot to deduct the weight of the wheelchair. LPN #24 denied interviewing staff to find out how resident was weighed and once informed it was recorded as a mechanical lift weight, RDLD #73 reported a wheelchair would not have been utilized. RDLD #73 reported no nutrition interventions were implemented after weight loss on 02/08/19 as the initial weight was felt to be inaccurate. Additional interviews on 02/28/19 at 9:54 A.M. and 11:23 A.M. with RDLD #73 reported all meal intakes were to be recorded electronically as these were utilized for plan of care. RDLD #73 acknowledged meal intakes for Resident #66 were only recorded on three days since admission to the facility, reported being aware of the lack of documentation, and reported it had been brought up in clinical meetings a few times. Resident #66 had been discussed only once, after admission, during a risk management meeting on 01/22/19 with interventions to reweigh the resident. RDLD #73 reported there wasn't any documented reweigh or refusal. RDLD #73 reported a trial of one cup of nutritional supplement after the meeting, prior to documented weight loss, which the resident refused. No further interventions or nutritional supplements were tried and there wasn't any documentation of this trial. There wasn't any follow up discussions about Resident #66 since the resident wasn't on weekly weights since being on hospice. Since the initial weight was felt to be inaccurate, the MD was not notified about Resident #66's weight loss. RDLD #73 reported being aware Resident #66's intakes fluctuated and were a hit or miss dependent upon mood, agitation, and staff as the resident cooperated better with some staff than others.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, staff and resident interviews, review of emergency room history and physical and discharge summary, review of staff statement, and review of policy and procedure the facility failed to ensure a sling, for a Hoyer (mechanical) lift, was in good repair to prevent an avoidable fall from the Hoyer lift during a transfer. This resulted in actual harm to Resident #2 when a strap on a Hoyer lift sling broke. The resident fell from the sling to the floor and sustained a fracture to her left trochanter femur (hip). The resident had to have her hip surgically repaired. This affected one Resident (#2) of three reviewed for Hoyer lifts/falls. The facility identified 10 residents who required the use of a mechanical lift. The facility census was 88. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE]. Resident was admitted to the hospital on [DATE] due to a [MEDICAL CONDITION] and returned to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of physician order [REDACTED]. Review of the care plan dated 08/20/18 revealed Resident #2 had a self-care deficit; an activity of daily living (ADL) decline may be expected related to disease process with interventions to assist with toileting, transfers, and use Hoyer lift for transfers. Review of progress note dated 01/07/19 at 8:10 A.M. revealed Resident #2 was heard by writer yelling my hip, my hip! State tested Nursing Assistants (STNA's) #28 and #29, who were transferring the resident, yelled out requesting for assistance. Upon entering Resident #2's room, the resident was observed lying on her back on the floor. Resident #2 was positioned on top of the legs of the Hoyer lift. Both STNA's indicated the Hoyer sling broke. Resident #2 was assessed and complained of pain to her left hip. The resident denied hitting her head. Resident #2 was sent to a local hospital for further evaluation. The Medical Director, Resident #2's daughter, and the Director of Nursing (DON) were all notified. Review of STNA #28's statement dated 01/07/19 revealed she and STNA #29 were getting Resident #2 up with the Hoyer lift. STNA #28 documented they checked the sling to make sure it was secure and proceeded to get the resident up. She documented one the loops of the sling split in half. Review of the emergency room (ER) History & Physical dated 01/07/19 revealed Resident #2 presented after a fall from facility when her Hoyer lift broke. The resident fell on her left hip and sustained a [MEDICAL CONDITION]. Review of the hospital discharge summary dated 01/09/19 revealed Resident #2 was admitted for fall when her Hoyer lift broke. Resident #2 was seen by orthopedic surgery and was status [REDACTED]. Resident #2 tolerated the surgery well and was being discharged in a stable condition back to the facility. Review of PO dated 01/10/19 revealed an order for [REDACTED]. PO dated 01/11/19 revealed to assess left femur site every shift for signs and symptoms of infection. Interview on 01/22/19 at 12:36 P.M. with the DON indicated she did not believe the Hoyer sling was checked prior to being used on Resident #2. The DON further indicated the facility did not have a system for checking Hoyer slings for wear and tear. She verified if a sling looked worn then it would be thrown away. The DON indicted the facility implemented a new system for laundry staff to check the slings weekly, and for the STNA's to check the slings prior to use. The DON indicated if a sling had any tears, rips, or looked worn it was to be given to the Administrator or the DON for disposal. Interview on 01/22/19 at 2:30 P.M. with Resident #2 reported she was not sure if the staff checked the Hoyer slings prior to using them. She reported that her pain was under control and she felt safe at the facility. Review of the facilities Lift Policy Program (dated 01/2019) revealed; Supervisors will ensure that mechanical lifting devices and other equipment/aids are maintained regularly and kept in proper working order, as housekeeping will check pads/equipment (Hoyer's/lifts) weekly to ensure they are maintained with no rips or tears and are in proper working order. Any pad/equipment that has any rip or tar or is not in working order will be immediately reported to the supervisor, who will notify the DON/Administrator, so they may remove the defect and replace with new. As a result of the incident, the facility took the following actions to correct the deficient practice by date 01/20/19: · On 01/07/19 the DON educated STNA's #28 & #29 on the proper way to use the Hoyer lift and to ensure Hoyer slings were inspected for damage. STNA's #28 and #29 were observed to complete a Hoyer transfer and to inspect the sling. · On 01/07/19 Licensed Practical Nurse (LPN) #30 completed a head to toe assessment on the other nine residents who utilized Hoyer lifts for transfer. No injuries were noted. · On 01/07/19 the DON created an audit tool for the laundry staff to check each Hoyer sling for rips tears and damage each time they are washed. Laundry staff is to document the findings and give any Hoyer sling with visible damage to the Administrator of the DON. · On 01/08/19 LPN #30 educated all staff on Hoyer sling care and Hoyer lift. Launder staff was educated on the responsibility of inspecting Hoyer slings and completing the audit tool. · Laundry staff completed audits on the Hoyer lift slings on 01/08/19, 01/10/19, 01/17/19, and 01/20/19. Hoyer lift slings are routinely washed weekly and as needed. · On 01/17/18 the Administrator and LPN #30 ordered additional Hoyer slings. · On 01/22/19 at 1:15 P.M. an observation was made of STNA's #20 and #21 doing a Hoyer lift transfer with Resident #6. They completed the transfer correctly with no issues. The sling was inspected for safety. Interview at the time of the observation revealed STNA's were knowledgeable of the procedure for completing safety checks of Hoyer lifts and slings prior to each use. · On 01/23/19 the new Hoyer pads arrived. · On 01/23/19 review of medical records for Residents #3 & #4 for Hoyer use was completed with no concerns. This deficiency substantiates Complaint Number OH 124.

Based on medical record review, observations, staff and physician interviews, review of usage recommendations for [MEDICATION NAME] ointment and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to timely implement interventions and treatments for pressure ulcers. This resulted in harm to Resident #44 when an open area was observed to the coccyx but preventative treatment was not changed until the area was assessed as a stage III pressure ulcer (full-thickness loss of skin, in which fat is visible in the ulcer), 11 days later. This affected one (#44) of two Residents reviewed for pressure ulcers. The facility identified two Residents in the facility with pressure ulcers. Facility census was 81. Findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with a re-entry date of 04/17/17. [DIAGNOSES REDACTED]. Review of significant change minimum data set (MDS) assessment dated [DATE] revealed severely impaired cognitive skills for daily decision making, extensive assistance was required with all activities of daily living (ADL's), and Resident #44 was at risk for pressure ulcers. Review of care plan initiated 07/25/15 revealed Resident #44 was at risk for impaired skin integrity related to incontinence episodes, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disorder, impaired mobility, [MEDICAL CONDITION], and cognitive impairments. On 11/10/17, a stage III pressure ulcer was noted to the coccyx and on 11/27/17 the pressure area progressed to a stage IV. Interventions included to assist with showers as scheduled, encourage fluids, explain all procedures prior to care, inspect skin during routine care daily, medications as ordered, pericare after each incontinence episode, report any changes in the residents skin integrity with care rendered, turn and reposition as needed, skin assessments per protocol, treatments as ordered, and on 11/13/17 a low air loss mattress was placed on the bed. Review of nursing progress note dated 10/30/17 at 7:07 A.M. revealed Resident #44 had an open area to the coccyx with minimal bleeding, no swelling or odor. An abdominal pad with foam border was placed on the wound until the wound nurse could address. The medical doctor (MD) and assistant director of nursing (ADON) were aware. On 11/03/17 at 8:03 A.M. Resident #44 was noted to have an open area to the coccyx and treatment was completed as ordered. The area was red, warm, and swollen. Minimal blood drainage was noted without odor. Laboratory (lab) work and antibiotic were requested from MD and the ADON was notified. On 11/03/17 at 1:51 P.M. an order was received for Keflex, an antibiotic, 500 milligrams four times daily by mouth for seven days. Labs were not indicated due to recent lab results dated 11/01/17. On 11/03/17 at 5:25 P.M., Resident #44 received the antibiotic for a possible infection of an open area to the coccyx. Review of treatment administration record (TAR) for October 2017 revealed house moisture barrier ointment was ordered on [DATE] to be applied after incontinent care and was applied on day shift on 10/30/17 and night shift on 10/31/17. A treatment to cleanse in between resident coccyx with normal saline, pat dry, and apply [MEDICATION NAME] every shift and as needed for wound care was ordered on [DATE]. This treatment was completed on 10/30/17 day shift and 10/31/17 night shift. Review of the TAR for November 2017 revealed house moisture barrier ointment was applied after incontinence care on day shift on 11/02/17, 11/03/17, 11/06/17, 11/07/17 and on night shift on 11/01/17, 11/03/17, 11/04/17, 11/05/17, 11/08/17, and 11/09/17. The coccyx was cleansed with normal saline, patted dry, and [MEDICATION NAME] was applied on day shift on 11/02/17, 11/03/17, 11/06/17, 11/07/17 and on night shift on 11/01/17, 11/03/17, 11/04/17, 11/05/17, 11/08/17, and 11/09/17. Review of Skin grid pressure V2 document dated 11/10/17 revealed an initial assessment of a wound to Resident #44's coccyx. Original date of the pressure area was 11/10/17 and the pressure area was not present upon admission/reentry or related to a leave of absence, emergency room visit, or outside appointment. Measurements were 4.5 centimeters (cm) by 4.5 cm by 1.5 cm. The wound bed was red with a moderate amount of slough, necrotic tissue, and revealed a stage III pressure ulcer. No prior assessment of the wound had been completed. The physician was notified of the presence of a new wound. Review of physician orders [REDACTED].#44's coccyx with normal saline, pat dry, and place Santyl ointment (a sterile enzymatic [MEDICATION NAME] ointment) 250 unit/gram on gauze, fluff the gauze to pack area and secure with gauze and tape. Change daily and as needed at bedtime for wound care. Observation on 12/06/17 at 10:23 A.M. of wound care to Resident #44 by ADON/registered nurse (RN) #29 and ADON/licensed practical nurse (LPN) treatment nurse #58 revealed removal of dressing to the coccyx dated 12/05/17 with minimal drainage and no odor. The pressure ulcer was about the size of a quarter and measured 3.2 cm by 3.7 cm by 1.5 cm. The wound bed was pink with a moderate amount of gray slough and undermining (deep tissue damage around the wound margin) throughout the wound edges. Resident #44 remained comfortable throughout the procedure and had a low air loss mattress to the bed. LPN #58 reported the pressure ulcer was now a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle). Interview on 12/06/17 at 3:17 P.M. with ADON/LPN treatment nurse #58 reported on 11/03/17, Resident #44 was assessed and had excoriation to the coccyx however this assessment was not documented in the medical record. Resident #44 had a history of [REDACTED]. It wasn't open but was superficial and red. [MEDICATION NAME] cream was continued as ordered. LPN #58 reported she was unaware of the reason an antibiotic was ordered on [DATE]. Resident #44 was assessed again on 11/10/17 as LPN #58 reported residents with skin issues were assessed weekly. ADON/LPN treatment nurse #58 reported she was not informed of an infection to the coccyx wound or deterioration of the wound until 11/10/17 at which time Resident #44 was initially assessed to have a stage III pressure ulcer, based on size and depth, to the coccyx. A treatment order was obtained on 11/10/17 and a low air loss mattress was applied to the bed on 11/13/17. Interview on 12/06/17 at 4:39 P.M. with LPN #67 reported Resident #44 originally had a superficial opened spot on her coccyx so [MEDICATION NAME] was continued for about two days. It then worsened, was more open with depth, had an odor, with slough and necrotic tissue observed in the wound bed. The MD was notified and an order was obtained for antibiotic for a possible wound infection. No treatment order was obtained and [MEDICATION NAME] continued to be applied as previously ordered. Review of fax dated 11/03/17 to MD revealed Resident #44 had an open area to the coccyx. The area was warm, red, swollen, and seeping. [MEDICATION NAME] cream twice daily was current treatment in place. Requested lab work and antibiotic. Return fax dated 11/03/17 revealed there was no need to repeat lab work as labs were completed on 11/01/17. Keflex 500 mg was ordered three times daily for seven days. No treatment was ordered. Interview on 12/06/17 at 5:42 P.M. with MD #126 reported Resident #44 was compromised with a history of pressure ulcers, worsening dementia, and poor nutritional intake. Once the coccyx wound developed, it deteriorated rapidly. Wound treatment with Santyl was ordered upon being notified of the wound condition and was the most appropriate treatment due to slough being present in the wound bed. Review of usage recommendations for [MEDICATION NAME] ointment revealed it was approved by the food and drug administration for use as a skin protectant drug. Uses included skin protection in incontinent adults and Stage 1 pressure ulcers (intact skin with localized area of non-blanchable redness). Review of information from the NPUAP revealed a Stage 1 Pressure Injury is non-blanchable [DIAGNOSES REDACTED] of intact skin with localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. A Stage 3 Pressure Injury is full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Based on medical record review, resident interview and staff interview, the facility failed to ensure a resident was free from physical restraint unnecessary to treat her medical symptoms. This resulted in Immediate Jeopardy for Resident #10 when she was physically restrained and given an intramuscular injection of [MEDICATION NAME], a long acting anti-psychotic medication, which she had repeatedly refused. Resident #10 reported facility staff had physically assaulted her. This affected one (#10) of eight residents reviewed for restraint use who were receiving injectable anti-psychotic medications. The facility census was 89. On 11/25/14 at 3:30 P.M., the Administrator was notified Immediate Jeopardy began on 11/20/14 at 1:20 P.M. when Resident #10 was physically restrained by State tested Nursing Assistants (STNA) #8 and #9 while Registered Nurse (RN) #34 administered [MEDICATION NAME], a long acting antipsychotic medication, by intramuscular injection. Activity Director (AD) #2 was in the room and witnessed the incident. Resident #10 had repeatedly refused the medication and had no dangerous behaviors noted prior to being held down to receive the forced medication. Subsequent to being held down for the injection, Resident #10 accused staff of physically assaulting her. The Immediate Jeopardy was removed on 11/25/14 at 7:30 P.M. when the facility implemented the following corrective actions: ? On 11/20/14 at 2:10 P.M., a head-to-toe assessment was completed on Resident #10. The physical assessment was completed by the Director of Nursing (DON) and revealed no issues or concerns. ? On 11/20/14 at 2:15 P.M., RN #34, STNA's #8 and #9, and AD #2 were removed from the unit and interviewed about the incident. An investigation was initiated to ensure the residents were safe. All residents on the behavioral unit were interviewed by the facility. ? On 11/20/14 at 4:15 P.M., facility staff completed interviews with staff and residents on the behavioral unit regarding forced medication orders and resident rights. An assessment of the residents on the behavioral unit was completed. The physical assessments were performed for evaluation of possible physical abuse. Resident #10 continued to indicate that she was assaulted by staff that physically held her and forced an injection. No other residents voiced concerns related to resident rights, physical abuse or forced medications. The Director of Nursing (DON) spoke with Administrator and discussed the specifics that Resident #10 was given a forced injection of [MEDICATION NAME] by an RN while STNA's #8 and #9 held the resident. The DON told the Administrator that it was given because there was an order for [REDACTED]. ? On 11/20/14 at 4:30 P.M., RN #34, STNA's #8 and #9 and AD #2 were educated and reinstated to the floor per the Administrator's directive by the DON. STNA's #8 and #9 were told that it was a resident's right to refuse medication. They were also told that it was against resident rights and the facility policy to force medications for routinely prescribed medications. ? On 11/20/14 at 5:00 P.M., the facility began in-servicing all staff on the abuse policy and resident rights. Telephone calls and letters were sent to staff that could not be reached. ? Beginning on 11/20/14 at 7:30 P.M., all resident's medical records were audited for physician orders [REDACTED].#10 and #12) had physician orders [REDACTED].#12 has never had medications administered by force. ? On 11/21/14, the Assistant Director of Nursing or designee will continue to complete a head-to-toe assessment on Resident #10 for seven days to identify any residual effects/injury are noted. As of 11/27/14, there were no concerns identified. ? On 11/21/14 at 9:30 A.M., the Administrator and DON were re-educated on the Abuse Policy and Resident Rights by Corporate Clinician #1. ? On 11/21/14 at 10:00 A.M., Residents #3, #10, #13, #15, #18, #20, #29 and #34, who had received intramuscular injections within the last two months, were interviewed about the care they received during and after the injection. Resident #10 was the only resident who voiced concern. ? On 11/25/14 at 7:30 P.M., all nurses had been in-serviced about the resident's right to refuse medications, interventions to utilize when a resident refuses medications, and notification of reporting refusals. ? As of 11/28/14, all in-servicing of floor staff including STNA's, PRN staff, housekeeping, activity, and dietary staff that had not already been in-serviced was completed. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as not enough time has elapsed for the facility to conduct audits to verify the corrective action taken was effective and being monitored for on-going compliance. Findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10 had been deemed incompetent and was appointed a guardian for person only for an indefinite time period on 11/28/12 by the Probate Court. Review of the comprehensive assessment completed on 04/10/14 indicated Resident #10 had moderate cognitive impairment. Resident #10 was without signs or symptoms of [MEDICAL CONDITION] and was without physical or verbal symptoms directed towards self or others. The assessment documented the resident did have delusions and received anti-psychotic and anti-anxiety medications. Review of the resident's care plan for non-compliance, initiated 04/21/14, documented Resident #10 was non-compliant with taking medications as ordered by the physician. The goals included the resident will not have any negative outcomes related to non-compliance and will have decreased non-compliance. The interventions included to document educational attempts made with resident in relation to compliance; educate the resident, family or responsible party on negative outcomes related to non-compliance; explain all procedures prior to starting them and the benefits of the procedure; and notify the physician or Nurse Practitioner (NP) of non-compliance. Planned interventions for Resident #10's non-compliance did not include administering refused medications by force. Review of a hand-written note dated 11/20/14 and signed by Psychiatric Nurse Practitioner #1 read: "To Whom It May Concern. Re: (Resident #10). Please force monthly [MEDICATION NAME] injections as discussed with guardian. Please increase [MEDICATION NAME] to 234 milligrams (mg) intramuscularly (IM) every month." Review of Resident #10's Medication Administration Record [REDACTED]. Review of a progress note dated 11/20/14 at 12:00 P.M. documented a new order to increase the [MEDICATION NAME] injection for 12/20/14 to 234 mg. The [MEDICATION NAME] injections may be forced per NP #1 and the guardian. Continue to monitor for effectiveness. Review of a progress note dated 11/20/14 at 1:20 P.M. documented the [MEDICATION NAME] was administered by forced injection to the resident ' s left buttock per the guardian and the guardian was notified. Review of weekly nursing documentation dated 11/22/14 documented Resident #10 was without harmful behaviors, complained at every meal, and rejected care daily. During an interview on 11/25/14 at 8:42 A.M., Resident #10 stated on 11/20/14 she was physically restrained and given an injection of medication that she did not want. The resident explained that on 11/20/14 she was lying in bed watching television and RN #34 came to the doorway of the room and told her it was time for her monthly injection. Resident #10 stated she told the nurse she did not want the medication and was not going to take it. The nurse left the doorway and returned to the room with STNA #8 and STNA #9. RN #34 told the resident she was getting the shot whether she wanted it or not. The resident told RN #34 again that she would not take the shot. Resident #10 stated at that time STNA #8 and STNA #9 grabbed her wrists and "pinned her up in the bed". She said she was on her "belly" on the bed with her face in the mattress and could no longer see what was happening. Someone attempted to pull her legs up towards her chest and at that moment she felt someone grab her pants and pull her pants down. She then felt a shot go into her "butt". Resident #10 indicated that she heard a man's voice during the incident, but was unsure if he touched her while being forced to take the injection. During an interview on 11/25/14 at 1:31 P.M., Corporate Nurse (CN) #3 who was in charge of corporate clinical services confirmed Resident #10 was forced to get an injection on 11/20/14. CN #3 indicated this was not common practice in the facility. During an interview on 11/25/14 at 2:50 P.M., STNA #8 stated on 11/20/14, she and STNA #9 assisted RN #34 to give an injection to Resident #10. STNA #8 explained that RN #34 said that Resident #10 refused the medication but that she must get the shot because the doctor ordered it. STNA #8 said RN #34 directed them (STNA #8 and STNA #9) to hold down Resident #10 so that a shot could be given. STNA #8 indicated Resident #10 was forced face down into the mattress and positioned on her stomach. STNA #8 indicated Resident #10 was held by the arms while the nurse injected the medication. STNA #8 indicated that AD #2 was present in the room, but did not help hold down Resident #10. When asked if she had training for restraint holds, STNA #8 said she used "PMT", but was unable to describe PMT. During an interview on 11/25/14 at 3:00 P.M., STNA #9 stated she and STNA #8 held down Resident #10 while RN #34 forced an injection. STNA #9 stated Resident #10 refused the injection and had refused injections before. STNA #9 indicated she had never assisted with holding a resident for an injection before this incident. STNA #9 indicated RN #34 directed that Resident #10 be held down for the injection "because the doctor and guardian wanted it." STNA #9 confirmed she had no training on how to physically restrain a resident. During an interview on 11/26/14 at 9:25 A.M., RN #34 stated Resident #10 refused her monthly [MEDICATION NAME] injection on 11/20/14. RN #34 stated STNA #8 and STNA #9 physically restrained Resident #10 so that a forced injection could be given. RN #34 stated AD #2 was in the room as a witness, but did not physically hold Resident #10 for the injection. RN #34 explained that there was an order for [REDACTED]. During an interview on 11/26/17 at 9:30 A.M., the Administrator confirmed Resident #10 was physically restrained on 11/20/14 after refusing her monthly [MEDICATION NAME] injection and was forced to take an injection. During an interview on 11/26/14 at 9:35 A.M., Psychiatrist #1 stated he wrote orders for Resident #10 to receive anti-psychotic medication by force if the resident refused the medication. Psychiatrist #1 explained that he wrote the forced medication orders because Resident #10 was appointed a guardian and no longer had rights to make her own decisions and because the guardian wanted the medication given. Psychiatrist #1 further explained when Resident #10 was appointed a guardian the court had decided that she no longer had any rights to make any decisions. Psychiatrist #1 gave the example that this was similar to a parent taking a two year old child to the pediatrician for immunizations; the child says no, but the child is held down and given the immunization anyway. This deficiency substantiated Complaint Number OH 090.

Based on record review and staff interview, the facility failed to ensure residents were provided adequate supervision and assistance devices during transfers. This affected one sampled resident (#26) who sustained a right hip fracture during an improper transfer by one staff member and one sampled resident (#12) who had a fall without injury when the resident's walker was left out of reach and she tried to self transfer. This affected two of 16 sampled residents in a current resident census of 80. Findings include: 1. Review of the medical record of Resident #26 revealed [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] stated the resident had short and long term memory impairment, poor decision making ability, exhibited a sad, pained, worried facial expression and was verbally abusive. Resident #26 was assessed as totally dependent on two staff for transfers and required physical help to maintain balance when standing and partial physical support to maintain balance when sitting. The assessment further stated the resident exhibited moderate pain less than daily. Review of the Cardex or nurse aide care plan in place on 01/23/10 revealed the resident required a Hoyer lift and the assistance of two staff for transfers. The additional notes section on the Cardex stated "Do Not use a stand up lift on this resident." Review of nurse's notes dated 01/23/10 revealed the nurse was called to the resident's room. STNA #39 stated she was using the lift and had to lower the resident to the floor. The resident stated she was not in any pain. A head to toe assessment was completed. Review of the medication administration record revealed no documentation of the resident having received any pain medication on 01/23/10. Review of a facility Self Reported Incident report dated 01/24/10 revealed the resident complained of right groin pain and stated she had been dropped the day before. The resident's physician and guardian were notified and orders were obtained for an x-ray. The x-ray was inconclusive for a fracture. The resident was sent to the emergency room for further evaluation and treatment. During the investigation state tested nurse aide(STNA) #39 stated she transferred Resident #26 in the morning on 01/23/10 and the resident was agitated and kicking during the transfer. During that time the resident slipped and struck her leg. The resident did not voice any complaints of pain at that time. The results of the investigation was the resident sustained [REDACTED]. Interview with STNA #39 on 07/15/10 at 10:00 A.M. revealed she wanted to give Resident #26 a shower around 8:00 A.M. and could not find anyone to assist her for 30 minutes. STNA #39 stated so she attempted to transfer the resident with the stand up lift by herself. STNA #39 stated she was aware the resident should have been transferred with the Hoyer lift and two staff. She stated Resident #26 was in the shower chair but not seated all the way to the back of the chair and was kicking which caused her to slide out of the chair. STNA #39 stated the resident was not very happy that day and she was the only one she wanted to complete her care. STNA #39 stated she lowered Resident #26 to the floor and her right leg was bent behind her. STNA #39 stated she informed the nurse. She stated the resident complained of some groin pain at that time and the nurse gave the resident something. She stated the resident did not complain much the rest of the day. She stated she went ahead and completed the resident's shower that day. Review of the facility's Hoyer Lift policy dated 10/01/08 and Sit to Stand Lift policy dated 04/17/09 revealed the policies stated always must have two staff for safety. Interview with the Director of Nursing on 07/15/10 at 2:00 P.M. verified STNA #39 used the incorrect lift and attempted to complete the transfer by herself. Interview with Resident #26 on 07/16/10 at 9:10 A.M. revealed STNA #39 was getting her in the chair and the strap wasn't on good. The resident states she was trying to stand and she slipped down. 2. Review of the medical record of Resident #12 revealed [DIAGNOSES REDACTED]. The resident's personal safety alarm to the bed was discontinued on 04/02/10 due to non-compliance with using it. The Minimum Data Set (MDS) assessment dated [DATE] stated the resident had short and long term memory intact, modified independence with decision making, required supervision with bed mobility, walking and toilet use. Resident #12 was unsteady but able to rebalance when standing. The assessment indicated the resident had fallen in the 30 days prior to the assessment period. The resident's care plan for fall injury intervention dated 11/02/09 included an intervention to keep the resident's walker in easy reach. Review of Fall Nurse's Notes revealed Resident #12 had fallen on 03/29/10, 05/31/10 and 06/10/10. No injury resulted in any of these falls. During interview on 07/14/10 at 10:25 A.M. Resident #12 stated she had fallen that morning trying to reach her walker. The resident stated Registered Nurse (RN) #5 had moved the walker when she came in to draw the resident's blood. Interview with state tested nurse aide (STNA) #37 on 07/14/10 at 10:30 A.M. verified the resident's walker was not where it should have been. Interview with the Director of Nursing (DON) on 07/14/10 at 12:55 P.M. revealed he assisted when the resident fell on [DATE]. The DON stated he was not aware how far the walker was from Resident #12 prior to the fall. Further interview with Resident #12 on 07/14/10 at 1:00 P.M. in the presence of the DON verified the walker was not within her reach when she fell . Interview with RN #5 on 07/15/10 at 6:45 A.M. revealed she would have moved the walker up towards the head of the bed but would not have moved it away. On 07/15/10 at 6:48 A.M. Resident #12 was observed independently ambulating to the bathroom with her walker.