Every finding on record at Avenue Care and Rehabilitation Center, The

Based on record review, observation, and interview, the facility failed to ensure edema treatments were completed as ordered. This affected one resident (Resident #37) of five residents reviewed for quality of care. The total census was 79.Findings include:Review of Resident #37's medical record revealed he was admitted [DATE] and had diagnoses including right knee arthritis, hemiplegia affecting the right side, and muscle weakness. He had a physician order dated 07/22/26 for the right leg to be wrapped with an ACE bandage (used as a compression bandage) from foot to knee from 6:00 A.M. to 5:00 P.M. daily, which was documented as completed for 08/10/26 at 6:00 A.M. A progress note dated 07/26/26 revealed he had moderate edema to his bilateral lower extremities. Observations of Resident #37 on 08/10/26 at 8:40 A.M. and 11:13 A.M. revealed his lower legs appeared swollen, and he was not wearing ACE bandage wraps. Interview at the time of the observation with Resident #37 revealed no one had asked to get his wraps on this morning and he wanted them on. He then stated staff did not regularly apply his ACE wraps. Interview with Registered Nurse #412 on 08/10/26 at 11:00 A.M. confirmed the above findings.

Based on record review, interviews, and facility policy review, the facility failed to ensure adequate bathing was provided and as resident preferred. This affected two residents (Resident #73 and #81) of three residents reviewed for showers. The facility census was 79.Findings include:1. Review of the medical record for Resident #73 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, dependence on dialysis, and asthma.Review of the care plan dated 04/24/26 revealed Resident #73 had an activity of daily living (ADL) self-care performance deficit with interventions that included providing a bed bath and/or shower as necessary.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. Resident #73 was impaired on one side of her upper extremities and required some assistance from staff for ADLs.Review of the current tasks for ADLs revealed Resident #73 was to receive a shower and/or bed bath as necessary. Review of the bathing task revealed no showers and/or bed baths were provided.Request for Resident #73's shower/bathing sheets for the last 30 days (07/11/26 to 08/11/26) revealed no documented showers and/or bed baths were provided.Interview on 08/11/26 at 10:30 A.M. with Resident #73 revealed she only received showers when there were decent aides working. She did not always get showers as she preferred. Certified nursing assistants (CNAs) rushed through her care when it was provided and only a select few CNAs completed their tasks during their 12-hour shifts.2. Review of the medical record for Resident #81 revealed he was admitted to the facility on [DATE] with diagnoses that included sepsis, end stage renal disease, and dependence on renal dialysis. Resident #81 discharged from the facility on 06/06/26.Review of the care plan dated 05/08/26 revealed Resident #81 had an ADL self-care performance deficit with interventions that included providing a bed bath and/or shower as necessary.Review of the MDS assessment dated [DATE] revealed Resident #81 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #81 required some assistance from staff for ADLs.Review of the resolved tasks for ADLs revealed Resident #81 was to receive a shower and/or bed bath on Tuesdays and Thursdays.Review of the shower sheets dated 05/07/26 through 06/06/26 revealed Resident #81 received two showers, one on 05/16/26 and the other on 06/04/26, throughout his time in the facility, a period of approximately 30 days.Interview on 8/11/26 at 10:49 A.M. with CNA #408 revealed sometimes residents went without showers due to low staffing. CNAs worked 12-hour shifts, but the night shift staff did not always complete showers and/or bed bath tasks, leaving day shift to be overloaded with resident care needs. Nurses often signed off on shower sheets although the task was not completed. CNA #408 confirmed and verified the above findings for Residents #73 and #81 at the time of the interview.Interview on 08/11/26 at 12:30 P.M. with Director of Nursing (DON) revealed residents received showers as needed and preferred. However, the DON was unable to provide documentation related to Resident #73's showers and/or bed baths for the last 30 days. DON confirmed and verified the above findings for Residents #73 and #81 at the time of the interview.Review of facility policy titled, Bathing-Personal Care, revised August 2022, revealed the facility had a policy in place to offer showers and/or bed baths twice a week, as needed and as often as the resident would like per choice to promote dignity, cleanliness, and general well-being. This deficiency represents non-compliance investigated under Complaint Number 3030614.

Based on interview and review of the Ohio e-licensure verification website, the facility failed to ensure nursing staff had an active nursing license. This had the potential to affect all residents residing in the facility. The facility census was 83.Findings include: Interview on 12/09/25 at 9:12 A.M. with the Administrator revealed the former Director of Nursing (DON) had resigned and Registered Nurse (RN) #256 assumed the role of Interim DON in October 2025.Review of the Ohio e-licensure verification website (https://elicense.ohio.gov/oh_verifylicense) on 12/10/25 at 7:11 A.M. revealed Interim Director of Nursing (DON)/RN #256's license was inactive, it had lapsed, with a listed expiration date of 10/31/25. Interview on 12/10/25 at 9:42 A.M. with Interim DON/RN #256 revealed she had been the Interim DON since October 2025 following the previous DON's resignation. Interim DON #256 stated her nursing license was current and she exited the room.Review of the Ohio e-licensure verification website on 12/10/25 at 10:20 A.M. with the Administrator confirmed the Interim DON/RN #256's nursing license was inactive and had lapsed. The Administrator stated she was unaware her nursing license was inactive and stated she had posted a notice at the time clock a few months ago to remind Registered Nurses of the renewal deadline.Interview on 12/10/25 at 12:32 P.M. with Human Resources (HR) #226 revealed she had placed a renewal reminder for RN's at the time clock on 08/19/25. HR #226 stated approximately a week prior to the deadline of 10/31/25, she noted the Interim DON/RN #256 had not renewed her nursing license and stated she had called her into her office and had assisted her with completing the license application. HR #226 stated the Interim DON/RN #256 had completed the application and stated she had to obtain a credit card from her car to pay the required fee for the application. HR #226 stated she had not followed up with the Interim DON/RN #256 and had not been aware the application had not been completed. HR #226 confirmed the Ohio e-licensure verification website had indicated the Interim DON/RN #256's nursing license was inactive and had lapsed.Review of the Ohio Administrative Code Chapter 4723-7, effective 01/01/18, revealed a registered nurse who does not renew a license to practice nursing on or before October thirty-first of odd numbered years and who has not requested inactive status, shall have a lapsed license. A licensee who continues to practice nursing in Ohio with an inactive or lapsed license shall be subject to disciplinary action under the Ohio Revised Code. This deficiency represents an incidental finding identified during the complaint investigation.

Based on interview, observation and review of photographs, the facility failed to ensure timely colostomy care was provided to residents. This affected one resident (#73) of one resident reviewed for colostomy care. The facility identified only one resident (#83) in-house with an ostomy. The facility census was 83.Findings include: Review of Resident #73's medical record revealed an admission date 11/03/25. Diagnoses included rectal cancer and enterostomy (surgical opening from the intestine through the abdominal wall to allow drainage of intestinal contents).Review of the care plan dated 11/10/25 revealed Resident #73 had an ileostomy related to colon cancer. Interventions included for staff to assist Resident #73 with toileting needs as needed, check and change on care rounds and as needed, and to complete ostomy care per orders.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had intact cognition and had an ostomy for stool elimination. Review of Resident #73's current physician orders for December 2025 revealed an order for staff to empty the resident's ostomy every shift and as needed and change the ostomy appliance every week and as needed.Interview on 12/09/25 at 9:41 A.M. with Resident #73 revealed a few weeks ago she had put her call light on for assistance with her colostomy bag that had burst open. Resident #73 stated a nurse (unknown name) had come in and had turned her call light off and had not provided her with care. Resident #73 stated she had continued to be covered in stool from her colostomy and she had begun to yell out for help and no one had come in and she had called a family member at that time. Resident #73 stated her family member had come to the facility shortly after and had observed her covered in stool and had taken photos at that time. Resident #73 stated she had been covered in stool for at least two hours without receiving any assistance from staff. Resident #73 stated her colostomy bag burst open often because staff did not empty, burp (expel air from the colostomy drainage bag), or change it timely. Observation of Resident #73's colostomy bag at the time of interview revealed the bag was approximately half full of liquid stool. Telephone interview on 12/09/25 at 10:41 A.M. with Resident #73's family member revealed on 11/20/25 at approximately 5:00 P.M., she received a call from Resident #73 who had been upset and crying because she had been lying in her stool for several hours. Resident #73's family member stated she immediately arrived at the facility and observed Resident #73 covered in stool. The family member stated she had taken photos at that time before she cleaned Resident #73 up and then had proceeded to speak with the unit manager about what had occurred. Resident #73's family member reported the unit manager had stated she would address the concerns, however the issue had still been occurring. At time of the telephone interview Resident #73's family member had provided photos. Review of photograph dated 11/20/25 timed 5:06 P.M. revealed a large amount of dried, liquid stool on Resident #73's gown and bedding and the resident's colostomy bag was not attached to Resident #73's abdomen. The family member provided permission to share the photograph with facility leadership. Observation on 12/09/25 at 12:50 P.M. revealed Resident #73 had a large amount of liquid stool covering her abdomen, her back and legs. Resident #73 stated no one had come in to care for or empty her bag since the last interview. At the time of observation, Registered Nurse (RN) #215 and RN #236 had entered and Resident #73 had informed them of what occurred. RN #215 and #236 then proceeded to assist Resident #73 with care. Interview on 12/10/25 at 9:42 A.M. with Interim Director of Nursing (DON) revealed she had been aware that Resident #73's colostomy bag had needed to be changed often due to it had been leaking, however she was unaware of concerns related to the bag not being emptied timely. The Interim DON was made aware of photo provided by Resident #73's granddaughter and Interim DON confirmed the photograph had what appeared to be dried stool on Resident #73 gown and sheets that indicated she had not been provided ostomy care timely.This deficiency represents non-compliance investigated under Master Complaint Number 2684078 and Complaint Number 2675296.

Based on observation, record review, interviews, and review of the facility assessment, the facility did not ensure staffing levels were sufficient to provide nursing and related services to maintain the highest practicable well-being of the residents. This affected four current Residents (#26, #34, #40, and #43) and one former resident (#84) of five residents reviewed for sufficient staffing and had potential to affect an additional 79 residents residing in the facility. The facility census was 83.Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 11/28/18 with medical diagnoses including cerebral infarction, hemiplegia affecting left side, aphasia (difficulty speaking), type two diabetes mellitus, vascular dementia and adjustment disorder.Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #26's cognition was moderately intact. Resident #26 was dependent on staff for toilet hygiene and did not attempt to transfer to the toilet. Resident #26 was always incontinent with bowel and bladder.Review of Resident #26's care plan, date initiated 10/19/19, revealed Resident #26 was incontinent of bowel and bladder with incontinence related to limited mobility. Interventions included check and change every two hours and as required for incontinence. Wash, rinse and dry perineum, and change clothing as needed after incontinent episodes.An observation on 10/29/25 at 2:44 P.M. revealed the call light was lit up/activated on the outside of Resident #26's door and could be seen lit up outside the door in the hallway. No staff were observed in the room with Resident #26 while the call light was activated until at 3:00 P.M. a female caretaker was observed to enter Resident #26's room, turned off the call light and stated to Resident #26 someone would be in soon. Observation at 3:00 P.M. of Resident #26 in her room revealed a smell of urine was in the room and Resident #26 stated she had been waiting a while to have her diaper changed. She stated she was sitting in a wet diaper and wanted to be changed. Observation at 3:12 P.M. revealed Certified Nursing Assistant (CNA) #340 entered Resident #26's room with linens to assist Resident #26 and verified this was the first chance they had to change Resident #26 since the call light was activated at 2:44 P.M.An interview on 10/29/25 at 3:12 P.M. with CNA #340 revealed the staffing levels made it difficult to get all the resident care done timely because so many residents needed to be fed and changed and were dependent on staff for care.2. Record review for Resident #34 revealed an admission date of 10/12/23. Diagnoses included visual loss of both eyes, acquired absence of the left leg below the knee and acquired absence of the right leg above the knee. Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 was always incontinent of bowel and bladder, required substantial/maximal assistance with bed mobility, was dependent for chair/bed to chair transfers, and for toileting hygiene. Review of the care plan for Resident #34 revealed Resident #34 had an activity of daily living (ADL) self-care performance deficit related to impaired balance and need for assistance for personal care. Interventions included the resident required assistance by staff for toileting. An interview on 10/28/25 at 10:10 A.M. with Resident #34 revealed sometimes she just got oaked with urine. When she called for assistance with incontinence care, staff would say they would be right back but then they don't come back for long periods of time if at all. Resident #34 revealed she was last changed at 6:20 A.M., and she stated she recalled the time because she looked at the clock, and it was before the 7:00 A.M. shift started. Resident #34 revealed that she had not been checked or changed since then and she needed changed. An interview on 10/28/25 at 11:00 A.M. with CNA #354 revealed she was running behind and confirmed she had just finished checking and changing Resident #34 for the first time on her shift. CNA #354 confirmed her shift started at 7:00 A.M. and revealed there was just not enough help. CNA #354 revealed Resident #34's brief was saturated and the pad under her was also wet with urine. Observation revealed CNA #354 applied new linen on Resident #34's bed and revealed she worked 12-hour shifts and at times residents were only checked and changed two times a shift. 3. Record review for Resident #40 revealed an admission date of 04/12/24. Diagnoses included unspecified hemiplegia affecting left non-dominant side and spinal stenosis of the cervical region. Review of the Modification of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 was always incontinent of bowel and bladder, required substantial/maximal assistants for bed mobility, was dependent for toileting hygiene and chair/bed to chair transfer. Review of the care plan initiated 04/14/24 and revised 08/18/25 revealed Resident #40 had a self-care deficit related to legally blind, limited mobility, and impaired cognition. Interventions included Resident #40 was dependent for toilet use. An interview on 10/27/25 at 10:16 A.M. with CNA #309 revealed there were not enough staff to check and change residents' or get them out of bed timely. CNA #309 revealed Resident #40 had not been checked or changed yet since the previous shift. Observation of Resident #40 with CNA #309 revealed Resident #40 was lying in bed. Resident #40 had a gauze wrap/dressing to the right leg. The bottom sheet near the dressing had multiple areas of dried blood. The dressing was dated 10/26/25 but had no blood on it. Resident #40 revealed when the staff help him, It's rush, rush, rush. Resident #40 revealed staff did not change him enough. An interview on 10/27/25 at 10:23 A.M. with Resident #40's wife revealed there was not enough staff to assist her husband timely, and at times while on the phone with him, she would have to call the facility to get assistance for him due to him asking her for help because the staff were not coming to change him.An observation on 10/27/25 at 10:30 A.M. of CNA #309 and #359 providing incontinence care for Resident #40 revealed Resident #40's brief was saturated with urine and stool. The stool was partially dried on Resident #40's skin. Resident #40 had a foul odor. Resident #40's abdominal fold, buttocks, upper thighs, peri area, and both arm pits were deep red. Resident #40 revealed the red areas of his skin were sensitive from sitting in urine and stool. Observation revealed the bed sheets, and the mattress Resident #40 was lying on had multiple food crumbs. CNA #309 and #359 verified the observations. An interview on 10/27/25 at 3:00 P.M. with Registered Nurse (RN) Regional Director of Clinical Operations #410 revealed residents' should be checked and changed every two to three hours. 4. Closed record review for Resident #84 revealed an admission date of 10/08/25 and a discharge date of 10/13/25. Diagnoses included sepsis due to enterococcus, altered mental status, dependance on renal dialysis, and adjustment disorder. Review of the Medicare five-day MDS 3.0 assessment dated [DATE] revealed Resident #84 was barely /never understood. Resident #84 had short- and long-term memory problems, was always continent of bowel and bladder, used a wheelchair and walker, had no impairment to the upper or lower extremities, required partial/moderate assistants with bed mobility, chair/bed to chair transfer, substantial/maximal assistants for toilet transfer and dependent for toileting hygiene. Review of the care plan for Resident #84 dated 10/08/25 revealed bowel and bladder incontinence care/catheter care. Interventions included toileting per request and as needed. An interview on 10/27/25 at 9:07 A.M. with Resident #84's Guarantor/Emergency Contact #1 revealed on Sunday, 10/12/25 from 2:00 P.M. until 8:00 P.M. Resident #84's family was at the facility with Resident #84. At 2:00 P.M. when they arrived, they asked for assistance from staff because Resident #84 was soiled. The nurse on the floor said she would be in soon. At 4:00 P.M. staff still had not come in to assist Resident #84. The nurse was again asked for assistance with care. No one came. Resident #84's Guarantor/Emergency Contact #1 revealed at 6:00 P.M she went and asked the nurse again and expressed again Resident #84 had urine and stool on her and required assistance. The nurse became upset and said, I am only one person, I cannot babysit your sister. Resident #84's Guarantor/Emergency Contact #1 revealed at that point her older aunt went and asked for supplies revealing they would change her themselves, and staff did not offer assistance. After receiving the supplies, they changed Resident #84 themselves. Resident #84's Guarantor/Emergency Contact #1 stated, The bed was so saturated it was a puddle of pee. The nurse said to put a cover over it. Resident #84's Guarantor/Emergency Contact #1 revealed she took pictures of the saturated bed. Resident #84's Guarantor/Emergency Contact #1 stated, The next morning she was again saturated in bed, I called the Assistant Director of Nursing (ADON #355) and Monday morning I had a meeting with her, and I showed her the pictures. Resident #84's Guarantor/Emergency Contact #1 confirmed it was ADON #355 she had spoken to about the lack of incontinence care for Resident #84. An interview on 10/27/25 at 4:49 P.M. with previous ADON #355 confirmed she was now the Interim Director of Nursing (DON). Interim DON confirmed she remembered Resident #84 and spoke with the daughter. Interim DON reviewed the five pictures provided by Resident #84's Guarantor/Emergency Contact #1. The first picture was a mattress with a blanket folded and lying in the middle of the mattress, the next was a saturated brief, and three remaining pictures were saturated bedding. Interim DON revealed she did see the same pictures with Resident #84's Guarantor/Emergency Contact #1 when they met on that day. Interim DON revealed it was not the level of care they strive for. The Licensed Practical Nurse (LPN) that worked that day was LPN #384. Interim DON revealed all the staff were given education after that, but nothing was written down. LPN #384 said she was going to get the supplies but by the time she did, the family had already changed her. Interim DON revealed the family did get supplies to change her; they just had to wait. Interim DON stated, I have had other families and residents express concerns about not getting checked or changed timely, I am sure the resident (Resident #84) was not changed timely, I saw the pictures, I spoke to the family, I spoke to the staff, it was clear she was not changed timely. Interim DON revealed residents 'should be checked and changed every two hours and as needed. An interview on 10/28/25 at 5:06 P.M. with CNA #309 revealed she cared for Resident #84. CNA #309 stated, She was continent, if we were busy, we would ask her to wait, she could hold it for about five minutes but not much longer or she would be incontinent, that's why we put a brief on her. Sometimes I came in in the mornings, she was soaked, saturated to the mattress. An interview on 10/28/25 at 5:08 P.M. with LPN #393 revealed he admitted Resident #84. On admission Resident #84 required the assistance of one member of staff to use the bathroom and was incontinent at times. 5. Record review for Resident #43 revealed an admission date of 09/21/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction and dementia. Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #43 was rarely or never understood. Resident #43 was always incontinent of bowel and bladder, had impairment to one side of the upper and lower extremities, used a wheelchair for mobility, was dependent for toileting hygiene, chair/bed to chair transfers, and wheelchair mobility. Review of the care plan initiated 07/16/22 and revised 08/25/25 for Resident #43 revealed Resident #43 was incontinent of bowel and bladder. Interventions included to check for incontinence every two hours and as needed. An observation on 10/27/25 at 9:30 A.M. revealed Resident #43 was sitting in a chair in the lounge area across from the nurse's station. Resident #43 looked at the surveyor when spoken to but did not verbally respond. Further observations on 10/27/25 at 9:58 A.M., 11:30 P.M., and 1:20 P.M. revealed Resident #43 was still in the same area, in the same position sitting in her chair in the lounge across from the nurses' station. An observation on 10/27/25 at 2:45 P.M. revealed Certified Nursing Assistant (CNA) #359 removed Resident #43 from the lounge and placed her in her room. CNA #354 gathered towels and washcloths and joined Resident #43 and CNA #359 in the resident room. CNA #354 confirmed she was Resident #43's primary CNA. CNA #354 revealed that her 12-hour shift began at 7:00 A.M. and revealed the night shift (third shift) got Resident #43 up at around 5:00 A.M. every day and placed her in her chair in the lounge across from the nurses' station. CNA #354 confirmed Resident #43 was not moved from the lounge across from the nurses' station since she was placed there around 5:00 A.M. and stated, This is the first time today she will be checked and changed, there is just not enough staff. Observation revealed CNA #359 and #354 assisted Resident #43 to bed. Resident #43's clothes were soiled with food and dried spills of liquid. CNA #354 confirmed Resident #43 had an odor of urine, and the brief was heavily saturated in urine. CNA #354 again confirmed Resident #43 had not had incontinence care provided for a duration of 5:00 A.M. to 2:45 P.M. Review of the Facility Assessment provided by the Administrator, dated 09/30/25, revealed the facility bed capacity was 97 and the average daily census at the facility was 91.75 percent of the capacity. Under Part Four: Acuity Levels: Self-Care, only nine residents were independent for eating and six residents were independent for oral hygiene. The remaining residents in the facility needed a range of staff assistance from set-up or clean up assistance, supervision or touching assistance, partial/moderate assistance, substantial/maximal assistance, or were dependent (helper does all the effort or needs the assistance of two or more helpers to complete activity) residents for eating, oral hygiene, toileting program, shower/bath, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, bed mobility, sit to stand, transferring and walking, picking up objects and using assistive devices. Part 12: Facility Wide Daily Staffing Needs (page 23) of the Facility Assessment under Nursing Services indicated first shift required one DON, one staff Registered Nurse (RN), three Licensed Practical Nurses (LPN) and six Certified Nursing Assistants (CNA) to meet resident acuity needs. Second shift was left blank and third shift required two LPNs and six CNAs. It was noted that Nursing Service Direct care staff worked 12-hour shifts (7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.) Further review of the Facility Assessment revealed the staffing plan in Part 13: Daily Staffing Needs by Unit for the Upper Level (page 28) was based on the staffing data outlined in Part 12. First shift on the upper level was to be staffed with two licensed nurses and three CNAs, and the lower level (page 29) was to be staffed with two licensed nurses and three CNAs for a total of four licensed nurses and six CNAs on first shift. Third shift on the upper level (page 28) was to be staffed with two licensed nurses and three CNAs and the lower level (page 29) was to be staffed with two licensed nurses and three CNAs for a total of four licensed nurses and six CNAs on third shift. The Facility Assessment noted that staffing needs will fluctuate based on population requirements. An interview was conducted on 10/28/25 at 10:00 A.M. with the Administrator who verified the contents of the Facility assessment dated [DATE] as the staffing plan for the facility and confirmed there were no additional policies and procedures related to nursing staffing for the facility. An interview on 10/29/25 at 2:20 P.M. with LPN/Minimum Data Set (MDS) Nurse # 310 revealed on 10/29/25 based on the current census of 83 residents, the facility had 14 residents who were totally dependent on staff to feed them, 28 residents who were totally dependent on two or more staff for a bath/shower, 25 residents who were totally dependent on two or more staff to dress upper body, 25 residents who were totally dependent on two or more staff to dress lower body, and 28 residents were totally dependent on two or more staff to provide personal hygiene. The facility also had a total of 25 residents who were totally dependent on two or more staff for transfers from bed to chair, toilet transfers and tub/shower transfers. LPN/MDS #310 confirmed other residents in the facility also needed varying levels of staff assistance with activities of daily living ranging from set-up/clean-up assistance to maximum assistance by staff. Additional concerns related to staffing were identified during the survey through the following interviews with direct care staff: An interview on 10/27/25 at 9:58 A.M. with LPN #393 revealed the CNAs were burnt out from working with less than sufficient staffing to care for residents. LPN #393 revealed that some days the facility was working short of staff and on those days the residents who required assistance to get out of bed were left in bed.An interview on 10/27/25 at 10:01 A.M. with CNA #359 revealed CNA #359 stated we try our best, at times showers are not completed so we will just wash them up in bed instead. Residents can't always get up or lay down timely, then they want water or Boost, but we can't always get to that. CNA #359 revealed sometimes they report to work in the mornings, and the residents were soaked and wet because the third shift stated they did not have enough staff. First shift also did not have enough staff either.An interview on 10/27/25 at 10:55 A.M. with CNA #362 revealed there was not enough staff to complete daily tasks. CNA #362 revealed residents on their assignments who were incontinent were usually changed one time per shift (a shift of 12 hours) and residents often received bed baths instead of showers because there were not enough staff to provide showers.An interview on 10/27/25 at 11:00 A.M. with CNA #354 revealed there were not enough CNAs, so residents were not changed timely. CNA #354 stated residents were changed two times during a 12 hour shift due to not having enough time to meet all the resident care needs. This deficiency represents noncompliance investigated under complaint number 2648929.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure timely incontinence care was provided for four residents (Resident #34, #40, #43 and #84) of four residents reviewed for incontinence care. The facility census was 83.Findings include: 1. Record review for Resident #43 revealed an admission date of 09/21/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction and dementia. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was rarely or never understood. Resident #43 was always incontinent of bowel and bladder, had impairment to one side of the upper and lower extremities, used a wheelchair for mobility, was dependent for toileting hygiene, chair/bed to chair transfers, and wheelchair mobility. Review of the care plan initiated 07/16/22 and revised 08/25/25 for Resident #43 revealed Resident #43 was incontinent of bowel and bladder. Interventions included to check for incontinence every two hours and as needed. Observation on 10/27/25 at 9:30 A.M. revealed Resident #43 was sitting in a chair in the lounge area across from the nurse's station. Resident #43 looked at the surveyor when spoken to but did not verbally respond. Further observations on 10/27/25 at 9:58 A.M., 11:30 P.M., and 1:20 P.M. revealed Resident #43 was still in the same area, in the same position sitting in her chair in the lounge across from the nurses' station. Observation on 10/27/25 at 2:45 P.M. revealed Certified Nursing Assistant (CNA) #359 removed Resident #43 from the lounge and placed her in her room. CNA #354 gathered towels and washcloths and joined Resident #43 and CNA #359 in the resident room. CNA #354 confirmed she was Resident #43's primary CNA. CNA #354 revealed that her 12-hour shift began at 7:00 A.M. and revealed the night shift (third shift) got Resident #43 up at around 5:00 A.M. every day and placed her in her chair in the lounge across from the nurses' station. CNA #354 confirmed Resident #43 was not moved from the lounge across from the nurses' station since she was placed there around 5:00 A.M. and stated, This is the first time today she will be checked and changed, there is just not enough staff. Observation revealed CNA #359 and #354 assisted Resident #43 to bed. Resident #43's clothes were soiled with food and dried spills of liquid. CNA #354 confirmed Resident #43 had an odor of urine, and the brief was heavily saturated in urine. CNA #354 again confirmed Resident #43 had not had incontinence care provided for a duration of 5:00 A.M. to 2:45 P.M. 2. Record review for Resident #34 revealed an admission date of 10/12/23. Diagnoses included visual loss of both eyes, acquired absence of the left leg below the knee and acquired absence of the right leg above the knee. Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 was always incontinent of bowel and bladder, required substantial/maximal assistance with bed mobility, was dependent for chair/bed to chair transfers, and for toileting hygiene. Review of the care plan for Resident #34 revealed Resident #34 had an activity of daily living (ADL) self-care performance deficit related to impaired balance and need for assistance for personal care. Interventions included the resident required assistance by staff for toileting. Interview on 10/28/25 at 10:10 A.M. with Resident #34 revealed sometimes she just got soaked with urine. When she called for assistance with incontinence care, staff would say they would be right back but then they don't come back for long periods of time if at all. Resident #34 revealed she was last changed at 6:20 A.M., and she stated she recalled the time because she looked at the clock, and it was before the 7:00 A.M. shift started. Resident #34 revealed that she had not been checked or changed since then and she needed changed. Interview on 10/28/25 at 11:00 A.M. with CNA #354 revealed she was running behind and confirmed she had just finished checking and changing Resident #34 for the first time on her shift. CNA #354 confirmed her shift started at 7:00 A.M. and revealed there was just not enough help. CNA #354 revealed Resident #34's brief was saturated and the pad under her was also wet with urine. Observation revealed CNA #354 applied new linen on Resident #34's bed and revealed she worked 12-hour shifts and at times residents were only checked and changed two times a shift. 3. Record review for Resident #40 revealed an admission date of 04/12/24. Diagnoses included unspecified hemiplegia affecting left non-dominant side and spinal stenosis of the cervical region. Review of the Modification of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 was always incontinent of bowel and bladder, required substantial/maximal assistants for bed mobility, was dependent for toileting hygiene and chair/bed to chair transfer. Review of the care plan initiated 04/14/24 and revised 08/18/25 revealed Resident #40 had a self-care deficit related to legally blind, limited mobility, and impaired cognition. Interventions included Resident #40 was dependent for toilet use. Interview on 10/27/25 at 10:16 A.M. with CNA #309 revealed there were not enough staff to check and change residents' or get them out of bed timely. CNA #309 revealed Resident #40 had not been checked or changed yet since the previous shift. Observation of Resident #40 with CNA #309 revealed Resident #40 was lying in bed. Resident #40 had a gauze wrap/dressing to the right leg. The bottom sheet near the dressing had multiple areas of dried blood. The dressing was dated 10/26/25 but had no blood on it. Resident #40 revealed when the staff help him, It's rush, rush, rush. Resident #40 revealed staff did not change him enough. Observation on 10/27/25 at10:30 A.M. of CNA #309 and #359 providing incontinence care for Resident #40 revealed Resident #40's brief was saturated with urine and stool. The stool was partially dried on Resident #40's skin. Resident #40 had a foul odor. Resident #40's abdominal fold, buttocks, upper thighs, peri area, and both arm pits were deep red. Resident #40 revealed the red areas of his skin were sensitive from sitting in urine and stool. Observation revealed the bed sheets and the mattress Resident #40 was lying on had multiple food crumbs. CNA #309 and #359 verified the observations. Interview on 10/27/25 at 3:00 P.M. with Registered Nurse (RN) Regional Director of Clinical Operations #410 revealed residents' should be checked and changed every two to three hours. 4. Closed record review for Resident #84 revealed an admission date of 10/08/25 and a discharge date of 10/13/25. Diagnoses included sepsis due to enterococcus, altered mental status, dependance on renal dialysis, and adjustment disorder. Review of the Medicare five-day MDS 3.0 assessment dated [DATE] revealed Resident #84 was barely /never understood. Resident #84 had short- and long-term memory problems, was always continent of bowel and bladder, used a wheelchair and walker, had no impairment to the upper or lower extremities, required partial/moderate assistants with bed mobility, chair/bed to chair transfer, substantial/maximal assistants for toilet transfer and dependent for toileting hygiene. Review of the care plan for Resident #84 dated 10/08/25 revealed bowel and bladder incontinence care/catheter care. Interventions included toileting per request and as needed. Interview on 10/27/25 at 9:07 A.M. with Resident #84's Guarantor/Emergency Contact #1 revealed on Sunday, 10/12/25 from 2:00 P.M. until 8:00 P.M. Resident #84's family was at the facility with Resident #84. At 2:00 P.M. when they arrived, they asked for assistance from staff because Resident #84 was soiled. The nurse on the floor said she would be in soon. At 4:00 P.M. staff still had not come in to assist Resident #84. The nurse was again asked for assistance with care. No one came. Resident #84's Guarantor/Emergency Contact #1 revealed at 6:00 P.M she went and asked the nurse again and expressed again Resident #84 had urine and stool on her and required assistance. The nurse became upset and said, I am only one person, I cannot babysit your sister. Resident #84's Guarantor/Emergency Contact #1 revealed at that point her older aunt went and asked for supplies revealing they would change her themselves, and staff did not offer assistance. After receiving the supplies, they changed Resident #84 themselves. Resident #84's Guarantor/Emergency Contact #1 stated, The bed was so saturated it was a puddle of pee. The nurse said to put a cover over it. Resident #84's Guarantor/Emergency Contact #1 revealed she took pictures of the saturated bed. Resident #84's Guarantor/Emergency Contact #1 stated, The next morning she was again saturated in bed, I called the Assistant Director of Nursing (ADON #355) and Monday morning I had a meeting with her and I showed her the pictures. Resident #84's Guarantor/Emergency Contact #1 confirmed it was ADON #355 she had spoken to about the lack of incontinence care for Resident #84. Interview on 10/27/25 at 4:49 P.M. with previous ADON #355 confirmed she was now the Interim DON. Interim DON confirmed she remembered Resident #84 and speaking with the daughter. Interim DON reviewed the five pictures provided by Resident #84's Guarantor/Emergency Contact #1. The first picture was a mattress with a blanket folded and lying in the middle of the mattress, the next was a saturated brief, and three remaining pictures were saturated bedding. Interim DON revealed she did see the same pictures with Resident #84's Guarantor/Emergency Contact #1 when they met on that day. Interim DON revealed it was not the level of care they strive for. The LPN that worked that day was LPN #384. Interim DON revealed all the staff were given education after that, but nothing was written down. LPN #384 said she was going to get the supplies but by the time she did, the family had already changed her. Interim DON revealed the family did get supplies to change her, they just had to wait. Interim DON stated, I have had other families and residents express concerns about not getting checked or changed timely, I am sure the resident (Resident #84) was not changed timely, I saw the pictures, I spoke to the family, I spoke to the staff, it was clear she was not changed timely. Interim DON revealed residents 'should be checked and changed every two hours and as needed. Interview on 10/28/25 at 5:06 P.M. with CNA #309 revealed she cared for Resident #84. CNA #309 stated, She was continent, if we were busy we would ask her to wait, she could hold it for about five minutes but not much longer or she would be incontinent, that's why we put a brief on her. Sometimes I came in in the mornings, she was soaked, saturated to the mattress. Interview on 10/28/25 at 5:08 P.M. with LPN #393 revealed he admitted Resident #84. On admission Resident #84 required the assistance of one staff to use the bathroom and was incontinent at times. Review of the facility policy titled, Activities of Daily Living (ADL's) dated March 2023 revealed to specify the responsibility to create and sustain an environment that humanizes and individualizes each residents quality of life by ensuring all staff , across all shifts and departments, understand the principals of quality of life, and honor and support these principals for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility will provide care and services for the following activities of daily living: Hygiene, mobility, elimination (toileting), repositioning, dining and communication. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents noncompliance investigated under complaint number 2648929 and represents continued non-compliance from the survey dated 08/13/25.

Based on observation, interview, record review, and review of the facility policy, the facility failed to maintain infection control practices while providing care to Resident #40 who required Enhanced Barrier Precautions (EBP). This affected one resident (Resident #40) of one resident observed for EBP and had the potential to affect an additional 41 residents (Resident #1, #2, #3, #6, #7, #8, #11, #15, #18, #19, #20, #21, #22, #23, #24, #26, #27, #28, #29, #31, #34, #35, #36, #39, #41, #43, #44, #46, #51, #55, #56, #59, #60, #61, #66, #75, #76, #77, #78, #81, and #83) who resided on the upper floor. The facility identified 19 residents (Resident #10, #11, #14, #17, #18, #20, #38, #39, #40, #45, #50, #53, #54, #56, #60, #66, #73, #74, and #75) as requiring EBP. The facility census was 83. Findings include:Record review for Resident #40 revealed an admission date of 04/12/24. Diagnoses included unspecified hemiplegia affecting left non-dominant side and spinal stenosis of the cervical region. Review of the Modification of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 had one unstageable pressure injury presenting as a deep tissue injury. Resident #40 was always incontinent of bowel and bladder, required substantial/maximal assistance for bed mobility, was dependent for toileting hygiene and chair/bed to chair transfer. Review of the care plan initiated 04/19/24 and revised 08/18/25 revealed Resident #40 required Enhanced Barrier Precautions (EBP) to reduce transmission of multidrug-resistant organisms (MRDO's) related to wounds. Interventions included to use disposable gowns and gloves during high contact care activities, remove gowns and gloves promptly after care activities and dispose of in proper receptacle. Review of the physician order for Resident #40 revealed Resident #40 had an order dated 10/21/25 to cleanse the right shin with normal saline, pat dry and apply collagen, cover with non-border super absorbent dressing and wrap with kerlix securing with paper tape every night shift. EBP: Gloves and gown to be worn when providing: Dressing, bathing, transferring, providing hygiene care, changing linen, changing brief or assisting with toileting, devise care and wound care dated 08/04/25. Observation on 10/27/25 at 10:16 A.M. with Certified Nursing Assistant (CNA) #309 revealed Resident #40 was lying in bed. Resident #40 had a gauze wrap/dressing to the right leg. The bottom sheet near the dressing had multiple areas of dried blood. The dressing was dated 10/26/25 but had no blood on it. Observation revealed Resident #40 had a sign at the entrance of the doorway for EBP. Observation revealed the sign had fallen to the floor. Observation revealed no Personal Protective Equipment (PPE) including gloves or gowns were available inside Resident #40's room or near the entrance to the room. Observation on 10/27/25 at 10:30 A.M. revealed CNA #309 went to several resident rooms to find gloves to provide care for Resident #40. Observation with CNA #309 and #359 providing incontinence care for Resident #40 revealed during the entire incontinence care provided (incontinent of stool and urine) to Resident #40 and the changing of Resident #40's linen, neither CNA #309 nor #359 wore an isolation gown. CNA #309 and #359 confirmed they never wore an isolation gown and confirmed none were available in Resident #40's room or outside the doorway near the entrance of the room. CNA #359 revealed he did not even know Resident #40 was on EBP. Both CNA's confirmed they assisted/have worked in all areas of the facility and gowns were often not readily available. CNA #309 and #359 confirmed they could potentially provide care to any of the 41 residents residing on the upper floor during their shift. Review of the facility policy titled, Enhanced Barrier Precautions dated August 2022 revealed EBP are utilized to prevent the spread of multi-drug-resistant organisms (MRDO's) to residents. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care use and wound care. This deficiency represents noncompliance investigated under complaint number 2648929 and represents continued non-compliance from the survey dated 08/13/25.

Based on record review, observation, interview, and review of facility policy, the facility did not ensure timely notification to the physician when Resident #67 displayed a change of condition from his baseline. This affected one resident ( Resident #67) of three residents reviewed for change of condition. The facility census was 83. Findings include: Record review for Resident #67 revealed an admission date of 09/10/25 with diagnoses including malignant neoplasm of the colon, malignant neoplasm of the liver and intrahepatic bile duct, neoplasm related pain, and encounter for palliative care. Resident #67 was admitted to hospice for malignant neoplasm of the colon per physician order dated 09/24/25. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #67's plan of care, date revised 10/01/25, revealed Resident #67 had a diagnosis of depression. Interventions included arrange for psychiatry consult and follow up as needed, monitor/document/report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky actions ( stockpiling pills, saying goodbye to family, giving away possessions, or writing a note) intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness.Review of the progress notes revealed a behavior note dated 10/26/25 at 3:18 A.M. written by Registered Nurse (RN) #301. The note indicated a certified nursing assistant (CNA) found Resident #67 in his room with the call light cord around his neck so the RN removed the cord and notified the doctor, hospice and the resident's daughter. RN #301 made another entry at 6:43 A.M. indicating that hospice called back and would be in to see Resident #67. At 8:53 A.M. RN #301 charted in a nursing note that the CNA at 1230 alerted the nurse Resident #67 had the call light cord around his neck and at that time the RN observed him to have no signs of pain, no injury and vital signs were obtained. Review of the Resident Transfer Form, dated 10/26/25 at 12:41 P.M. revealed Resident #67 was transferred to the hospital at 10:30 A.M. due to concerns regarding demonstrated self-harm behavior. Review of the facility document Resident Acute Change in Condition , dated 10/26/25 at 3:51 P.M. revealed Resident #67 was found with call light cord wrapped around his neck by night shift staff. The problem started 10/26/25. The Hospice provider visited. Report was given to the physician on 10/26/25 at 10:00 A.M.Review of the hospital records dated 10/26/25 revealed Resident #67 was being evaluated for suicidal ideation. Resident #67 said he was not trying to hurt himself, and he thought he was trying to put an oxygen cord around his nose. He was not attempting to harm himself. Resident #67 was calm and cooperative. Resident #67 was readmitted to the facility on [DATE]. An observation on 10/28/25 at 2:24 P.M. of Resident #67 lying in bed with family at the bedside and the Hospice RN in the room revealed Resident #67 was alert, and in no distress at the time of the observation. Resident #67 presented as weak and frail.An interview on 10/28/25 at 2:30 P.M. with Hospice RN #413 revealed Hospice had a one-on-one presence with Resident #67 since he returned from the hospital, as he was having an overall decline which they felt was he was in the process of transitioning.An interview on 10/28/25 at 7:00 A.M. with Resident #67's Power of Attorney (POA) confirmed the nurse did notify them via FaceTime video call on 10/26/25 at 12:23 A.M. to show her Resident #67 had the call light cord around his neck. The POA stated the nurse was concerned Resident #67 might be trying to hurt himself. The POA stated Resident #67 was not strong enough to strangulate himself and the POA watched as Resident #67 allowed the nurse to remove the cord. Interviews on 10/28/25 from 4:45 P.M. to 4:50 P.M. with Unit Manager RN #333 and LPN #350 revealed any resident with suspected suicidal ideation or self-harm would not be left alone and a phone call to the physician would be placed immediately. LPN #350 stated all dangerous items would be removed. An interview on 10/28/25 at 8:45 A.M. with RN #301 revealed she worked the night shift and Resident #67 wrapped the call light cord around his neck. RN #301 stated at 12:30 A.M. CNA #387 alerted her Resident #67 had a call light cord around his neck. RN #301 FaceTime video called Resident #67's POA. All cords were removed from the room, and the CNAs took turns providing one-on-one observation the whole night until Hospice nurses came in the next morning because RN #301 was concerned Resident #67 may try to hurt himself. RN #301 stated she texted the physician after the incident happened, did not received a response, and did not call the physician until 9:04 A.M. RN #301 confirmed this was over eight hours after Resident #67 had been found with the call light cord around his neck. RN #301 stated the note on 10/26/25 at 3:18 A.M was a late note summarizing the events that occurred around 12:30 A.M. An interview on 10/29/25 at 9:35 A.M. with CNA #387 revealed CNA #379 first found Resident #67 with a cord around his neck. CNA #379 never left him. CNA #387 could not remember the time she alerted the nurse . CNA #387 observed Resident #67 to be confused and in distress when she observed Resident #67 in his bed with the cord around his neck. CNA #387 verified the POA was video called to observe the situation and speak to Resident #67.Interview on 10/29/25 at 9:46 A.M. with CNA #379 revealed she observed Resident #67's call light on, and it was unusual for Resident #67 to ring his call light. CNA #379 stated she observed Resident #67 with the call light cord around his neck and that was a change in behavior for Resident #67. CNA #379 verified the POA was video called to observe the situation and speak to Resident #67.Interview on 10/29/25 at 11:00 A.M. with Unit Supervisor RN #333 revealed if a resident had a change in condition the nurse needed to report the findings to the physician immediately for interventions, and this needed to be done by a phone call regarding a change in condition, not a text message.Review of the facility policy titled Resident Change In Condition, dated 07/28/22, revealed an Acute Change in Condition was a sudden, clinically important deviation from a resident's baseline. Without interventions the condition may result in complications or death . In the event the physician could not be reached within thirty (30) minutes and the resident maintained stable condition, 911 would be called for transport, then the doctor would be updated on transfer.This deficiency resulted from incidental findings during investigation of Complaint Number 2653275 and represents continued non-compliance from the survey dated 08/13/25.

Based on record review, review of the facility Self-Reported Incident (SRI), interview and policy review, the facility failed to ensure Resident #14 was free of sexual abuse from another resident (Resident #86). This affected one (Resident #14) of three residents reviewed for sexual abuse. The facility census was 93. Findings include:Review of the medial record for Resident #14 revealed an admission date of 07/03/23 with diagnoses including cerebral infarction (stroke), hemiplegia (paralysis) affecting right dominant side, chronic respiratory failure and paranoid schizophrenia (condition that includes paranoia, delusions and hallucinations).Review of Resident #14's care plan revealed it was originally dated 07/03/23. There were no updates to her care plan noted after 09/16/25. She was noted to have a communication problem and self-care deficit both related to impaired cognition.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had highly impaired vision, highly impaired hearing, sometimes understood staff and sometimes staff understood her. She was noted to have severely impaired cognition. She was dependent on staff for hygiene, dressing and transfers. Review of a nursing progress note by Licensed Practical Nurse (LPN) #204 dated 09/17/25 at 9:32 P.M. for Resident #14 revealed the nurse observed Resident #14 and Resident #86 in the common area kissing. LPN #204 stated she intervened and separated the two residents. The incident was reported to management and a head to toe assessment was performed. The physician and Resident #14's representative were updated. Staff were aware to keep the residents separated. Review of the facility investigation dated 09/17/25 for Resident #14 and Resident #86 revealed LPN #204 was walking through the dining area and she witnessed Resident #14's and Resident #86's heads turned towards each other and they kissed on the lips, a peck. She stated she immediately separated the two residents and reported it to the manager. There was a nursing progress note in Resident #86's medical record by Director of Social Services #207 created on 09/30/25 at 10:06 A.M. with the effective date of 09/17/25 at 2:01 P.M. stating that herself and Registered Nurse (RN) #205 met with Resident #86 to discuss the inappropriate relationship including inappropriate touching of Resident #14. It stated Resident #86 was educated on the inappropriate relationship with Resident #14 pertaining to kissing. The note stated Resident #86 understood. The Director of Social Services #207 and RN #205 discussed the difference of mental capabilities and her inability to give consent. Resident #86 stated he would not touch or kiss Resident #14.Review of a nursing progress note by RN #205 dated 09/29/25 at 11:56 P.M. for Resident #14 revealed an aide alerted the nurse there was a male resident (Resident #86) inside Resident #14's room, on top of her bed. Resident #86 was escorted out of Resident #14's room and placed on one-on-one observation. Resident #14 was assessed and placed in a safe place. The nurse practitioner, manager and Resident #14's representative were updated.Review of SRI #265853 dated 09/29/25 revealed while Certified Nursing Assistant (CNA) #209 was doing rounds, she observed Resident #86 with his pants down laying on top of Resident #14 in her bed. RN #205 was alerted and went to the room and separated both residents. She performed assessments and spoke with each resident. Resident #14 denied sexual intercourse with Resident #86. She stated she wanted him to have sex with her. RN #205 then interviewed Resident #86. He stated Resident #14 wanted him in her room. He was reminded of the education he had been provided on 09/17/25 that he was to have no personal or private contact with Resident #14. Resident #86 stated nothing happened. The police were notified and a report was filed. The police report was not available in the SRI.Review of a nursing progress note dated 09/30/25 at 5:10 P.M. for Resident #14 revealed the nurse practitioner provided a new order to send her to the emergency room to complete a rape test kit.Review of the hospital history and physical dated 09/30/25 for Resident #14 revealed she was at the emergency room for suspected sexual assault. The emergency medical services had reported that Resident #14 was found by the facility staff with another resident on top of her with his pants down. Resident #14 stated her pants were still on. Resident #14 reported to the Sexual Assault Nurse Examiner (SANE) nurse that she felt safe around Resident #86. There was no record if the rape test kit was positive or negative.Interview on 10/06/25 at 9:41 A.M. with LPN #204 revealed she had observed Resident #14 and Resident #86 kissing on 09/17/25 and separated them. She stated staff were updated to keep them separated and nursing had educated all staff during shift change report. LPN #204 revealed after the incident on 09/30/25 where Resident #86 was found with his pants off lying on Resident #14 in her bed, the facility placed him on one-on-one supervision, which they were still doing. Interview on 10/06/25 at 10:23 A.M. with Resident #14's representative revealed he had been updated on 09/17/25 of Resident #14 and Resident #86 kissing. He stated the facility told him that they were going to keep the two residents separated. He stated on 09/29/25 he received an update that Resident #86 was found with no pants on laying on top of Resident #14 in her bed. He stated he asked the staff how this had happened if they were keeping the residents separated. He stated they told him staff were busy during the time when it had occurred. Resident #14's representative stated the rape kit test at the hospital on [DATE] was negative.Interview on 10/06/25 at 10:28 A.M. with RN #205 revealed she had spoken to Resident #86 on 09/17/25 after Resident #14 and Resident #86 had been observed kissing. She stated she went with the Director of Social Services #207 and they educated him on inappropriate touching and physical contact with other residents. She stated he had intact cognition and understood that Resident #14 had impaired cognition. She stated staff ensured they were not in unsupervised areas after the kiss on 09/17/25. RN #205 stated she was working on 09/29/25 and was alerted to Resident #86 being in Resident #14's room with his pants off lying on top of Resident #14 on her bed. She stated when she got to the room she observed him fixing his pants and sitting on the side of the bed. She stated Resident #14 was fully dressed. RN #205 stated she separated the residents and assessed Resident #14. Interview on 10/06/25 at 12:17 P.M. with the Director of Social Services #207 revealed she had spoken to Resident #86 after the kissing incident with Resident #14 on 09/17/25. She stated they spoke about inappropriate relationships. He was educated that he could not put his hands on Resident #14 or go into her room. She stated RN #205 was present during this discussion and had relayed the information to her staff. Review of the facility policy titled, Abuse Prohibition, undated, revealed each resident has the right to be free from abuse by anyone. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Types of abuse included sexual harassment, sexual assault, or sexual coercion. Residents have the right to engage in consensual activity. Anytime the facility ahs reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must ensure the resident is protected from abuse, including evaluating whether the resident has the capacity to consent to sexual activity. This deficiency represents non-compliance investigated under Complaint Number 265853.

Based on review of staffing schedules and staff interview, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 87 residents currently residing in the facility. The census was 87.Findings include: Review of the nursing staff information and staff schedules for 06/28/25 and 07/04/26 revealed no RNs were present working in the facility during those days.On 08/13/25 at 3:15 P.M., interview with Human Resources Director (HRD) #890 verified the facility did not have an RN on duty on 06/28/25 and 07/04/26.This deficiency represents non-compliance investigated under Complaint Number OH00161573 (1254625), Complaint Number OH00164532 (1254632), and Complaint Number OH00166711 (1254468).

Based on observation, staff interview, and policy review, the facility failed to maintain a clean, sanitary, and safe environment. This deficient practice had the potential to affect all 87 residents residing in the facility. The facility census was 87.Findings included:Observation during an environmental tour conducted on 08/06/25 between 1:00 P.M. and 1:55 P.M. with Maintenance Supervisor (MS) #748 revealed carpeted areas throughout resident rooms and common areas were noted with stains and debris, the room occupied by Resident #59 had a two-inch long hole in the wall, the air conditioning cover in Resident #124's room was dislodged and on the floor, the wall trim on the bathroom door in Resident #31's room was half secured to the wall, the outlet for the telephone line in Resident #25's room was broken in half, the supplemental tube feeding poles used by Resident #19 and Resident #72 had residual dried tube feed on the pole and base, the private bathroom used by Resident #33 had multiple brown stains on the tub floor, the pillowcases and blankets on Resident #27's bed were stained brown, Resident #77's bathroom contained approximately ten to fifteen articles of wet clothing on the floor producing a strong musty odor, Resident #36, Resident #82, and Resident #83's rooms had multiple areas of water stains on the ceiling, the closed closet door in Resident #81's room had multiple brown spots, the walls in Resident #14 and Resident #83's rooms were severely scratched with chipped paint, the wall above the air conditioning unit in Resident #4 and Resident #13's rooms was starting to crumble, Resident #67's bed had a blanket with multiple brown and orange stains, and the fall mats used by Resident #14 and Resident #65 were dirty, torn, and tattered.Interview with MS #748 during the observations on 08/06/25 between 1:00 P.M. and 1:55 P.M. verified all the above findings at the time of discovery. Review of the facility policy titled, Environmental Services Cleaning Guidebook, dated 04/20/23, revealed the guidebook was provided to all housekeeping employees to maximize efficiency, outline preferred cleaning methods for infection control and presentation, and emphasize the proper use of chemicals as critical to the success of maintaining a safe and sanitary environment.This deficiency represents non-compliance investigated under Complaint Number OH00166853 (1254633) and Complaint Number OH00164532 (1254632).

Based on medical record review, staff interview, medical record review, and policy review, the facility failed to revise the care plans as required and failed to ensure resident care planning conference were held as required. This affected four (#72, #25, #29, and #59) of seven residents reviewed for care plans and care planning conferences. The facility census was 87. Findings Include: 1. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis affecting the right dominant side after a stroke, aphasia (the inability to speak) after a stroke, osteomyelitis of vertebrae of the sacral and sacrococcygeal region, diabetes, high blood pressure, obstructive and reflux uropathy, and Alzheimer's disease with early onset.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was rarely/never understood, was dependent on staff for all aspects of care, had a Stage IV pressure ulcer (full-thickness skin and tissue loss) to her sacral area, was incontinent of both bowel and bladder, and received enteral nutrition through a feeding tube.Review of the care plans for Resident #72 revealed a care plan for pressure wounds to the left medial foot and coccyx and was last revised on 03/14/25. Review of the progress note dated 05/28/25 revealed the wound to the left foot had healed.Resident #72 had a care plan initiated 11/11/24 for being placed on antibiotics for a diagnosis of sepsis. No revisions were made. The care plan was not marked as resolved.Resident #72 had a care plan for a diagnosis of sepsis initiated on 12/31/24. The goal was to be free of infection by the review date (no date listed). The interventions were to administer antibiotics per the physician orders, monitor for signs and symptoms of a urinary tract infection, and to report any signs or symptoms of delirium to the physician.Resident #72 had a care plan for being at high risk for rehospitalizations. The care plan was initiated on 10/29/23 with no revisions made since it was initiated despite being hospitalized since initiation. The resident was recently hospitalized on [DATE].Interview with Licensed Practical Nurse (LPN) #744 on 08/13/25 at 1:45 P.M. revealed she was the facility's MDS nurse and was responsible for initiating, revising, and resolving the care plans for residents. LPN #744 was unaware Resident #72's pressure wound to the left foot had resolved. She confirmed Resident #72 was no longer septic as of August 2025 and the care plan should have been revised/resolved. Regarding rehospitalizations, LPN #744 said she initiated the care plan as part of her baseline care plan but social services was responsible for revising the care plan with any hospitalizations and did not know why it had not been updated. LPN #744 was unable to explain why the care plans for Resident #72 had not been revised.Review of the facility policy titled, Care Plan and Advanced Care Plan Process, last revised in October 2017, revealed care plans would be reviewed quarterly, annually, and when a significant change in status occurred. The care plan should identify the date, problem, measurable and realistic goals, time frames for achievement, interventions specific to discipline and frequency, resolution, goal analysis, and discharge options.2. Review of Resident #25's medical record revealed an admission date of 07/03/23, with diagnoses that included cerebral infarction, hemiplegia and hemiparesis, dysphagia, chronic respiratory failure, paranoid schizophrenia, bipolar disorder, anxiety disorder, and muscle weakness. The resident's son and daughter were both listed as emergency contact number one.Review of the most recent annual MDS assessment dated [DATE] revealed Resident #25 was not able to be understood and staff assessed the resident as severely cognitively impaired.Review of the electronic medical record found only one care conference dated 08/07/25 at 5:47 P.M. held with Resident #25 and the son. Further review of the medical record revealed no other documented care conferences.Interview on 08/08/25 at 9:59 A.M. with Social Service Designee (SSD) #805 revealed she had been at the facility since March 2025 and her first care planning conference with Resident #25 was held 08/07/25. SSD #805 did not know if any additional care conferences had been held for Resident #25 with the previous SSD.Interview with 08/12/25 at 11:03 A.M. Administrator verified there was no documentation for any additional care conferences for Resident #25.Review of Resident #25's medical record revealed an admission date of 07/03/23, with diagnoses that included cerebral infarction, hemiplegia and hemiparesis, dysphagia, chronic respiratory failure, paranoid schizophrenia, bipolar disorder, anxiety disorder, and muscle weakness. The Resident's son and daughter were both listed as emergency contact number one.3. Review of Resident #29's medical record revealed an admission date of 12/21/21 and a re-entry date of 08/15/22. Resident #29's diagnoses included senile degeneration of the brain, anxiety disorder, and embolism and thrombosis of unspecified parts of the aorta.Review of Resident #29's Annual MDS assessment dated [DATE] revealed Resident #29 had severe cognitive impairment.Review of Resident #29's social service progress notes dated 02/21/23 included the interdisciplinary team (IDT) met with Resident #29 and Resident #29's niece for a care plan conference.Review of Resident #29's social service progress notes dated 02/21/23 through 08/05/25 did not reveal evidence Resident #29 had additional care plan conferences.Review of the May 2025 care conference schedule revealed Resident #29 was scheduled for a care conference on 05/20/25. There was no documentation a care conference letter was mailed to the responsible party or family for this care conference.4. Review of Resident #59's medical record revealed an admission date of 10/20/17 and a re-entry date of 04/10/25. Resident #59's diagnoses included chronic obstructive pulmonary disease, asthma, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side.Review of Resident #59's quarterly MDS assessment dated [DATE] revealed Resident #59 was cognitively intact.Review of Resident #59's social service progress notes dated 04/11/23 included the IDT team met with Resident #59 and his son for a care plan conference.Review of Resident #59's social service progress notes dated 04/11/23 through 08/06/25 did not reveal a care conference was conducted during this time frame.Review of the May 2025 care conference schedule did not reveal evidence Resident #59 had a care conference scheduled.Interview on 08/06/25 at 10:56 A.M. of SSD #805 revealed she started working in the facility about five months ago. SSD #805 stated she arranged resident care conferences. Care conferences were conducted for new admissions within the first five days of admission then quarterly. SSD #805 stated notices were mailed to families and delivered by the receptionist to residents in the facility. SSD #805 stated she was up do date with care conferences and she documented the care conferences in the resident electronic record. SSD #805 stated Resident #29 was supposed to have a care conferences in May 2025, but that did not happen. SSD #805 confirmed Resident #29 did not have care conferences documented in her electronic records since 2023. SSD #805 stated Resident #29 had a care conference scheduled but a letter was not mailed to the family, responsible party and there was no evidence in Resident #29's medical record the family or the responsible party were contacted. SSD #805 further stated Resident #59 was supposed to have a care conference in May 2025 as well, but that did not happen. SSD #805 confirmed Resident's #59 did not have care conferences documented in his electronic records since 2023 and stated there was no evidence a letter was mailed to Resident #59's responsible party about a care conference.

Based on medical record review, staff interview, and policy review, the facility failed to ensure medical records were accurate and complete. This affected five (#1, #6, #30, #105, and #112) of 33 resident records reviewed. The facility census was 87.Findings include:1. Record review revealed Resident #1 was admitted [DATE] with diagnoses of sepsis, malignant neoplasm of left kidney, end stage renal disease, and dependance on renal dialysis. Review of the hospital admission referral packet dated [DATE] revealed Resident #1 was an end stage renal disease patient on a dialysis regimen with a Tuesday, Thursday, and Saturday schedule. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment, required hemodialysis, and required maximal assistance with toileting hygiene, showers, dressing, and personal hygiene. Review of the physician orders for [DATE] revealed Resident #1 had orders for atorvastatin calcium 10 milligrams (mg), donepezil five (5) mg, tamsulosin 0.4 mg, apaxiban 5 mg two times a day, aspirin 81 mg, midodrine three times a day. The physician orders did not include an order for dialysis. Review of Resident #1's medication administration record (MAR) and the treatment administration record (TAR) for [DATE] revealed documentation was not completed on [DATE] and [DATE] for the administration of the aforementioned medications at bedtime and treatments during the shift including turning/repositioning rounds, monitoring for signs/symptoms of infection every shift, and pressure reducing mattress and wheelchair cushion every shift. The TAR was broken down into two shifts, 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M. The documentation was not completed on the 7:00 P.M. to 7:00 A.M. shift. Interview on [DATE] at 9:56 A.M. with Licensed Practical Nurse (LPN) Unit Manager #745 confirmed there was no physician order for dialysis in the electronic record for Resident #1; however, dialysis was received at the facility Monday, Wednesday, and Friday. Interview on [DATE] at 3:50 P.M. with Resident #1 confirmed dialysis was received as scheduled and evening medications were received on [DATE] and [DATE]. Interview on [DATE] at 10:13 A.M. with the Director of Nursing (DON) confirmed there was no physician order for dialysis in the electronic record for Resident #1. Interview on [DATE] at 7:58 A.M. with LPN #732 confirmed she worked the evening of [DATE] but was unable to recall if the medications were administered or if documentation was completed. Interview on [DATE] at 8:02 A.M. with LPN #724 confirmed she worked the night shift on [DATE] and did administer Resident #1’s evening medications but admitted to forgetting to complete documentation at times. 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including emphysema, cerebral palsy, diabetes, and post traumatic stress syndrome. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was cognitively intact and used a noninvasive ventilator (NIV). Review of the nurses notes for Resident #30 from June through [DATE] revealed respiratory therapy routinely documented the hours of use for the NIV. The pharmacist documented monthly regarding the review of the resident’s medications. Registered Nurse (RN) Unit Manager #801 documented on [DATE] regarding an update on a computed tomography (CT) scan the resident was scheduled for of the abdomen and pelvis. No other documentation regarding the resident’s care or the results of the CT scan and when it was completed were documented. Interview with the Director of Nursing (DON) on [DATE] at 1:10 P.M. confirmed the nurses should be documenting any changes regarding the resident and confirmed there was no documentation in Resident #30's medical record regarding results of the CT scan. 3. Review of the medical record revealed Resident #105 was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, end stage renal disease dependent on hemodialysis, diabetes, a stroke, and vascular dementia without behavioral disturbance. The resident was admitted to hospice on [DATE] with a diagnosis of end stage renal disease after refusing to attend any further dialysis treatments. Resident #105 died on [DATE]. Review of the nurses notes for Resident #105 revealed on [DATE] the resident requested to be sent to the hospital for diarrhea. The nurse practitioner approved the transfer to the local emergency room (ER). The next note dated [DATE] revealed Resident #105 returned from the hospital positive for clostridium difficile. Review of the nursing admission assessment completed on [DATE] revealed Resident #105’s vital signs were documented but the rest of the admission assessment was left blank. Interview with the DON on [DATE] at 2:00 P.M. revealed she does not know why Resident #105’s admission assessment on [DATE] was blank, but stated there was probably a glitch in the facility's electronic health record that removed the assessment information. The DON said she was planning on in-servicing nursing on documentation. 4. Record review for Resident #6 revealed an admission date of [DATE]. Diagnoses included end stage renal disease, diabetes mellitus II, and paroxysmal atrial fibrillation. Review of Resident #6’s electronic medical record (EMR) revealed a physician note dated [DATE] at 1:58 P.M. for Resident #112 and on [DATE] at 3:14 P.M. a physician note was found for Resident #112. On [DATE] at 8:00 A.M. the DON verified two physician notes for Resident #112 were found in the EMR for Resident #6. Review of the facility policy titled, “EHR Records and Documentation,” dated 12/22, revealed the facility the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized. The medical record must reflect the resident’s condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. This deficiency represents non-compliance investigated under Master Complaint Number 2564323, Complaint Number OH00167217 (1254635), and Complaint Number OH00166806 (1254522).

Based on observation and staff interview, the facility failed to ensure outdated drinks and food and beverage additives were stored in a manner to prevent spoilage. This had the potential to affect four ( #3, #28, #70, and #77) of four residents identified by the facility as receiving on thickened liquids. The facility census was 87.Findings include:Observation during a tour of the facility on 08/06/25 from 8:40 A.M. to 9:35 A.M. revealed two 46 ounce containers of nectar thickened orange juice were found in the [NAME] panties on the units. There was no date written on them to show when they had been opened. The use by date was June 2025. Further observation revealed eight individual thick and easy instant food and beverage thickener packets with a use by date of 10/29/23 found in the [NAME] pantries. On 08/06/25 at 9:41 A.M., Regional Director of Clinical Operations #808 verified the two containers of outdated nectar thickened orange juice and the eight outdated thick and easy instant food and beverage thickener packets. This deficiency represents non-compliance investigated under Complaint Number OH00166853 (1254633).

Based on medical record review, staff interview, and review of an Ombudsman notification log, the facility failed to ensure the Ombudsman was notified of resident hospitalizations as required. This affected three (#6, #17, and #24) of five residents reviewed for discharges. The census was 87. Findings include: 1. Record review for Resident #6 revealed an admission to the facility on [DATE]. Diagnoses included end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II, and paroxysmal atrial fibrillation. Review of the electronic medical record (EMR) from 01/11/25 to present revealed Resident #6 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of the EMR revealed Resident #6 was admitted to the hospital on [DATE] and returned on 03/07/25. Resident #6 was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the EMR revealed Resident #6 was sent to the hospital 06/10/25 and returned 06/12/25. Review of the Ombudsman Notification Log of Community Transfer and Discharges revealed no transfers or discharges were documented for the whole months of February, March 2025, and no documentation of the Ombudsman being notified of Resident #6 discharging to the hospital the being readmitted to the facility in June 2025. Interview with the Social Service Designee (SSD) on 08/13/25 at 10:10 A.M. revealed the previous SSD did not document any transfer or discharges for the whole month of February 2025, including Resident #6's hospitalization. 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease stage III, cerebrovascular disease, hemiplegia affecting left non-dominant side, and acute respiratory failure with hypoxia. Review of the EMR revealed Resident #17 was admitted to the hospital 05/15/25 and returned to the facility on [DATE]. Resident #17 was also admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of the Ombudsman Notification Log of Community Transfer and Discharges revealed no documentation of Resident #17 discharging to the hospital and readmitting to the facility notification was sent to the Ombudsman. 3. Record review for Resident #24 revealed an admission date of 05/21/25. Diagnoses included acute respiratory failure with hypoxia, end stage renal disease, diabetes mellitus II with diabetes neuropathy, chronic diastolic congestive heart failure, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the EMR for Resident #24 revealed the resident was hospitalized on [DATE] and readmitted to the facility on [DATE]. Resident #24 was also hospitalized in July 2025 and readmitted to the facility on [DATE]. Review of the Ombudsman Notification Log of Community Transfer and Discharges revealed no documentation of Resident #24's hospitalizations with notification sent to the Ombudsman. Interview with the SSD and the Business Office Manager (BOM) on 08/12/25 at 10:15 A.M. confirmed neither have send notice to the Ombudsman to providing notification of Resident #6, #17, and #24's hospitalizations and provided no evidence it was done by anyone with the facility for those three residents.

Based on medical record review, staff interviews, review of self-reported incidents, review of discharge notices, and review of a policy review, the facility failed to ensure residents were permitted to return to the facility following a hospitalization and failed to ensure documentation of the need for discharge was reflected in the medical record to establish the need for discharge from the facility. This affected three residents (#18, #26 and #89) out of five residents reviewed for discharge. The facility census was 87.Findings include:1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses that included Parkinson’s disease, borderline intellectual functioning, and dementia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was severely cognitively impaired and required the assistance of one staff member for completing activities of daily living (ADLs). Review of the discharge notice issued on 07/31/25 revealed Resident #18 would be discharged to another nursing facility on 08/30/25 for, “violating the rights of others to have a homelike environment.” 2. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, cannabis use disorder, and high cholesterol. Review of the most recent MDS assessment dated [DATE] revealed Resident #89 was cognitively intact and required supervision to complete ADLs. Review of facility self-reported incidents (SRIs) revealed on 07/28/25 Resident #89 was found in possession of another resident’s cell phone, which he promptly returned without incident. Further review of the SRIs revealed no prior incidents involving abuse, neglect, or misappropriation by Resident #89 since 08/21/08. Review of the discharge notice provided to Resident #89 on 07/31/25 revealed Resident #89 would be discharged to another nursing facility on 08/30/25, the resident is violating the rights of others to privacy/personal possessions, respect, and the right to be free from abuse. Interview with the Administrator on 08/06/25 at 10:15 A.M. confirmed the discharge notices issued for Resident #18 and Resident #89 were not supported by appropriate documentation. 3. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any condition that affects the brain's structure or function, leading to impaired mental state), diabetes, dementia without behavioral disturbance, and anxiety disorder. Review of the comprehensive admission MDS assessment, dated 07/25/25, revealed Resident #26 was moderately cognitively impaired and had no behaviors during the assessment period. Review of the nurses’ notes dated 08/08/25 at 7:58 P.M. revealed Resident #26 was restless and became extremely agitated after dinner. The resident unbuttoned his pants to urinate in a trash can. Registered Nurse (RN) #799 attempted to redirect the resident to his room as the common area was not an appropriate place to urinate. The resident refused redirection and attempted to remove other residents dinner plates while they ate. Other attempts at redirection were ineffective. The resident started walking the halls heading toward the lobby stating he was going to get to his car as he needed to work on it. RN #799 and a certified nurse aide (CNA) continued to try and redirect the resident to his room. Resident #26 attempted to open the secured door to the main entrance. RN #799 held the door shut and the resident became more agitated and attempted to hit RN #799. A second nurse notified Nurse Practitioner (NP) #811 of the resident’s aggressive behavior and gave an order to transport the resident to a local emergency room (ER) for evaluation. At 7:15 P.M. Resident #26 was transferred to the ER. No further documentation was noted regarding what occurred with the resident after transport. Interview with the Mobile Director of Nursing on 08/11/25 at 3:35 P.M. revealed Resident #26 was admitted to the hospital. When he was discharged he would be transferred to another facility with a secured unit. He will not be returning to the facility. Interview with the Director of Nursing (DON) on 08/11/25 at 5:10 P.M. revealed anyone who was sent to the ER for evaluation was considered discharged . The DON was unable to explain why no further documentation was in the chart regarding what happened to Resident #26 after his transfer. The DON was unable to provide any discharge paperwork regarding the resident or where he went. No immediate discharge documentation was provided regarding Resident #26 not being able to return to the facility. Review of the facility’s policy titled, “Discharge Planning & Managing Length of Stay,” dated 12/01/22, revealed discharge planning should involve identifying each resident’s discharge goals and needs, implementing appropriate interventions, and regularly evaluating those interventions throughout the resident’s stay. When a facility anticipates discharge, a discharge summary includes a recapitulation history will be completed. A final discharge summary will be completed upon discharge that should be given to the resident or responsible party including medication reconciliation, discharge medication orders, and a post discharge plan of care including where the resident plans to reside, any appointments made for follow up care and any post discharge medical services. This deficiency represents non-compliance investigated under Complaint Number OH00166711 (1254468) and Complaint Number OH00167217 (1254635).

Based on medical record review and staff interview, the facility failed to ensure Notices of Medicare Non-Coverage (NOMNCs) were provided to Medicare Part A beneficiaries prior to the discontinuation of skilled services in a timely manner. This deficient practice affected two (#110 and #111) out of three residents reviewed for beneficiary notices. The facility census was 87. Findings included:1. Review of the medical record revealed Resident #110 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse, metabolic disorder, and high blood pressure.Review of the NOMNC presented to and signed by Resident #110 on 05/08/25 revealed the notice indicated his skilled physical therapy, occupational therapy, and speech therapy services would end on 05/08/25. This provided no advance notice.2. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included a right femur fracture, type II diabetes, and high blood pressure.Record review of the NOMNC presented to and signed by Resident #111 on 06/09/25 revealed the notice indicated his skilled physical therapy, occupational therapy, and speech therapy services would end on 06/09/25. This also provided no advance notice.Interview with Social Service Designee (SSD) #805 on 08/05/25 at 4:30 P.M. confirmed the NOMNCs for Resident #110 and Resident #111 were not provided at least 48 hours prior to the discontinuation of skilled services as required.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's family or responsible party were notified of changes in condition. This affected one (#6) of two residents reviewed for change in condition. The census was 87.Findings include:Record review for Resident #6 revealed admission to the facility on [DATE]. Diagnoses included end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II and paroxysmal atrial fibrillation.Review of Resident #6's electronic medical record (EMR) revealed a nurse note dated 02/14/25 at 6:57 P.M. that Resident #6 was ordered to be sent to the hospital. There was no indication the family was notified. Further review revealed a note dated 02/19/25 at 4:10 P.M. that Resident #6 returned to the facility. There is no indication the family was notified.Review of Resident #6's EMR revealed a nurse note dated 02/26/25 at 2:29 P.M. that Resident #6 was ordered to be sent to the hospital. There was no indication the family was notified.Review of Resident #6's EMR revealed a nurse note dated 03/05/25 at 4:04 P.M. that Resident #6 was sent to the hospital from dialysis. There was no indication the family was notified.Review of Resident #6's EMR revealed a nurse note dated 03/13/25 at 12:37 P.M. that Resident #6 went to the hospital from the doctor's office. There was no indication the family was notified. Further review revealed she was sent out again on 03/13/25 at 1:22 A.M. and returned same day at 4:49 A.M. There was no indication the family was notified when Resident #6 left or returned to the facility.Review of Resident #6's EMR revealed a nurse note dated 03/15/25 at 3:11 P.M. that Resident #6 was ordered to go to the hospital. There was no indication the family was notified. Further review revealed a physician note dated 03/21/25 that Resident #6 was readmitted . There was no documentation that the family was notified.Interview with the Unit Manager Licensed Practical Nurse (LPN) #745 on 08/13/25 at 11:29 A.M. verified there was no documentation informing Resident #6's family was notified of her being sent out of the facility and to the hospital on [DATE], 02/26/25, 03/05/25, 03/13/25, or 03/15/25.Review of the facility policy titled, Resident Change in Condition, dated 07/28/22, revealed the purpose was to ensure staff provided timely and appropriate care and services when residents experience a change in condition that had or was likely to cause adverse negative health outcomes. The facility would promptly notify the resident, his or her attending physician and responsible party of changes in the resident's condition and, or status. This deficiency represents non-compliance investigated under Complaint Number OH00163811 (1254630).

Based on observation, resident and staff interview, medical record review, review of an invoice, and review of the facility policy, the facility failed to ensure a resident's bed was appropriate to accommodate his height and weight and failed to ensure call lights were within reach for resident use. This affected three (#76, #44, and #95) out of seven residents reviewed for appropriate accommodation of needs. The facility census was 87.Findings include:1. Review of Resident #76's medical record revealed an admission date of 02/22/24 and diagnoses included paroxysmal atrial fibrillation, muscle weakness, difficulty walking, and pain. Review of Resident #76's height dated 02/22/24 revealed he was 81.0 inches (six (6) feet nine (9) inches) tall. Review of Resident #76's care plan dated 03/06/24 included Resident #76 had an alteration in musculoskeletal status related to muscle spasms, muscle weakness, and osteoarthritis. Resident #76 would remain free of complications related to fracture, such as contracture formation, embolism and immobility through the review date. Resident #76 would remain free from pain or at a level of discomfort acceptable to the resident. Interventions included to anticipate and meet needs and Resident #76 needed to change position every two hours and as needed. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact. Resident #76 used a motorized wheelchair. Resident #76 required substantial to maximal assistance for toileting hygiene, personal hygiene, bathing and upper body dressing. Resident #76 was dependent for lower body dressing and chair-to-bed-to-chair transfer. Review of Resident #76's weight dated 07/09/25 revealed Resident #76 weighed 387.2 pounds. Observation on 08/04/25 at 10:17 A.M. of Resident #76 revealed he was lying in bed, the head of the bed was elevated about 45-degrees and Resident #76's head was even with the top of the mattress. Resident #76's pillow was on the floor at the head of the bed. Interview during the observation with Resident #76 stated he was 6 feet 9 inches, he was too tall for the bed, and did not fit in the bed. Resident #76 confirmed his pillow fell off the bed and it happened often. Resident #76 stated he had been begging for a bigger bed and the nurses and aides say they would be back and they do not come back. Resident #76 stated it was hard for him to roll side-to-side in the bed because it was not wide enough. Resident #76 rolled from side-to-side to show how hard it was for him. Observation showed Resident #76 could not roll freely. Observation on 08/05/25 at 8:32 A.M. of Resident #76 with the Administrator revealed Resident #76 was lying in bed and the foot of the bed was extended. There was a gap of about eight to twelve inches between the end of the mattress and the footboard. A long vinyl wrapped foam piece was placed in the gap between the mattress and the footboard, but the foam piece did not fit the area and was not tall enough for Resident #76 to rest his heels on it. The foam piece did not fit across the width of the gap between the mattress and the footboard. The Administrator confirmed the foam piece did not fit the open area between the mattress and the footboard and was not helping in any way. Review of Resident #76's invoice dated 08/05/25 included a bed was ordered and shipped to the facility and would arrive to the facility on [DATE]. The bed description was multi-layered pressure reduction mattress with firm perimeter and fire barrier, 650 pound cap. The bed dimensions were 48 inches by 84 inches. Interview on 08/06/25 at 11:11 A.M. of the Administrator revealed she ordered another bed for Resident #76. The Administrator stated Resident #76's current bed dimensions were 36 inches by 80 inches (three (3) feet by 6 feet eight (8) inches). The new bed dimensions were 48 inches ( four (4) feet) by 84 inches ( seven (7) feet). Review of the facility policy titled, Resident Rights and Facility Responsibilities, included the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses that included depression, chronic obstructive pulmonary disease, and hemiplegia. Review of the most recent MDS assessment dated [DATE] revealed Resident #95 was moderately cognitively impaired and required extensive assistance of one staff person for completing his activities of daily living Observation of Resident #44 on 08/04/25 at 11:59 A.M. revealed Resident #44 was up in her wheelchair and his call light was on the floor and out of reach. Interview with Certified Nurse Aide (CNA) #764 verified the placement of the call light at the time of observation. 3. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] with diagnoses that included type two diabetes, end stage renal disease, and chronic pain. Review of the most recent MDS assessment dated [DATE] revealed Resident #95 was moderately cognitively impaired and required extensive assistance of one staff person for completing his activities of daily living. The assessment also noted Resident #95 as completely blind with zero visual perception noted. Observation of Resident #95 on 08/05/25 at 8:06 A.M. revealed Resident #95 was up in his wheelchair and his call light was on the floor and out of reach. Interview with Licensed Practical Nurse (LPN) #741 verified the placement of the call light at the time of observation. This deficiency represents non-compliance investigated under Complaint Number OH00167095 (1254634).

Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure residents were provided with a dignified dining experience. This affected two (#25 and #95) out of three reviewed for respect and dignity. The facility census was 87. Findings include: 1. Review of Resident #95's medical record revealed an admission date of 06/18/24 and diagnoses included type two diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral, end stage renal disease (ESRD), and depression.Review of Resident #95's care plan revised 04/16/25 included Resident #95 had a self care deficit related to weakness, ESRD with hemodialysis, blindness to both eyes and limited mobility. Resident #95 would maintain the highest level of independence possible through the review date. Interventions included to provide eating set up and supervision.Observation on 08/05/25 at 8:44 A.M. of Certified Nurse Aide (CNA) #772 revealed she carried Resident #95's meal tray in his room and set the tray up but did not offer to assist Resident #95 and did not stay in the room to supervise him while he was eating. CNA #772 did not return to the room to check on Resident #95 after she set his tray up and left the room.Observation on 08/05/25 at 1:13 P.M. revealed CNA #772 delivered Resident #95's meal tray to his room, set the tray up and did not stay in the room to assist Resident #95. CNA #772 did not show Resident #95 where his silverware was and did not ensure a piece of meat with gravy on top was cut up before she left Resident #95's room. Further observation revealed there was no knife on the tray and no way to cut the piece of meat into bite size pieces. Resident #95 began eating his mashed potatoes with his fingers and interview with the resident during the observation confirmed he was using his fingers and stated no was assisting him. When asked about the whole piece of meat and no knife on the meal tray and Resident #95 eating his mashed potatoes with his fingers, interview with Licensed Practical Nurse (LPN) #733 during the observation confirmed there was no way to cut the meat up and left the room to find a knife. LPN #733 confirmed Resident #95 was eating mashed potatoes with his fingers and showed him where the spoon was.2. Review of Resident #25's medical record revealed an admission date of 07/03/23 and diagnoses included cerebral infarction due to embolism of unspecified cerebral artery, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side, and dysphagia following cerebral infarction.Review of Resident #25's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status was not conducted due to Resident #25 being rarely or never understood. Resident #25 had impairment on both sides of her upper extremities and impairment on one side of her lower extremities. Resident #25 required substantial to maximal assistance with eating and was dependent for toileting hygiene, bathing, and oral hygiene. Resident #25 was always incontinent of urine and bowel. Review of Resident #25's care plan revised 08/06/25 included Resident #25 had a self-care deficit related to dementia, history of cerebrovascular accident with hemiplegia, impaired mobility, dysphagia. Resident #25's activities of daily living (ADL) needs would be met by staff while allowing her to participate as able. Interventions included the resident needed dependent assistance of one for eating and was dependent on the assistance of one for incontinence care.Observation on 08/05/25 at 8:47 A.M. of Resident #25 revealed she was lying in bed and the head of the bed was elevated at approximately a 30-degree angle. Interview during the observation with LPN #733 stated Resident #25 required assistance with feeding and if the nurse aides had enough time they assisted her out of bed into her wheelchair and took her to the dining room to eat, but otherwise she was fed in her room. Certified Nurse Aide (CNA) #772 carried Resident #25's meal tray in the room and stated she was going to feed her. CNA #772 set Resident #25's meal tray up, stood next to her, did not raise the height of Resident #25's bed and began feeding her while the head of her bed was still at a 30-degree angle. CNA #772 dropped food on Resident #25's gown and continued to feed her while Resident #25's head of the bed was at a 30-degree angle. After a few minutes, CNA #772 raised Resident #25's head of bed to about a 90-degree angle and continued to stand next to her while she was assisting her with eating. CNA #772 confirmed she was standing while feeding Resident #25 and dropped food on her gown. CNA #772 stated she always stood when she fed Resident #25 in the room and when she was in the dining room she sat while she fed her.Review of the facility policy titled, Resident Rights and Facility Responsibilities, dated 10/03/23, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00167217 (1254635), Complaint Number OH00164532 (1254632) , and Complaint Number OH00162468 (1254628).

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed medical record review, review of the local police report, staff interviews, review of the National Weather Service forecast, review of the facility Elopement Policy and Procedure, review of Abuse, Neglect and Misappropriation Policy and Procedure, and review of camera footage, the facility failed to provide adequate supervision to prevent Resident #95, who had diagnoses of metabolic encephalopathy, malnutrition, and adult failure to thrive and severe cognitive impairment, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and actual harm leading to death beginning on [DATE] at approximately 8:40 P.M. when Resident #95 was last seen inside the facility. On [DATE] at 9:30 P.M., [DATE] at 12:36 A.M. and [DATE] at approximately 4:00 A.M. staff identified Resident #95 was not in the facility but failed to take sufficient action to determine her whereabouts. On [DATE] at 6:09 A.M., Licensed Practical Nurse (LPN) #500 began phoning nursing management regarding Resident #95 missing from the facility. At 6:22 A.M., LPN #500 reached Registered Nurse (RN) #484, who was off-duty and off-site, via phone and informed her Resident #95 was missing. A code purple (facility code for an elopement) was called and a search of the facility and property began. RN #484 arrived at the facility at approximately 7:30 A.M. and assisted with search efforts. The local police department was then called, responded to the facility and assisted in search efforts. On [DATE] at approximately 8:10 A.M., RN #484 was informed a wheelchair was observed in the stairwell of the lower level. RN #484 observed the chair, continued up the stairs near where the wheelchair was found and opened the door which exited to the outside, where she met resistance. RN #484 observed Resident #95 lying on the patio outside the exit door to the facility. Resident #95 was observed cold to touch, wet, and without respirations or a heart rate. RN #484 screamed for help and initiated cardiopulmonary resuscitation (CPR). Additional staff responded to the area. Emergency Medical Services (EMS) was contacted, and Resident #95 was transported to a local hospital where she was unable to be resuscitated and was pronounced deceased on [DATE] at 8:57 A.M. On [DATE] at 11:14 A.M., the Administrator, Corporate Regional Director of Operations #507, and Corporate Director of Clinical Services #508 were notified Immediate Jeopardy began on [DATE] at 8:40 P.M. when the facility failed to provide adequate supervision to prevent Resident #95 from eloping. Between [DATE] at 8:40 P.M. and [DATE] at 8:10 A.M. the facility failed to have adequate and effective systems in place to ensure the resident's safety and supervisory needs were met. During this time period, facility staff failed to recognize the resident had exited the facility unsupervised and was missing from the facility. On [DATE] at 8:10 A.M. Resident #95 was found lying on the patio outside the exit door to the facility. Resident #95 was observed cold to touch, wet, and without respirations or a heart rate. RN #484 screamed for help and initiated cardiopulmonary resuscitation (CPR). Additional staff responded to the area. Emergency Medical Services (EMS) was contacted, and Resident #95 was transported to a local hospital where she was unable to be resuscitated and was pronounced deceased on [DATE] at 8:57 A.M. due to environmental exposure. The Immediate Jeopardy was removed on [DATE] and the deficiency corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 6:22 A.M., LPN #500 phoned RN #484 and informed her Resident #95 was missing and attempts to reach the resident's brother were unsuccessful. RN #484 provided instructions to activate a code purple. RN #484 notified Certified Nurse Practitioner (CNP) #502. RN #484 arrived at the facility at 7:18 A.M. On [DATE] at approximately 7:25 A.M., the local police department was notified Resident #95 was missing. Officer #506 responded and collected information and staff statements. On [DATE] at approximately 7:45 A.M., the facility remained in a code purple and continued to search for Resident #95. On [DATE] at approximately 8:10 A.M., Housekeeping Staff #485 informed RN #484 of a wheelchair he observed in a lower-level stairwell. Housekeeping Staff #485 escorted RN #484 to the wheelchair. RN #484 identified the chair as Resident #95's, proceeded up the stairs, and opened the exit door (to the outside) at the top of the stairs. RN #484 identified Resident #95 was lying outside of the facility door and yelled for help. Resident #95 was unresponsive, and CPR was initiated and continued until EMS arrived and transported Resident #95 to a local hospital where she was pronounced deceased . On [DATE], the facility's elopement policy was reviewed by Corporate Regional Nurse #505. No updates or revisions were made. On [DATE], Corporate Regional Nurse #505 re-educated the Administrator and Director of Nursing (DON) on the facility's elopement policy and procedures including assessment, identification, monitoring, and managing the elopement policy. On [DATE] at 8:30 A.M., the Administrator began education with all staff on the elopement policy and procedure, including door alarms and prompt response. Education was additionally provided on abuse, neglect and misappropriation. Nursing staff members received further education on nurse-to-nurse responsibilities regarding census. The education was completed on [DATE] by 5:00 P.M. On [DATE] at 9:00 A.M., Corporate Regional Nurse #505, Corporate Director of Operations #507, Corporate Director of Clinical Services #508, and the Former Administrator #504 walked the building and checked all doors to ensure the doors alarmed and worked properly. On [DATE] at 9:15 A.M. a head count of all residents was completed by LPN #438. All residents were accounted for except for Resident #95. On [DATE] at 9:10 A.M. a contracted door alarm company was contacted to check doors, change door keypad codes, and discuss options to enhance the sounding of the door alarms. The door alarm company installed six additional remote sounders in different locations of the facility, including inside the door at the top of the stairs Resident #95 used to exit the facility. These sounders were installed on [DATE] by 6:00 P.M. On [DATE] all residents residing in the facility were assessed by RN #379 and RN #407. No residents were identified to have any injuries or adverse effects. The resident assessments were completed on [DATE] by 2:30 P.M. On [DATE] all residents were re-assessed for elopement risk by LPN Unit Manager (UM) #434. The assessments were completed by 3:00 P.M. The facility identified zero in-house residents at risk for elopement. Ongoing audits would be completed by the DON or designee upon admission, re-admission, quarterly, with significant changes, and as needed. On [DATE], LPN #438 verified all elopement risk assessments were completed with no residents at risks. No care plan revisions related to elopement were required for in-house residents. This was completed on [DATE] by 5:00 P.M. On [DATE] at 2:00 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held. In attendance were Former Administrator #504, the DON, ADON #411, Maintenance Supervisor #381, Social Service Designee (SSD) #447, LPN #438, Human Resources (HR) Staff #601, Business Office Manager (BOM) #404, Corporate Regional Nurse #505, Corporate Director of Clinical Services #508, Corporate Director of Operations #507. Medical Director (MD) #503 attended via phone. During the meeting, the corrective action plan for Resident #95's elopement was presented by the Administrator and approved by the interdisciplinary team (IDT). On [DATE], the facility implemented random and unannounced elopement drills to be performed three times weekly for four weeks, monthly on all shifts for four months, then monthly on rotating shifts. The elopement drills were coordinated by the Administrator or designee. The results of the drills would be reviewed by the IDT in monthly QAPI meetings. Ongoing audits were implemented to ensure staff hears and responds to alarms timely and appropriately three times weekly for four weeks. The results of the audits would be reviewed by the IDT in monthly QAPI meetings. Ongoing audits were implemented to ensure that with each change of nurse shift, a head count was performed and verified with census records. The results of the audits would be reviewed by the DON or designee daily for 30 days. The results of the audits would be reviewed by the IDT in monthly QAPI meetings. On [DATE], all exterior doors added a door alarm that required alarm de-activation to be turned off with a manual key entry. All doors with alarms were noted to be functioning properly. Findings include: Review of the closed medical record for Resident #95 revealed an admitted [DATE] with medical diagnoses including metabolic encephalopathy, malnutrition, and adult failure to thrive. Resident #95 was transported to a local hospital where she was pronounced deceased on [DATE]. Review of the most recent elopement assessment dated [DATE] revealed the assessment did not identify Resident #95 to be at risk for elopement. The assessment noted the resident was cognitively impaired with poor decision-making skills and confusion. Resident #95 was noted to be a recent admission (within the last 30 days) and not accepting of the situation. Review of a social service progress note, dated [DATE], revealed Resident #95 admitted to the facility for short term rehabilitation services after a recent hospitalization . She was a full code status (advance directives) and her discharge plan was to return to her private residence where she lived alone. The note indicated Resident #95 received support from her brother. Resident #95 used a cane and a walker at home. The note indicated Resident #95 was a questionable historian who seemed confused. Review of Resident #95's care plan, initiated on [DATE] revealed the resident was identified to be a falls/safety/risk/elopement risk. A listed goal included Resident #95 would remain free from injuries and falls. Care planned interventions included to encourage use of the call light, if unable to utilize call light nursing assistants would assess the resident every ,d+[DATE] minutes, instruct the resident on safety measures, and keep call light in reach. Review of Resident #95's Minimum Data Set (MDS) 5-day assessment, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. Resident #95 required partial/moderate (staff) assistance for activities of daily living (ADLs). Resident #95's mood interview could not be conducted as the resident was rarely/never understood. The assessment indicated Resident #95 had no behaviors. Review of the National Weather Service forecast at www.weather.gov revealed the weather in the Cleveland area on [DATE] revealed a high temperature of 41 degrees Fahrenheit (F) and a low of 20 degrees F. The forecast for [DATE] and [DATE] called for rain on-and-off. Review of a police report dated [DATE] revealed a call was placed at 7:27 A.M. in regard to a resident of the facility that had not been seen since [DATE] at 8:40 P.M. Officer #506 arrived on site at the facility at 7:32 A.M. and met with facility staff. The report noted RN #423 began her assigned nursing shift on [DATE] at 7:00 P.M. and completed her assigned check on Resident #95 at approximately 8:40 P.M. At approximately 9:00 P.M., RN #423 was re-assigned to another unit, and LPN #500 assumed care (for this resident). LPN #500 was noted in the report as having completed her first check on Resident #95 at approximately 9:30 P.M. LPN #500 noted Resident #95 was not in her room and assumed the resident had left the facility with her brother, as she had previously left the faciity on a prior date for a few hours. LPN #500 stated she checked the visitors log, but noted no visitors had come inside the facility to visit Resident #95. No further action was taken until [DATE] at approximately 12:36 A.M., LPN #500 attempted to call Resident #95's brother multiple times without success. The report noted LPN #500 stated multiple times that she was a new nurse and was unsure what to do after that. On [DATE] at approximately 6:30 A.M., LPN #500 contacted an off-duty nurse, RN #484 about Resident #95's disappearance. Following the phone call, a code purple was called, after which Resident #95 was still not found. LPN #500 was instructed by RN #484 to complete a thorough search both inside and of the perimeter outside of the building. While awaiting administration in the lobby, Resident #95's brother returned a phone call to LPN #500 and provided the phone to the officer. Resident #95's brother did not know where Resident #95 was and stated he had not picked her up. The brother reported to the officer he visited the resident on [DATE] at approximately 5:30 P.M. and the resident stated she wanted out of the facility. The brother provided a prior address where the resident could be, or stated there was a chance the resident remained on the property and was hiding from the nurses. The report indicated a short time later, multiple screams were heard, and the officer ran in the direction of the screams. Nurses escorted the officer outside to the north side patio of the building, outside the activity room exit, where Resident #95 was observed lying on her back in the corner of the patio. Resident #95 was unresponsive, her eyes and mouth wide open. Resident #95 was cold to the touch. The officer called for dispatch to send Emergency Medical Services (EMS). While waiting for EMS to arrive, nurses began to perform CPR on Resident #95. Resident #95 was placed on a stretcher and transported to a local hospital where she was pronounced deceased on [DATE] at 8:57 A.M. Review of a progress note dated [DATE] at 6:45 A.M., authored by LPN #500, revealed upon the start of her shift she had checked on Resident #95, who was not in her room. The note indicated a thorough check of the nursing unit was completed. LPN #500 checked Resident #95's electronic medical record and LOA in notes verified. At 12:36 A.M., LPN #500 noted the resident had not returned to the facility and LPN #500 attempted to call Resident #95's brother at least 15 times with no answer. At 6:09 A.M., LPN #500 began to call an unnamed Unit Manager without success. At 6:22 A.M., LPN #500 phoned RN #484 and informed her Resident #95 had not returned to the facility. Review of the facility investigation into Resident #95's elopement revealed the following witness statements following the incident: a. LPN #500 provided a written statement on [DATE] at 9:00 A.M. The statement revealed LPN #500 arrived to work on [DATE] at approximately 9:15 P.M. and took over the lower level nursing assignment from RN #423. She indicated the nurse had written out shift change report and needed to finish passing resident medications. LPN #500 first walked down the hall to check on the residents. LPN #500 recalled looking into Resident #95's room and saw the resident was missing at 9:27 P.M. After she checked the notes to see if there was a LOA for the resident, there was a prior note indicating the resident was LOA. The statement indicated after midnight ([DATE]) at 12:36 A.M. LPN #500 attempted to contact Resident #95's brother, and later at 6:22 A.M. she called RN #484. Resident #95 was later found on the patio balcony near the activities room and the resident was taken [off facility grounds] by EMS. b. RN #423's undated witness statement revealed she was Resident #95's nurse on [DATE] from 7:20 P.M. until approximately 9:45 P.M. RN #423 administered Resident #95 her evening medication at 7:45 P.M. At that time, Resident #95 was seated in her wheelchair beside the nurse's station and had no signs of anxiety or agitation. Around 8:30 P.M., RN #423 received information from the facility scheduler of a change of assignment to the upper level of the facility and another nurse was coming in to take over her assignment. RN #423 recalled the oncoming nurse arrived at the facility on [DATE] at approximately 9:45 P.M., she gave her the keys to the [medication] cart and gave LPN #500 report before heading to the upper level for the remainder of her shift. RN #423 stated she did not know or hear anything about Resident #94 until [DATE] at approximately 6:00 A.M. when the lower-level nurse reported the resident was not in her room since 10:30 P.M. c. LPN #429 was interviewed on [DATE] by phone by HR Staff #601. LPN #429 recalled she was the nurse assigned to cart 1 of the lower level. LPN #429 revealed she clocked in [on [DATE]] at approximately 10:45 P.M. and was unfamiliar with Resident #95. LPN #429 recalled that [on [DATE]] at approximately 6:20 A.M., she was informed the resident was missing. d. Certified Nursing Assistant (CNA) #501 was interviewed on [DATE] by HR Staff #601. CNA #501 arrived at the facility [on [DATE]] at approximately 9:00 P.M. CNA #501 recalled he looked into Resident #95's room for the first time on his shift [on [DATE]] between 12:00 A.M. and 1:00 A.M. but never went inside the resident's room and assumed she was sleeping. CNA #501 stated it was after 4:00 A.M. when he inside Resident #95's room for the first time on his shift and he assumed she was gone based on the condition of the resident's room; the resident's bed was unmade, and linen and trash was on the floor. CNA #501 stated he meant to ask LPN #500, but it slipped his mind. Review of a Root Cause Analysis (RCA) dated [DATE] revealed the incident involved a resident (Resident #95) being found unresponsive outside of the facility, on the patio outside the activity room door. A 5 Whys was reviewed and indicated the resident had gone up the stairs unattended and out the exterior door. Staff did not respond to alarm going off on the first floor into the stairwell appropriately, did not check the area and perform a headcount, nor did staff complete routine checks. The RCA listed LPN #500 assumed Resident #95 was on LOA, CNA #501 stated he did not see the resident on [DATE] at 4:00 A.M. and forgot to tell his nurse. CNA #501 additionally had stated he did not see the resident his whole shift. No staff admitted to turning off the alarm, and the facility cameras did not show this area. LPN #500 had received an order from the provider for Resident #95 to go on LOA visits with her brother, and assumed the resident was out on an LOA. The RCA concluded there was ineffective shift-to-shift report, a lack of urgency around code purple with a failure to identify a missing resident versus an assumed LOA, lack of validation of frequent checks and rounding, and a failure to respond appropriately to the door alarms with an immediate head count and checking of the surrounding area. The RCA action plan and monitoring referenced the facility's abatement plan. Interview on [DATE] at 9:20 A.M. with the Administrator, Corporate Regional Nurse #505, and Corporate Director of Clinical Services #508 revealed Resident #95 had not been identified as an elopement risk upon admission to the facility, but did elope from the facility and was found unresponsive on the morning of [DATE] outside the facility doors on a back patio. Corporate Regional Nurse #505 confirmed the staff working that night had not performed their routine, every 2-hour checks on Resident #95. The facility investigated the incident and implemented corrective action following the incident. Interview on [DATE] at 1:49 P.M. with Corporate Regional Nurse #505 confirmed the facility had an alarm to the lower-level stairwell door. Corporate Regional Nurse #505 confirmed the door had to have been alarming at the time Resident #95 exited; however, no staff members working recalled or admitted de-activating an alarm between [DATE] at 9:00 P.M. and [DATE] at 8:00 A.M. All staff in the building who worked between [DATE] at 7:00 P.M. and [DATE] at 7:00 A.M. were interviewed and none reported hearing any door alarm going off during their shift, nor had any staff reported turning off or deactivating any sounding alarm during their shift. The two staff members assigned to care for Resident #95 on the night of [DATE], LPN #500 and CNA #501, were terminated following this incident. Interview and observation on [DATE] at 1:54 P.M. of the facility with Corporate Regional Nurse #505 revealed Resident #95 resided on the lower level of the facility. The location Resident #95's wheelchair was found at the base of the stairs was not visible from the small window of the door to the stairwell. At the top of the stairs, a one-way swing gate was present, and two doors were noted on the second-floor landing. One door with a keypad alarm was locked and had a key code (to enter the main/second level) and one door exited to the outside back patio. Corporate Regional Nurse #505 stated the exit door to the back patio was unlocked for safety. The door alarm had the capability to alarm, but the key was stored in the alarm and turned to the off position on the date Resident #95 eloped from the facility. Corporate Regional Nurse #505 confirmed following the incident, the door alarm company added a louder-sounding alarm requiring a manual key to de-activate. The key was removed from the door alarm and was held by administrative and nursing staff. If the alarm was activated, administrative or nursing staff would respond with the key, deactivate the alarm, and would be responsible for ensuring all residents were accounted for. Interview on [DATE] at 3:48 P.M. with RN #484 revealed she received a call from LPN #500 on [DATE] at approximately 6:20 A.M. RN #484 stated she was unsure why LPN #500 phoned her but said she had tried to call other department leaders without success. LPN #500 told her Resident #95 was missing, she advised LPN #500 to call a code purple, to check the building and the outside perimeter of the building and that she would be on her way into the facility. RN #484 estimated she arrived at the facility on [DATE] at approximately 7:15 A.M. and upon arrival LPN #500 and LPN #429 informed her they had checked the building and perimeter, and Resident #95 remained missing. RN #484 instructed them to phone the police, who responded a few minutes later at approximately 7:30 A.M. During this time, staff continued to search for Resident #95, and RN #484 and Officer #506 waited for Former Administrator #504 at the front door to update her. A short time later, RN #484 was informed by Housekeeping Staff #485 that he located a wheelchair in the lower-level stairwell. Housekeeping Staff #485 escorted RN #484 to the wheelchair. RN #484 identified the chair as Resident #95's, proceeded up the stairs, and opened the exit door (to the outside) at the top of the stairs. RN #484 identified Resident #95 was lying outside of the facility door and yelled for help. Resident #95 was soaking wet, as it had rained all night. Resident #95 was unresponsive, and CPR was initiated and continued until EMS arrived and transported Resident #95 to a local hospital where she was pronounced deceased . Review of the police report addendum dated [DATE] revealed Officer #509 visited the facility that day to see the room Resident #95 had resided in and see the route she traveled to get outside the facility. Officer #509 was accompanied by Corporate Director of Operations #507. The report noted across Resident #95's former room was a door that led to a stairwell. The door to the stairwell had a keypad and a horizontal push bar to open the door. Once the push bar was pressed, a faint audible alarm does sound. If the push bar was pressed and held for 15 seconds, the door automatically opens without the code. At the top of the stairwell, the door to the right was locked with a keypad and led to the interior of the main floor. If the door handle was held for 15 seconds, the door would open. The door to the left was the door Resident #95 exited out of, which lead to an exterior patio area. The door does not have an alarm or keypad when opened, was not locked, and could be opened without a code and without waiting for 15 seconds like the other doors did. The police report addendum noted on [DATE], Officer #509 typed up paperwork for criminal charges related to this incident for an unnamed individual. The charges included Involuntary Manslaughter and Gross Patient Neglect. The report noted the paperwork was signed by a local judge and returned to the officer. No further information or addendum was available at the time of the on-site investigation. Attempts to reach Former Administrator #504 on [DATE] at 9:50 A.M. and 12:59 P.M. were unsuccessful. A telephone interview was attempted on [DATE] at 9:52 A.M. with LPN #500 but was unsuccessful. Telephone interview on [DATE] at 10:54 A.M. with CNA #501 revealed he had been told (on [DATE]) by an unnamed staff member Resident #95 was out on a LOA. CNA #501 recalled he went about his duties, answered call lights and assisted other residents. CNA #501 stated he did not work with Resident #95 often. When he entered the room later in the shift, Resident #95 was not in her room. CNA #501 stated he assumed she was not in the building. CNA #501 stated he went home at the conclusion of his shift on [DATE] at 7:00 A.M. CNA #501 stated he never heard any alarm, nor had to enter any codes to de-activate any door alarms during his shift. Observation on [DATE] at 2:00 P.M. with Director of IT #610 revealed the facility had both interior and exterior cameras that covered the facility common areas, the front door, the back service hall, the front parking lot, and the generator area near the back patio. Director of IT #610 pulled up camera footage from [DATE] to [DATE] and there was no evidence or video of Resident #95 exiting the facility. Director of IT #610 stated the facility's cameras were not infrared, and once it becomes dark outside, the video footage appeared all dark. The area where Resident #95 was located on the back patio was not visible from any camera angle. The only evidence of Resident #95 on the facility's video footage was when she was on a gurney being removed from the back patio to be transported to a local hospital by the EMS providers. At that time, Resident #95 was observed wearing grey pants and a long-sleeved top. A telephone interview was attempted on [DATE] at 1:11 P.M. with Resident #95's brother and was unsuccessful. An interview on [DATE] at 1:20 P.M. with Corporate Director of Clinical Services #508 revealed the facility was informed Resident #95's preliminary cause of death was environmental exposure and hypothermia. Resident #95's official death certificate remained pending at the time of the on-site investigation. Review of the undated facility policy titled Abuse Prohibition revealed each resident has the right to be free from abuse and neglect. The policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. All allegations of abuse, neglect, and misappropriation of property are immediately reported, thoroughly investigated and appropriate actions taken. Review of the facility policy titled Elopement revised ,d+[DATE] revealed a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety. If a resident is missing from the facility, the Administrator and Director of Nursing will be notified immediately. The physician and responsible party will be notified. The nurse or designee will initiate a full house head count of the residents. A staff member will announce code purple over the intercom system to alert the staff that a search will begin for the resident. Once the announcement has been made, staff will report to the nurse's station and await further instruction from the Administrator, DON, or charge nurse. A thorough search of the inside of the facility and outside grounds of the facility will be conducted. If the resident is not located after the staff has searched the internal and external grounds, the local police department will be notified. Following the incident, a detailed investigation into the circumstances surrounding the incident will be completed by the Administrator and Director of Nursing. The Interdisciplinary Team (IDT) will meet following an elopement. Cases of elopement will have correction action and tracking by the Quality Assurance committee. This deficiency represents noncompliance investigated under Complaint Number OH00161082 and Complaint Number OH00161073.

Based on closed record review and interview the facility failed to ensure Resident #94 was provided a safe transfer via mechanical lift to prevent a fall with injury. This affected one resident (#94) of five residents reviewed for accidents. The facility identified 20 additional residents (#11, #14, #17, #18, #24, #26, #27, #32, #33, #36, #41, #46, #47, #49, #55, #71, #75, #82, #84, and #92) who required a mechanical lift for transfers. The facility census was 87. Actual Harm occurred on 04/19/24 when Resident #94, who was a bilateral above the knee amputee, exhibited balance deficits, was moderately cognitively impaired and was dependent on staff for transfers sustained a fall during a staff assisted mechanical (Hoyer) lift transfer. At the time of the incident, State tested Nursing Assistant (STNA) #605 and STNA #617 were transferring Resident #94 from the bed to the chair. After placing Resident #94 in the chair, the staff removed the bottom half of the mechanical lift sling, and Resident #94 began sliding to the floor. As STNA #605 and STNA #617 attempted to lower Resident #94 to the ground, his left above the knee amputation site hit the ground causing his incision to reopen, bleeding profusely and causing the resident pain. The resident was transferred to the emergency room and required (per family interview) 26 stitches to the area. The resident did not return to the facility. Findings include: Review of the closed medical record for Resident #94 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #94 had diagnoses including pleural effusions, peripheral vascular angioplasty status, peripheral vascular disease, chronic obstructive pulmonary disease, type two diabetes mellitus, absence of right and left leg above the knee. Review of the physician's order dated 04/16/24 revealed an order to administer Heparin (anticoagulant) 5000 units subcutaneously three times a day. Review of the medication administration record (MAR) revealed Resident #94 received his morning injection on 04/19/24 at 5:00 A.M. Review of the fall risk assessment dated [DATE] revealed Resident #94 was not identified as a fall risk. Review of the nursing care plan for Resident #94 dated 04/16/24 revealed a focus of rehabilitation potential with interventions including transferring with assistance of one staff member. Review of the physical therapy evaluation dated 04/17/24 revealed Resident #94 presented with balance deficits, decreased dynamic balance, decreased functional capacity, decreased safety awareness, decreased static balance, deficits in judgement, decreased insight, muscle disuse/atrophy, which required skilled physical therapy services to analyze gait pattern, assess functional abilities, decrease complaints of pain, evaluate need for assistive devices, and facilitate discharge planning. Resident #94 was dependent for chair to bed and bed to chair transfers. Review of the occupational therapy evaluation dated 04/17/24 revealed Resident #94 was at risk for falls, required oxygen, and noted to keep the head of the resident's bed elevated 30 degrees. The therapy evaluation revealed Resident #94 was dependent (on staff) for transfers. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had moderate cognitive impairment. The assessment revealed Resident #94 required substantial/maximal assistance for rolling left to right, sitting to lying, and lying to sitting. Resident #94 was dependent for chair to bed and bed to chair transfers. Review of the nursing progress note dated 04/19/24 at 7:50 A.M. revealed the nurse was informed by the nursing assistant Resident #94 slid out of his chair while they were getting him ready for dialysis and his left leg was bleeding profusely. Resident #94 was found sitting up on the floor leaning up against his chair with blood exuding from his left leg amputation incision site. Resident #94 was assessed and reported pain in his left leg, buttocks, and back. A towel was held to his left leg and 911 was called. Resident #94 was sent to the emergency room and his physician, his spouse, and the Director of Nursing (DON) were notified. Review of a repeat fall risk assessment dated [DATE] (after the resident slid out of the chair) revealed he was at a high risk for falls. Review of the facility fall investigation dated 04/19/24 revealed the nurse was informed by nursing assistants Resident #94 was lowered to the floor by two nursing assistants. The aides reported Resident #94 started to slide out of his chair while they were getting him ready for dialysis and that his left leg was bleeding profusely. The nurse observed Resident #94 sitting up on the floor leaning his back against his chair with blood exiting from his left leg. The nurse assessed the resident. Resident #94 complained of pain in his leg, buttocks, and back. Range of motion was within normal limits for his upper and lower extremities. The nurse held a towel to Resident #94's left leg and called 911. Resident #94 was sent to the emergency room and the spouse, and the DON were made aware of the situation. Resident #94 was medicated with Tylenol for pain prior to leaving. The investigation documented Resident #94 was alert and oriented to person and place. Interview on 04/24/24 at 12:39 P.M. with a family member of Resident #94 stated the resident was currently in intensive care and has thus far received 26 stitches and has major bruising. Interview on 04/24/24 at 2:00 P.M. with the Director of Nursing (DON) confirmed Resident #94 did sustain a fall in the facility. The DON reported the resident was newly admitted to the facility and had been a double amputee less than a month prior. She reported following the incident, she interviewed the two nursing assistants (STNA #605 and STNA #617) who were transferring Resident #94 with the mechanical lift from the bed to his wheelchair. They reported to her that when they were lowering Resident #94 into the chair, he was not positioned all the way to the back of the chair, so when they went to adjust him (since he had no legs to balance him), he began sliding forward. The DON reported one aide who was behind Resident #94 grabbed his pants and the aide in front of him positioned herself in front of him and hooked her arms underneath his armpits and placed her leg in between his legs and began lowering him to the ground. Resident #94 had both of his pant legs knotted at the ends with big knots due to his bilateral above the knee amputations and stated he landed right on top of the knots. One aide stayed with Resident #94 while the other went to get the nurse. While the aide was leaving the room she noticed the blood on the bottom of each of his pants. The nurse assessed the resident and reported to the DON the resident was on Heparin. Emergency medical services then transported Resident #94 to the emergency room . Interview on 04/24/24 at 2:20 P.M. with STNA #605 and STNA #617 revealed when they were getting Resident #94 up for dialysis (on 04/19/24), they placed him in the mechanical lift and then transferred him into his wheelchair. While they were placing him in the wheelchair, they noticed that he was not positioned far enough back. They removed the bottom straps of the mechanical lift harness and were going to position him back further in the chair. Resident #94 began screaming he was slipping. STNA #617 reported she was standing behind the wheelchair and went to grab his pants to stop him from sliding and pull him back. STNA #605 was standing in front of Resident #94 and reported because he was a bilateral above the knee amputation on both legs, she hooked her arms under his arm pits and then placed her right leg in between each stump to stop him from sliding but he was not stopping, so they both gently lowered him to the ground. Both ends of his pants were knotted in big knots due to his amputations and Resident #94 hit the ground right on top of those knots and then lowered to the ground causing his stumps to slide forward causing the knots on his pant ends to slide over his stump incisions. STNA #617 stayed with Resident #94 while STNA #605 went to get the nurse. STNA #605 reported as she was leaving the room she noticed the blood on the resident's left pant leg. The nurse came to assess Resident #94 and called the emergency services, and the nurse applied pressure to both stumps until the ambulance got there. They reported that they were both trained on mechanical lift transfers prior to being hired and reported the facility did retrain them on mechanical lift transfers after the incident. STNA #617 reported that they had already unhooked the bottom of the mechanical lift pad when they realized he was sitting on the edge of the chair, and he immediately began sliding. The top of the mechanical lift pad was still attached. Review of the facility policy, Fall Management, revised December 2022, revealed a fall can be defined as when a resident was found on the floor, a resident slid on the floor unassisted, a resident rolled out of bed or chair, a resident falls off or out of any equipment used for transferring or therapy. Review of the facility policy, Mechanical Lift, revised October 2022, revealed the health care facilities of Progressive Quality Care would maintain safety when lifting and transferring residents with a mechanical lift. The facility would also maintain adequate comfort and body alignment. The staff should position the lift over the chair, lower the resident into the chair, be sure that the resident was comfortable, and then remove the hooks from the lift. This deficiency represents non-compliance investigated under Complaint Number OH00153136.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #84 was free from significant medication error. Actual Harm occurred on [DATE] at 12:00 P.M. when Resident #84 who received Hospice services was administered 5 milliliters (ml) of Morphine Concentrate 20 milligrams (mg) per ml by mouth which equaled 100 mg medication, ten times the amount ordered, resulting in a medication overdose. Resident #84 was monitored by the facility nurses for respiratory distress and failure and was administered Narcan for respiratory distress on [DATE] at 7:03 P.M. This affected one resident (Resident #84) out of five reviewed for medication administration. The facility census was 79. Findings include: Review of Resident #84's medical record revealed an admitted [DATE] and diagnoses included malignant neoplasm of unspecified part of unspecified bronchus or lung, secondary neoplasm of the brain and chronic obstructive pulmonary disease. Resident #84 expired at the facility on [DATE]. Review of Resident #84's Nursing Admission assessment dated [DATE] did not specify Resident #84's orientation to time, place, person or if he was disoriented. The Assessment stated Resident #84 was friendly, cooperative and non-questioning. Review of Resident #84's Nursing Admission Care Plan dated [DATE] included Resident #84 had pain. Resident #84 would be as comfortable as possible. Interventions included to monitor pain and administer pain medications as ordered. Review of Resident #84's progress notes dated [DATE] at 2:41 P.M. included Resident #84 was admitted to the facility and received hospice services. Resident #84 was alert and oriented to time, place and had moments of forgetfulness. Review of Resident #84's progress notes dated [DATE] through [DATE] did not reveal documentation Physician #24 was contacted to verify Resident #24's admission orders. Review of Resident #84's Hospice handwritten orders, undated, included Morphine Concentrate 20 mg per ml, give 0.25 ml (5 mg) by mouth, sublingual (under tongue), every three hours as needed for shortness of breath, pain, restlessness. Review of Resident #84's electronic physician orders dated [DATE] at 2:37 P.M. revealed Morphine Sulfate oral solution 20 milligram (mg) per 5 milliliters (ml), give 0.25 ml by mouth every three hours as needed for SOB (shortness of breath), pain and restlessness (0.25 ml of Morphine Sulfate oral solution 20 mg per 5 ml equals one mg). This order was discontinued on [DATE]. Review of Resident #84's physician Telephone Orders dated [DATE] at 11:00 A.M. and written by Hospice Nurse #28 revealed orders for Morphine 20 mg per ml, give 10 mg every six hours ATC (around the clock) scheduled for SOB, pain. Further review revealed additional orders for Morphine 20 mg per ml, give 10 mg every two hours as needed for SOB, pain. Review of Resident #84's electronic physician orders dated [DATE] at 4:39 P.M. revealed orders for Morphine Sulfate oral solution 20 mg per 5 ml, give 10 mg by mouth every six hours for SOB. This order was discontinued on [DATE] at 4:58 P.M. Review of Resident #84's electronic physician orders dated [DATE] at 4:52 P.M. revealed orders for Morphine Sulfate oral solution 10 mg per 5 ml, give 5 ml by mouth every six hours for SOB. This order was discontinued on [DATE]. Review of Resident #84's electronic physician orders dated [DATE] at 5:02 P.M. revealed orders for Morphine Sulfate oral solution 20 mg per 5 ml, give 0.25 ml by mouth every two hours as needed for SOB, pain, and restlessness. This order was discontinued on [DATE]. Review of Resident #84's physician Telephone Orders dated [DATE] revealed orders for Morphine 100 mg per 5 ml, give 10 mg (0.5 ml), every six hours scheduled for SOB, pain. Further review revealed additional orders for Morphine 100 mg per 5 ml, give 10 mg every two hours as needed SOB, Pain. On [DATE] Hospice Nurse (HN) #25 wrote on the Telephone order that she added 10 mg equaled 0.5 ml to prevent future confusion. Review of Resident #84's Controlled Substance Accountability Sheet (was handwritten and did not have a printed pharmacy label) revealed Morphine 100 milligram (mg) per 5 milliliters (ml), take 0.25 ml by mouth or under the tongue every three hours as needed for SOB (shortness of breath), pain or restlessness. Further review revealed on [DATE] at 12:00 P.M. Licensed Practical Nurse #10 administered 5 ml (100 mg) of morphine 100 mg per 5 ml to Resident #84. Review of Resident #84's Medication Administration Record (MAR) dated [DATE] at 12:00 P.M. revealed Morphine Sulfate Oral Solution 10 mg per 5 ml, give 5 ml by mouth every six hours for SOB was administered to Resident #84 by LPN #10. Review of Resident #84's electronic physician orders dated [DATE] at 2:34 P.M. revealed orders for Morphine Sulfate (concentrate) oral solution 20 mg per ml, give 0.5 ml by mouth every six hours for SOB related to malignant neoplasm of unspecified part of unspecified bronchus or lung. This order was discontinued on [DATE]. Review of Resident #84's electronic physician orders dated [DATE] at 2:44 P.M. revealed orders for Morphine Sulfate (concentrate) oral solution 20 mg per ml, give 0.25 ml by mouth every two hours as needed for SOB, pain related to malignant neoplasm of unspecified part of unspecified bronchus or lung. This order was discontinued [DATE]. Review of Resident #84's progress notes revealed a late entry noted dated [DATE] at 3:18 P.M. indicated order was clarified and changed in the electronic record, and resident's daughter notified. Review of Resident #84's progress notes revealed a late entry note dated [DATE] at 4:40 P.M. The note stated Resident #84's daughter expressed concern about Resident #84 not looking right. Resident #84 was assessed and was responsive to stimulation, no distress was observed and Resident #84 had normal respirations. Review of Resident #84's physician orders dated [DATE] at 7:03 P.M. revealed orders for Narcan (Naloxone HCl (hydrochloride) nasal liquid 4 milligram (mg) per 0.1 milliliter (ml), one spray alternating nostrils as needed for respiratory distress related to malignant neoplasm of unspecified part of unspecified bronchus or lung. Review of Resident #84's Medication Administration Record (MAR) dated [DATE] revealed Narcan (Naloxone HCl (hydrochloride) nasal liquid 4 mg per 0.1 milliliter (ml), one spray was administered at 7:03 P.M. and was effective. Review of Resident #84's progress notes revealed a late entry note dated [DATE] at 8:34 P.M. revealed morphine order clarified, Resident #84 was lethargic with decreased respirations. Physician #24 was notified and gave a new order for Narcan 4 mg. Narcan was administered with effectiveness. Review of Resident #84's progress notes revealed a late entry order clarification note dated [DATE] at 8:38 P.M. revealed Resident #84 remained alert for a small period of time and then became lethargic. Physician #24 was notified and ordered Narcan 4 milligram (mg) and repeat as necessary. Report any new changes in condition. Family at bedside, Narcan was effective and Resident #84 was alert and oriented, back to baseline. Review of Resident #84's physician orders dated [DATE] at 1:13 P.M. revealed orders for Morphine Sulfate (Concentrate) Oral Solution 20 mg per ml, give 0.25 ml by mouth every six hours for pain related to malignant neoplasm of unspecified part of unspecified bronchus or lung, chest pain, or shortness of breath. Further review revealed orders at 1:18 P.M. for Morphine Sulfate (Concentrate) Oral Solution 20 mg per ml, give 0.25 ml by mouth every two hours as needed for pain. Review of Resident #84's facility pharmacy packing slip dated [DATE] revealed two bottles of Morphine Sulfate Solution 100 mg per 5 ml were delivered to the facility. Observation on [DATE] at 4:05 P.M. of Resident #84 revealed he was lying in bed with the head of the bed slightly elevated. Resident #84 looked at the surveyor, but did not speak or answer questions. Resident #84 was breathing slowly and heavily during observation. Interview on [DATE] at 4:05 P.M. with Daughter #26 indicated on [DATE] at around 11:00 A.M. LPN #10 entered Resident #84's room and asked Daughter #26 if she would like her to wake Resident #84 to give him pain medicine. Daughter #26 stated Resident #84 received morphine and then left the room to participate in an Activity program. Later Daughter #26 indicated she told the nurses several times she did not like the way Resident #84 looked, but the nurses said he was just tired. Daughter #26 revealed Resident #84 was supposed to receive 0.5 mg of morphine by mouth, and LPN #10 told her she administered 5 ml of morphine to him. Daughter #26 stated she asked if she could see the syringe LPN #10 used to administer Resident #84's morphine because the syringe LPN #10 used looked different than the syringe which was used at home to administer Resident #84's morphine. Daughter #26 stated when LPN #10 looked at the syringe with her LPN #10 realized she gave Resident #84 an incorrect dose of morphine. Daughter #26 stated the she had LPN #10 come in the room because Resident #84 would breathe a couple times, then there would be a long pause before he breathed again. Daughter #26 stated after that Resident #84 received Narcan. Daughter #26 stated after the Narcan was administered Resident #84 would seem alright for awhile then he would become lethargic again. Daughter #26 stated she was not in denial about Resident #84's dying, but if the correct dose of morphine had been given she could guarantee he would not be in the state he was in now. Daughter #26 stated she did not know how many incorrect doses of morphine Resident #84 received. Daughter #26 indicated on [DATE] the Director of Nursing talked to her and apologized for the error. Daughter #26 stated LPN #10 told her she thought it was a high dose of morphine and if she thought that why did she give the 5 ml of morphine which was a high dose. Daughter #26 stated she felt there should be a report filed about the incident. Interview on [DATE] at 6:10 A.M. with LPN #14 revealed she worked on the nursing unit Resident #84 resided on, but he was never or rarely in her assignment. LPN #14 stated Resident #84 was not in her assignment, but she often assisted the nurse who was assigned to the area Resident #84 resided. LPN #14 stated she put morphine orders in Resident #84's electronic record on [DATE] to assist LPN #16 and on [DATE] to help LPN #27. When asked about Resident #84's Telephone Order date of [DATE], LPN #14 stated the Telephone Order was written by Hospice Nurse (HN) #28 and dated [DATE] but the Telephone Order was actually written and put in the electronic record on [DATE]. LPN #14 stated Hospice Nurses usually wrote orders for residents receiving hospice services and the facility nurses put the orders in the electronic record. LPN #14 stated when she searched for Morphine in the system to enter the order in Resident #84's electronic orders she could not find the concentrated Morphine 20 mg per ml. LPN #14 stated Morphine 20 mg per ml was not a choice she could choose in the electronic system used by the facility, and she chose the Morphine which most closely resembled the order. LPN #14 stated on [DATE] she chose the Morphine 20 mg per 5 ml option and on [DATE] she chose the Morphine 10 mg per 5 ml choice and also Morphine 20 mg per 5 ml choice. LPN #14 stated she did not ask the Director of Nursing for assistance in locating the concentrated Morphine 20 mg per ml in the system. LPN #14 stated a Nurse Practitioner was in the facility and helped her pick the Morphine dose which most closely resembled the orders. LPN #14 stated the Morphine she ordered which was 10 mg per 5 ml and 20 mg per 5 ml was never delivered by the pharmacy so the open bottle of morphine Resident #84 brought with him to the facility was used by the nurses to administer Morphine (Morphine Sulfate Concentrate 100 mg per 5 ml). LPN #14 stated she did not administer Morphine to Resident #84, she only helped put orders in his electronic record. LPN #14 indicated Resident #84 was admitted with a comfort care kit which included the concentrated Morphine 20 mg per ml. LPN #14 stated the Morphine 20 mg per ml did not come with a box, it was in a baggie, was opened, did not have a plunger and did not have a seal. LPN #14 stated Daughter #26 brought the box for the Morphine in later. LPN #14 revealed she did not think she verified Resident #84's orders with Physician #24 because she was assisting LPN #16 and LPN #16 probably verified the orders. LPN #14 indicated she thought Hospice nurses took care of resident's Morphine and called the Hospice physician for orders and a signed prescription. LPN #14 stated facility nurses did not have to call our own doctor to get a signed prescription. When asked about the orders on [DATE] and [DATE] for Morphine Sulfate 20 mg per 5 ml and the amount to be administered (0.25 ml) equaled 1 mg LPN #14 stated 0.25 ml equaled 5 mg. Interview on [DATE] at 9:27 A.M. of Hospice Nurse (HN) #25 revealed Resident #84 was on home hospice care and was admitted to the facility after Daughter #26 felt like she could not care for him at home. HN #25 stated Resident #84 had a Hospice home team and when he was admitted to the facility he changed to a Hospice facility team. HN #25 confirmed Resident #84 brought medications from home to the facility. HN #25 stated HN #28 was covering the weekend and wrote a Telephone Order which was correct but not clear. HN #25 stated the facility nurse on duty the day of the Morphine incident mixed up the concentration of Morphine with the dose ordered and accidentally gave Morphine 5 ml by mouth which was 100 mg of Morphine instead of the 10 mg ordered. HN #25 stated after Resident #84 was administered 100 mg of Morphine by mouth he was groggy for a period of hours and was given Narcan times one dose. HN #25 stated Resident #84 was in decline since he received the Narcan, and did not think he received any additional Morphine after the 100 mg was given. HN #25 indicated the Morphine was being held until [DATE] to let it disperse from his system. HN #25 stated she called the coroner and the coroner told her she did not have to call him when Resident #25 passed because an acute overdose of Morphine did not cause his death. HN #25 stated the nurse did not realize she was giving the incorrect dose of Morphine, and did say to Daughter #26 she thought it was a higher dose than normal, but did not call to clarify before administering the Morphine. HN #25 indicated she told the facility nurses if there were any questions about the orders to call for clarification. HN #25 stated she spoke with the Director of Nursing (DON) and told her the concentrated morphine was administered with a one ml syringe. HN #25 stated she did not place Morphine orders for Resident #84 because the nurse on duty told her his medications were in place. HN #25 stated Physician #24 was Resident #84's primary care physician and in facilities the primary care physician was contacted first for orders and if that wasn't successful then the Hospice nurses would use the Hospice physician. Interview on [DATE] at 10:12 A.M. of Hospice Nurse (HN) #28 revealed she made a mistake on the date of the Telephone Orders she placed and the date of the Telephone Order was [DATE] and not [DATE]. HN #28 stated she told the nurse on duty and the nurse said the date did not matter because the correct date was in the system and would be on the order after it was placed in the electronic system. HN #28 stated on [DATE] Resident #84 was very SOB and the nurses were not doing a lot about the SOB so she stayed about an hour and a half. HN #28 stated the orders the facility had for Resident #84 did not match the orders that were in the Hospice system. HN #28 stated Resident #84 was receiving Morphine 0.25 ml every three hours as needed and did not have a scheduled dose of Morphine ordered. HN #28 stated the Hospice orders had a scheduled dose of Morphine 10 mg (0.5 ml) and an as needed dose of Morphine 5 mg (0.25 ml) ordered. HN #28 stated the Hospice Nurse Practitioner told her she could give Resident #84 scheduled and as needed Morphine and approved the orders. HN #28 indicated Resident #84 only received 0.25 ml of Morphine and needed to receive another 0.25 ml to complete the full dose (10 mg) of the scheduled Morphine which was in the Hospice orders. HN #28 stated LPN #27 showed her the handwritten Hospice orders which were not the same as the orders in the Hospice electronic system. HN #28 stated the Telephone Orders she wrote on [DATE] were the same as the orders in the Hospice electronic system. HN #28 stated she told LPN #27 Resident #84 needed another Morphine 0.25 ml to complete the scheduled dose but did not know if LPN #27 administered it because HN #28 had to leave the facility to continue her work assignment. HN #28 stated it did not make sense that Resident #84 was given 100 mg of Morphine because the concentrated Morphine came with its own 1 ml syringe. Interview on [DATE] at 11:16 A.M. of LPN #10 revealed on [DATE] Resident #84 had a scheduled dose of Morphine due at 12:00 P.M. LPN #10 stated Resident #84's orders stated to give 5 ml and she gave him 5 ml from the Morphine bottle which was in the medication cart. LPN #10 stated after she gave Morphine 5 ml to Resident #84 she realized the Morphine in the medication cart was 20 mg per ml and not 10 mg per 5 ml. LPN #10 stated Resident #84 was given 100 mg of Morphine by mouth, and she immediately contacted Resident #84's physician. LPN #10 stated Daughter #26 was notified and Resident #84's Morphine orders were clarified. LPN #10 stated she kept assessing Resident #84 and it took about three hours for him to become lethargic. LPN #10 indicated she took Resident #84's vital signs and documented the vital signs on Resident #84's neuro check sheet which was on paper and not in the electronic medical record. Physician #24 gave orders to monitor Resident #84. LPN #10 stated Resident #24's vital signs changed and he developed apnea (stop breathing or have almost no airflow). LPN #10 stated Resident #84 received Narcan when he developed apnea. LPN #10 stated she thought the 5 ml was weird but Resident #84's MAR made it seem like she should give Morphine 5 ml. LPN #10 revealed the orders in Resident #84's MAR were very confusing. Interview on [DATE] at 12:45 P.M. of the DON revealed Resident #84 was admitted on [DATE] and was receiving hospice services. The DON stated hospice provided orders and the orders would have been verified with Physician #24. The DON stated the Hospice home care team could have communicated more effectively with the Hospice facility team to help prevent Resident #84's Morphine mistake. The DON stated Resident #84's Morphine was initially ordered by Hospice and was 0.25 ml every three hours as needed. The DON stated HN #28 came in on the weekend and bumped the Morphine up to 0.5 ml on a scheduled basis. The DON stated LPN #14 was helping the other nurses on [DATE] and [DATE] when she placed Resident #84's Morphine order incorrectly in the electronic system. The DON stated LPN #14 did not ask for help or tell her she could not find the correct Morphine concentration when she placed the order in the system. Observation on [DATE] at 12:45 P.M. with the DON of Resident #84's open Morphine bottle revealed Morphine Sulfate 100 mg per 5 ml. Interview on [DATE] at 1:32 P.M. of Physician #24 revealed giving 100 mg of Morphine by mouth could depress respirations and cause respiratory arrest. Physician #24 stated Resident #84 was monitored continuously after he received Morphine 100 mg by mouth. Physician #24 stated he called an emergency room physician to ask if Resident #84 should be transported to the Emergency Department and the emergency room physician told him if Resident #84 was stable he could be monitored at the facility after Narcan was administered. Physician #24 stated Resident #84 had one dose of 100 mg of Morphine, it could potentially induce respiratory failure, but it did not. Physician #24 stated Morphine would not have a lingering effect on Resident #84. Interview on [DATE] at 1:51 P.M. of Pharmacist #29 revealed he worked for the facility pharmacy. Pharmacist #29 stated the pharmacy did not receive orders and Resident #84 did not have Morphine dispensed from the pharmacy until [DATE] at 7:00 P.M. which was after the incident when Resident #94 received Morphine 100 mg by mouth. Pharmacist #29 stated an order for Resident #84's Morphine might have been sent to the pharmacy but it would not have been filled until there was a signed prescription from the physician. Pharmacist #29 stated the facility pharmacy would have no eyes on medications brought from home including Morphine and would not know what was brought from home. Pharmacist #29 stated the facility pharmacy could not repackage medications and would never approve the use of another pharmacy's controlled two substance (Morphine). Interview on [DATE] at 2:29 P.M. of the DON, the Administrator and Regional Nurse #30 revealed LPN #30 might have seen orders from Hospice for Resident #84 but there was not a valid prescription for Morphine. Regional Nurse #30 stated LPN #14 knew Resident #84's family brought his medications including a bottle of Morphine to the facility and the medications were filled at an outside pharmacy and not the facility pharmacy. Regional Nurse #30 stated she thought LPN #14 saw Resident #84's Morphine bottle was labeled 100 mg per 5 ml, saw Morphine 20 mg per 5 ml in the electronic system and did not realize what she had was different from the template. Regional Nurse #30 stated Resident #84's Morphine orders were probably sitting in the queue at the facility pharmacy waiting for a prescription from the physician. Interview on [DATE] at 8:04 A.M. of LPN #16 revealed she verified Resident #84's orders with Physician #24 when Resident #84 was admitted to the facility. LPN #16 confirmed there was no documentation in Resident #84's progress notes stating she verified his orders with Physician #24. LPN #16 stated Resident #84 brought his medications from home, she made sure the medications including the Morphine bottle matched the Hospice orders. LPN #16 stated Resident #84's Morphine bottle was opened and had been used prior to his admittance to the facility. LPN #16 stated LPN #14 helped her and placed Resident #84's orders including Morphine in the electronic system. LPN #16 stated Resident #84's Morphine order changed a few times. Interview on [DATE] at 9:41 A.M. of Hospice Chief Quality Officer (HCQO) #31 revealed the facility was provided handwritten orders for Resident #84 when he was admitted to the facility. HCQO #31 stated the facility would not be able to view orders in the Hospice electronic system and that was the reason orders were handwritten and given to the facility. HCQO #31 stated the handwritten Hospice orders including Morphine needed to be verified by Resident #84's physician. HCQO #31 confirmed the facility was not given Resident #84's most recent Hospice Morphine orders and that was why HN #28 called the Hospice Nurse Practitioner on [DATE] and updated Resident #84's Morphine Orders via a Telephone Order. Interview on [DATE] at 10:11 A.M. of the DON revealed the facility would accept Resident #84's medications from home. The DON stated the Hospice nurses provided Resident #84's orders, and the facility nurses would verify the orders with the facility physician. The DON stated Resident #84's Morphine which was brought from home was alright for the facility to use even if the bottle was open and unsealed. The DON stated Resident #84's Morphine was filled from an outside pharmacy and Physician #24 (Resident #84's physician) did not know Resident #84 and would direct the facility to get a prescription from hospice. The DON stated the facility physicians would not give a signed prescription for a Hospice resident. The DON indicated Physician #24 gave the okay to continue doing what hospice was doing. The DON confirmed the facility would not know what happened to the Morphine bottle after it was opened at home and it was not uncommon to accept open bottles of Morphine from resident's receiving Hospice services admitted to the facility. The DON stated she was not sure if Physician #24 was aware Resident #84's Morphine bottle was opened and unsealed. Interview on [DATE] at 10:22 A.M. of Physician #24 revealed he did not remember being called to verify Resident #84's medications by a facility nurse, but he was called to verify so many orders it was hard to remember all the residents. Physician #24 stated he would always want to write a new prescription for Morphine, and he did not know Resident #84 brought a bottle of Morphine with him when he was admitted to the facility. Physician #24 stated he would order Resident #84's Morphine from the facility pharmacy. Physician #24 stated he would not okay the use of an open bottle of Morphine brought to the facility from home. Review of the facility policy titled Medication Ordering and Receiving from Pharmacy and Medications Brought to the Facility by a Resident or Responsible Party, undated, included medications brought into the facility by a resident or responsible party were used only upon written order by the resident's attending physician, after the contents were verified, and if the packaging meets the facility's guidelines. Unauthorized medications were not accepted by the facility. Use of medications brought to the facility by a resident or responsible party was allowed only when the following conditions were met; the medication was ordered by the resident's physician and entered in the resident's medical record for bedside storage and self-administration by the resident, the medication container was clearly labeled in accordance with the facility procedures for medication labeling and packaged in a manner consistent with facility guidelines for medications. Medications not ordered by the resident's physician, or unacceptable for other reasons, are returned to the responsible party or designated agent. Review of the facility policy titled Medication Administration-General Guidelines revised ,d+[DATE], included the Five Rights, the right resident, right drug, right dose, right route and right time were applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration, when the medication was selected, when the dose was removed from the container, and just after the dose was prepared and the medication put away.

Based on interview and record review, the facility failed to ensure interventions were put in place to prevent falls for Residents #11, #5 and #7. Harm occurred for Resident #11 when the facility failed to ensure appropriate interventions had been initiated to prevent a fall from wheelchair resulting in a fracture of the left femur. This affected three of four residents reviewed for falls, with a facility census of 78. Findings include: 1. Review of the record revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's quarterly minimum data set assessment dated [DATE] revealed he was severely cognitively impaired and required the extensive assistance of one staff member for all of his activities of daily living, including bed mobility, transfers and toileting. Review of nursing notes dated 01/21/17 at 6:49 A.M. revealed the resident was found outside the facility on the ground, after walking out a door into a closed patio. He was confused and sustained a hematoma to his forehead. The resident was placed on one to one supervision for 72 hours to prevent further exit from the building and falls and his room was moved further from the exit. Review of the nursing notes dated 02/22/17 at 3:33 P.M. revealed the nurse heard a chair alarm but could not reach Resident #11, who was in the dining room, before he stood up from his wheelchair and fell . Review of the investigation of the incident revealed the resident had dementia and was impulsive with a lack of safety awareness. A referral was to be made for therapy. Review of a nursing note dated 02/24/17 at 6:24 A.M. revealed the resident was in the nurses station area to be monitored but stood up and fell before the nurse could get to him. Review of the investigation of the incident revealed the resident again was able to stand but lost his balance and fell before staff could get to him. The investigation summary revealed the resident had been referred to therapy and he was to be encouraged to be in common areas as much as possible. Review of the therapy evaluation dated 02/23/17 revealed the therapist had recommended starting therapy, but required insurance approval. The resident did not start therapy until 02/27/17. Review of a note on 04/11/17 at 4:10 P.M. revealed the resident stood again from his wheelchair, in view of staff, who were unable to reach him before he fell . He initially had no evidence of injury but when seen by therapy later that day, had complaints of pain and was noted with an acute left femur fracture. He was discharged to the hospital and returned after having surgery on 04/19/17. The only care plan provided by the facility regarding falls was dated 06/14/17, with all interventions also dated 06/14/17. This date was after the resident returned from a hospital stay on 06/03/17. The facility did not provide a care plan with dates prior to 06/14/17. Review of the fall management policy dated November 2016 revealed if a resident fell , the nurse would initiate an immediate intervention to attempt to prevent future falls and the interdisciplinary team would also review falls to determine the most appropriate type of intervention to put in place to prevent future falls. Interview with the facility administrator and director of nursing on 06/15/17 at 11:30 A.M. verified the resident was impulsive and fell despite being in full view of staff on 02/22/17, 02/24/17 and 04/11/17. The director of nursing verified the intervention put in place after the fall on 02/22/17 was to start therapy but the actual therapy sessions did not start due to insurance concerns, until 02/26/17, during which time the resident fell again. The intervention put in place after that fall was to encourage the resident to be in common areas, although he was in common areas for all the falls and both falls were witnessed by staff. She verified the chair alarm in place was functioning but staff could not react in time to assist the resident or reach him to prevent the fall. She further verified the resident sustained [REDACTED]. She stated the facility had considered a pull away alarm to signal staff that he was moving forward in his chair before he stood, but verified there was no order put in place for this and the record or fall investigations did not provide documentation or discussion of other interventions with staff that could be attempted to prevent the resident from quickly and impulsively standing without assistance. 2. Review of the record of Resident #5 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his admission minimum data set assessment dated [DATE] revealed he was severely cognitively impaired and required the extensive assistance of one to two staff members for all activities of daily living. Review of a nursing note dated 04/25/17 at 1:56 P.M. revealed the resident was found on the floor in the common area. An investigation of the incident revealed the resident indicated he was standing up to find something to spit in, as he had a lot of secretions. The investigation indicated the resident was to be given a cup to spit in, but did not indicate an intervention to address the fall, including if he was weak, or had lost his balance. Review of a nursing note dated 05/12/17 at 7:04 P.M. revealed the resident was found on the floor by his family when they visited. The investigation indicated he was ordered a bed and chair alarm to signal staff of unassisted transfers. Review of a nursing note dated 06/05/17 at 6:50 P.M. revealed the resident was found on the floor in his room, and stated he was attempting to go to the bathroom. Review of the investigation of the incident revealed the resident was placed on every two hour checks. There was no indication in the investigation as to when the resident was last taken to the bathroom before the fall or if his alarm was functioning at the time of the fall. Review of a nursing note dated 06/10/17 at 3:52 P.M. revealed the nurse was passing medication and saw the resident walking toward his door. He fell before the staff member could reach him. The note indicated the resident turns off his alarms and had been on one hour checks. The resident sustained [REDACTED]. Review of the investigation revealed the resident was placed on 30 minute checks but did not indicate when the resident was last checked before he was seen in the doorway. The investigation did not contain statements by staff to indicate if the alarm had been put in place and when it was last checked. The record also did not contain documentation of the resident removing the alarms prior to the fall or any interventions put in place to ensure the alarms were in place and functional if he had a history of [REDACTED]. Review of the fall management policy dated November 2016 revealed if a resident fell , the nurse would initiate an immediate intervention to attempt to prevent future falls and the interdisciplinary team would also review falls to determine the most appropriate type of intervention to put in place to prevent future falls. An interview with the administrator and director of nursing on 06/15/17 at 12:15 P.M. verified the fall investigations did not indicate when the resident was last checked or toileted or if the alarms were in place and functional prior to the resident falling. She stated the intervention for the fall on 04/25/17 did not address the inability of the resident to maintain balance and transfer. She verified although interventions for more frequent checks were put in place, there was no evidence in the investigation to indicate that staff were actually checking on the resident as stated in the interventions and assessing his needs to prevent falls. 3. Review of the record of Resident #7 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her quarterly minimum data set assessment dated [DATE] revealed she was severely cognitively impaired and required the extensive assistance of one to two staff members for activities of daily living. She was a totally dependent on one staff for transfers. Review of her nursing notes dated 03/07/17 at 2:22 P.M. revealed the resident was found on the floor of her room in front of her chair. She stated she needed to use the bathroom or she was going to be incontinent. Review of the investigation of the fall revealed the details of the fall and indicated she had no injuries, but did not indicate when she had last been taken to the bathroom before the fall. The investigation did not include an intervention to prevent future falls. Review of the nursing notes dated 03/22/17 at 4:43 P.M. revealed the resident was observed by a staff member sliding out of her wheelchair. She was in the common area at the time of the incident. Review of the investigation of the incident revealed a non skid material was placed on her wheelchair to prevent sliding. Review of a nursing note dated 05/07/17 at 3:40 A.M. revealed the resident was sitting on the floor near her bed. Review of the investigation of the incident revealed floor mats were placed by the bed and a bed alarm was put in place. Review of a nursing note dated 05/26/17 at 11:30 P.M. revealed the resident was found on her knees on mat by the bedside. Review of the investigation of the incident revealed the resident could not state what she was doing. The investigation indicated the resident was assisted to her wheelchair and taken to a common area. The investigation did not indicate if the resident's bed alarm was sounding and did not indicate any other interventions to prevent future falls when she was in her bed. Review of the fall management policy dated November 2016 revealed if a resident fell , the nurse would initiate an immediate intervention to attempt to prevent future falls and the interdisciplinary team would also review falls to determine the most appropriate type of intervention to put in place to prevent future falls. Interview with the administrator and director of nursing on 06/15/17 at 12:30 P.M. verified there were no interventions put in place after the falls on 03/07/17 and 05/26/17. The director of nursing further verified there was no indication to indicate the resident's bed alarm was in place and functional when she was found on the floor on 05/26/17. This citation substantiates Complaint Number OH 701.

Based on interview and record review, the facility failed to ensure residents remained free from significant medication errors related to the administration of narcotic [MEDICATION NAME]. This affected one (Resident #1) of four residents reviewed for medication errors. Harm occurred when Resident #1 received 200 milligrams (mg) of a narcotic [MEDICATION NAME] instead of her physician ordered 10 mg, and was transported to a hospital emergency room for treatment. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of an incident report revealed on 10/12/15 at 9:15 P.M., Licensed Practical Nurse (LPN) #200 was informed Resident #1 had an urgent need for pain medication. The Medication Administration Record [REDACTED]. According to the incident report, LPN #200 gave 10 ml of the available liquid narcotic [MEDICATION NAME], which was a concentration of 100 mg/5 ml (this concentration was previously obtained from the emergency drug kit on 10/02/15 to respond to the resident's pain management needs). After administration, LPN #200 immediately noticed the medication error, obtained vital signs (blood pressure 108/74; heart rate 78, respirations 16; pulse ox 96% room air) and notified the resident's physician. The physician ordered the resident sent to the emergency room and LPN #200 called 911. According to the emergency medical service report, upon arrival the emergency transport personnel applied oxygen and administered [MEDICATION NAME]. When Resident #1 was transported to the hospital, her vital signs were documented as blood pressure 143/87, heart rate 105, pulse ox 99%, respiration 14 (normal). Interview with the assistant director of nursing (ADON) on 12/17/15 at 4:48 P.M. verified the significant medication error. The ADON verified the same liquid narcotic medication, but of a different concentration, had been pulled from the emergency drug kit for use on 10/02/15, as that was immediately available to address the resident's pain. Review of the narcotic records on 01/04/16, revealed Resident #1 had received three doses of the 100 mg/5ml concentration previously without error on 10/02/15, 10/03/15, and 10/05/15. Review of the hospital record for Resident #1 revealed on 10/12/15 the resident was admitted to the hospital and received [MEDICATION NAME] (an antidote to narcotic overdose) in the emergency room , with some improvement. A [MEDICATION NAME] drip (continuous intravenous administration) was initiated, and the resident was admitted to the hospital. On 10/16/15, staff education occurred with 20 LPN's and 9 RN's which included medication administration, the six rights of medication administration, discontinuing medication orders, and two nurses verifying narcotic conversion calculations. On 10/19/15, the facility implemented a new procedure that included a second nurse verifying the narcotic conversion calculations to ensure the prescribed dose was administered. Review of LPN #200's personnel record revealed she was terminated on 10/19/15. This deficiency substantiates Complaint Number OH 993.

Based on interview and record review the facility failed to ensure all residents, who were assessed to require staff assistance for toileting were afforded the opportunity to maintain as much bladder continence as possible and failed to ensure comprehensive assessments were completed to ensure residents maintained normal bladder function. This affected six residents (Resident #4, #7, #3, #2, #5 and #1) reviewed for bladder function. The facility identified 95 residents who required assistance and/or were dependent of staff for toileting needs. Findings include: Review of the bladder and bowel tracking /urinary assessment, revised November 2013 revealed the facility would initiate the tracking of bowel and bladder habits to identify a pattern of incontinence and establish appropriate programming. The policy listed the types of urinary incontinence and symptoms. The procedure included: 1. Initiate a bowel and bladder toileting record for all residents upon admission, quarterly and with significant change for those residents that have been determined to be incontinent. 2. Record the bowel and bladder habits for three days on the bowel and bladder toileting record. 3. Upon completion of the three day tracking, perform a urinary incontinence assessment upon admission, quarterly and with significant change. 4. Then establish an appropriate toileting program. 5. Implement a care plan. 6. Delivery of the toileting program would be recorded on the treatment administration record. On 04/13/15 at 3:35 P.M., interview with restorative nurse/registered nurse (RN) #109 revealed the RN had started at the facility about a month prior. RN #109 revealed no bladder/urinary assessments had been completed since October 2014 and she was trying to get caught up on the assessments but had not implemented any voiding tracking or care plans. On 04/13/15 at 4:55 P.M., interview with Minimum Data Set (MDS) 3.0 licensed practical nurse (LPN) #110 revealed she obtained the information to complete resident MDS assessments from the STNA documentation of bladder continence. LPN #110 revealed she did not interview residents or staff and revealed the times the STNAs enter documentation might not actually be the times of actual toileting or changing a resident, therefore the data available might not be useful to attempt to establish a pattern of incontince or to determine the accurate needs of a resident. On 04/13/15 at 5:10 P.M., interview with the DON revealed the facility had no evidence three day bladder trackers were being completed for residents. The DON also revealed there was no evidence appropriate toileting programs were put into place, no evidence care plans were in place, and there was no evidence of toileting programs on the treatment administration records as noted in the above facility policy and procedure. The DON verified bowel and bladder assessments had not been completed since October 2014 but a new restorative nurse had started a month ago and was working on getting the assessments up to date. The DON verified there were no residents on restorative bladder or re-training programs. The following resident specific concerns were identified during the onsite investigation: 1. Record review revealed Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the facility for therapy with a goal to be discharged home. Review of the admission urinary incontinence evaluation, dated 10/10/14, which was the most current assessment completed, revealed the resident was continent of urine at time of admission, had a history of [REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/17/15 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident's cognition was intact with no deficits. The assessment revealed the resident required extensive assistance from two or more staff for transfers and one staff assistance for toileting. No toileting plan was in place. Review of the STNA kardex revealed the resident needed two staff for transfers with the mechanical lift. The resident was not toileted per the kardex information. Review of the current bladder continence care plan revealed, the resident was not toileted. Review of the April 2015 bladder elimination record revealed the resident was continent six of the 33 times documented. On 04/14/15 at 10:05 A.M., interview with Resident #7 revealed staff were very slow in responding to a request for assistance especially at night. Sometimes they come in and say they will be back because they are busy and they do not return. The STNAs say they do not have enough help and tell me to be patient. The resident verified she had the urge and perception to urinate, but the STNAs say they cannot take me to the toilet because it takes two of them so I have to pee in my diaper. The resident verified the was humiliating to her and she would like to be toileted. The resident stated she just needed someone to help because she could not control her left leg. 2. Record review revealed Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was continent when admitted to the facility. Review of the urinary incontinence evaluation dated 04/08/15 revealed the resident was continent prior to admission. The resident required the assistance of one staff for transfers and toileting. Review of the quarterly MDS 3.0 assessment, dated 01/31/15 revealed the resident's BIMS score was 15 reflecting the resident's cognition was intact. Review of the STNA kardex information related to toilet use, revealed the resident required limited assistance from one staff person. Review of the current care plan revealed there was no plan in place related to bladder function and/or bladder continence. On 04/14/15 at 10:15 A.M., interview with Resident #4 revealed the STNAs make her feel bad when she asks for help with perineal care after toileting. The STNAs say things like you have to pee again you just went. The resident stated she needed assistance with perineal care and pulling up her pants. The resident stated because she was on a water pill sometimes she had to urinate quickly but usually the STNAs did not respond in time and I have to soil myself and I do not like that. The resident stated she had waited up to 45 minutes to one hour at times. 3. Record review revealed Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission urinary incontinence evaluation, dated 11/04/14, which was the most current assessment, revealed the resident was continent of urine at time of admission, had a history of [REDACTED]. The resident needed assistance of one staff for transfers and toileting. Review of the admission MDS 3.0 assessment, dated 11/27/14 revealed a BIMS score of 15 which indicated intact cognition. The resident required extensive assistance of two or more staff for transfers and toileting. Record review revealed no toileting plan was in place. Review of the STNA kardex documentation revealed no guidelines for bladder continence. Review of the current plan of care revealed there was none in place for bladder continence. On 04/14/15 at 1:30 P.M., interview with Resident #2's family revealed they visit daily to assist the resident with bathing, eating and dressing and all the staff have to do was toilet her. Resident #2 was alert and oriented but sleeping at the time of the interview. The family indicated the resident had the sensation when needing to void but the facility lets her pee in her diaper and only toilets her after meals but sometimes it is hours after a meal. The resident tells us (family) she hesitates to use the call light anymore because it took so long for any staff to respond it was very aggravating. Sometimes she had to wait 45 minutes to an hour for assistance. 4. Record review revealed Resident #5 was admitted to the facility on [DATE]. Review of the admission MDS 3.0 assessment, dated 03/31/15 revealed the resident's BIMS score was a 12 which indicated moderate cognitive impairment. Record review revealed no toileting plan was in place. The resident was noted to be occasionally incontinent of bladder. Review of the urinary incontinence evaluation, dated 04/06/15 revealed the resident was continent prior to admission, and needed one staff assistance for toileting. The plan indicated the resident had only rare incidents of incontinence due to urgency. Review of the STNA kardex documentation revealed to provide incontinence care with care rounds each shift. Record review revealed no voiding pattern had been completed to establish a toileting plan to ensure the resident remained as continent as possible. Review of the current plan of care revealed there was none in place for bladder continence. On 04/14/15 at 5:20 P.M., interview with Resident #5 revealed she needed staff assistance for toileting but had three accidents this week because she had to wait too long. The resident stated it usually took 30 minutes for staff to assist her. 5. Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 assessment, dated 04/03/15 revealed the residents BIMS score was a 13 which indicated intact cognition. Record review revealed no toileting plan was in place. The resident was occasionally incontinent of bowel and bladder and needed one staff for assistance for toileting. Review of the urinary incontinence evaluation, dated 04/06/15 revealed the resident was continent prior to admission. The resident needed one staff assistance for toileting. The plan stated the resident had occasional mixed incontinence. The resident was aware of the need to void but had some difficulty getting to the restroom quick enough. Review of the STNA kardex related to toilet use revealed the resident required limited to extensive assist on one staff for toileting. Record review revealed there was no voiding pattern completed to establish a toileting plan to ensure resident remained as continent as possible. Review of the current plan of care revealed there was none in place for bladder continence. On 04/14/15 at 1:50 P.M., interview with Resident #3 revealed the only time she saw staff in the day was when they made her bed and brought meals. Otherwise no one comes to assist her when she used the call light. The resident stated she took a water pill and sometimes had to urinate quickly but staff does not assist her and she has to pee herself and it was degrading. The resident stated she was not supposed to transfer herself, but had because she didn't want to pee herself. 6. Record review revealed Resident #1 was admitted to the facility on [DATE]. Review of the quarterly MDS 3.0 assessment, dated 02/01/15 revealed the residents BIMS score was a 15 which reflected intact cognition. Record review revealed no toileting plan was in place. The resident was frequently incontinent of bladder. Review of the STNA kardex revealed no evidence of a bladder continence plan. Record review revealed there was no voiding pattern completed to establish a toileting plan to ensure resident remained as continent as possible. Review of the current plan of care revealed there was none in place for bladder continence. On 04/14/15 at 1:45 P.M., interview with Resident #1 revealed she waited sometimes up to an hour and half for assistance and had incontinent episodes as a result of staff not providing timely assistance with toileting. This deficiency substantiates Complaint Number OH 555.