Every finding on record at Autumnwood Nursing & Rehab Center

Based on record review, observation, interview, and review of facility policy, the facility did not maintain a homelike environment. This affected six Residents (#6, #8, #25, #36, #55, and #58) out of 11 residents reviewed for environment. The facility census was 57. Findings included:1. Review of an email dated 06/24/26 at 9:44 A.M. from Maintenance Director #601 to Director of Strategic Sourcing #701, Administrator and Regional Maintenance Director #700 revealed many air conditioning units were out and mid 90 temperatures were expected. He revealed the facility required rental air conditioning units for the hallways. Review of an email dated 06/24/26 at 8:14 P.M. from Director of Strategic Sourcing #701 to Maintenance Director #601, Administrator and Regional Maintenance Director #700 revealed they were working on getting all 24 air-conditioning units ordered and delivered. Review of an email dated 07/01/26 at 2:21 P.M. from Maintenance Director #601 to Director of Strategic Sourcing #701, Administrator and Regional Maintenance Director #700 revealed the facility was unable to keep parts of the building below 84 degrees Fahrenheit (F) and in need of three more temporary air conditioning units. Environmental tour on 07/09/26 from 12:40 P.M. to 1:37 P.M. with Maintenance Director #601 revealed the following identified concerns: -Resident #36's air conditioner did not work in her room, and the temperature of her room was 86 degrees F. -Resident #25's air conditioner did not work in her room, and the temperature of her room was 83 degrees F. -Resident #8 had a large garbage can underneath the sprinkler head in his room. The ceiling had a five inch diameter brown circular area and an oblong seven inch by five-inch brown area to his ceiling. The garbage can contained one inch of water. -Resident #55 had a large garbage can collecting water from a sprinkler head from his ceiling, and the can contained approximately one inch of water. The ceiling had approximately two feet by 18 inches of unfinished ceiling area by the door, the ceiling above the sink also contained a whole sheet of dry wall that was unfinished, and an area by the sprinkler head with unfinished ceiling as the ceiling texture was peeling and coming off.-Resident #6's air conditioning did not work in his room, and the temperature of his room was 81 degrees F. -Former Resident #58's room had a large garbage can collecting water from a leak underneath a sprinkler head with peeling ceiling texture. The garbage can contained approximately one half inch of water. Interviews conducted on 07/09/26 at 12:29 P.M. and 07/14/26 at 10:41 P.M. with Maintenance Director #601 revealed that 12 air conditioning units in residents' rooms were not functioning, and he stated the units were already inoperable when he began working at the facility about four months ago. He reported ordering replacement units and parts at the end of June and confirmed that all supplies arrived on 07/09/26, though installation would take two to three weeks due to limited staffing. The Maintenance Director also confirmed ongoing water leaks caused by issues with the sprinkler system; after initial repairs, additional leaks occurred, leading to the sprinkler system being turned off and the facility placed on fire watch. He believed the leaks affecting Resident #8, Resident #55, and Former Resident #58's rooms occurred around 07/02/26 but was unsure of the exact date, whether residents were offered room changes, or whether any interventions were completed, and he had no documentation. He could not confirm whether ceiling damage in Resident #55's room existed prior to the resident moving in but stated he was currently repairing all damaged ceilings. He verified that Resident #6 was admitted on [DATE] to a room without working air conditioning, and the facility was aware of this issue beforehand. He acknowledged that the facility should ensure all rooms are in proper condition prior to resident admission, including having no ceiling leaks and functioning air conditioning, and stated that residents should be considered for relocation if a ceiling leak is present, particularly when the resident is at risk for falls.2. Review of the closed medical record for Former Resident #58 revealed an admission date of 11/04/25 and a discharge home date of 07/05/26. His diagnoses included chronic obstructive pulmonary disease, chronic kidney disease with heart failure, muscle weakness, and abnormalities of gait and mobility. The nursing notes revealed he had falls at the facility on 04/26/26, 05/30/26, and 06/17/26. There was nothing in the nursing notes regarding his ceiling leaking and/or interventions including offering a room change. Review of the care plan dated 03/18/26 revealed Former Resident #58 was at risk for falls due to cognitive function, repeated falls, and decreased physical functioning ability. Interventions included non-skid footwear, call before fall signage, and call light in reach. There was nothing in the care plan regarding ensuring the floor was dry. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Former Resident #58 had moderately impaired decision-making abilities, required supervision with transfers and was independent with ambulation. Review of the fall risk assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #626 revealed Former Resident #58 was at high risk for falls. Interview on 07/13/26 at 3:20 P.M. and 07/14/26 at 10:55 A.M. with Former Resident #58's brother revealed when Former Resident #58 was at the facility his ceiling by the sprinkler head was leaking above his bed for about one week until he finally took him home because of safety concerns. He revealed he had come in and there was a puddle of water on the floor next to his bed where he exited to ambulate to the bathroom causing a fall hazard. He stated he told the nurse, and the staff did come in and mop up the area, but the ceiling continued to leak. He revealed the next day there was another puddle in the same spot on the floor, and again, he told the nurse. He stated he was concerned as Former Resident #58 had already had three falls at the facility and did not want him to slip and fall while trying to go to the bathroom. He revealed the facility did not fix the leak, offer a room change and/or do anything about safety concerns. He stated he finally took Former Resident #58 home due to multiple factors including safety as he did not feel he should have had to stay in a room with a leaking ceiling. 3. Review of the medical record for Resident #36 revealed an admission date of 08/29/24 with diagnoses including congestive heart failure, chronic respiratory failure with hypoxia, and diabetes. There was nothing documented in her medical record regarding the temperature of her room and/or interventions due to increased temperature, including being offered a room change. Review of the care plan last revised 07/19/24 revealed Resident #36 required assistance with activities of daily living related to decreased mobility, and morbid obesity. Interventions totally dependence on bed mobility, transfers, toileting, bathing, and dressing.Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #36 had impaired cognition as her Brief Interview for Mental Status (BIMS) score was an 11/15. She was dependent on staff for most of her activities of daily living including toileting hygiene, dressing and personal hygiene. Interview on 07/09/26 at 12:43 P.M. and 07/13/26 at 8:33 A.M. with Resident #36 revealed on 07/09/26 at 12:43 P.M. that she was comfortable and had no issues. Resident #36 then revealed on 07/13/26 at 8:33 A.M. she did not want to tell this surveyor on 07/09/26 that her room had been uncomfortable for quite some time (weeks) as she felt her room was too hot, especially because she was on oxygen. She revealed a concern she had was that staff did not want to come into her room to provide care as they stated her room was too hot. She revealed there had been many occasions that they did not provide care because of the temperature of her room. She revealed she felt staff treated her like it was her fault that her room was too hot, and that she could not help that her air conditioner did not work. 4. Review of the medical record for Resident #25 revealed an admission date of 09/09/24 with diagnoses including congestive heart failure, atrial fibrillation, morbid obesity, hypertension, and chronic obstructive pulmonary disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #25 had intact cognition.Review of the nursing note dated 07/01/26 at 1:39 P.M. completed by LPN #626 revealed Resident #25 complained of her room being too hot and was advised new cooling units would be getting installed. She was told that she was able to move to another room, but she declined. Interview on 07/09/26 at 12:45 P.M. and 07/13/26 at 8:42 A.M. with Resident #25 revealed she was upset as she felt her room was too hot, miserable, and it was uncomfortable. She revealed she was upset as maintenance knew the air conditioners did not work for quite a long time and they did not do anything about it. She revealed they then waited until the temperature got above 90 degrees F outside until the facility finally did anything including ordering new units. She revealed they did offer her a room change but that she did not want to move rooms as she did not feel that was right, especially since maintenance knew for a long time the air conditioner in her room did not work. She revealed she had told maintenance and the nurses multiple times as she liked to run her air conditioning even in the winter, but she felt they did not do anything about it. 4. Review of the medical record for Resident #8 revealed an admission date of 09/10/24 with diagnoses including dementia, anxiety, and diabetes. There was nothing documented in his medical record in relation to his leaking ceiling or if Resident #8 was offered a room change. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #8 had impaired cognition with a BIMS score of 12/15. Interview on 07/13/26 at 8:59 A.M. with Resident #8 revealed that his ceiling had been in that condition for some time, though he was unable to state how long. He reported there had been a leak that caused the damage and shook his head back and forth, appearing frustrated.5. Review of the medical record for Resident #55 revealed an admission date of 07/03/26 with diagnoses including hypertension, diabetes, chronic obstructive pulmonary disease, and anxiety. There was nothing documented in his medical record in relation to his leaking ceiling or if Resident #55 was offered a room change.Review of Medicare Five-Day MDS 3.0 assessment dated [DATE] revealed Resident #55 had intact cognition. Interview on 07/13/26 at 9:24 A.M. with Resident #55 revealed that most of the ceiling damage in his room had already been present before he moved in, and it appeared to him that the ceiling had a history of leaking. He stated that shortly after his admission, another leak occurred near the sprinkler head, and staff placed a garbage can underneath it. He expressed concern, saying, I am unsure why they moved me into a room that already was leaking, and reported that the facility never asked whether he wanted to move rooms despite the leaking ceiling.6. Review of Resident #6's medical record revealed an admission date of 07/01/26 with diagnoses including chronic respiratory failure with hypoxia and hypertension. The record contained no documentation indicating that his air conditioning was not working, that he was offered a room change, or that any other interventions were completed.Review of Medicare Five-Day MDS 3.0 assessment dated [DATE] revealed Resident #6 had intact cognition. Interview on 07/09/26 at 1:28 P.M. with Resident #6 revealed that his room was warm and continued to get hotter. He stated he was uncomfortable because he could not control the temperature, as the air conditioner in his room was broken. He reported he had recently moved in and that the air conditioning had been nonfunctional since his admission.Review of the facility policy labeled, Safe and Homelike Environment, dated 2023, revealed in accordance with resident rights the facility would provide a safe, clean, comfortable and homelike environment. The facility would maintain comfortable and safe temperature levels. The facility would keep the temperature in common resident areas between 71- and 81-degrees F. Housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly and comfortable environment. This deficiency represents non-compliance investigated under Complaint Number 3074334.

Based on interviews, observations, review of the Self-Report Incident (SRI) and facility investigation, medical record review, and review of facility policy, the facility did not ensure that interventions were implemented to prevent actual elopement or the potential for elopement as required by physician orders and/or the care plan. This affected two residents (#14 and #59) out of three reviewed for elopement and had the potential to affect 11 residents (#3, #14, #15, #17, #19, #21, #28, #30, #32, #38, and #59) identified by the facility as being at risk for elopement.Findings include: 1. Review of the closed medical record for Former Resident #59 revealed an admission date of 12/05/25 and a discharge with family date of 07/09/26. His diagnoses included Alzheimer's disease with late onset, anxiety disorder, restlessness, agitation, dementia with psychotic disturbance, malignant neoplasm of the gallbladder, and cerebrovascular insufficiency.Review of the care plan initiated on 12/05/25 and last revised on 05/08/26 revealed Former Resident #59 was at high risk for elopement. Interventions included a Wanderguard (bracelet or anklet worn by a resident at risk for elopement to alert staff if they attempt to leave the facility) to the right ankle, check function and placement every shift, and on 05/08/26, one-on-one supervision was implemented until discharge. Review of the care plan dated 02/09/26 revealed Former Resident #59 did not understand boundaries of socially accepted behaviors as he wandered in and out of other residents' rooms, urinated on the floor, attempted to hit staff, and moved furniture. Interventions included reminding the resident to respect other residents' rights and psychological services per facility protocol. Review of the Wander/ Elopement Evaluation- V1 dated 03/05/26 and completed by Former Licensed Practical Nurse (LPN) #622 revealed Former Resident #59 was at risk for elopement due to impaired cognition, diagnosis of Alzheimer's disease, ambulated independently, wandered aimlessly, history of elopement, and family had voiced concerns that indicated the resident may leave the facility. Interventions included a Wanderguard and checking the Wanderguard device for proper functioning. Review of SRI tracking #273777 dated 04/24/26 revealed the facility substantiated an incident for neglect. On 04/24/26 at 7:30 P.M. Former Resident #59 was outside of the facility without staff. The SRI revealed at approximately 7:30 P.M. the nurse heard the therapy door alarming as another nurse was leaving and was informed by a bystander that Former Resident #59 was walking down the street. Former Resident #59 was observed walking down the road about two minutes away and was brought back to the facility with no injury noted. The weather at the time of the incident was dusk and dry with a temperature of 67 degrees Fahrenheit (F). Per the SRI, Former Resident #59 was dressed in a sweater and pants. He was sent to the Emergency Department (ED) for evaluation and when he returned, he was placed on one-on-one supervision until discharged to another facility with a secured memory care unit. Review of a witness statement dated 04/24/26 and completed by Certified Nursing Assistant (CNA) #609 revealed she had last seen Former Resident #59 on 04/24/26 at 7:25 P.M. walking down the hallway on the North Unit. The statement then noted she heard a door alarming and thought it was the front door, but it was the therapy door. CNA #609 stated she proceeded to go over to the South unit to see about it and told the nurse, I didn't know the code. The statement then revealed that we walked to the door and didn't see anyone. Review of a witness statement dated 04/24/26 and completed by CNA #612 revealed he had last seen Former Resident #59 in the hallway walking around while he was in between patient care. The statement revealed he had redirected him multiple times during the shift. CNA #612 sat down to do his charting for about 20 minutes and then was notified Former Resident #59 was outside of the building. The statement revealed he had not heard any door alarms go off at the time of the incident. Review of the nursing note dated 04/25/26 at 1:30 A.M. and completed by Registered Nurse (RN) #625 revealed Former Resident #59 was sent to the ED for evaluation due to exiting the facility unattended. Review of the ED Progress Note dated 04/25/26 at 3:58 A.M. and completed by ED Physician #623 revealed Former Resident #59 was from a facility and had dementia. He was alert to self only and he wore a Wanderguard. The note revealed Former Resident #59 got out of the facility and was found a few miles away at a restaurant. He had no injury and the facility needed him to be medically cleared. No concerns were noted on examination. Review of the Wander/ Elopement Evaluation- V1 dated 04/25/26 and completed by Former LPN #611 revealed Former Resident #59 continued to be at risk for elopement due to impaired cognition, diagnosis of Alzheimer's disease, ambulated independently, wandered aimlessly, and he had stated he wanted to leave the facility. Interventions included a Wanderguard and checking the Wanderguard device for proper functioning. Review of the nursing note dated 04/25/26 at 3:01 P.M. and completed by LPN #624 revealed Former Resident #59 returned from the ED at 8:00 A.M. with no new orders and was on one-on-one monitoring. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Former Resident #59 had impaired cognition as his Brief Interview for Mental Status (BIMS) score was a 3/15. He required partial to moderate staff assistance with toileting hygiene, personal hygiene, and dressing. He required supervision with transfers and ambulation. Review of the timesheet from 05/31/26 to 06/13/26 revealed on 06/06/26 Former CNA #615 worked from 6:34 A.M. to 1:56 P.M.Review of the June 2026 Treatment Administration Record (TAR) revealed Former Resident #59 had an order to have a Wanderguard to his right ankle, and check function and placement every shift. The TAR was blank from 6:00 P.M. to 6:00 A.M. on 06/04/26, 06/09/26, 06/10/26, 06/11/26, 06/12/26, 06/13/26, 06/14/26, 06/18/26, 06/22/26, 06/27/26, and 06/28/26.Review of the July 2026 Physician Orders revealed Former Resident #59 had an order dated 12/08/25 to have a Wanderguard to his right ankle and every shift staff were to check the function and placement of it. He also had an order dated 05/13/26 to be on one-on-one supervision until discharge. Review of the nursing note dated 06/06/26 at 7:00 P.M. and completed by LPN #616 revealed the door alarm went off around 7:00 P.M., a CNA and nurse on South unit were giving resident care when the therapy door sounded. The note revealed the nurse started over to the South unit and the CNA took off to the therapy door. A CNA had pulled into the parking lot, called in and said that Former Resident #59 was coming off the sidewalk outside the therapy door, and he was walking him back inside. Interviews on 07/13/26 at 12:39 P.M. and 07/14/26 at 12:09 P.M. with the Director of Nursing (DON) revealed that she completed the investigation on 04/24/26 and stated that CNA #609 responded to the therapy door alarm but did not know the code to silence it. She reported that staff searched the immediate area but did not locate anyone and only became aware of the situation when a bystander stopped at the facility and informed Former LPN #610 that a resident was down the road. Former LPN #610 then retrieved Former Resident #59. The DON stated she believed staff responded to the alarm in a timely manner, yet she was unable to explain how Former Resident #59 was able to ambulate down the road without being noticed until the bystander intervened. She confirmed she was unsure whether staff conducted a head count after checking the immediate area and not finding any residents and acknowledged that Former LPN #610 did not complete a witness statement for the investigation. The DON stated that Former Resident #59 was placed on one on one supervision on 04/24/26, to remain in place until his discharge to a memory care facility. She verified that on 06/06/26 at 7:00 P.M., Former Resident #59 again exited the facility and reached the end of the sidewalk without one on one supervision. She stated that Former CNA #615, who had been assigned his one on one supervision, left the facility without notifying anyone at 1:56 P.M. on 06/06/26, and it was likely that Former Resident #59 was not monitored per physician order and care plan from 1:56 P.M. until he exited the building at 7:00 P.M. She also stated she had no documentation identifying who was assigned to provide one on one supervision on any day, including 06/06/26. In addition, she verified that the June 2026 TAR contained blanks indicating that Former Resident #59's Wanderguard was not checked for function or placement. She explained she had recently noticed these omissions and stated the facility had transitioned to using certified medication aides (CMAs), and the CMAs believed they were not permitted to complete treatments; therefore, they did not complete or document any treatments on the TAR, including the Wanderguard checks.Interview on 07/13/26 at 2:06 P.M. with Former LPN #610 revealed that she had just finished her shift on 04/24/26 and was completing the shift to shift controlled substance count with Former LPN #611 when they heard the therapy door alarm. She stated that CNA #609 went to check the alarm and then returned, telling Former LPN #611 she did not know the door code. Former LPN #610 reported that Former LPN #611 sent another CNA with CNA #609 to enter the code, and they continued completing the controlled substance count. She stated that as she was leaving the facility, a bystander in the parking lot told her that a resident matching a specific description was seen up the street. Former LPN #610 recognized the description as Former Resident #59, got into her car, and drove up the road to locate him. She stated he was near a restaurant close to the intersection, approximately one mile from the facility. She reported that Former Resident #59 got into her car and she returned him to the facility. Former LPN #610 stated she felt the situation was handled poorly, noting that Former LPN #611 did not respond directly to the alarm when it sounded. She reported that even after CNA #609 told him she did not know the code, he still did not go to the door and instead sent another CNA to assist. She stated that by the time they responded, Former Resident #59 had already made it nearly a mile away. She added that throughout the day, Former Resident #59 had repeatedly attempted to leave the building by exit seeking and pushing on doors, and she believed it was only a matter of time before he succeeded. When asked why she did not respond to the alarm herself, Former LPN #610 stated that Former LPN #611 was already late that day, she should not have still been in the building, and that Former LPN #611 was now his nurse.Interview on 07/13/26 at 2:26 P.M. with Former LPN #611 revealed that when the therapy door alarm sounded, CNA #609 did not know the code, so he had CNA #614 show her how to clear the alarm. Once the alarm was cleared, he and CNA #609 went outside to check the area but did not see any residents, including Former Resident #59. He stated he was unsure whether a head count was conducted afterward, as he could not recall. He reported that a bystander later arrived at the facility and informed staff that Former Resident #59 was walking down the street. Former LPN #610 then went up the road and brought him back. Former LPN #611 stated he found it unusual that Former Resident #59, who ambulated slowly, was able to make it as far as he did. He reported that when Former Resident #59 returned, he assessed him and found no injuries.Interview on 07/13/26 at 2:35 P.M. with CNA #609 revealed that on the evening of 04/24/26 she heard an alarm and was trying to determine its source. She stated she discovered it was the therapy door alarm but did not know the code, so she went back and informed another CNA (whose name she could not recall) and then notified Former LPN #611. She reported that Former LPN #611 and she then went outside and checked the immediate area but did not see anyone. She stated that Former Resident #59 was later located, though she was unsure of the details of where he was found. She acknowledged there may have been a delay from the time the alarm sounded to the time she notified the CNA and nurse and then went outside to check, but she did not believe the delay was long.Interview on 07/13/26 at 2:52 P.M. with LPN #616 revealed that on 06/06/26 at approximately 7:00 P.M., Former Resident #59 exited through the therapy door and was caught by CNA #612 just as he stepped off the sidewalk into the parking lot. She confirmed he was supposed to be on one on one supervision but was unsure who was assigned to monitor him at that time. She reported that Former CNA #615 had been assigned as his one on one on one occasion but could not recall whether it was the same day Former CNA #615 left the facility without notifying anyone. She added that there were times when staffing levels were insufficient to provide one on one monitoring, resulting in periods where Former Resident #59 went without supervision. She stated that there was no alternative, as other residents required care and, without enough staff, one on one monitoring could not always be maintained. She verified that both the care plan and physician order required continuous one on one supervision.2. Review of the medical record for Resident #14 revealed an admission date of 02/11/25 with diagnoses including Alzheimer's disease, emphysema, hypertension, anxiety disorder, and disorientation. Review of the nursing note dated 07/27/25 at 1:24 P.M. and completed by LPN #618 revealed Resident #14 cut off his Wanderguard. A new Wanderguard was applied to his right leg. The resident was visiting with family, and staff reiterated the need for the Wanderguard. Review of the care plan last revised 07/29/25 revealed Resident #14 was at high risk for elopement and had a history of cutting his Wanderguard off with eating utensils on his tray. Interventions included Wanderguard to right lower leg, check placement and function every shift, and if resident was wandering in potentially unsafe areas or situation, redirect him to safer area and as of 07/28/26, plastic utensils at mealtime. Review of the Wander/ Elopement Evaluation- V1 dated 05/22/26 and completed by LPN #619 revealed Resident #14 was at high risk for elopement due to he had cognitive impairment with poor decision-making skills, diagnosis of Alzheimer's' disease, ambulated independently, wandered aimlessly, had stated he wanted to leave the facility, and family had voiced concerns that indicated resident may attempt to leave the facility. Review of the Significant Change MDS 3.0 assessment dated [DATE] revealed Resident #14 had impaired cognition as his BIMS score was 3/15. He required partial to moderate staff assistance with transfers and was independent with ambulating ten feet. Review of the June 2026 TAR revealed an order dated 09/16/24 for Resident #14 to have a Wanderguard to his right ankle, and staff were to check placement and function every shift for safety; an order dated 07/28/25 to have plastic utensils at mealtimes every shift. The TAR was blank from 6:00 P.M. to 6:00 A.M. on 06/04/26, 06/09/26, 06/10/26, 06/11/26, 06/12/26, 06/13/26, 06/14/26, 06/18/26, 06/22/26, 06/27/26, and 06/28/26 for both these interventions. Review of the July 2026 TAR revealed an order dated 09/16/24 for Resident #14 to have a Wanderguard to his right ankle and staff were to check placement and function every shift for safety; an order dated 07/28/25 to have plastic utensils at mealtimes every shift. The TAR was blank on 07/02/26 from 6:00 P.M. to 6:00 A.M., 07/03/26 from 6:00 A.M. to 6:00 P.M., and 07/06/26 from 6:00 P.M. to 6:00 A.M. for both these interventions. Observation on 07/14/26 at 12:05 P.M. revealed CNA #620 passed Resident #14 his lunch tray that contained regular metal silverware, not plastic, including a knife, fork and spoon and then proceeded to walk out of his room. Interview on 07/14/26 at 12:06 P.M. with CNA #620 verified she had passed Resident #14, and his tray that had regular metal silverware on it including a knife, fork and spoon. She revealed she thought that intervention had been discontinued as she had not seen or given plastic silverware on his tray for several months. Interview on 07/14/26 at 12:09 P.M. with the DON verified that Resident #14 had a current physician order dated 07/28/25 to use plastic silverware with meals, and that this was also an intervention in his care plan to prevent elopement. She stated she had not been aware that he previously cut off his Wanderguard using silverware, as that occurred before her employment, and therefore she did not know the plastic silverware intervention and physician order were related to that incident. She also verified the blanks on the June 2026 and July 2026 TAR regarding the order for a Wanderguard on his right ankle, which required staff to check placement and function each shift, as well as the order dated 07/28/25 for plastic utensils at mealtimes. She explained that she recently noticed the blank entries and stated the facility had transitioned to using CMAs, who believed they were not permitted to complete treatments; therefore, they were not completing or documenting any treatments on the TAR, including these orders.Review of the facility policy labeled, Elopements and Wandering Residents dated 01/26/26 revealed the facility was to ensure residents who exhibited wandering behaviors and/or are at risk for elopement received adequate supervision to prevent accidents and received care in accordance with their person-centered plan of care addressing unique factors contributing to elopement risk. Alarms were not a replacement for necessary supervision and staff were to be vigilant in responding to alarms in a timely manner. Interventions to increase staff awareness would be added to the residents' care plan. The policy revealed adequate supervision would be provided to prevent elopements. This deficiency represents non-compliance investigated under Complaint Number 3074334.

Based on closed medical record review, review of a facility self-reported incident (SRI), review of facility policy, and interview the facility failed to ensure Resident #52 was free from physical restraints. Actual Harm occurred on 03/08/25 at approximately 7:00 A.M. when Resident #52 was physically restrained and tied to his wheelchair with a bed sheet by Licensed Practical Nurse (LPN) #526 in an attempt to address Resident #52's behaviors and to prevent Resident #52 from standing from the chair. Resident #52 was found by visiting Hospice LPN #603 tied to his wheelchair with a bed sheet knotted behind him. The resident was unattended, seated in his wheelchair, agitated, and reported a pain rating of a 10 on a one-to-ten scale (with ten indicating the worst possible pain). Other interventions in place and available at the time of the incident, including as-needed (PRN) medications for pain, anxiety, and agitation, were not utilized by the nurse prior to Resident #52 being restrained. Hospice LPN #603 released Resident #52's restraint and hospice staff stayed one-on-one with the resident until his transfer out of the facility. This affected one resident (#52) of one resident reviewed for restraints. The facility census was 52. Findings include: Review of the closed medical record for Resident #52 revealed an admission date of 02/27/25. Medical diagnoses included congestive heart failure (CHF), anxiety disorder, and obstructive and reflux uropathy. Resident #52 received hospice services with Hospice #600 since his admission to the facility. Resident #52 discharged from the facility on 03/09/25. Review of Resident #52's physician orders revealed an order dated 02/27/25 to call Hospice #600 with any changes or concerns. Resident #52 had an additional order dated 02/27/25 for Oxycodone HCL (a narcotic pain reliever used to treat moderate to severe pain) 10 milligrams (mg) by mouth every two hours as needed (PRN) for pain. Review of the admission note dated 02/27/25 at 5:10 P.M. completed by LPN #526 revealed Resident #52 was alert and oriented to person, place, and time. Resident #52 communicated verbally, his speech was clear, and he was able to understand and be understood when speaking. Resident #52's mood was pleasant, and he had no unwanted behaviors. The resident had an indwelling catheter in place due to urinary retention. Resident #52's skin was warm and dry, his skin color was within normal limits, and skin turgor was normal. The note indicated Resident #52 sleeps through the night. Review of the Fall Risk evaluation dated 02/27/25 at 5:36 P.M., completed by LPN #526, revealed Resident #52 had one to two prior falls in the last three months. Resident #52 was noted to be ambulatory and continent. His fall risk score was 2.0 Review of the care plan dated 02/28/25 revealed Resident #52 was at risk for episodes of anxiety related to altered breathing and a terminal diagnosis. Listed interventions included addressing reasons for anxiety, social withdrawal, and crying, administering medications as ordered, monitor for medication side effects and effectiveness, and providing a quiet room or area for Resident #52 to go to when anxiety increases. Additional interventions included providing relaxation techniques as needed, removing excess stimulation as able, spending time talking with the resident, and allowing the resident to express their feelings. Further review of Resident #52's care plan dated 02/28/25 revealed the resident was at potential risk for falls related to age, decreased physical function, history of falls, and medication use. Listed interventions included to assist with transfers as needed, and an additional intervention added on 03/08/25 noted Resident #52 was to be one-on-one with hospice staff until transferred to an inpatient hospice facility. Further review of the care plan dated 02/28/25 and revised on 03/14/25 (after the resident's discharge) revealed Resident #52 had the potential for mood and behavioral issues related to depression, anxiety, terminal diagnosis, and insomnia. Resident #52 was combative with care, called emergency services at times, screamed out frequently, and had hallucinations. Listed interventions included administering medications as ordered, observing medication effectiveness and adverse reactions, attempting to provide a calm environment during acute phases, and approaching the resident in a calm and soothing manner. Additional interventions noted if the resident was demonstrating socially inappropriate behaviors, attempting to redirect the behavior. If the resident was unable to redirect, remove the resident from a public area. If the resident is resistive to care, leave the resident and return later if safety was not a concern. Review of the progress note for Resident #52 dated 02/28/25 at 8:47 A.M. completed by Assistant Director of Nursing (ADON) #519 included Resident #52 was pleasant and cooperative during assessment. Resident #52 denied urination since Foley (indwelling urinary catheter) was removed. The note indicated the resident was educated the Foley may need replaced if he was unable to void. Resident #52 verbalized understanding. Review of the Skilled Evaluation dated 02/28/25 at 7:17 P.M. completed by LPN #549 revealed Resident #52 followed commands. Resident #52 denied weakness, tremors, numbness or tingling. He was alert and oriented to person, place and time. Resident #52 communicated verbally, his speech was clear, and he was able to understand and be understood when speaking. Resident #52's mood was pleasant and there were no unwanted behaviors witnessed. Resident #52's urinary catheter was noted to be intact. Review of a nursing note dated 03/01/25 at 6:46 P.M. revealed Resident #52 was seated on his buttocks with his legs extended into the hallway. The resident reported he slid down the door frame and sat on the floor. Resident #52 had denied injury but was yelling at staff to call the police. Resident #52 was noted to be very combative with staff while he was being assessed. Review of the Skilled Evaluation dated 03/02/25 at 3:31 P.M. completed by LPN #509 revealed Resident #52 followed commands. Resident #52 denied weakness, tremors, numbness or tingling. He was alert and oriented to person, place and time. Resident #52 communicated verbally, his speech was clear, and he was able to understand and be understood when speaking. Resident #52's mood was pleasant and there were no unwanted behaviors witnessed. Further review of Resident #52's physician's orders revealed an order dated 03/02/25 at 4:15 P.M. for Ativan (an anxiolytic medication used to decrease anxiety) one mg every two hours as needed for anxiety. Review of the Brief Interview for Mental Status (BIMS) evaluation completed on 03/04/25 at 12:29 P.M. revealed Social Worker (SW) #529 completed the evaluation. Resident #52 was recorded to have a BIMS score of 13, indicating the resident was cognitively intact. Review of a nursing note dated 03/07/25 at 5:50 P.M. authored by LPN #526 revealed Resident #52 was very combative. The note referenced the resident's behaviors began around 8:00 A.M. with the resident hitting, biting, and pulling on his indwelling urinary catheter. Blood was noted in the urinary drainage bag. Resident #52's hospice provider, Hospice #600, was notified and medication changes were made. Resident #52 was given Haldol (an antipsychotic medication) by intramuscular route. The note referenced Resident #52 calmed down for 20 to 30 minutes. Resident #52 was noted to be very paranoid and hallucinating. Review of Resident #52's physician's orders revealed an order dated 03/07/25 at 1:45 P.M. for Haldol Lactate (Immediate release) injection five mg by intramuscular route, one-time only. Record review of the Medication Administration Record (MAR) revealed the one-time dose of Haldol Lactate was administered at on 03/07/25 4:27 P.M. Review of Resident #52's additional physician's orders revealed an order dated 03/07/25 at 7:15 P.M. for Haldol Lactate injection five mg by intramuscular route every six hours as needed for agitation. Review of Resident #52's MAR for March 2025 revealed the Haldol order (from 03/07/25 at 7:15 P.M.) was to be used as needed and was never recorded as administered. Review of a nursing note dated 03/08/25 at 1:35 A.M. authored by LPN #538 revealed Resident #52 was seen by an (unnamed) visiting hospice nurse and new orders were received for Haldol and Ativan due to agitation. Resident #52 was very restless and was tugging at his Foley catheter all night. The note stated Resident #52 was unable to be redirected. Resident #52 was transferring himself to the wheelchair without assistance, was wandering up and down the hallways, and was in and out of other residents' rooms. Resident #52 was difficult to redirect. Resident #52 was recorded as having been medicated with new orders without effectiveness. Resident #52 pulled his Foley catheter out with the balloon inflated and refused to allow the nurse to reinsert the catheter. Review of a nursing note dated 03/08/25 at 7:00 A.M. authored by Registered Nurse (RN) #550 revealed Resident #52 was propelling his wheelchair in the hallway. When Resident #52 reached the treatment cart, he held onto it and attempted to stand unassisted. Resident #52 lost his balance and fell with his right side against the wall before staff could reach him. He then slid down to the floor. Resident #52 denied any pain or discomfort following the incident. Review of the Self-Reported Incident (SRI) tracking number 257988 dated 03/08/25 at 12:44 P.M. revealed the SRI report was created by Regional Director of Clinical Services (RDCS) #557 and completed on 03/11/25 at 5:48 P.M. The SRI reported an allegation/suspicion of neglect or mistreatment abuse by LPN #526. The brief description noted on 03/08/25 at 7:00 A.M., in an attempt to prevent Resident #52 from standing unassisted or falling out of his wheelchair, an employee placed a sheet over his lap and secured it behind the back of the wheelchair by tying it. The sheet was untied, and the resident was assessed for injury. There were no injuries found. The employee, LPN #526, was suspended immediately. The report noted the allegation was investigated by the facility and unsubstantiated, noting the evidence indicated abuse, neglect, or misappropriation did not occur. Review of a witness statement dated 03/08/25 at 7:00 A.M. authored by Housekeeping/Laundry Staff #501 revealed she was coming down the hall and Resident #52 went to get up and fell. The statement noted the nurse tried to catch him, but the resident went down. Resident #52 would not stay in the chair, so the nurse tried to keep him in the chair. The statement sated the nurse did what she needed to do to protect him, she did nothing wrong. At least she tried to protect him. Review of a witness statement dated 03/08/25 at 7:00 A.M. completed by LPN #526 revealed Resident #52 was up walking without a device, grabbing the medication cart. RN #550 tried to get to the patient before he fell. Resident #52's fall was witnessed; the resident did not hit his head or back but fell onto his buttocks to the floor. Resident #52 was put back into his wheelchair and became combative. Resident #52 was trying to get at staff and residents in the hallway. Resident #52 was put at nurse's station. This nurse applied a sheet around the resident's waist, loosely tied behind his back for his safety and other residents. Sheet loose enough he could pull and get out. Review of a witness statement dated 03/08/25 at 7:00 A.M. completed by Certified Nursing Assistant (CNA) #503 revealed Resident #52 was being combative and stood up from his wheelchair and grabbed onto the medication treatment cart and fell while pushing it. Resident #52 was very combative, so the nurse got a sheet and loosely put it around the resident's waist. He was going to hurt himself or others who were in the hallway, so it was tied loosely so he would not go face-first. Resident #52 had been combative since yesterday 03/07/25. The note referenced an unnamed hospice nurse was at the nurse's station with Resident #52. Resident #52 was eating snacks, she (unnamed hospice nurse) was standing beside him doing charting, and she was there for at least 45 minutes. Review of Resident #52's physician's orders revealed an order dated 03/08/25 at 9:00 A.M. for Oxycodone HCL five mg by mouth, a one-time dose, for agitation. Review of Resident #52's MAR for March 2025 revealed the one-time dose of Oxycodone was recorded as administered on 03/08/25 at 9:00 A.M. for a pain level of 10 on a one-to-ten scale, indicating the worst possible pain. The MAR listed the medication had been effective. Further review of Resident #52's MAR revealed the resident received one as-needed dose of Oxycodone on 03/08/25 at 8:59 P.M. Resident #52 additionally received as-needed doses of Ativan on 03/08/25 at 3:19 P.M. and 8:58 P.M., both of which were recorded as effective. There were no additional as needed medications recorded as administered on 03/08/25. Review of a nursing note dated 03/08/25 at 10:46 A.M. authored by LPN #526 revealed Resident #52 was combative in the morning. Resident #52 was kept at the nurse's station for safety. The resident was attempting to hit the staff and trying to hit other residents. Resident #52 had grabbed a hold of a cart and was trying to stand up, almost pulling the cart onto himself and causing himself to fall. Staff were unable to catch the patient before the resident fell. The note referenced staff had tried to redirect the resident with coffee and a snack without success. Resident #52's hospice provider had been called and came for a visit. New orders were obtained. Hospice was performing one-on-one with the resident. Resident #52 was noted to be agitated. Review of Resident #52's physician's orders revealed an order dated 03/08/25 at 11:15 A.M. for Phenobarbital 60 mg, give one tablet by mouth every six hours as needed for agitation/restlessness. Review of a health status note for Resident #52 dated 03/08/25 at 12:30 P.M. authored by ADON #519 revealed it had been reported the resident was sitting up in his wheelchair with a blanket around him, secured loosely behind his chair. Staff reported the resident was still able to move around and could have stood if he tried. ADON #519 and an unnamed hospice nurse assessed Resident #52 for injury. The note referenced there was no injury observed, with the exception of a soft lump to the resident's shoulder. Resident #52 was recorded to have no pain with palpation, and the area was not discolored. An x-ray examination was ordered. Resident #52 denied pain. The note concluded by referencing Resident #52 was resting in bed with hospice staff at the resident's bedside. Review of the progress notes for Resident #52 dated 03/08/25 at 11:57 P.M. authored by LPN #538 revealed Resident #52 was agitated and pulling at his Foley catheter again. PRN medications were referenced as given and effective for a short amount of time. The note concluded by referencing hospice staff remained at the resident's bedside throughout the night. A subsequent note dated 03/09/25 at 1:22 A.M. referenced Resident #52 remained restless and agitated. PRN medications were referenced as given and effective. Resident #52 remained resting in bed. Review of Resident #52's MAR for March 2025 revealed the resident received doses of as-needed Phenobarbital 60 mg on 03/08/25 at 12:42 P.M. and 8:58 P.M. and on 03/09/25 at 4:29 A.M. All three doses were recorded as effective. Review of the Orders Administration note dated 03/09/25 at 3:16 P.M. authored by RN #550 revealed Resident #52 discharged from the facility to an inpatient hospice facility. Review of email correspondence dated 03/12/25 and timed 9:31 A.M., provided to the survey team on 05/14/25 at 5:16 P.M., revealed Hospice LPN #603 emailed her statement and summary of events from 03/08/25 to the DON. The written statement noted Hospice Nurse #603 entered the facility on 03/08/25 at 7:45 A.M. Upon entering the facility, LPN #526 was coming down the hall and stated to Hospice LPN #603 I am not going to lie, I have him in a wheelchair at the nurse's station with a sheet around him and he is tied to the wheelchair. Hospice LPN #603 immediately went to the nurse's station where the resident was observed tied with a sheet. Hospice LPN #603 untied the resident, and Resident #52 stated my belly hurts and pointed to his left lower quadrant of his abdomen. Hospice LPN #603 questioned LPN #526 as to what medications had been provided to Resident #52 and was told to look in the narcotic book. Hospice LPN# 603 noted no intramuscular, as-needed Haldol had been administered even though the order provided on 03/07/25 to be administered as-needed every six hours. Hospice LPN #603 noted there had been no calls to Hospice #600 throughout the night (03/07/25 into the morning of 03/08/25). Hospice LPN #603 requested a dose of Haldol IM be administered. LPN #526 prepared and administered the dose of medication. Resident #52 had no reaction to the injection and was not combative or aggressive. Resident #52 was able to answer short questions appropriately and had intermittent confusion. Hospice LPN# 603 notified the Hospice provider on 03/08/25 at 8:02 A.M. and obtained STAT, one-time doses of Oxycodone 10 mg and Ativan one mg. Hospice LPN #603 also obtained an order for crisis care (around the clock, one-on-one care by a hospice staff member). Hospice LPN #603 communicated the stat orders to LPN #526 and requested they be administered. Hospice LPN #603 stayed with Resident #52 and approximately 20 minutes later the STAT doses of medications were administered by LPN #526. Hospice LPN #603 then assisted Resident #52 to stand, walk to, and sit down in another wheelchair. She later assisted Resident #52 to his room for oxygen to be applied and for administration of a breathing treatment. Hospice LPN #603 remained at the resident's side. A telephone interview on 05/13/25 at 4:19 P.M. with Hospice RN Team Leader #602 revealed resident #52 was supposed to be a long-term resident of the facility. Another nurse, Hospice LPN #603, was the nurse who arrived at the facility on 03/08/25 and saw the resident tied up. Hospice RN Team Leader #602 referenced after the incident; crisis care was provided after that. Hospice LPN #603 talked to Hospice RN Team Leader #602 about what she saw. Hospice LPN #603 reported to her that when she arrived at the facility, she was greeted by LPN #526 as she entered the hallway Resident #52's room was on. LPN #526 stated she was not going to lie, that she had Resident #52 in a wheelchair at the nurse's station with a sheet around him, tied to the wheelchair. Hospice LPN #603 had stated she went immediately to the nurse's station, located Resident #52, and untied the patient. The sheet was tied around Resident #52's waist and tied behind his back in the wheelchair. The sheet was tied under the handlebars (between the armrests), and the resident was unable to release it. As the hospice nurse untied Resident #52, he fidgeted with the sheet and reported abdominal pain in his lower abdomen. Resident #52 was later transferred to an inpatient hospice facility and passed away on 03/13/25. A telephone interview on 05/13/25 at 5:31 P.M. with Hospice LPN #603 revealed she received a phone call on 03/08/25 at 6:47 A.M. from the facility that Resident #52 was agitated and pulled his urinary catheter out. Hospice LPN# 603 confirmed she arrived at the facility on 03/08/25 at 7:45 A.m. When she walked into the facility, LPN #526 walked up the hall and stated to her I am not going to lie, I have him tied to the wheelchair at the nurse's station. Hospice LPN #603 revealed she immediately went to the nurse's station and found Resident #52 seated in the wheelchair at the nurse's station. A sheet was tied around his waist, tied in the back with a traditional knot and tucked in between the armrest so it had him against the chair. Hospice LPN #603 stated Resident #52 could not get up. There were no staff at the nurse's station, there were no staff nearby monitoring the resident. Resident #52 was observed attempting to pull at the sheet, trying to get it loose, but was unsuccessful. Hospice LPN# 603 untied the resident. Hospice LPN #603 was able to get her hand between the sheet and the resident's abdomen, but there was no way the resident could have stood on his own. Resident #52 was complaining of abdominal pain. Hospice LPN #603 further reported staff had stated the resident had been agitated all night, but no phone call had been made to Hospice #600 to request a visit or any intervention. Hospice LPN #603 phoned the hospice provider and obtained new medication orders for a STAT (immediate) dose of Oxycodone and Ativan. At 8:00 A.M., I also gave him Haldol to make him more comfortable. She assisted Resident #52 to his room to help him reposition. Resident #52 was terminally restless and agitated from heart failure with a reduced ejection fraction. Hospice LPN #603 stated Resident #52 was transitioning into dying, and terminal restlessness is common during this period. Hospice LPN #603 additionally obtained an order for crisis care, around the clock hospice care at the resident's bedside. Some of the facility nurses felt the resident was overmedicated and would not administer medications, even though Resident #52 continued to have terminal restlessness. Hospice LPN #603 noted if Resident #52 had been properly medicated, there would not have been a need to restrain the resident. Hospice LPN #603 stated there were multiple medications that were not used prior to the facility staff physically restraining the resident. Hospice LPN #603 stated she was shocked and livid when she saw Resident #52 tied up, her heart broke for the resident as it was so unnecessary when there were unattempted interventions available. Interview on 05/14/25 at 8:33 A.M. with CNA #503 confirmed she was the CNA working on 03/08/25. CNA #503 revealed she saw resident #52 up walking around and revealed before he fell, he had the medication cart and attempted to push it when he fell. Following the resident's fall, CNA #503 stated we put him in his wheelchair by the nurse's station, he was eating snacks, and was standing up by the snacks. LPN #526 asked CNA #503 to get her a sheet. She retrieved the sheet, gave it to LPN #526, and then proceeded to go assist another resident. When she came back from assisting another resident, she saw the sheet tied around resident #52's waist. CNA #503 stated her shift started at 6:00 A.M. She was unsure what time it was when LPN #526 tied up Resident #52. CNA #503 stated after the sheet was tied, Resident #52 was just sitting there. She estimated the hospice nurse arrived approximately an hour or two later and untied the resident when she arrived. After the hospice nurse arrived and untied the resident, she stayed with him. Interview on 05/14/25 at 8:53 A.M. with the Director of Nursing (DON) confirmed the incident with Resident #52 being restrained was on a weekend and confirmed it was a Saturday. The DON confirmed he was not at the facility working that day. The DON revealed nurses absolutely should not tie residents up and believed the sheet was loosely tied so it did not prevent him from standing. The DON stated the nurse involved had a clean record and he felt her intentions were for the best of the resident. Review of LPN #526's personnel record on 05/14/25 at approximately 8:55 A.M. with the DON revealed a date of hire of 10/19/21. LPN #526 did not have an evaluation completed in 2025 or 2025, and there was no evidence the nurse had received behavioral training since being employed at the facility. The DON confirmed LPN #526 remained an active employee of the facility. A follow up phone interview on 05/14/25 at 11:06 A.M. with Hospice LPN #603 confirmed Resident #52 had been tied up using a traditional knot, there was no slip pull on the sheet which restrained Resident #52 to the wheelchair. Hospice LPN #603 stated the resident had been trying to stand while she was attempting to untie the resident but was unable to. She described the knot as having two ties, in a knot which could not be released. After she had found Resident #52 restrained, Hospice LPN #603 called Hospice #600's administration and Hospice RN Team Leader #602 who contacted the facility's management. A follow up phone interview on 05/14/25 at 3:37 P.M. with Hospice RN Team Leader #602 revealed she notified ADON #519 on 03/08/25 at 10:01 A.M. via phone of the incident with Resident #52 being physically restrained. She notified ADON #519 via phone as it was a weekend the facility reported there was no administration present in the facility at that time. Interviews on 05/14/25 at 5:16 P.M. and 05/15/25 at 11:57 A.M. with the DON and RDCS #557 confirmed LPN #526 had not received behavioral training during her employment with the facility. RDCS #557 additionally confirmed the hospice notes or statements, including the emailed statement, were not included in the facility's investigation into the incident with Resident #52. The DON revealed Hospice LPN #603's emailed statement was still in her email. The DON printed and provided the email to the survey team during the interview. RDCS #557 revealed she was unaware of all the information regarding the incident with the restraint. The DON and RDCS #557 confirmed the facility documented in the witness statements that they were aware the nurse tied up Resident #52 at 7:00 A.M. and no staff working at the facility notified facility administration of the event. The DON reported this was part of abuse training which had previously been provided to all staff. RDCS #557 additionally confirmed facility administration was notified of this incident on 03/08/25 at 10:03 A.M. by Hospice RN Team Leader #602. The facility initiated a SRI and began their investigation. The Administrator did not obtain Resident #52's hospice notes or interview the hospice staff, yet submitted the final SRI three days after the initial SRI. Hospice staff emailed a statement to the DON four days after the event, after the final SRI had been submitted. The facility did not wait to ensure a complete investigation was completed. RDCS #557 stated if she had known, the outcome of the SRI could have been different. RDCS #557 revealed she was unsure why the SRI was unsubstantiated. Review of the facility policy titled, Restraint Free Environment revised 06/01/24 revealed it is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definition Physical Restraint refers to any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but not limited to tucking in a sheet tightly so that the resident cannot get out of bed or fastening fabric or clothing so that the resident's freedom of movement is restricted. Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts that the resident cannot remove and prevents the resident from rising. Convenience refers to any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience and not required to treat the resident's medical symptoms. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner, unless the resident has previously made a valid refusal of the treatment in question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of physical restraints. Before the resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints and determine how the restraint would treat the medical symptom, the length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint and the time and frequency the restraint will be released. The type of direct monitoring and supervision that will be provided during the use of the restraint. This deficiency represents non-compliance investigated under Complaint Number OH00163484.

Based on observations, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure safety measures and interventions were implemented to prevent potential accidents and hazards. Actual Harm occurred to Resident #21 on 02/01/25 when the facility failed to ensure Resident #21's smoking apron was in place during smoking and Resident #21 sustained a burn from his cigarette dropping on his right thigh. The burn had full thickness tissue loss with 100 percent (%) slough (dead tissue) in the wound bed, and required debridement. This affected three residents (#21, #28 and #47) and had the potential to affect an additional five additional residents, Residents #3, #33, #40, #42, and #303 who were identified by the facility as being independently mobile, cognitively impaired and able to reach the unsecured box with cigarettes and lighters. The facility census was 54. Findings include: 1. Record review for Resident #21 revealed a readmission date of 07/23/23 with diagnoses including dementia, anxiety disorder, and Alzheimer's disease. Review of the care plan dated 03/25/21 revealed Resident #21 had impaired cognitive process for daily decision making. Resident #21 was at risk for further decline in cognitive status. Interventions included to anticipate needs and keep resident clean, dry and comfortable every shift and provide a stable and supportive environment through consistencies in daily routine as able. Resident #21 also had a care plan related to a potential for safety hazard or injury related to smoking. The care plan revealed Resident #21 was able to smoke with supervision by staff or family. Smoking apron would be provided to Resident #21 during smoking times, effective 12/08/20. The care plan also revealed smoking materials were to be returned to nurse's station after smoke break and while smoking, (resident) would have direct supervision by staff or family member. Review of the Smoking and Safety assessment for Resident #21 dated 12/09/24 completed by Licensed Practical Nurse (LPN) #526 revealed Resident #21 used tobacco, had limited or no range of motion in arms and hands, insufficient fine motor skills needed to securely hold tobacco, marijuana or vape products, and drops ashes on self. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was moderately cognitively impaired. Resident #21 used a wheelchair for mobility, was independent for eating and wheelchair mobility, and was dependent on staff for oral hygiene, upper and lower body dressing, and transfers. Review of the progress note for Resident #21 dated 02/01/25 completed by LPN #549 revealed found cigarette burn on right thigh, and the area was cleaned with normal saline (NS), Xeroform and bordered foam dressing applied. The progress note revealed education was given to wear smoking apron at smoke breaks. Review of an Incident Report (IR) for Resident #21 dated 02/01/25 completed by LPN #549 revealed found burn mark on resident's right thigh. Resident description I dropped my cigarette on my lap. The report revealed educated staff on smoking apron use. The IR included reviewed with interdisciplinary team (IDT) and agree with intervention plan of educating staff on need of wearing apron to smoke dated 02/05/25. Review of the skin grid for Resident #21 dated 02/04/25 at 11:04 A.M. completed by Assistant Director of Nursing (ADON) #519 revealed burn originated on 02/01/25, full thickness tissue loss with 100% slough (dead tissue) in the wound bed, Xeroform used for autolytic debridement. Observation on 05/15/25 at 1:52 P.M. of the North side where Resident #21 resided revealed a smoking box sitting on the counter at the nurse's station. The smoking box had a locking mechanism available on the box but was left unlocked. Observation revealed multiple packs of cigarettes and lighters in the box. Observation revealed no staff were in the vicinity as visitors and residents were nearby until 2:05 P.M. Observation on 05/15/25 at 2:05 P.M. revealed LPN #549 returned to the nurse's station. LPN #549 confirmed the smoking box was unlocked and unsecured and within reach of any residents passing by. The facility identified five additional residents, Resident #3, #33, #40, #42, and #303 who were independently mobile, cognitively impaired and able to reach the unsecured box with cigarettes and lighters creating a potential accident hazard for these residents. Interview on 05/15/25 at 3:27 PM with LPN #549 verified the burn on Resident #21's leg was from a cigarette burn. LPN #549 stated she educated the certified nursing assistants (CNA) to make sure the resident had his smoking apron. However, LPN #549 stated she did not put the education in writing, she just told them stating, They should know, he was always supposed to have one. LPN #549 revealed there were two CNAs that she in-serviced on that day but she could not remember who they were and confirmed she did not in service any other staff. Interview on 05/15/25 at 3:39 P.M. with Director of Nursing (DON) confirmed he was aware of Resident #21 burning his leg with a cigarette and confirmed the intervention was to in-service staff on the need for Resident #21 to wear a smoking apron when he smokes. The DON revealed the in-service was one that was placed at the nurse's station for staff to read and sign. The DON revealed he was unable to find the in-service and confirmed he was unsure if all the staff read and signed the in-service. The DON confirmed the box located at the nurse's station with resident's smoking supplies should be locked when not in use. Review of the facility policy titled Resident Smoking revised 01/16/25 revealed it was the policy of the facility to provide a safe and healthy environment for residents, visitors and employees, including safety as related to smoking. Smoking materials would be maintained by nursing staff. All safe smoking measures would be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who would be responsible for supervising residents while smoking, 2. Record review for Resident #47 revealed an admission date of 01/21/25. Diagnoses included severe protein calorie malnutrition, altered mental status, chronic obstructive pulmonary disease (COPD) and weakness. Review of Resident #47's history of falls for the past 60 days revealed Resident #47 had a fall on 03/26/25, 04/10/25, and 04/26/25. Review of the care plan for Resident #47 dated 04/25/25 revealed Resident #47 was a potential risk for falls related to age, medication, confusion, restlessness, attempting to transfer without assist. Interventions included to ensure the call light was within reach at all times. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 was dependent on staff for bed mobility and transfers. Resident #47 had falls since admission. Observation on 05/12/25 at 7:01 A.M. revealed Resident #47 was lying in bed. The call light was located behind the head board at the head of the bed. Observation and interview on 05/12/25 at 7:07 A.M. with LPN #553 verified Resident #47's call light was behind the headboard and verified Resident #47 would not be able to reach the call light to use it. Observation and interview on 05/19/25 at 10:12 A.M. with LPN #509 verified Resident #47's call light was in the top drawer of the night stand with the door closed. Resident #47 confirmed he could not reach the call light. LPN #509 also confirmed Resident #47 could not reach the call light and verified Resident #47 would not have been able to place the call light in the nightstand drawer and close the drawer. LPN #509 stated his CNA #503 must have put it there and stated Resident #47 falls when he tries to get up unattended. Resident #47 does use the call light when he can reach it. Interview on 05/19/25 at 10:19 A.M. with CNA #503 stated she did not put Resident #47's call light in his night stand drawer and said night shift staff must have put in the drawer. CNA #503 confirmed Resident #47 understands how to use the call light. 3. Review of the medical record for Resident #28 revealed an admission date of 01/29/24 with diagnoses including atrial fibrillation, cerebral infarction, mood affective disorder, major depressive disorder, hypertension, cognitive communication deficit, muscle weakness, anxiety disorder, and unsteadiness on feet. Review of the care plan, initiated 02/22/24, revealed Resident #28 had a potential risk for falls related to age, cognitive function, decreased physical function, history of falls, medications, transferring and ambulating without assistance, and buckling his knees at time while staff were providing assistance. Interventions included fall risk assessments to be completed on admission, quarterly, and as needed (initiated 02/22/24), ensure call light within reach (initiated 02/22/24), assist with transfers as needed (initiated 02/22/24), encourage use of assistive devices for transfers or ambulation (initiated 02/22/24), a call don't fall sign for a visual reminder to ask for assistance (initiated 04/17/24), medication review (initiated 11/30/24), and a dycem to recliner (initiated 03/07/25). Review of the fall risk evaluation, dated 01/15/25, revealed Resident #28 scored a three and the evaluation indicated a score of 10.0 or higher was considered high risk. Review of the progress note dated 03/07/25 at 5:15 P.M. revealed Resident #28 slid to the floor from the chair and there were no visible injuries noted. Vital signs were within normal limits, Resident #28 refused to speak about the incident, and the resident was assisted back into the chair with call light within reach. Review of the fall investigation dated 03/07/25 revealed Resident #28 had an unwitnessed fall with no injury. Resident #28 was oriented to person only at the time of the fall. The new intervention was a dycem (non-skid pad) placed in the recliner to help reduce the chance of sliding. Review of the annual Minimum Data Set (MDS) assessment, dated 04/15/25, revealed Resident #28 had moderate cognitive impairment, required substantial/maximal assistance or total dependence for activities of daily living (ADLs), and had one fall without injury since the last assessment. On 05/12/25 at 9:56 A.M., an observation of Resident #28's room revealed there was no dycem in the recliner. Resident #28 was in his recliner and his call light was not within reach. Interview with Certified Nursing Assistant (CNA) #517 verified there was no dycem in the recliner and the call light was within reach of Resident #28. CNA #517 stated the call light was on the opposite side of bed. On 05/12/25 at 1:16 P.M., an observation of Resident #28's room revealed Resident #28 was in his recliner and there was still no dycem in the recliner. Interview at the time of observation with CNA #517 verified there was no dycem in the recliner. On 05/15/25 at 10:31 A.M., an interview with Licensed Practical Nurse (LPN) #549 confirmed Resident #28 had experienced falls. LPN #549 was unable to state what fall interventions were supposed to be in place for Resident #28 and when looking it up in the chart, LPN #549 only looked at physician's orders and stated there were no orders for any fall interventions. LPN #549 was unaware of where to locate the fall interventions in the chart for Resident #28. Review of the facility policy titled Fall Prevention and Management, dated 01/08/24, revealed residents would be assessed for fall risk on admission, quarterly, after a fall, and as needed. Individualized interventions would be implemented based on the assessment and risk factors, interventions would be monitored for effectiveness, and the plan of care would be revised as needed. In the event of a fall, an intervention aimed to prevent further falls would be implemented, the interdisciplinary team would review the fall and new interventions that were identified or implemented, and discuss any new interventions that may help prevent further falls. This deficiency represents non-compliance investigated under Complaint Number OH00161001.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 54 residents residing in the facility. Findings include: Review of the PBJ Staffing Data Report form submitted from 07/01/24 through 09/30/24 revealed the following dates submitted for the third quarter of the fiscal year 2024, the facility was low on RN hours in the building on the seven following dates: 07/26/25, 07/31/25, 08/01/25, 08/05/25, 08/10/25, 08/11/25, and 08/28/25. Interview on 05/14/25 at 9:08 A.M. with the Administrator revealed he started in June 2024 and was told there was a concern with getting RNs hired. The Administrator stated they hired RNs and should be okay now. Review of the schedules and assignment sheets from 07/01/24 through 09/30/24 with Human Resource Manager (HR) #535 and the Administrator on 05/15/25 at 11:17 A.M. revealed a RN was present in the building for at least eight consecutive hours a day, seven days a week as required except for the following dates during the fourth quarter of the fiscal year 2024, the facility was low on RN hours in the building on the following dates: 08/10/25 and 08/11/25. Review of schedules, assignment sheets, time cards and census revealed the Director of Nursing (DON) who was an RN was present in the facility and the census was less than 60 residents for the following dates: 07/26/25, 07/31/25, 08/01/25, 08/05/25, and 08/28/25. The deficient practice was corrected when the facility implemented the following corrective actions which were implemented on 08/16/24: • On 08/16/24, Scheduler #528, the Director of Nursing (DON), and the current Administrator were in-serviced by Former Administrator #600. • On 08/16/24, the facility started daily meetings to ensure RN coverage. The attendees included Administrator, DON, Assistant DON #519, Human Resource Manager #535, and Scheduler #528. The daily meetings will look forward to staff needs so facility staff and staff in sister facilities can be offered extra hours, and/or agency if need be. • On 08/16/24, the facility has implemented a RN on-call rotation. • On 08/16/24, the facility offered a $10,000 sign-on bonus for RNs. The facility has hired the following RNs and were still working in the facility: RN #550 was hired on 11/05/24 and RN #536 on 01/24/25. Licensed Practical Nurse (LPN) #511 was hired on 03/11/25 and was obtaining her RN degree which will be obtained in June 2025. • Further review of PBJ reports, schedules and assignment sheets from 08/16/25 through 04/30/25 revealed a RN was present in the building for at least eight consecutive hours a day, seven days a week as required when the census was below 60 residents.

Based on record review, resident and staff interviews, and observation of a test tray, the facility failed to serve foods at a palatable temperature. This had the potential to affect all 54 residents residing in the facility who receive food from the kitchen. Findings include: Review of the diet order listing report revealed there were no residents with orders for nothing by mouth (NPO) and all 54 residents had oral diet orders in place. On 05/12/25 at 8:13 A.M., an interview with Resident #36 stated the food was awful. On 05/12/25 at 10:31 A.M., an interview with Resident #25 stated the food was cold. On 05/12/25 at 11:40 A.M., an interview with Resident #153 stated the food was horrible. On 05/14/25 from 10:49 A.M. to 12:12 P.M., an observation of the tray line for lunch service and review of a test tray with Dietary Manager (DM) #525 revealed the following: at 11:52 A.M., the test tray was plated on the line; at 11:56 A.M., the test tray was put on the delivery cart and the delivery cart left the kitchen immediately after; at 11:57 A.M., the cart was delivered to the unit; from 11:59 A.M. to 12:12 P.M., nursing staff were observed passing resident lunch trays; at 12:12 P.M., the test tray was delivered to the nurse's station. The test tray temperatures were measured by DM #525 using the facility's thermometer. The creamed spinach was 116.2 degrees Fahrenheit (F) and felt lukewarm upon tasting, the pork chop was 116.4 degrees F and felt lukewarm upon tasting, the diced potatoes were 116.4 degrees F and felt lukewarm upon tasting. Interview at the time of observation with DM #525 verified the temperatures of the foods on the test tray and stated hot food should be a minimum 125 degrees F at the time of service.

Based on record review, interview, observations, review of chemical sanitizer directions for use, and review of dishwasher manufacturer's directions, the facility failed to properly sanitize dishware after washing, discard expired foods in a timely manner, and maintain food storage areas in a clean manner. This had the potential to affect all 54 residents residing at the facility who receive food from the kitchen. Findings include: Review of the diet order listing report revealed there were no residents with orders for nothing by mouth (NPO) and all 54 residents had oral diet orders in place. Review of an email dated 04/21/25 at 7:52 A.M., between the facility and the chemical company who maintains their dish machine, indicated the Administrator had spent a week to verify there was no lease on the dish machine and that the facility needed someone out as soon as possible to resolve the temperature issues. An email, dated 04/21/25 at 8:15 A.M. requested an expedited process because this has been a problem for a while. An email dated 04/21/25 at 9:36 A.M. requested someone come to the facility as soon as possible because the high temperature was out and the unit has been down for a while. On 05/12/25 from 6:55 A.M. to 7:22 A.M., the initial tour of the kitchen revealed the sanitizer solution concentration was tested using the Hydrion QT-40 test strips, which have the following indicators: no color change represents a concentration of zero parts per million (ppm), pale yellow represents a concentration of 150 ppm, light green represents a concentration of 200 ppm, bright green represents a concentration of 400 ppm, and dark green represents a concentration of 500 ppm. At the time of the initial tour of the kitchen, three separate test strips turned pale yellow which was indicative of a concentration of 150 ppm. At the time of observation, Dietary Manager (DM) #525 verified with a color match against the test strip packaging that the sanitizer solution concentration was 150 ppm. At no point during the initial tour was the sanitizer solution discarded or fresh sanitizer solution mixed. Review of an email dated 05/12/25 at 11:50 A.M., between the facility's corporate office and the dish machine repair contractor, indicated the problem with the dish machine has been on-going for a while now and the quote for repairs was approved. On 05/13/25 at 8:53 A.M., an interview with DM #525 stated the facility had been having issues with the dish machine for multiple weeks and the machine was not reaching the minimum temperature of 180 degrees Fahrenheit (F) necessary for proper sanitization. Observation at the time of interview of the dish machine being run with an electronic thermometer inside the machine revealed the maximum temperature reached was 160.7 degrees F. The thermometer temperature was verified by DM #525 at the time of observation. DM #525 stated dietary staff had been running dishware through the dish machine and then using a bucket of sanitizer solution afterward. DM #525 then demonstrated by dipping each dish in the sanitizer solution and immediately removing it from the solution, stacking the dishes to the side of the sanitizer and not leaving all dishes fully submerged in the solution. On 05/13/25 at 11:32 A.M., an interview with the Administrator verified the contents of multiple emails indicated the dish machine had not been working properly for a while. On 05/13/25 at 11:36 A.M., an observation of the south unit medication storage room revealed the snack storage area contained Jello with an expiration date of 02/20/25, applesauce with an expiration date of March 2025, excessive ice buildup in the mini fridge used for food storage, hair stuck to the shelf inside the fridge, and multiple spills inside the fridge. Interview at the time of observation with the Director of Nursing (DON) verified the fridge condition and the expired food items. On 05/13/25 at 11:53 A.M., an interview with the Administrator stated he was alerted to the problem with the dish machine about a week and a half prior to the first email sent. He further stated all communication prior to that email was via telephone and he had no documentation for those conversations. He also said he personally went to the kitchen to observe their process for sanitizing dishes. The Administrator verified DM #525 was not following the proper procedures for sanitizing the dishes because DM #525 was just dipping the dishes in the sanitizer solution, immediately taking them back out and then stacking them to the side of the sanitizer without leaving all dishes submerged for the proper amount of time. Review of the manufacturer's label for the sanitizer solution revealed it was an effective sanitizer at an active quaternary concentration of 200 ppm to 400 ppm. The label further indicated that items such as drinking glasses, dishes, and eating utensils should be fully immersed in the 200 ppm to 400 ppm solution for at least 60 seconds for sanitization. Review of the manufacturer's information for the dish machine revealed the machine was a high temperature machine and the final rinse temperature should be between 180 degrees F and 195 degrees F during the sanitizing rinse every cycle.

2. Review of the medical record for Resident #2 revealed an admission date of 04/25/10 and a readmission date of 03/23/20 with diagnoses to include but not limited to heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact and was independent for activities of daily living. An interview on 05/12/25 at 11:08 A.M. with Resident #2 revealed that the heater in his room did not work. Observation during a tour of the facility with the Director of Maintenance (DM) #502 on 05/12/25 at 11:19 A.M. revealed the air temperature in Resident #2's room was 69 degrees F. DM #502 verified the air temperature at the time of observation. 3. Review of the medical record for Resident #45 revealed an admission date of 02/28/25 with diagnoses to include but not limited to Alzheimer's Disease, bipolar disorder, and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #12 was severely cognitively impaired and required substantial assistance for activities of daily living. Observation during a tour of the facility with the Director of Maintenance (DM) #502 on 05/12/25 at 11:21 A.M. revealed Resident #45's air room temperature was 68 degrees F. DM #502 verified the air temperature at the time of observation. DM #502 confirmed the heater coils in some rooms have been broken since November 2024. DM #502 confirmed the facility just kept the doors to the residents' rooms open to maintain heat in resident rooms. Interview on 05/13/25 at 11:57 A.M. with the Administrator revealed that the heating and cooling system in the facility circulated water through the registers. He stated that to fix the registers, the heat in the entire building would have to be shut off, and it is on DM #502's schedule to be completed when it is warmer, but before it's too hot. Review of the facility policy titled, Safe and Homelike Environment revised 06/01/24 revealed in accordance with resident rights, the facility will provide a safe, clean, comfortable and homelike environment; includes but not limited to preventing the spread of disease-causing organisms by keeping residents care equipment clean and properly stored. Resident's care equipment includes, but is not limited to , equipment used in the completion of the activities of daily living. The facility will maintain comfortable and safe temperature levels. This deficiency represents non-compliance investigated under Complaint Number OH00163020. Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure residents' bathing areas were kept clean and homelike and failed to ensure ambient room temperatures were comfortable and at least 70 degrees Fahrenheit (F). This affected two residents (#2 and #45) and had the potential to affect all but six residents (#11, #19, #28, #41, #43, and #46) who were identified by the facility as residents who did not use the South or North shower rooms. The facility census was 54. Findings include: Record review for Resident #32 revealed an admission date of 12/11/23. Diagnosis included Alzheimer's disease, Parkinsonism, muscle weakness and need for assistants with care. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #32 was severely cognitively impaired. Resident #42 was dependent for bathing/showering. Interview on 05/13/25 at 9:00 A.M. with Resident #32's wife revealed she assisted with showering Resident #32 routinely. Resident #32's wife revealed she was very concerned, both shower rooms were very dirty, (there were only two shower rooms shared by residents residing in the facility) odorous, and had broken parts that she had spoken to several staff members multiple times, and felt nothing had changed or been addressed. Observation on 05/13/25 at 9:41 A.M. of the North shower room with Licensed Practical Nurse (LPN) #549 revealed the shower room had a strong foul, musty odor, floor bases were corroded with a dark scummy substance surrounding the entire room. There were multiple broken tiles in the shower stall, and the edging in the three stalls were corroded. There was a soiled, wet washcloth lying on the floor and a pillow was lying on the floor next to the soiled toilet. Trash was on the floor including a used glove. Near the sink were several broken floor tiles, the ramp to the middle shower was embedded with dirt and scum and had broken pieces of material on both sides. The first shower stall had standing water on the floor with a brown/green ring surrounding a puddle of water. There was a shower bed against the wall with a brown smear in the center of the bed. LPN #549 verified the findings at the time of the observation. Observation on 05/13/25 at 9:48 A.M. of the South shower room with LPN #549 confirmed there was a strong musty odor and broken floor tiles broken and cracked along the base. There were three showers and two toilets. One toilet was broken, the second toilet was soiled with a dirty ring in the bowl with splattered fecal matter present. There were broken tiles, the ramp to the third shower was embedded with dirt. Paint was peeling and chipping off the ceiling. Grip tape was peeling off the grab bars in all three shower stalls, and floor strips were dirty and peeling. LPN #549 verified the findings at the time of the observation and stated many staff members complained about the state of the shower room, but the North and South shower rooms were the only two options for residents to shower. Observation of the North and South Shower rooms with DON on 05/14/25 at 12:26 P.M. also confirmed the vent on the ceiling in the South shower room was corroded and contained dust and scum build up. The DON confirmed the foul odor and revealed it was probably from the broken toilet. The DON confirmed both shower rooms were cleaned from the previous surveyor observations on 05/13/25 and confirmed both shower rooms remained odorous and contained multiple broken tiles and parts.

Based on record review and staff interview, the facility failed to thoroughly assess the needs of its resident population by accurately evaluating residents with diseases, conditions, and physical and behavioral health needs to determine what resources were necessary to care for its residents competently. This had the potential to affect 37 residents (Residents #1, #3, #4, #5, #6, #8, #9, #10, #11, #14, #18, #19, #20, #21, #23, #24, #25, #26, #28, #29, #30, #32, #34, #36, #37, #38, #39, #40, #42, #44, #45, #47, #48, #152, #153, #303, and #304) who resided in the facility at time of entrance and had a psychiatric and/or mood diagnosis. Findings include: Review of the facility assessment dated [DATE] revealed no residents were identified with psychiatric and/or mood disorder diagnoses. Staffing was identified as being adequate for caring for residents with dementia, mental health conditions, needed because behavioral health services or history of trauma as evidenced by the facility noted it was not applicable (N/A). Interview on 05/15/25 at 11:28 A.M. with the Administrator verified the facility assessment did not identify any residents with psychiatric and/or mood disorder diagnoses. Interview on 05/15/25 at 11:32 A.M. with Director of Nursing (DON) confirmed 37 residents (Residents #1, #3, #4, #5, #6, #8, #9, #10, #11, #14, #18, #19, #20, #21, #23, #24, #25, #26, #28, #29, #30, #32, #34, #36, #37, #38, #39, #40, #42, #44, #45, #47, #48, #152, #153, #303, and #304) who resided in the facility at time of entrance had a psychiatric and/or mood diagnosis.

Based on review of personnel files, record review, and staff interview, the facility failed to ensure all staff received behavior health training. This had the potential to affect 37 residents (Residents #1, #3, #4, #5, #6, #8, #9, #10, #11, #14, #18, #19, #20, #21, #23, #24, #25, #26, #28, #29, #30, #32, #34, #36, #37, #38, #39, #40, #42, #44, #45, #47, #48, #152, #153, #303, and #304) who resided in the facility at time of entrance and had a psychiatric and/or mood diagnosis. Findings include: Review of the personnel file for Licensed Practical Nurse (LPN) #526 revealed a hire date of 10/19/21. The file contained no evidence that LPN #526 received training on mental health behaviors. Review of the personnel file for LPN #553 revealed a hire date of 04/16/25. The file contained no evidence that LPN #553 received training on mental health behaviors. Review of the personnel file for Certified Nursing Assistant (CNA) #531 revealed a hire date of 12/12/19. The file contained no evidence that CNA #531 received training on mental health behaviors. Review of the personnel file for Human Resource Manager (HR) #535 revealed a hire date of 02/29/25. The file contained no evidence that HR #535 received training on mental health behaviors. Review of the personnel file for the Administrator revealed a hire date of 06/03/24. The file contained no evidence that the Administrator received training on mental health behaviors. Review of the personnel file for CNA #521 revealed a hire date of 09/18/23. The file contained no evidence that CNA #521 received training on mental health behaviors. Review of the personnel file for CNA #545 revealed a hire date of 04/21/25. The file contained no evidence that CNA #545 received training on mental health behaviors. Review of the personnel file for CNA #516 revealed a hire date of 06/27/24. The file contained no evidence that CNA #516 received training on mental health behaviors. Review of the personnel file for CNA #540 revealed a hire date of 03/03/25. The file contained no evidence that CNA #540 received training on mental health behaviors. Review of the personnel file for Dietary Aide (DA) #547 revealed a hire date of 03/12/25. The file contained no evidence that DA #547 received training on mental health behaviors. Review of the personnel file for Activity Director (AD) #515 revealed a hire date of 04/05/21. The file contained no evidence that AD #515 received training on mental health behaviors. Review of the facility assessment dated [DATE] revealed the facility did not provide care to their residents who had psychiatric/mood disorders. However, staff interview revealed they had 37 residents who had psychiatric/mood disorders. The resident acuity affecting nurse aides revealed the nurse aides provided assistance with behavioral health symptoms. Care and assistance was provided as necessary to the resident's behavioral and mental health. Interview on 05/15/25 at 11:17 A.M. with Human Resource Manager (HR) #535 verified no behavioral health training was completed for LPN #526, LPN #553, CNA #531, HR #535, Administrator, CNA #521, CNA #545, CNA #516, CNA #540, DA #547, and AD #515. Interview on 05/15/25 at 11:32 A.M. with Director of Nursing (DON) confirmed 37 residents (Residents #1, #3, #4, #5, #6, #8, #9, #10, #11, #14, #18, #19, #20, #21, #23, #24, #25, #26, #28, #29, #30, #32, #34, #36, #37, #38, #39, #40, #42, #44, #45, #47, #48, #152, #153, #303, and #304) who resided in the facility at time of entrance had a psychiatric and/or mood diagnosis. This deficiency represents non-compliance investigated under Complaint Number OH00163020.

Based on observation, interview, and record review, the facility failed to ensure equipment used for residents' activities of daily living (ADLs) were maintained in good working condition. This affected one resident (#26) of one resident reviewed for equipment and had the potential to affect one additional resident (#8) who utilized a shower bed for bathing. The facility census was 54. Findings include: Review of the medical record for Resident #26 revealed a readmission date of 11/23/22. Diagnosis included chronic diastolic congestive heart failure (CHF) and morbid severe obesity. Review of the care plan dated 07/19/24 revealed Resident #26 required assistance for activities of daily living (ADLs). Interventions included Resident #26 was totally dependent and does not participate in any aspect of the task for bathing. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 had an impairment to both sides of the lower extremities and was dependent on staff for showers and bathing. Interview on 05/12/25 at 7:35 A.M. Resident #26 revealed she cannot take a shower because the facility's shower bed was broke. Resident #26 stated, They do give me bed baths, but I really would prefer a shower. Observation revealed Resident #26's hair was oily. Interview on 05/15/25 at 8:58 A.M. with Certified Nursing Assistant (CNA) #517 revealed Resident #26 was unable to take a shower because the wheels on the shower bed was broken, they kept getting stuck and were unusable. CNA #517 estimated the shower bed had been broken for the approximately two or three months. She had previously informed the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON). Observation of the shower bed located in the North Shower room revealed the shower bed was against the wall. CNA #517 revealed the bed can be moved if there was no weight on it but as soon as a resident laid on it, it would not move. Interview on 05/15/25 at 9:03 A.M. with ADON #519 revealed Resident #26 used to take a shower using the shower bed, and so did Resident #8, until the bearings on the shower bed broke. ADON #519 revealed, It's been weeks, they wanted to try to replace the bearings before buying a new bed. ADON #519 confirmed Residents #26 and #8 were only getting bed baths because that was the only bariatric shower bed the facility had. Interview on 05/15/25 at 9:10 A.M. with Maintenance Director #610 revealed the bearings in the wheels of the shower bed were worn out and stated, I have to change them, it's been about a month, they came in, I just have to get in there to do it. Record review and interview on 05/19/25 with DON of Resident #26's Shower records revealed Resident #26 was last showered around 02/23/25 and bed baths began on 02/26/25. The DON confirmed that was about the time the shower bed broke and Residents #26 and #8 were no longer able to take a shower.

Based on record review and interview, the facility failed to ensure residents had accurate advance directive orders and information in place throughout the medical record for Resident #45. This affected one resident (#45) of 34 residents reviewed for advance directives. The facility census was 54. Findings include: Review of the medical record for Resident #45 revealed an admission date of 02/28/25 with diagnoses to include but not limited to Alzheimer's Disease, bipolar disorder, and post-traumatic stress disorder. Review of the physician's orders for Resident #45 revealed an order dated 02/28/25 for a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) code status (meaning invasive or extreme life-supporting measures were allowed under any circumstance except for cardiac or respiratory arrest. In the event of cardiac or respiratory arrest only comfort measures would be initiated). Review of the plan of care dated 03/04/25 for Resident #45 revealed the resident was a DNRCCA. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #12 was severely cognitively impaired and required substantial assistance for activities of daily living. Review of the hard medical chart for Resident #45 revealed an unsigned Do Not Resuscitate Comfort Care- Arrest (DNRCCA) code status. Interview on 05/13/25 at 7:35 A.M. with Director of Nursing (DON) verified that Resident #45's DNRCC-A was not signed by a physician. The DNRCC-A paper only had Resident #45's name on it. Review of the facility's policy dated 06/01/24 titled, Resident Rights Regarding Treatment and Advance Directives, revealed it is the policy to support and facilitate a resident's right to discontinue medical treatment and formulate an advance directive.

Based on interview, record review, and review of the facility policy, the facility failed to report an injury of unknown origin to the Ohio Department of Health (ODH) as required. This affected one resident (#47) of two residents reviewed for reporting abuse, neglect, misappropriation or injuries of unknown origin. The facility census was 54. Findings include: Record review for Resident #47 revealed an admission date of 01/21/25. On 03/26/25 Resident #47 was transferred to the Hospital #604 and readmitted on [DATE]. Diagnosis included severe protein calorie malnutrition, altered mental status, chronic obstructive pulmonary disease (COPD) and weakness. Review of Hospital #604's discharge record dated 04/04/25 completed by Physician #605 included Resident #47 was admitted to Hospital #604 on 03/27/25. Documentation included the wound to the left lateral back was healed. Review of the admission Progress note dated 04/05/25 at 12:57 A.M. completed by Licensed Practical Nurse (LPN) #538 revealed Resident #47 returned to the facility. Record review revealed there was no documentation of any skin concerns to Resident #47's back. Review of the facility re-entry Clinical admission Assessment for Resident #47 dated 04/05/25 untimed completed by LPN #538 revealed there were no concerns documented to Resident #47's back. Review of the Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 required substantial/maximal assistants with upper and lower body dressing, partial/moderate assistance with personal hygiene, bed mobility, dependent for chair/bed-to-chair transfer. Resident #47 had no skin tears. Review of the Skin Grid Non-Pressure dated 04/22/25 at 11:10 A.M. completed by Assistant Director of Nursing (ADON) #519 revealed Resident #47 had a new skin tear acquired to the lower back measuring 7.0 centimeters (cm) in length by 15.0 cm in width by 0.1 cm in depth with a scant amount of drainage. Documentation included, During wound rounds noted to have new skin tear to mid back region. Area cleansed with normal saline, xeroform and dry clean dressing (DCD) applied. Further record review of Resident #47's medical record revealed no information was documented to how and when the skin tear occurred. Review of the ODH Certification and Licensure System (CALS) website confirmed there was no SRI completed for the injury of unknown origin to Resident #47's lower back. Interview on 05/19/25 at 10:30 A.M. with ADON #519 revealed she found the skin tear on Resident #47's lower back on 04/22/25 when she rolled him over. ADON #519 confirmed the skin tear was new and confirmed she did not know how or when it happened. ADON #519 revealed she obtained orders for the treatment of the wound but never investigated how or when the wound occurred. Interview on 05/19/25 at 10:34 A.M. with the Administrator revealed if a resident had an injury of unknown origin, an SRI should have been completed to report the injury of unknown origin. Interview on 05/19/24 at 1:01 P.M. with Regional Director of Clinical Services (RDCS) #557 confirmed no SRI was completed for Resident #47's skin tear to the back. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property undated revealed the Administrator or his/her designee will notify the Ohio Department of Health of all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property and injuries of unknown source as soon as possible but in no event later than twenty-four (24) hours from the time the incident/allegation was made known to the staff member.

Based on interview, medical record review, review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS), and review of the facility policy, the facility failed to thoroughly investigate incidents of potential abuse for two residents (#47 and #52) of two residents reviewed for investigations of abuse, neglect, misappropriation, or injuries of unknown origin. The facility census was 54. Findings include: 1. Record review for Resident #47 revealed an admission date of 01/21/25. On 03/26/25 Resident #47 was transferred to the Hospital #604 and readmitted on [DATE]. Diagnosis included severe protein calorie malnutrition, altered mental status, chronic obstructive pulmonary disease (COPD) and weakness. Review of Hospital #604's discharge record dated 04/04/25 completed by Physician #605 included Resident #47 was admitted to Hospital #604 on 03/27/25. Documentation included the wound to the left lateral back healed. Review of the admission Progress note dated 04/05/25 at 12:57 A.M. completed by Licensed Practical Nurse (LPN) #538 revealed Resident #47 returned to the facility. Record review revealed there was no documentation of any skin concerns to Resident #47's back. Review of the facility re-entry Clinical admission Assessment for Resident #47 dated 04/05/25 untimed completed by LPN #538 revealed there were no concerns documented to Resident #47's back. Review of the Minimum Data Set (MDS) Medicare five-day assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 required substantial/maximal assistants with upper and lower body dressing, partial/moderate assistants with personal hygiene, bed mobility, dependent for chair/bed to chair transfer. Resident #47 had no skin tears. Review of the Skin Grid Non-Pressure dated 04/22/25 at 11:10 A.M. completed by Assistant Director of Nursing (ADON) #519 revealed Resident #47 had a new skin tear acquired to the lower back measuring 7.0 centimeters (cm) in length by 15.0 cm in width by 0.1 cm in depth with a scant amount of drainage. Documentation included, During wound rounds noted to have new skin tear to mid back region. Area cleansed with normal saline, xeroform and dry clean dressing (DCD) applied. Further record review of Resident #47's medical record revealed no information was documented to how and when the skin tear occurred. Review of the ODH CALS website revealed no Self-Reported Incidents (SRI) was completed for the wound of unknown source to Resident #47's lower back. Interview on 05/19/25 at 10:30 A.M. with ADON #519 revealed she found the skin tear on Resident #47's lower back on 04/22/25 when she rolled him over. ADON #519 confirmed the skin tear was new and confirmed she did not know how or when it happened. ADON #519 revealed she obtained orders for the treatment of the wound but never investigated how or when the wound occurred. Interview on 05/19/25 at 10:34 A.M. with the Administrator revealed if a resident had an injury of unknown origin, an investigation should be initiated immediately to find the cause of the injury, and a SRI should have been completed to report the injury of unknown origin. Interview and record review with Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #557 on 05/19/25 at 1:01 P.M. confirmed Resident #47 had a new skin tear to the lower back documented on 04/22/25 at 11:10 A.M. RDCS #557 confirmed no SRI was completed for Resident #47's skin tear to the back. DON confirmed there was no investigation completed at any time to determine how the skin tear that measured 7.0 cm in length by 15.0 cm in width by 0.1 cm in depth occurred. 2. Review of the closed medical record for Resident #52 revealed an admission date of 02/27/25 and a discharge date of 03/09/25. Diagnosis for Resident #52 included congestive heart failure (CHF), anxiety disorder, and obstructive and reflux uropathy. Review of the Minimum Data Assessment (MDS) discharge return not anticipated assessment dated [DATE] revealed Resident #52's short term memory was ok and the cognitive skills for decision making was severely impaired. Resident #52 received scheduled and as needed (PRN) pain medication and had a condition or chronic disease that may result in a life expectancy of less than six months. Review of the physician orders for Resident #52 initiated 02/27/25 included to call Hospice #600 with changes or concerns. Review of the nursing note for Resident #52 dated 03/08/25 at 10:46 A.M. completed by LPN #526 included Resident #52 had been combative that morning. Resident #52 was kept at the nurse's station for safety. The note referenced the resident had been hitting staff and trying to hit other residents. The resident grabbed ahold of the medication cart, attempted to stand, and almost pulled the cart on himself causing himself to fall. Staff were unable to catch the resident before falling. Staff had attempted to redirect the resident with coffee and a snack without success. Hospice was called and arrived for a visit. New orders obtained. Hospice doing one-on-one with the Resident #52 who was noted to be agitated. Review of the Health Status note for Resident #52 dated 03/08/25 at 12:30 P.M. completed by ADON #519 included it had been reported Resident #52 was seated up in his wheelchair with a blanket around him, secured loosely behind his chair. Staff reported Resident #52 was still able to move around and could have stood if he tried. ADON #519 and an unnamed hospice nurse assessed the resident for injury. No injury was observed with the exception of a soft lump on Resident #52's shoulder. The note referenced the resident had no pain with palpation and no discoloration. An x-ray examination was ordered. Resident denied pain and the note concluded by referencing the resident remained resting in bed with hospice staff at his bedside. Review of the Orders Administration note for Resident #52 dated 03/09/25 at 3:16 P.M. completed by RN #550 revealed Resident discharged to hospice inpatient center. Review of the SRI with tracking number 257988 dated 03/08/25 at 12:44 P.M. created by Regional Director of Clinical Services (RDCS) #557 and completed 03/11/25 at 5:48 P.M. completed by RDCS #557 revealed the alleged perpetrator was listed as LPN #526. The Resident/Victim was listed as Resident #52. The brief description of the allegation/suspicion revealed that in an attempt to prevent Resident #52 from standing unassisted or falling out of wheelchair, an employee placed a sheet over his lap and secured it behind the back of the wheelchair by tying it. The sheet was untied and Resident #52 was assessed for injury. There was no injury noted. LPN #526 was suspended immediately. The conclusion listed the SRI was unsubstantiated and evidence indicated abuse, neglect or misappropriation did not occur. Review of the facility investigation file revealed there was no information/witness statement obtained from Hospice LPN #603 or any other hospice staff regarding the incident involving Resident #52 on 03/08/25. Review of the Witness Statement located in the facility investigation file revealed a written statement dated 03/08/25 at 7:00 A.M. completed by LPN #526 included this nurse applied a sheet around waste loosely tied behind back for his safety and other residents. Sheet loose enough he could pull and get out. Sheet removed when staff was able when calm. Review of the Witness Statement located in the facility investigation file revealed a written statement dated 03/08/25 at 7:00 A.M. completed by Certified Nursing Assistant (CNA) #503 which included so nurse got sheet and loosely put around resident he his waste was going to hurt himself or others who were in the hallway. Phone interview on 05/13/25 at 5:31 P.M. with Hospice LPN #603 revealed she received a phone call at 6:47 A.M. from the facility that Resident #52 was agitated and pulled his catheter out. Hospice LPN #603 confirmed she arrived at the facility at 7:45 A.M. Hospice LPN #603 revealed when she walked in the facility, LPN #526 was walking up the hall. Hospice LPN #603 stated LPN #526 looked at her and stated I am not going to lie, I have him tied to the wheelchair at the nurses station. Hospice LPN #603 revealed she immediately went to the nurses station, where Resident #52 was seated in the wheelchair. The sheet was tied around his waist, secured in the back with a traditional knot, and tucked in between the armrest so it had him against the chair. LPN #526 confirmed Resident #52 could not get up and she did not see staff present at or near the nurse's station monitoring him. Hospice LPN #603 stated she untied Resident #52. Before she untied him, Resident #52 was pulling at the sheet trying to get it loose, and confirmed Resident #52 was unable to get the sheet loose. Hospice LPN #603 stated if he had been properly medicated, he would not have been a need to restrain him. The facility staff had had a whole additional (hospice) team to utilize, and there were as-needed medications available that were unused. Hospice LPN #603 stated she was shocked and livid when she saw Resident #52 tied up. She stated tying up the resident was so unnecessary when there were so many resources for him that were unused. Interview on 05/14/25 at 8:33 A.M. with CNA #503 confirmed she was the CNA working on 03/08/25. CNA #503 revealed LPN #526 asked CNA #503 to get her a sheet. CNA #503 then went to help another resident. CNA #503 revealed her shift had started that day at 6:00 A.M. but she did not recall what time LPN #526 tied up Resident #52. CNA #503 confirmed the hospice nurse arrived an hour or two later and untied Resident #52 when she arrived. An additional phone interview on 05/14/25 at 11:06 A.M. with Hospice LPN #603 confirmed there was not a quick-release, slip-pull knot on the restraint. Resident #52 tried to stand when he was taking the knot out he was trying to stand and could not, it had two ties, it was a knot which could not be released. Interviews on 05/14/25 at 5:16 P.M. and 05/15/25 at 11:57 A.M. with the DON and RDCS #557 confirmed the hospice notes or statements, including the emailed statement, were not included in the facility's investigation into the incident with Resident #52 on 03/08/25. The DON revealed Hospice LPN #603's emailed statement was still in her email. The DON printed and provided the email to the survey team during the interview. RDCS #557 revealed she was unaware of all the information regarding the incident with the restraint. The DON and RDCS #557 confirmed the facility documented in the witness statements that they were aware the nurse tied up Resident #52 at 7:00 A.M. and no staff working at the facility notified facility administration of the event. The DON reported this was part of abuse training which had previously been provided to all staff. RDCS #557 additionally confirmed facility administration was notified of this incident on 03/08/25 at 10:03 A.M. by Hospice RN Team Leader #602. The facility initiated a SRI and began their investigation. The Administrator did not obtain Resident #52's hospice notes or interview the hospice staff, yet submitted the final SRI three days after the initial SRI. Hospice staff emailed a statement to the DON four days after the event, after the final SRI had been submitted. The facility did not wait to ensure a complete investigation was completed. RDCS #557 stated if she had known, the outcome of the SRI could have been different. RDCS #557 revealed she was unsure why the SRI was unsubstantiated. Review of the facility policy titled, Unexplained Injuries dated 01/01/20 revealed all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property undated revealed the investigation protocol included the person investigating the incident should generally take the following actions: Interview the resident, the accused, and all witnesses. Witnesses generally included anyone who witnessed or heard the incident; came in close contact with the resident the day of the incident; and employees who worked closely with the accused employee and or alleged victim the day of the incident.

Based on record review, interview, and review of facility policy, the facility failed to permit Resident #302 to return to the facility after a hospitalization. This affected one (#302) of four residents reviewed for discharge. The facility census was 54. Findings include: Review of the medical record for Resident #302 revealed an admission date of 12/21/24 with diagnoses including chronic obstructive pulmonary disease, lung cancer, opioid dependence, anxiety disorder, hypertension, depression, and encounter following alleged adult physical abuse. Review of the 30-day discharge notice, issued 01/07/25, revealed Resident #302 received the notice due to failure to comply with facility rules and behavior contract. The planned discharge location on the notice was listed as Haven of Rest in Akron (a homeless shelter). Resident #302 did not discharge at the end of the time period stated in the notice and remained in the facility. Review of the significant change Minimum Data Set (MDS) assessment, dated 03/25/25, revealed Resident #302 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13) and verbal behaviors toward others one-to-three days with an overall presence of behavioral symptoms. Review of the physician's assistant progress note, dated 04/21/25, revealed multiple calls were received over the weekend regarding Resident #302's behaviors, including threatening other residents and staff. The police were called twice for Resident #302. The resident was informed that a drug screen would be completed via blood draw and that his medications would be reduced. Resident #302 had rapid and repeating thoughts during conversation. The nursing staff reported Resident #302 had not been sleeping and had been displaying manic behaviors. Resident #302 declined a psychiatric consult at that time. Resident #302 was informed that he could not threaten those around him and further action would be taken if symptoms continued. Review of the progress note dated 04/22/25 at 11:40 A.M. revealed Resident #302 had been very manic that morning, yelling and cursing at staff, traveling at a high speed in his wheelchair throughout the facility, threatening to send staff to jail, had possession of beer, and the physician ordered to send Resident #302 to the hospital for a psychiatric evaluation. Emergency services were called and Resident #302 had to be physically picked up by three police officers and placed on the transport cot. Resident #302 left the facility at approximately 11:15 A.M. There were no progress notes indicating there were any attempts made to have Resident #302 return to the facility after 04/22/25. On 05/19/25 at 8:34 A.M., an interview with Social Services Designee (SSD) #529 confirmed Resident #302 was transferred out of the facility for a psychiatric evaluation and was not permitted to return, which was a decision made by the higher powers at the facility. SSD #529 stated she was aware the facility was required to allow Resident #302 to return. On 05/19/25 at 8:42 A.M., an interview with SSD #529 stated Resident #302 went to a homeless shelter after being discharged from the hospital and the facility delivered his belongings and wheelchair to the homeless shelter afterward. On 05/19/25 at 10:11 A.M., an interview with the Director of Nursing (DON) stated Resident #302 had displayed behaviors toward other residents and staff, was using alcohol and marijuana, and had been issued a previous 30-day discharge notice. The DON said after the 30-day discharge was issued, the Long-Term Care Ombudsman informed the facility that the plan to discharge Resident #302 to a homeless shelter was not a safe discharge. The DON said Resident #302 was ultimately sent to the hospital for a psychiatric evaluation due to his continued behaviors, unwillingness to listen to staff, and unwillingness to follow the facility's rules. The DON confirmed Resident #302 did not return to the facility after the hospitalization and was discharged from the hospital to a homeless shelter. Review of the facility's policy titled Transfer and Discharge (including against medical advice (AMA), dated 02/05/25, indicated residents had the right to remain at the facility unless their transfer or discharge met one of the specified exemptions, which included the resident's welfare and needs could not be met by the facility, the safety of individuals in the facility were endangered due to the clinical or behavioral status of the resident, and/or the health of individuals in the facility would otherwise be endangered. The policy also included that if a resident was transferred from the facility to an acute care setting, the resident would be permitted to return to the facility upon discharge from the acute care setting. This deficiency represents non-compliance investigated under Complaint Number OH00165156.

Based on record review, interview, and review of facility policy, the facility failed to issue a discharge notice to Resident #302 prior to discharge. This affected one (#302) of four residents reviewed for discharge. The facility census was 54. Findings include: Review of the medical record for Resident #302 revealed an admission date of 12/21/24 with diagnoses including chronic obstructive pulmonary disease, lung cancer, opioid dependence, anxiety disorder, hypertension, depression, and encounter following alleged adult physical abuse. Review of the 30-day discharge notice, issued 01/07/25, revealed Resident #302 received the notice due to failure to comply with facility rules and behavior contract. The planned discharge location on the notice was listed as Homeless Shelter #900. Resident #302 did not discharge at the end of the time period stated in the notice and remained in the facility. Review of the significant change Minimum Data Set (MDS) assessment, dated 03/25/25, revealed Resident #302 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13) and verbal behaviors toward others one-to-three days with an overall presence of behavioral symptoms. Review of the physician's assistant progress note, dated 04/21/25, revealed multiple calls were received over the weekend regarding Resident #302's behaviors, including threatening other residents and staff. The police were called twice for Resident #302. The resident was informed that a drug screen would be completed via blood draw and that his medications would be reduced. Resident #302 had rapid and repeating thoughts during conversation. The nursing staff reported Resident #302 had not been sleeping and had been displaying manic behaviors. Resident #302 declined a psychiatric consult at that time. Resident #302 was informed that he could not threaten those around him and further action would be taken if symptoms continued. Review of the progress note dated 04/22/25 at 11:40 A.M. revealed Resident #302 had been very manic that morning, yelling and cursing at staff, traveling at a high speed in his wheelchair throughout the facility, threatening to send staff to jail, had possession of beer, and the physician ordered to send Resident #302 to the hospital for a psychiatric evaluation. Emergency services were called and Resident #302 had to be physically picked up by three police officers and placed on the transport cot. Resident #302 left the facility at approximately 11:15 A.M. Review of the progress notes, assessments, and documents uploaded to the chart revealed there was no evidence of a discharge notice was provided to Resident #302 after the resident was transferred to the hospital on [DATE] and Resident #302 not permitted to return to the facility. On 05/19/25 at 1:48 P.M., an interview with the Director of Nursing (DON) confirmed Resident #302 should have received a discharge notice when he was not permitted to return to the facility from the hospital. On 05/19/25 at 2:00 P.M., an interview with Social Services Designee (SSD) #529 stated Resident #302 was provided a transfer notice at the time he was sent out for the psychiatric evaluation and verified there was no discharge notice provided at that time. On 05/19/25 at 2:07 P.M., SSD #529 confirmed there was no discharge notice provided to Resident #302 once the facility decided to discharge him and not permit him to return to the facility. Review of the facility's policy titled Transfer and Discharge (including against medical advice (AMA), dated 02/05/25, indicated a discharge notice would be provided to the resident and representative in a language and manner in which they could understand prior to the discharge. This deficiency represents non-compliance investigated under Complaint Number OH00165156.

Based on observation, resident, family, and staff interview, record review, and review of the facility policy, the facility failed to ensure the residents received activities to meet their needs and preferences. This affected one (Resident #47) of two residents reviewed for activities. The facility census was 54. Findings include: Record review for Resident #47 revealed an admission date of 01/21/25. Diagnoses included severe protein calorie malnutrition, altered mental status, chronic obstructive pulmonary disease (COPD) and weakness. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 felt it was somewhat important to listen to music, pets, keeping up with the news, and going outside to get fresh air. Review of the care plan for Resident #47 dated 01/24/25 revealed Resident #47 needed encouragement to participate in activities of interest. Resident #47 preferred independent activities in room. Interventions included to give resident verbal reminders of activity before commencement of activity. Turn on television and music in room to provide sensory stimulation. Review of the Building Relationships Resident and Family Interview Questions for Resident #47 undated provided by Activity Director #515 revealed Resident #47 was in the Army, enjoyed hunting, country music, trivia and exercise. Review of the Activity Calendar for March 2025 revealed no activities were provided past 2:00 P.M.; The Activity Calendar for April 2025 revealed activities included a 6:00 P.M. evening film scheduled on Mondays, Tuesdays, Wednesdays, and Thursdays. No activities were scheduled between 2:00 P.M. and 6:00 P.M. and no activities were scheduled after 6:00 P.M.; Review of the Activity Schedule for May 2025 revealed the 6:00 P.M. evening film was scheduled two days a week, Wednesdays and Fridays. No activities were scheduled between 1:00 P.M. and 6:00 P.M. Monday through Friday and no activities were scheduled after 2:00 P.M. on Saturday or Sunday. Interview on 05/12/25 at 11:02 A.M. with Resident #47's family member revealed, He is so tired of just lying in bed, he gets bored, then he falls, he is sick and tired of just looking at walls, he would like to get out of the room; I told the nurse please get him out room, activities don't do anything with him. Multiple observations of Resident #47 on 05/12/25, 05/13/25, 05/14/25, and 05/15/25 revealed Resident #47 never got out of bed or participated in activities. Interview on 05/19/25 at 8:45 A.M. with Resident #47 revealed sometimes he would like to get out of bed more, look outside and go outside when its warmer. Resident #47 confirmed he liked music and use to enjoy trivia but now usually stays in his room and denied having activities provided by staff. Interview on 05/19/25 at 8:58 A.M. with Activity Director (AD) #515 revealed she provided activities for residents in person Monday through Friday. AD #515 stated Resident #47 usually did not participate in group activities and she provided one on one (1:1) visits for residents who did not participate in group activities. AD #515 confirmed Resident #47 enjoyed country music, trivia and exercise. AD #515 stated she could put music in his room, she stated never asked him, and it was a good idea to offer him music in his room. AD #515 revealed Resident #47 also liked trivia and exercise according to the Building Relationships Resident and Family Interview Questions and confirmed she never offered him any trivia books, magazines, or exercises and stated But that is a good idea. AD #515 stated she was the only activity person for the residents, and there were no assistants in activities. She stated it was challenging but she does her best. AD #515 stated she worked at the facility Monday through Friday, and she sets stuff for activities on the weekends. The items she sets out for residents were self-initiated. Churches also come on the weekend and gather residents for services. AD #515 revealed all 6:00 P.M. evening films were resident self-initiated since her activities she provides were only done until 2:00 P.M AT #515 will set the movie up, then the residents were to go in at 6:00 P.M. and turn the movie on themselves. She worked some weekends as weekend manager, four hours a day Saturday and Sunday, usually one weekend a month or sometimes every other month. When she does that, she gets a day off during the week. When she has off during the week and on most weekends, all activities except church were self-initiated which she confirmed Resident #47 was unable to do. AD #515 revealed on 10/20/24 she became AD and confirmed she was not certified to be an AD. AD #515 confirmed she visited 1:1 with Resident #47 two to three times a month reiterating she was the only activities person for all the residents. Interview on 05/19/25 at 9:38 A.M. with the Administrator stated all residents should have evening and weekends activities offered that were provided by staff, not just resident-initiated. Interview on 05/19/25 at 10:49 A.M. with Corporate Director of Life Enrichment and Memory Care #559 revealed it was the expectation that two evenings a week were staff driven or have staff there in the case of a music program and weekend activities. Review of the facility policy titled Activities dated 06/01/24 revealed it is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences.

Based on observations, interview, record review, and review of the facility policy, the facility failed to ensure a resident had physician orders for oxygen therapy and to maintain the oxygen supplies. This affected one (Resident #47) of two residents reviewed for oxygen. Findings include: Record review for Resident #47 revealed an admission date of 01/21/25. Diagnoses included chronic obstructive pulmonary disease (COPD), adult failure to thrive and weakness. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 was dependent with eating, dressing and personal hygiene. Resident #47 had shortness of breath or trouble breathing while lying flat. Resident #47 did not receive oxygen therapy. Review of the active physician orders for Resident #47 revealed there was no orders for Resident #47 to receive oxygen therapy. Resident #47 had an order dated 04/26/25 to admit to Hospice Services #606. Observation on 05/12/25 at 7:01 A.M. revealed Resident #47 was resting quietly in bed. An oxygen concentrator was sitting next to the bed and was running at four liters per minute. Resident #47 had a nasal cannula in his nostrils. The oxygen tubing was lying on the floor and not connected to the concentrator. Observation and interview on 05/12/25 at 7:08 A.M. with Licensed Practical Nurse (LPN) #553 confirmed the oxygen concentrator was sitting next to the bed and was running at four liters per minute, Resident #47 had a nasal cannula in his nostrils, and the oxygen tubing was lying on the floor and not connected to the concentrator. LPN #553 reconnected the tubing to the concentrator and stated she was not sure why it was disconnected or how long it was disconnected for. Interview on 05/12/25 at 8:41 A.M. with LPN #553 confirmed Resident #47 did not have an order for oxygen therapy and confirmed Resident #47 received continuous oxygen. Observation on 05/15/25 at 2:31 P.M. revealed Resident #47 was resting in bed quietly. Resident #47 had oxygen on via nasal cannula at four liters per minute. Observation and interview on 05/15/25 between 2:34 P.M. and 2:49 P.M. with LPN #549 verified Resident #47 was receiving oxygen at four liters per minute and confirmed the humidifier bottle on the concentrator was empty. Resident #47 revealed his nose felt, very dry and sore inside LPN #549 confirmed there was no physician order for Resident #47 to receive oxygen therapy. Interview on 05/15/25 at 2:56 P.M. with Director of Nursing (DON) revealed if a resident received oxygen therapy, they should have an order in the electronic medical record and a magnet on the outside of their door. The oxygen tubing would be changed weekly and as needed and staff would make sure the solution in the humidifying bottle did not run empty. Interview on 05/19/25 at 8:31 A.M. with DON confirmed Resident #47 had been receiving oxygen therapy prior to Hospice initiating services and confirmed Resident #47 received the oxygen therapy without a physicians order. Review of the facility policy titled Oxygen Administration revised 01/04/23 revealed oxygen is administered under the orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.

Based on observations, staff interviews, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure residents who had indwelling medical devices and/or wounds were on enhanced barrier precautions (EBP), ensure staff wore the appropriate personal protective equipment (PPE) for residents on EBP, and ensure staff followed proper hand hygiene when providing care to the residents. This affected three residents (Resident #5, #47, and #152). The facility census was 54. Findings include: 1. Record review for Resident #47 revealed an admission date of 01/21/25. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired and was dependent on staff for activities of daily living. Review of the physician orders for May 2025 revealed Resident #47 had a physician order dated 04/22/25 to change the peripherally inserted central catheter (PICC) dressing weekly every Tuesday. An additional order dated 04/17/25 revealed to flush the PICC line every shift for skin integrity. Review of the care plan dated 04/28/25 revealed Resident #47 had potential for complications related to use of intravenous (IV) medications and had a PICC line on right arm with single lumen. Interventions included EBP. Observation and interview on 05/12/25 at 11:38 A.M. with Licensed Practical Nurse (LPN) #553 revealed Resident #47 was lying in bed and had a PICC line in his right upper arm. LPN #553 stated she did not know Resident #47 had a PICC line. LPN #553 confirmed Resident #47 was not on EBP and confirmed there was no PPE outside or inside his doorway. LPN #553 confirmed the dressing covering the PICC line was loose at the bottom exposing the insertion site and the dressing had no date on it to verify the last time it was changed. LPN #553 returned to the medication cart, gathered equipment to flush the PICC line with then returned to Resident #47's room. LPN #553 put on disposable gloves, no gown, flushed Resident #47's PICC line with 10 milliliters (ml) of saline flush. LPN #553 then assessed Resident #47's colostomy and burped (opening the bag, letting the air out then re-closing the bag) the colostomy bag. LPN #553 then removed her gloves and exited the room without washing her hands. LPN #553 confirmed she did not wash her hands after removing her gloves and exiting Resident #47's room. Interview with Assistant Director of Nursing (ADON) #519 on 05/12/25 at 11:45 A.M. confirmed Resident #47 should be on EBP and confirmed there was no PPE available inside or outside Resident #47's room. 2. Record review for Resident #5 revealed a re-admission date of 01/15/25. Review of the State Optional Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact and required extensive assistance with bed mobility and toilet use and had one unhealed stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Review of the care plan revised 04/16/25 revealed Resident #5 had an actual area of skin impairment related to a pressure ulcer to the mid back. Interventions included EBP. Observation and interview on 05/14/25 at 12:41 P.M. of incontinence care for Resident #5 provided by Certified Nursing Assistant (CNA) #531 revealed CNA #531 did not wear an isolation gown while providing peri care for Resident #5. There was an isolation container outside Resident #5's doorway with appropriate PPE. CNA #531 confirmed she did not wear an isolation gown and confirmed she was required to were an isolation gown while providing care for Resident #5. CNA #531 stated she forgot to put on a isolation gown. 3. Record review for Resident #152 revealed a readmission date of 04/23/25. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #152 was moderately cognitively impaired and had diabetes mellitus (DM). Review of the physician orders for Resident #152 revealed an order dated 04/24/25 for insulin lispro inject 10 units subcutaneous (SQ) before meals related to DM, and hold if the blood sugar under 150. Observation on 05/13/25 at 11:21 A.M. revealed Licensed Practical Nurse (LPN) #549 placed disposable gloves on, entered Resident #152's room and assessed Resident #152's blood sugar via fingerstick. LPN #549 then returned to the medication cart, did not remove her gloves or wash her hands, documented the blood sugar results in the electronic documentation system, returned to Resident #152's room with the insulin and administered the insulin. LPN #549 then removed her gloves, returned to the medication cart. LPN #549 confirmed she left Resident #152's room wearing her gloves, documented in the computer with the gloves on, returned to the room with the same gloves and administered the insulin leaving the room once again without washing her hands or using hand sanitizer at any time during the observation. Review of the facility policy titled Enhanced Barrier Precautions revised 07/13/22 revealed EBP referred to the use of gown and gloves for certain residents during specific high contact resident care activities that have been found to increase the risk for transmission of multi-drug resistant organisms. Masks, gowns and gloves available immediately outside of the residents room. High contact resident care activities include providing hygiene and device care including central lines. Review of the facility policy titled Hand Hygiene revised 12/01/21 revealed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Indications for use included between resident contacts, before performing resident procedures, after assisting with personal body functions, before applying or after removing PPE including gloves, before preparing or handling medications, and after handling items potentially contaminated with blood or body fluids. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Review of CDC guidance titled Clinical Safety: Hand Hygiene for Healthcare Workers found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html and dated 02/27/24 revealed hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of deadly germs to patients. Recommendations included on know when to wear (and change) gloves stated gloves are not a substitute for hand hygiene. If your tasks requires gloves, perform hand hygiene before donning gloves and touching the patient or the patients surroundings; always clean your hands after removing gloves. When to change gloves and clean hands included if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if clinical indication for hand hygiene occurs, and before exiting a patient room.

Based on residents' interview, staff interview, and review of the facility policy, the facility failed to ensure residents received mail on the weekends. This had the potential to affect residents residing in the facility. The facility census was 54. Findings include: Interviews on 05/14/25 at 1:05 P.M. during resident council meeting with Residents #4, # 7, #13 and #34 revealed mail was not delivered on the weekends, only Monday through Friday. Interview on 05/11/24 at 11:13 A.M. with Activities Director (AD) #515 verified resident mail is not always delivered on the weekend. AD #515 further stated that the manager scheduled on the weekend should be delivering the residents their mail during the weekend. Review of the policy Resident Rights revealed the resident had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident thought a means other than a postal service including privacy of such communication consistent with this section, and access to stationary, postage, and writing implements at the resident's own expense.

Based on medical record review, observation, staff interview and policy review, the facility failed to supervise Resident #14, who had a known history of self-injurious behaviors and failed to ensure potentially harmful items were safely stored resulting in ongoing Immediate Jeopardy for Resident #14. The facility also failed to provide the necessary supervision to prevent Resident #1, who had [DIAGNOSES REDACTED].#1. This affected two of six residents reviewed for supervision. The facility census was 64. On 06/30/14 at 3:55 P.M. the administrator, regional administrator (RA) #2 and regional nurse (RRN #1) were informed of continued noncompliance at F323 and ongoing Immediate Jeopardy that began on 06/22/14 when Resident #14 who was assessed to require one on one (1:1) supervision and had a history of [REDACTED]. On 06/30/14 observations revealed Resident #14 not being provided required one on one (1:1) supervision and unsecured razors, scissors and a wire hanger were accessible to the resident. In addition, Immediate Jeopardy existed on 06/22/14 at 6:15 P.M. for Resident #1 who was identified as requiring increased supervision, after multiple attempts, eloped from the facility and was found by local emergency medical services in a field a half mile from the facility with multiple abrasions and a laceration requiring sutures. The Immediate Jeopardy was removed on 07/07/14 at 9:00 A.M. when the facility implemented the following corrective actions: ? On 06/30/14 the Wanderguard default code was changed by the fire alarm company; ? On 06/30/14 small group discussions were initiated with direct care staff by RN #5 and the RA #2. Topics included responsibility of every 15 minute checks, proper documentation of supervision, what is 1:1 supervision, room sweep procedure, and handling resident behaviors. The small group discussions included slides, copies of the facility's 1:1 policy and procedure with a revision date of 06/23/14 and time for questions and answers; ? On 07/01/14 Resident #14 was discharged from the facility; ? On 07/01/14 Resident #1 was provided 1:1 supervision according to the facility procedure; ? On 07/02/14 Resident #1 discharged to a facility with a secured dementia unit; ? On 07/03/14 all staff in-service training on 1:1 supervision; every 15 minute checks and elopement risks was completed; A team of supervisory staff to cover all shifts was implemented. Additional aides were scheduled on units where 1:1 supervision was required. ? Interviews with staff across all shifts including two registered Nurses (RNs) #51 and #3, three Licensed Practical Nurse (LPNs) #6, #9, and #1 and 12 State tested Nurse Aides ( STNAs) #12, #10, #4, #26, #21, #34, #9,#29, #25, #14, #28 and #11 revealed they were knowledgeable regarding 1:1 supervision, every 15 minute checks, elopement risks, securing hazardous items policy and procedures and accurate documentation. ? During observations on 07/03/14, 07/04/14, 07/05/14, 07/06/14 and 07/07/14 the surveyor observed all utility rooms were locked, there were no hazardous items observed in the shower rooms or any other resident areas, 1:1 supervision and every 15 minute checks were maintained per facility policy and procedure, supervisory staff was visible and providing direction to the staff. Although the Immediate Jeopardy was removed when the facility established systems to ensure supervision was maintained, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) because the effectiveness of the auditing tools and facility plans for ongoing quality assurance and monitoring had not been verified. Findings Include: 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the pre-admission screening and resident review dated 12/13/13 revealed a psychiatric history including suicide attempts and other violence. Resident #14 was previously hospitalized at a local psychiatric unit due to symptoms of increased auditory hallucinations, paranoia, delusions and an altercation with another resident after breaking windows. Within the previous 30 day time frame, Resident #14 experienced feelings of hopelessness, suicidal thoughts, disorganized behavior, delusions, hallucinations, paranoia, anxiety/worry, restlessness, verbal aggression, physical aggression, combative behaviors, destructive behaviors toward others, inappropriate communication of anger, self-injurious/self-abusive behaviors and distrust. The recommendations included room security sweeps and behavior management. The assessment identified continued room security sweeps to maintain his safety and security. Review of the most recent comprehensive assessment minimum data set (MDS 3.0) dated 05/05/14 identified moderate cognitive impairment and behavioral symptoms directed towards others. Physician orders [REDACTED].#14 was to have room sweeps as indicated and 15 minute checks for resident safety due to self-inflicted injury and suicidal ideation. Review of the plan of care related to suicidal ideation dated 02/19/14 revealed a history of self-mutilation. Interventions to keep the resident safe included giving silverware to staff after meals, providing positive affirmations, providing 15 minute checks, staying with the STNA for supervision, searching Resident #14's room and removing any sharp items that could be used to inflict self-harm, smoking material should be kept at the nurses ' station, room sweeps as indicated, and attempt non-pharmacological interventions such as one to one. Review of the medical record revealed Resident #14 made two separate suicide attempts while at the facility. On 04/28/14 at 2:40 A.M. the resident cut his throat with a razor because no one would give him a cigarette. On 05/21/14 at 1:00 A.M., the resident was found with a metal clothes hanger around his neck. All metal hangers were removed, a room sweep was completed and 15 minute checks were implemented. Further medical review revealed on 06/09/14, the facility implemented 1:1 supervision for the resident to protect him from self-injurious behaviors. Review of nurses notes dated 06/22/14 at 3:00 A.M. revealed Resident #14 had a lighter and cigarettes on his person. When confronted over the lighter and cigarettes, Resident #14 stated he "was going to kill himself and take everyone with him." There was no evidence 1:1 supervision was being provided. Observation on 06/30/14 with LPN #2 at 9:25 A.M., revealed a wire hanger on a grab bar in the south side common shower room accessible to Resident #14. Observation on 06/30/14 at 9:30 A.M., revealed Resident #14 entering the activity room from the outdoor smoking area. He was in a wheelchair that he easily maneuvered. He was alert and oriented and his speech was clear. Observation on 06/30/14 at 9:35 A.M. revealed a small room on the South hall unlocked and unattended. Upon entering the room, four disposable razors were observed on a desk and a drawer to the desk contained a pair of large scissors and a lighter. Interview with STNA #50 at that time revealed this room was called the "shower room" and she always left the shower room unlocked when she was working on the South hall, because she was "right there." However, STNA #50 verified she could not visualize the shower room when she was in a resident room. Interview with STNA #12 on 06/30/14 at 9:40 A.M. revealed she was assigned to care for Resident #14 who required 1:1 supervision. STNA #12 indicated this meant supervision and eyes on the resident at all times. However, if Resident #14 was in his room she could leave to attend other residents. His door was to remain open at all times and she needed to stay within hearing distance. In addition to being assigned to the 1:1 supervision of Resident #14, she was assigned to six additional residents that resided on the North Short Hall. Interview with LPN #7 on 06/30/14 at 9:45 A.M. confirmed Resident #14 required 1:1 staff supervision. LPN #7 indicated this meant staff was to stay with him at all times or be within hearing distance. If the resident was in his room, the staff assigned to the 1:1 supervision was to stay close to the room. LPN #7 confirmed STNA #12's assignment included caring for Resident #14 and the additional six residents on the North Short Hall. Observation during the interview with LPN #7 revealed STNA #12 standing at the nurse ' s station while Resident #14 was alone in his room. Observation also revealed the smoke doors to the North Short Hall where Resident #14's room was located were closed. The nurse ' s station and Resident #14's room were located on opposite sides of the closed smoke doors. Review of the facility's resident 1:1 supervision policy and procedure dated 06/23/14 revealed a resident on 1:1 supervision could be in their room for privacy but the staff member should be able to "view" the resident from nearby location. An example included sitting outside of the door if the resident was inside the room sleeping. When a resident was awake, staff was responsible for staying with the resident as they moved around the facility from location to location. The person assigned to the resident was to transfer the 1:1 supervision to another staff person if they would not be with the resident, such as breaks, meals or end of shift. A follow up interview with STNA #12 on 06/30/14 at 2:15 P.M. revealed during resident smoke breaks, she provided supervision to Resident #14 and three additional residents. While Resident #14 was at lunch, she left him alone in the dining room while she completed a safety sweep of his room. STNA #12 said her assignment included meeting the care needs of all the residents on the North Short Hall. STNA #12 had a Walkie-Talkie to contact additional staff if needed in an emergency. If there was a problem with another resident, she would leave Resident #14 unattended until additional staff arrived. STNA #12 was responsible for the 1:1 supervision of Resident #14, the transfer of one resident who required a mechanical lift, and she was to complete three showers during her shift. STNA #12 said that was a " typical day. " When STNA #12 was in the shower with a resident, the North Short Hall was left unattended. STNA #12 denied staff from another unit was assigned to assist her throughout the day. Review of staffing schedules from 06/23/14 through 06/30/14 with Staffing Scheduler #1 on 07/01/14 at 11:35 A.M. revealed one staff member was assigned to work on the North Short Hall on each shift for the dates of 06/23/24, 06/25/14, 06/26/14/, 06/27/14 and 06/28/14. On 06/24/14 one person was scheduled on each shift except on the night shift from 10:00 P.M. until 2:00 A.M. when there were two STNAs assigned. Staffing Scheduler #1 revealed one staff member assigned to the North Long Hall was to provide assistance to the STNA assigned to work on the North Short Hall when needed. The STNAs were to decide amongst themselves who would provide the assistance. There was no documentation to indicate which STNA took on the additional responsibility of assisting the STNA assigned to the North Short Hall. 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Wandering Risk Evaluation dated 06/18/14 revealed Resident #1 was confused to person, place and time and wandered aimlessly. The evaluation also revealed Resident #1 had a Wanderguard bracelet (triggers an alarm if a selected door is opened) in place to his right ankle. Review of physician orders [REDACTED].#1 was to wear a Wanderguard to his ankle to alert staff of attempts to exit the facility unattended. The order indicated to check placement of the Wanderguard every shift and to check the function of the Wanderguard every week. Review of Resident #1's initial care plan dated 06/18/14 revealed interventions including a Wanderguard at all times and every 15 minute checks for 24 hours. Review of a nurse's note dated 06/21/14 at 6:06 P.M. revealed Resident #1 attempted to leave the building several times. Review of a nursing assessment dated [DATE] at 10:46 A.M. revealed Resident #1 was disoriented, short tempered, wandered and was independent with ambulation. Review of a facility investigation summary dated 06/22/14 revealed Resident #1 exited the facility at 11:45 A.M. via the therapy entrance. The door alarmed. STNA #50 responded to the alarm, found the resident in the parking lot and returned the resident to the facility. The conclusion of the investigation revealed the facility's immediate intervention was to show Resident #1 how to get to the enclosed courtyard and staff was instructed to be aware of the resident's location. Review of a witness statement written by STNA #50 revealed Resident #1 went out the door and set the alarm off. STNA #50 ran out the door after Resident #1. Resident #1 was " half way across the parking lot. " Resident #1 hit STNA #50 and told her he was leaving West Virginia and going to Rittman to find his wife. Review of a second facility investigation summary dated 06/22/14 revealed Resident #1 exited the building again, this time via the front entrance sometime between 4:30 P.M. and 4:45 P.M. The door alarmed. RN #51 responded to the alarm, found Resident #1 in the grass field next to the building and returned the resident to the facility. The conclusion of the investigation revealed the facility's immediate intervention was to take Resident #1 to the dining room for dinner and staff was instructed to be aware of the resident's location. Review of a third facility investigation summary dated 06/22/14, revealed at 6:15 P.M. staff was unable to locate Resident #1. Various facility staff searched the facility grounds and could not locate Resident #1. Local emergency medical services (EMS) found the resident approximately one half mile from the facility in a field. EMS took Resident #1 to the local emergency room for an evaluation. Resident #1 was returned to the facility at 9:30 P.M. Resident #1 returned to the facility with a laceration to his finger and " some scratches." The investigation summary indicated another resident, Resident #4, heard the door alarm sound and entered the code to disarm the alarm. No facility staff checked the door or outside after the alarm sounded. Review of a nurse's notes dated 06/22/14 revealed at 12:49 A.M. Resident #1 attempted to exit the building and enter other resident rooms. The Wanderguard bracelet was present and functional. At 3:07 P.M. Resident #1 tried to exit the facility multiple times. He was redirected with difficulty, he was slapping the staff. The Wanderguard bracelet was on and working. Resident #1 was very confused, looking for his wife. At 4:56 P.M. Resident #1 was restless at the dinner meal. He was last observed in the activity room at 5:45 P.M. At 6:10 P.M. the resident could not be located in the facility. The search was extended. The administrator and the police were notified. EMS called the facility at 7:30 P.M. and reported they found Resident #1 and were taking the resident to the emergency room for evaluation. Review of the EMS Run Report dated 06/22/14 revealed they were called on 06/22/14 at 6:34 P.M. for a missing person with dementia. The person/resident tried to get out earlier in the day as well. This time resident was able to bypass the alarm. Per dispatch the facility waited 40 minutes to call and report resident was missing. A farm owner called to report a male seen in their barn that fit the description of the missing person/resident. The person/resident was confirmed as the missing resident at 7:27 P.M. Upon arrival the resident was alert with skin tears to elbows and laceration to right ring finger. The resident was transported to the hospital. Review of a witness statement dated 06/22/14 and written by RN #51 revealed Resident #1's Wanderguard device was checked at 4:45 P.M. and the resident was last observed at 5:45 P.M. in the activity room. RN #51 revealed an extensive search was started at 6:10 P.M., when Resident #1 was not found in the halls or the courtyard. Review of a witness statement dated 06/22/14 and written by STNA #13 revealed " last time I saw (Resident #1) was in the dining room getting upset, saying his wife was getting murdered and he needed to go to West Virginia. I told him it didn ' t happen and redirected him; he got mad and left the dining room." STNA #13 also documented Resident #1 " has been very aggressive today and wandering a lot." Review of a witness statement dated 06/22/14 and written by STNA #21 revealed "Resident was saying wife was dead and he needs to get a ride to West Virginia. Resident was walking around and got out of doors. I last seen resident about 5:30 P.M. in the courtyard." STNA #21 indicated she started to look for Resident #1 around 6:00 P.M. and she did not hear an alarm go off. Review of a witness statement dated 06/22/14 and written by LPN #5 revealed on 06/22/14, LPN #5 arrived at the facility at 5:53 P.M. After LPN #5 received report from the day shift nurse, LPN #5 was unable to find Resident #1 in the building. LPN #5 alerted the facility staff by paging overhead and called the Administrator, the police and the Director of Nursing. LPN #5 searched the nearby neighborhood on foot until he received notification indicating Resident #1 was found and on his way to the hospital. Review of a witness statement dated 06/22/14 and written by STNA #23 revealed Resident #1 was in the dining room at the dinner meal on 06/22/14. Resident #1 stated his wife was murdered, he needed to go to West Virginia and he needed a ride. STNA #23 indicated a nurse later asked where Resident #1 was and then went out looking for him. STNA #23 revealed she did not see Resident #1 leave the building. STNA #23 revealed she heard the courtyard alarm sound, did not see Resident #1 so she turned the alarm off. Review of the nurse ' s note dated 06/22/14 at 10:14 P.M. revealed Resident #1 returned to the facility at 9:30 P.M. via an ambulance. Review of a Nursing assessment dated [DATE] (no time) revealed three wounds. The wounds were documented as follows. The right fourth finger had six sutures. The right elbow had a skin tear measuring 1.5 centimeters (cm) by 1.1 cm. The left elbow had a skin tear measuring 2.4 cm by 1.6 cm. Each wound was documented as identified on 06/22/14. Review of an untitled document dated 06/23/14 and written by the administrator revealed Resident #4 was interviewed. Resident #4 was questioned if he had knowledge of the Wanderguard pass code and if he reset the door alarm on 06/22/14. Resident #4 admitted to the administrator that he did turn off the alarm on 06/22/14. Resident #4 indicated he did not see a resident go out the door; he just wanted to help the staff by turning off the alarm. This document did not address how Resident #4 received the alarm pass code. The administrator also documented the fire alarm company would be out the next week to change the pass code. Observation and interview with Resident #1 on 06/30/14 at 10:30 A.M. revealed Resident #1 was lying in bed. An abrasion was noted to his right forearm. When asked how he sustained the injury, he said he was out running in the woods. He showed the surveyor other injuries he sustained while out in the woods. Resident #1 had multiple healing skin tears and abrasions to both arms and legs. He had a large purple bruise about the size of the surveyor's hand to the left posterior thigh and posterior knee area. Observation of Resident #1 on 06/30/14 at 11:00 A.M. revealed he had a slow steady gait. He had a Wanderguard bracelet on his right ankle. Resident #1 said he was lucky he did not break a leg but was unable to indicate when and where he could have broken his leg. He was alert to self but confused to time, person, place and situation. Interview with the administrator on 06/30/14 at 2:20 P.M. verified the code to the doors had not yet been changed. The administrator revealed the fire alarm company was expected to change the code sometime this week. Interview with RN #51 on 06/30/14 at 3:38 P.M., revealed Resident #1 was oriented to self and his family members and confused to time and place. On 06/22/14 he mentioned " church. " She assumed he wanted to go to church. Before lunch she heard an alarm going off, RN #51 and two STNAs responded to the alarm. Resident #1 had exited via the therapy door and was in the parking lot. One of the STNAs walked him around for a little while and brought him back in. Then sometime between 3:30 P.M. and 3:45 P.M. the alarm went off again. Resident #1 had exited via the front door; he was about 50 feet off, in the yard to the left of the facility. Resident #1 was more agitated at this time. He was taken to the dining room for supper. He stayed in the dining room well past 5:30 P.M. sitting with a STNA. At 5:50 P.M. Resident #1 was standing at a medication cart near the nurse ' s station. Someone asked if they could go out, this person was not staff and RN #51 could not be sure who it was. The person was told he could go out to the courtyard. Shift change came, RN #51 was very busy trying to complete new admission paper work and giving report. During report, an alarm went off, but it was not the outside alarm, it was the courtyard alarm. LPN #5 (the night shift nurse) said "we better look for our folks". They looked everywhere inside the building and could not find Resident #1. Interview with Resident #4 on 07/01/14 at 8:30 A.M. revealed he remembered the day Resident #1 got out of the facility and staff could not find him. He said the resident "walked out the front door." Resident #4 said he could not recall if the door alarmed when Resident #4 walked out. Resident #4 confirmed he knew the code to disarm the alarm but said he had no reason to use it because he could come and go as he wanted. Resident #4 said lots of residents knew the code. When asked if he silenced the alarm the day Resident #1 walked out the front door, he said he could not remember for sure but he "might have." Resident #4 said he learned the code from watching staff use it every day, "someone was always trying to get out of the facility." Resident #4 said he knew it was unsafe for some residents to leave the facility; they could get out on the highway and get killed. Interview with LPN #5 on 07/01/14 at 3:50 P.M. revealed his shift began at 6:00 P.M. on 06/22/14. After receiving report from RN #51, LPN #5 told the STNAs he wanted "eyes on the residents." There were no alarms sounding but the facility had several residents that were elopement risks and Resident #1 had verbalized that he wanted to go home the previous day. LPN #5 said he wanted to begin his shift knowing all residents were present. The STNAs reported back to him they could not locate Resident #1 and he immediately initiated the elopement protocol. Review of the facility ' s undated Elopement Policy and Procedure revealed when a resident was deemed missing the nurse on the unit made an overhead page, the staff was notified of who the resident was, the nurse contacted the administrator, the DON and the resident ' s physician. The DON notified the resident ' s family and the police department. Search of the interior and exterior grounds would follow. After the administrator and the DON arrived at the facility, the search would expand beyond the facility grounds. Once the resident was located, first aid would be rendered and the resident would be returned to the facility. The police, administrator, DON, the resident ' s family and physician would be notified and an " all clear " would be made on the overhead page. This deficiency substantiates complaint #OH 344. This deficiency is an example of continued non-compliance from the annual survey dated 06/10/14.

Based on observation, medical record review, policy review, and staff interview, the facility failed to supervise one resident with a known history of self-injurious behaviors who lacerated his throat with a disposable razor requiring medical intervention. This resulted in Immediate Jeopardy for one resident (#14) of five residents reviewed for supervision. The facility census was 65 residents. On 06/06/14 the administrator and the director of nursing (DON) were informed Immediate Jeopardy began on 04/28/14 at 2:40 A.M. when Resident #14 was not supervised and lacerated his throat using a disposable razor. Resident #14 was transferred to a local hospital for treatment. Police were called to the facility at the time of the incident and discovered a broken razor, a clear tube with an attached needle, and two cigarette lighters in Resident #14's pockets. The Immediate Jeopardy continued on 05/21/14 at 1:00 A.M. when Resident #14 was unsupervised and found with a metal clothes hanger around his neck. The Immediate Jeopardy was removed on 05/21/14 when the facility implemented the following corrective actions: ? On 04/28/14 and 04/29/14 the assistant director of nursing (ADON) began inservicing nursing staff on suicide attempts/ideations. ? On 05/21/14 after Resident #14's incident at 1:00 A.M. all metal hangers were removed and a room sweep completed. Also, there was evidence of 15 minute checks implemented for Resident #14. ? The facility had evidence room sweeps were completed daily from 05/21/14 after the incident to 06/09/14 and 15 minute checks were completed daily for Resident #14. ? On 06/04/14 through 06/06/14 the facility began training on the facility's room sweep policy and on behavior management for the north hall nursing staff. Although the Immediate Jeopardy was removed on 05/21/14 when room sweeps were implemented for Resident #14 and additional supervision was provided, the facility remained out of compliance at Severity Level 2, (no actual harm with the potential for more than minimal harm that was not immediate jeopardy) as the facility had not completed training for all facility staff related to the room sweep policy. Findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the pre-admission screening and resident review dated 12/13/13 identified a psychiatric history including suicide attempts and other violence. Resident #14 had been hospitalized at a local psychiatric unit due to symptoms of increased auditory hallucinations, paranoia, delusions and an altercation with another resident after breaking windows. Within the previous 30 day time frame, Resident #14 experienced feelings of hopelessness, suicidal thoughts, disorganized behavior, delusions, hallucinations, paranoia, anxiety/worry, restlessness, verbal aggression, physical aggression, combative behaviors, destructive behaviors toward others, inappropriate communication of anger, self-injurious/self-abusive behaviors and distrust. The recommendations included room security sweeps and behavior management. The assessment identified continued room security sweeps to maintain his safety and security. Review of the comprehensive admission assessment (MDS 3.0) dated 02/28/14 identified moderate cognitive impairment. The physician orders [REDACTED].#14 was to have room sweeps as indicated and 15 minute checks for resident safety due to self-inflicted injury and suicidal ideations. Review of the plan of care related to suicidal ideation and history of self-mutilation included giving silverware to staff after meals, providing positive affirmations, providing 15 minute checks, staying with the STNA for supervision, searching Resident #14's room and removing any sharp items that could be used to inflict self-harm, room sweeps as indicated, attempting non-pharmacological interventions such as one to one, change in position or scenery, bargaining, offer of food or fluids, redirection, activities of choice, and toileting. According to the nursing note dated 04/28/14 at 2:40 A.M. STNA #26 reported to LPN #24 that another resident told her Resident #14 "sliced" his throat. LPN #24 noted Resident #14 was sitting outside in the enclosed courtyard. Resident #14 told the nurse he slit his throat because no one would give him cigarettes. The nurse noted a laceration to the right side of Resident #14's neck and center of the neck from below the chin to the chest area. Resident #14 refused treatment unless he could have a cigarette. The police and emergency squad were notified and arrived at 3:00 A.M. Resident #14 was searched by the police. The police found a piece of a disposable razor in Resident #14's pocket, a clear tube with an attached needle, plus some lighters. According to the nurse's note, Resident #14 agreed to go to the hospital for treatment stating "put a gun to my head and kill me". Resident #14 agreed to go to the hospital for treatment on 04/28/14 at 4:00 A.M. Resident #14 returned to the facility on [DATE] at 5:59 A.M. Six Steri strips (an adhesive strip to close small wounds) were used to close the wound at the hospital. On 05/12/14 at 9:38 A.M. the ADON was informed of Resident #14's complaints of pain. She indicated to the surveyor that she was very familiar with the resident because she worked with him for the last 4-5 years at another facility. She indicated he was doing better at this facility because there was less commotion here. The ADON indicated Resident #14 had a history of [REDACTED]. She indicated he had a history of [REDACTED]. The ADON indicated there had been no further incidents of self-harm using a razor. On 05/13/14 at 10:00 A.M. Resident #14 was observed with a dark red linear scabbed area across the front right part of his neck. Interview with the administrator with the DON present on 05/13/14 at 4:15 P.M. affirmed some of the residents on the North short hall were on one to one supervision especially when off the North short hall. The administrator verified when one STNA was with multiple residents for the smoke break, one to one supervision was not performed. The facility provided documentation the shower rooms were checked every two hours beginning 04/29/14. During the environmental tour of the facility on 05/13/14 at 12:42 P.M. the surveyor entered the unlocked North common shower room and a used disposable blue razor was observed on the sink. Further record review revealed there was no documented evidence room sweeps were completed as indicated for Resident #14 until the incident on 04/28/14. Further review of the medical record on 06/06/14 revealed Resident #14 continued to display self-injurious behaviors as evidenced by the following nursing notes: On 05/21/14 at 1:00 A.M. Resident #14 was found to have a metal clothes hanger around his neck. STNA #27 removed the hanger and completed a room sweep. All other metal hangers were removed from his room. LPN #28 completed a skin check and found no issues. Interview with STNA #25 on 06/06/14 at 5:45 P.M. revealed she was the only STNA assigned to the unit. She stated there were 10 males residing on the unit. She stated although one to one supervision had been discontinued, eight residents were on 15 minute checks including Resident #14. Observations on 06/06/14 and 06/09/14 throughout the day revealed no hazardous items were found in resident rooms or the bathrooms. The facility did have a room sweep/checks policy and procedure dated September 2013. Review of this procedure included guidelines for room sweep/checks indicated the following: the staff person member should be informed of what was being looked for: examples included a lighter, cigarettes, specifically stated objects such as sharp objects, weapons, etc., areas listed to be checked included closets.