Every finding on record at Bella Terrace Rehabilitation and Nursing Center

Based on record review, staff interview, review of the facility investigation, review of hospital records, review of police report, and policy review, the facility failed to provide the appropriate supervision for one cognitively impaired resident (Resident #46) who was at high risk for elopement and required the supervision of a secured memory care unit for his safety. Resident #46 eloped from the facility without staff knowledge on 07/05/25. This resulted in Immediate Jeopardy on 07/05/25 at 11:20 A.M. when Resident #46 was taken off the secured memory care unit to go outside with the memory care unit residents who smoke. Resident #46 was brought back in the building and left unattended at the elevator in the lobby on the first floor by Certified Nursing Assistant (CNA) #501, after being outside with the smoke group. Resident #46 was not discovered missing until 12:37 P.M. when staff could not locate the resident on the secured memory care unit. At 3:20 P.M. Resident #46's brother notified the facility the resident was taken to the hospital at 12:55 P.M. Report from the hospital provided at 3:40 P.M. revealed a pedestrian had found Resident #46 on the ground on the sidewalk approximately one mile away from the facility and the pedestrian had called emergency medical services (EMS) who transported the resident to the hospital. Additionally, the facility failed to provide supervision to Resident #159 who was cognitively impaired, high risk for elopement and eloped from the facility on 12/20/25 which placed the resident at potential risk for more than minimal harm that was not Immediate Jeopardy. The facility also failed to ensure a safe environment and placed all facility residents at risk for more than minimal harm that was not Immediate Jeopardy, when a staff member brought a firearm into the facility and the firearm discharged in a common area near resident rooms on the second floor. The facility census was 82.On 01/06/25 at 12:40 P.M. the Administrator, Regional Director of Operations (RDO) #602, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #601 were notified Immediate Jeopardy began on 07/05/25 at 11:20 A.M. when Resident #46, who was high risk for elopement, was left at the elevator on an unsecured unit by facility staff. Resident #46 walked out of the facility two minutes later and was discovered missing from the facility until 12:37 P.M. Resident #46 was treated at the hospital for a heart attack, slight dehydration, and acute kidney injury. The Immediate Jeopardy was removed on 07/05/25 when the facility completed the following actions:On 07/05/25 at 3:45 P.M., a Root Cause Analysis was completed by the Administrator with input from the management team.On 07/05/25 4:00 P.M., the Former DON created a list of residents on the secured unit who are smokers and distributed to the staff.On 07/05/25 at 4:00 P.M., DON and Unit Manager Licensed Practical Nurse (UMLPN) # 262 completed whole house elopement risk assessments and updated care plans accordingly.On 07/05/25 at 4:15 P.M., the Administrator had an ad-hoc Quality Assurance Performance Improvement (QAPI) meeting to discuss elopement policy best practices, and supervision of secured unit residents while off the secured unit.On 07/05/25 at 4:15 P.M., Admissions Director #276, after review of current resident room locations and new elopement risk assessment, updated the bed board to included leave of absence status.On 07/05/25 at 4:30 P.M., Human Resource Director (HRD) #313 educated all staff on the elopement policy best practices and supervision of residents off the secured unit.On 07/05/25 at 4:45 P.M., HR #313 and the former DON updated the staff smoking assignments.On 07/05/25 at 5:00P.M., the Former DON updated facility's elopement binders after review with elopement risk to include resident's name and picture, current smokers list, elopement policy and missing resident best practices.Audits will be conducted three times a week for four weeks to ensure any resident taken off the secured unit are supervised at all times while off the unit.Elopement drills to be conducted once a week on day shift and once a week on night shift for four weeks. Although the Immediate Jeopardy was removed on 07/05/25, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include:1.Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including alcoholic cirrhosis, severe protein malnutrition, vascular dementia, rheumatoid arthritis and sensorineural hearing loss. Review of Resident #46's Secured Unit Screener assessment, dated 09/18/24 revealed the reason for the screen was an as needed (PRN) review. Resident #46 had a diagnosis of Alzheimer's or related diagnosis or cognitive impairment which put the resident's safety at risk, wanders or would wander out of the facility and would not be able to find way back, less restrictive alternatives have been unsuccessful, resident able to ambulate or is mobile in wheelchair and resident is able to benefit from a structured environment with specialized activities. The conclusion was for Resident #46 to remain on the secured unit. Review of Resident #46's comprehensive care plans dated 09/17/24 and 09/20/24 revealed the resident was an elopement risk/wanderer related to disoriented to place, impaired safety and high risk of elopement; interventions included: identify pattern of wandering, divert as needed and intervene as appropriate and resident resides on the secure unit. Resident #46 also had a care plan which revealed the resident resided on a secured unit related to dementia and resident was an elopement risk related to previous recent history of elopement; interventions included: secured unit per physician's order. Resident #46 had a communication problem related to vascular dementia, mental disorder, cognitive communication deficit; intervention included: Anticipate and meet needs. Review of Resident #46's physician's orders dated 09/18/24 revealed he may reside on the secured unit related to the diagnosis of vascular dementia. Review of Resident #46's Elopement Risk Review assessment dated [DATE] revealed he was at high risk for elopement. Resident #46 was ambulatory with an assistive device, having intermittent confusion, no history of elopement episodes in the last three months, a diagnosis of vascular dementia and the need to remain on the secure unit. Review of Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. He required the use of a walker and staff assistance with transfers and ambulation. Review of the facility investigation and incident report dated 07/05/25 at 4:00 P.M. revealed the resident left the facility unattended. A search of the facility was conducted, and the resident was not found. The DON notified the police, physician's call service, and the resident's responsible parties. Management staff searched nearby streets, the library, Hospital #700 and local businesses. Resident #46 was not found. The facility received a call from Resident #46's family stating the resident was at Hospital #800's Emergency Department (ED). The DON contacted Hospital #800's ED and spoke to a nurse who reported the resident was brought into the ED by paramedics due to a fall without injuries. The DON also spoke with a police officer who stated bystanders witnessed the resident fall and called 911. Review of Resident #46's progress notes, dated 07/05/25 at 4:19 P.M. documented the same information as the investigation and incident report. Review of the preliminary police report investigation revealed the police were notified by Licensed Practical Nurse (LPN) # 349 on 07/05/25 at 1:01 P.M. of a missing person. Police arrived at the facility at 3:16 P.M. The investigation report revealed the resident walked away from the facility. The missing resident's guardian revealed the resident resided on a secure floor but was taken to the first floor and then was able to walk away. Review of the Columbus, Ohio [NAME] Columbus International Airport Station weather history report revealed on 07/05/25 between 10:51 A.M. and 12:51 P.M. temperatures were between 87-88 degrees Fahrenheit (F) with humidity between 45-49 percent and partly cloudy skies. Review of an undated handwritten witness statement from Certified Nursing Assistant (CNA) #501 revealed she took Resident #46 out to smoke where he was out for about 15 minutes. She brought him back in the building and walked him toward the elevator. She pressed the elevator button twice before walking away from him at 11:20 A.M. Review of undated handwritten witness statement from CNA #701 revealed Resident #46 was seen at the beginning of her shift and during breakfast and morning rounds. States around 11:15 A.M. CNA #501 came to get smokers. At around 11:30 A.M. to 12:00 P.M. she went to give the resident his lunch tray, and he was not in his room. She notified the nurse immediately and searched the unit, but the resident was not found. Review of undated handwritten witness statement from LPN #349, the nurse assigned to Resident #46, revealed she was notified Resident #46 was unable to be found at 2:22 P.M. She notified staff to look throughout the building and searched outside the facility, at the hospital and library. She stated she called the DON and the on-call supervisor with no answer. She also called 911 and family. LPN #349's statement revealed she requested facility cameras be checked. Review of undated handwritten witness statement from Activities Assistant (AA) #270 revealed she was notified by LPN #349 at 12:37 P.M. of Resident #46 missing. She stated she confirmed he was not in activities with her and assisted with searching for the resident outside the facility around 12:40 P.M. to 12:45 P.M. She stated she was the staff who checked the facility cameras, and it showed Resident #46 left the facility at 11:22 A.M. Review of handwritten witness statement from Registered Nurse (RN) #256 revealed he was notified by LPN #349 around 11:00 A.M. that Resident #46 was missing. He assigned CNA #327 to do a search of all rooms and bathrooms on his assigned unit. RN #256 stated DON, physician's call service, and the resident's responsible party were notified. Review of witness statement from LPN #244 revealed she was made aware Resident #46 was missing around 12:00 P.M. and assisted with the search. LPN #244 stated Resident #46 was let out to smoke at 11:15 A.M. The receptionist at the front desk was at lunch and the resident left out front door at 11:22 A.M. Review of Hospital #800 ED History/patient triage note dated 07/05/25 at 9:28 P.M. revealed Resident #46 was walking on the street with his walker when bystanders saw him fall and called 911. The triage note documented Resident #46 reportedly left the nursing home and was found down on [NAME] Road and since in the ED he had repeatedly told nurses that he was hot and asked for water. Resident #46 had an increase in his Troponin T (laboratory test used to indicate damage or stress to the heart muscle) levels from 41ng/L (nanograms per liter) on 07/05/25 at 1:37 P.M. to 98 ng/L (normal level is less than 10 ng/L) on 07/05/25 at 4:12 P.M. and an abnormal electrocardiogram (EKG). Resident #46 was admitted to the hospital for witnessed falls, acute kidney injury and elevated troponin levels. Resident #46 was started on baby Aspirin (anti platelet) and a Heparin (anticoagulant) drip/infusion for treatment of elevated troponin levels. Resident #46 was discharged back to facility with a diagnosis of non-ST elevation myocardial infarction (NSTEMI) (heart attack) and orders to follow up with primary care provider. Review of google maps revealed the walking distance from the facility to the street where Resident #46 was 1.2 miles. Resident #46 had to cross a street that was high traffic with six to eight lanes to get to where he was found. During an interview on 12/31/25 at 1:50 P.M., Activity Assistant (AA) #270 stated she was working at the time of elopement and was notified by LPN #349 that Resident #46 was missing. Resident #46 went out on a smoke break with CNA #501. CNA #501 then left Resident #46 at the elevator. Resident #46 walked out the front door. She confirmed the time the nurse notified her of the missing resident was 12:37 P.M. and by watching camera footage the facility was able to confirm the resident left out of the front door on 07/05/25 at 11:22 A.M. During an interview on 12/31/25 at 2:20 P.M., LPN #244 stated Resident #46 was taken on a smoke break at 11:15 A.M. by CNA #501. She stated memory care residents have their own nursing assistant to escort them to smoking breaks so they can be supervised. She confirmed Resident #46 was left in the lobby by CNA #501. Resident #46 went out the front door at 11:22 A.M. She stated Resident #46 was alert and oriented with confusion at times and was able to ambulate with a walker with staff assist. LPN #244 verified after Resident #46 eloped, education was provided immediately and again at the monthly staff meeting. During an interview on 01/06/26 at 8:17 A.M., LPN #349 stated she was unsure what time CNA #501 took residents out to smoke. She stated CNA #501 was aware that she had to stay with all the memory care residents the whole time. LPN #349 stated when residents returned to the unit, Resident #46 was not accounted for and she announced a missing resident code via Signal (an internal message center for facility staff). LPN #349 stated she also called the resident's responsible party and Hospital #700 and notified the DON, all administration and manager on duty and began searching for the resident. During an interview on 01/06/26 at 12:38 P.M., RDO #602 stated Resident #46 eloped on 07/05/25 at 11:22 A.M. via the front entrance of the facility. This was confirmed by video footage from facility cameras, and the facility completed an investigation and timeline of events. The camera footage was requested. RDO #602 stated the cameras had been stolen and the facility did not have the footage for review. On 01/07/26 at 7:02 A.M. two attempts were made to CNA #501 without success. During an interview on 01/07/26 at 3:15 P.M., HRD #313 stated CNA #501 was trained on the elopement policy, smoking policy and dementia care upon hire. HRD #313 also confirmed she received education for elopement on 07/05/25 and was terminated for job abandonment. During an interview on 01/12/26 at 10:27 A.M., Nurse Practitioner (NP) #705 stated Resident # 46 eloped from the facility on 07/05/25 and physician's call service was notified per protocol. NP #705 stated she had a follow-up visit on 07/08/25 and had no concerns. Medical Director (MD) #710 stated he was notified of Resident #46's elopement and the resident was treated at the hospital for falls and NSTEMI. 2.Review of Resident #159's medical record revealed the resident was admitted to the facility on [DATE] with pertinent diagnoses including: aphasia following cerebral infarction, chronic obstructive pulmonary disease and heart failure. Review of Resident#159's Elopement Review form dated 12/17/25 for Resident #159 revealed she was assessed to be disoriented at all times and assessed to be high risk for elopement due to her being a new admission in a new room and should be monitored. Review of the facility interim care plan dated 12/17/25 revealed Resident #159 was noted to have cognitive and visual impairment, and Resident #159 would not be able to easily communicate with staff. This document also noted she was assessed to be able to smoke with supervision. The care plan was updated on 12/21/25 to include Resident #159 having an activities of daily living (ADL) self-care performance deficit due to activity intolerance, impaired balance, limited mobility and stroke. Further review of the medical record revealed Resident #159 did not have a care plan for her identified high risk for elopement. Review of Resident #159's physician orders revealed an order to monitor behaviors including wandering dated 12/17/25. Review of the facility Brief Interview for Mental Status (BIMS) completed 12/20/25 revealed Resident #159 was assessed to be moderately impaired. Review of progress note dated 12/20/25 at 6:45 A.M. revealed the nurse passing the morning medications was notified by another (unnamed) resident that they saw Resident #159 had packed her bags and was seen crossing the streets near the facility parking lot. The nurse charted, they looked around the building and outside the parking lot and did not see Resident #159. They notified the physician and the on-call night nurse. The note stated Resident #159 was her own responsible party and that the daughter was notified. Review of progress note for Resident #159 dated 12/20/25 at 8:49 A.M. revealed the facility units, rooms, bathrooms and surrounding grounds searched for the resident at that time and she was not located. Review of the progress note for Resident #159 dated 12/20/25 at 9:05 A.M. revealed they attempted to call the resident's daughter and they spoke with another family member who said the resident had tried to call in the morning, but he missed the call. The note indicated he was unaware of where the resident was and if she reached back out, he will encourage her to return to the facility to sign AMA paperwork. Review of the progress note for Resident #159 dated 12/20/25 at 5:34 P.M. revealed she returned safely to the facility and was given a head to toe assessment. She was given a drug screen, and it was found to be negative. The author noted they updated the physician and family. Review of Columbus Police Report Preliminary Investigation dated 12/20/25 at 10:38 A.M. revealed the facility said they have video footage of Resident #159 leaving the facility at 3:17 A.M. and that she had not come back. The police report noted they had reviewed the footage themselves. Review of the facility discharge Minimum Data Set (2.0) completed on 12/22/25 revealed Resident #159 was independent for eating, toileting, dressing, hygiene and walking 150 feet. Review of hospital documentation obtained from Hospital #577 revealed Resident #159 was admitted to the hospital on [DATE] and remained at the hospital until 12/17/25. Speech pathology note dated 12/08/25 indicated Resident #159 was oriented to person and place and was not oriented to time or situation. This note also stated her functional limitations included: communication deficits, impaired insight, impaired memory. The note's author indicated that due to her aphasia (ability to speak) her words would only be understood at most 25%-50% of the time. Further review of the hospital record revealed on 12/09/25 Physician #588 met with Resident #159 and determined she did not have medical decision-making capacity and had significant verbal and written aphasia. Interview on 1/26/25 at 2:20 P.M. with the Director of Nursing (DON) revealed Resident #159 was alert and oriented times four and she left the faciity on [DATE] and forgot to sign out. She said the resident left around 7:00 A.M. and returned around 5:30 P.M. She said they were only worried because it was cold outside. She said we were in constant communication with the resident, and she just wanted to finish her shopping. Interview on 01/27/25 at 12:33 P.M. with Licensed Practical Nurse (LPN) #805 revealed he was working the night Resident #159 left the facility. He said she went out several times during the evening to smoke and usually she would tell him and he would send an aide to go with her but the last time she went out she didn't tell him. He said someone had told him that she had left but they didn't say what time it was and he was in the middle of medication pass and it was cold outside. He said he didn't go outside to look for her, but he looked out the windows. He said there are several residents who go outside in the middle of the night to smoke. He said they are supposed to sign out but he doubted they do. Interview on 01/27/26 at 8:53 A.M. with Family Member #533 revealed he had received text message on 12/20/25 at 5:00 A.M. in the morning from Resident #159 when he was sleeping and when he saw it later it made no sense to him. He said she left a voicemail at 5:21 A.M. which also made no sense. He said he texted her back in the morning at 8:14 A.M. and told her he was sleeping. He said he received a phone call from the facility around 9:00 A.M. and he told them about her calling him at 5:21 A.M. and he said the facility stated that was the time the resident left the facility. He said they asked if he had heard from her. He texted her and she called him and they talked for about seven minutes. He said he was trying to find out where she was, but he couldn't understand what she was saying and she sounded confused. He said it was really cold that day and he was worried that she was able to just walk out of the facility in the middle of the night. Interview on 01/27/25 at 9:41 A.M. with family member #522 who said the facility called her on 12/20/25 at around 9:20A.M. or 9:30 A.M. She said she was very surprised that Resident #159 had left so early in the morning and it took them so long to call her. She said she asked them if they had called the police and they hadn't at that time. She said she absolutely did not think Resident #159 was safe to be leaving the facility on her own because you can't understand anything she said. She said she thought the facility should have taken better care of Resident #159 because she can't communicate. She said she didn't think Resident #159 understood what she was doing and the situation was concerning because if Resident #159 needed help she wouldn't have been able to ask for it due to her aphasia. Interview on 01/27/25 at 1:50 P.M. with Family Member #544 revealed she had been called a couple of times regarding Resident #159 having left the facility. She said when Resident #159 was in the hospital, the social worker who was doing the discharge planning had called her several times and had said repeatedly that Resident #159 was not safe to be home by herself. Interview on 01/29/26 at 9:35 A.M. with Missing Persons Detective #566, confirmed they were notified at 10:38 A.M. about Resident #159 leaving the facility unattended. He said when the call came in, the facility had stated Resident #159 had low mental capacity and had a recent stroke. He said they were going to have helicopters and [NAME] looking for her until the officers were on site and found out there was over a seven-hour delay from when Resident #159 left the building and when the police were contacted. He said those measures would not be effective at that point. Review of the weather record from world-weather.info revealed that on 12/20/25 the low temperature in Columbus, Ohio was 21 degrees Fahrenheit and the high temperature was 43 degrees Fahrenheit. Review of the facility policy titled, Elopements, revised December 2007 revealed staff shall investigate and report all cases of missing residents. The policy contained no safety measures or protocols to identify residents at risk for potential elopement. 3. Review of the Columbus Division of Police Preliminary Investigation Report dated 12/01/25 at 2:21 P.M. revealed RN #505 had accidentally discharged a firearm at the facility on 12/01/25 at 3:00 A.M. Per the report, the officer observed a bullet hole in the floor as well as in the wall next to it. The report noted the bullet appeared to have ricocheted off the floor and into the wall of room [ROOM NUMBER]. The report noted management declined to pursue legal action. Interview on 01/06/26 at 12:45 P.M. with RDO #602 it was confirmed a RN #505 entered the facility with a firearm in their coat pocket. RDO #602 revealed RN #505 stated they did not remember the firearm was in his coat pocket when he came to work but prior to getting to his assigned hallway, realized the firearm was in his coat. RN #505 said when he got to his assigned hallway, he hung his coat in the locked medication room to secure it. Then when he took his break, he placed his coat on, put his hand in his pocket and the firearm discharged . RDO #602 stated the staff member did not tell other staff at the time what had happened or what the cause of loud noise and smoke was. It was not until management was made aware and performed an investigation that it was known that a firearm was inside the facility and discharged . Observation on 01/07/26 at 11:32 A.M. of the second floor near the nurses station where, the facility reported the firearm had discharged revealed the holes in the floor and the wall had been repaired. Interview with Resident #94 on 01/07/26 at 11:36 A.M. revealed he had no recollection of the firearm incident. Resident #94 resided in the immediate vicinity of the firearm was discharged . Interview with Resident #74 on 01/07/26 at 11:45 A.M. revealed resident heard the firearm go off but she said she didn't know what the sound was, and stated she found out the next day it was a gun. She said she didn't know anyone who saw it happen. Interview with CNA #381 on 01/07/26 at 1:02 P.M. revealed he didn't see the firearm but heard the sound when it discharged , but did not know what the sound was from at the time. He said he saw RN #505 running up the stairs afterwards and RN #505 had asked him if he had heard the sound. He said there was dust everywhere. He said he did not know of anyone other than RN #505 who was present at the time the firearm discharged . Interview with CNA #323 on 01/22/26 at 5:50 P.M. revealed she was on break when the firearm went off and she heard a loud bang but did not see what happened. She said she saw the hole in the floor and she found bullet casings on the floor. Interview with Licensed Practical Nurse (LPN) #365 on 01/22/26 at 4:55 P.M. revealed she was working that evening in another area of the facility. She did not hear the firearm go off but heard about the incident that evening and saw the damage to the floor. Interview with LPN #805 on 01/26/26 at 10:37 A.M. revealed he heard the sound of the firearm when it discharged but did not see the firearm. Review of personnel file for RN #505 revealed his last day of employment was 12/01/25. Interview on 01/07/26 with Human Resources Manager #313 confirmed RN #505 was terminated on 12/01/25. Review of facility policy titled, Firearms and Other Weapons, revised April 2007 revealed the facility prohibited employees, residents, visitors, vendors or others from possessing firearms or other weapons while in/on facility premises. This deficiency represents non-compliance investigated under Complaint Numbers OH001295678 and OH001295679.

Based on observation, resident interview and staff interview, the facility failed to ensure a safe, sanitary and home-like environment. This had the potential to affect all 85 residents in the facility. Facility census was 85.Findings include:1. Observation on 12/30/25 at 12:37 P.M. of the third-floor dining cart revealed it was held together with duct tape along the edges and meals were being dispersed in polystyrene foam (disposable) containers and residents were eating with plastic utensils.Interview on 12/31/25 at 8:59 A.M. with Resident #88 shared that it was difficult to cut food with a plastic fork on the disposable containers.Interview on 01/06/26 at 9:53 A.M. with Resident #76 noted he was tired of eating on disposable plates.Interview on 01/08/26 at 8:39 A.M. with Dietary Supervisor #238 confirmed they had been using disposable plates because the boiler was being repaired.2. Observation on 12/31/25 at 9:30 A.M. in the hallway of the memory care unit revealed an approximately four foot by four foot area where the ceiling tiles were missing. Interview on 12/31/25 at 9:34 A.M. with Maintenance Director #258 confirmed the ceiling had collapsed and the area was missing the tiles. He said he would fix it when he could be he had to prioritize fixing the heater first.3. Observations on 12/30/25 between 12:10 P.M. and 1:15 P.M. revealed the following:a. In the main elevator on all three sides, there were extensive scratches on the wood railing and on the painted wall area below. The painted area had gouges missing as well. There was a grid ceiling and there was extensive dust collected on the grid.b. The hallway to the left of the lobby had extensive scuffing along the wall below the railing.c. By the vending machine, there was ceiling tile missing above it and it appeared that the ceiling had fell next to the vending machine. In the center of the room by the post, three ceiling tiles had brownish water stains and the tiles were ripped. The floors were extensively scuffed and dirty.d. On the first floor in the bathroom, off of the dining room, revealed an out of order sign, indicating that the bathroom was not working. On the second floor the bathroom door across from room [ROOM NUMBER] had an out of order sign, indicating that the bathroom was not working, and the door had streaks several inches long where the wood was marred. On the third floor, the bathroom outside room [ROOM NUMBER] had an out of order sign, indicating that the bathroom was not working. e. Next to the elevator on the third floor, outside of the nursing station there were extensive scuff marks on the paint below the railing and missing wood and paint around the bottom of the blue pillars by the station.f. Across from room [ROOM NUMBER], the bottom of the post and the area under the railing was extensively scuffed and missing paint.g. Observation and interview on 01/05/26 at 9:27 A.M. with Resident #87 in room [ROOM NUMBER] confirmed that she only had a desk in her room and no dresser and that her sink was draining slowly.h. Observations on 01/07/26 between 8:57 A.M. and 9:15 A.M. revealed: In the second-floor shower room above the showerhead area, a ceiling tile appeared to be crumbling and the empty area above was exposed.In the second-floor hallway there was a pile of wet blankets on the floor up against the wall and a yellow caution sign.On the first floor in the chapel room, there was a pile of wet blankets, a bucket, a yellow caution sign and an active water leak from a burst pipe.Interview on 01/07/26 at 9:25 A.M. with the [NAME] President of Plant Operations #511 stated the building had very old cast iron pipes and they were only able to fix them as they broke. He said there was no way to proactively fix them because they were behind drywall. He confirmed the ceiling was crumbling in the second floor bathroom and said the pipes linked through all three floors and that there was a different pipe that just broke above where the towels were.i. Observation on 01/07/26 at 11:26 A.M. of the back elevator (across from room [ROOM NUMBER]) had out of order sign on it, indicating it was not in working order. Observation on 01/22/26 at 12:35 P.M. There was still an out of order sign on the back elevator.j. Observation and interview on 01/07/26 at 11:45 A.M. with Resident #74 in room [ROOM NUMBER] confirmed the door to her room was swollen and it took considerable effort to open it. She said the door had been like that for a while and she had told multiple staff members about it. Her sink also wasn't draining and the lamination around the edge of the sink was loose.k. Observation and interview on 01/07/26 at 2:12 P.M. with Resident #56 in room [ROOM NUMBER] revealed the resident demonstrated that the foot of his bed would not raise up and the headboard was detached. There was a telephone outlet dangling from the wall with exposed wires. The resident said that he had told maintenance about the bed previously and it was not fixed.On 01/08/26 between 4:30 P.M. and 5:00 P.M., the Maintenance Director #258 and the Regional Director of Culinary Operations #515 toured the above areas and verified the described areas had not been maintained. Maintenance Manager #258 said the bathrooms on the three floors were out of order because of a previously burst pipe. He also confirmed the back elevator was now out of order because someone had damaged the panel on the third floor. 4. Observations on 01/12/26 between 10:23 A.M. and 5:10 P.M. revealed the following: a. Resident #41's room [ROOM NUMBER] had a rusty sink bowl and drain.b. Resident #45's room [ROOM NUMBER] with all lights on, was very dim.c. Resident #46 was in room [ROOM NUMBER]. The sink was rusted, the baseboard cover under the sink was missing and the wall under the sink was crumbling. There was what appeared to be food substance on the wall by the bed.d. Resident #48 was not in their room [ROOM NUMBER], however, the sink was observed to be rusted around the drain and the bowl was missing laminate.e. room [ROOM NUMBER] where Resident #49 resided, had very loose grab bars by the toilet, rust around the base of the plumbing, and a rusted sink.f. room [ROOM NUMBER] where Resident #50 resided had extensive wall damage around the sink in the room.g room [ROOM NUMBER] where Resident #51 resided had long gashes in the door to his room. h. room [ROOM NUMBER] had a side bar on the wall next to the bed that was falling off and a rusted sink.i. room [ROOM NUMBER] had a side bar on the wall next to the bed that was falling off, a rusted sink, and in the corner behind the sink there was exposed cable and apparent water damage with dark staining potentially resembling mold. There was also a chip in the tile flooring.j. room [ROOM NUMBER] had rusty sink.k. room [ROOM NUMBER] had grime build up on the floor around the bottom of the trash can.l. room [ROOM NUMBER] had rust on the sink, a chipped bedside table, and missing paint on the wall.m. The bedside table in room [ROOM NUMBER] was old and in disrepair, and there was an apparent water stain across the length of the ceiling.n. Observation and interview on 01/12/26 at 3:17 P.M. with Resident #32 who was laying in bed in room [ROOM NUMBER] revealed the call light was pulled out from the wall. When asked how she got assistance, Resident #32 said she had to yell out. She also had missing drywall around her sink area, her bedside table was old and in disrepair, and her front door was marred. Interview on 01/12/26 at 3:23 P.M. with Unit Manager #262 revealed she was unaware the call light was broken [for room [ROOM NUMBER]] and that she would put in a work order request.o. Observation and interview on 01/12/26 at 3:25 P.M. with Resident #35 in his room [ROOM NUMBER] revealed the wall around the sink was missing drywall and under the sink there was no baseboard and a crack in the wall. The bedside table was old and in disrepair. Resident #35 said a wingnut fell off the table and he told a staff member about it for repair and he felt they blew him off. He said the wall and the area under the sink bothered him.p. Observation and interview on 01/12/26 at 3:36 P.M. with Resident #36 in room [ROOM NUMBER] revealed Resident #36 shared that he didn't like the marred corner area by the sink or the marks on the wall by the footboard and he noted the wall area by the headboard needed touched up. His sink also had rust around the drain.q. room [ROOM NUMBER] had a bar on the wall next to the bed that was falling off, the laminate on the edge of the sink was worn off, and the door to the bathroom wouldn't close.r. Observation and interview on 01/12/26 at 4:28 P.M. with Resident #81 in room [ROOM NUMBER] revealed Resident #81 said when he turned his sink on, water came out on the floor. This was verified in the moment as well as the entire sink and cabinet were not attached to the wall and a light touch would tilt it forward.s. room [ROOM NUMBER] had missing laminate around the edge of the sink and rust in the sink. The light over the sink was missing the cover and just a light bulb was exposed.t. The hallway across from room [ROOM NUMBER] had chunks of the wall and paint missing on two corners.u. room [ROOM NUMBER] had a chip in the floor tile in the front of the room, near the door, that was approximately a half an inch by an inch.v. Observation and interview on 01/12/26 at 4:52 P.M. with Resident #11 in room [ROOM NUMBER] revealed Resident #11 confirmed the room felt dim to him and he would like more light for the evenings.w. Observation and interview on 01/12/26 at 5:00 P.M. with Resident #12 in room [ROOM NUMBER] confirmed her wardrobe drawers were stuck together, and she wasn't able to open one without both opening. She also said it would be helpful to have the top sliding door on her wardrobe. Additionally, the lights were all on and it was still very dim.x. room [ROOM NUMBER] had damaged laminate around the sink, torn paint on the wall near the entrance, water damage on the ceiling on the back right corner, and holes in the wall outside the room from where an apparent soap dispenser was removed. y. Observation and interview on 01/12/26 at 5:10 P.M. with Resident #16 in room [ROOM NUMBER] revealed he would like more light. He had all the lights on in the room and it was still very dim.On 01/13/26 between 10:12 P.M. and 11:28 A.M. the Maintenance Director #258, the Regional Maintenance Director #605 and the Regional [NAME] President of Plant Operations #511 toured the areas mentioned and verified the described areas had not been maintained.5. Observations on 01/13/26 between 9:04 A.M. and 9:24 A.M. revealed the following:a. Observation and interview on 01/13/26 at 9:04 A.M. with Resident #18 in room [ROOM NUMBER] revealed a very loose handrail by the toilet and rust near the pipe. Resident #18 confirmed he did use that bathroom. The sink was missing enamel, and the edge of the sink was sharp. There was exposed dry wall on the corner by the sink, the wall was missing paint, and the drywall was ripped in the back area. There were stains on the ceiling right above the head of the bed and Resident #18 said they were unsettling because he didn't know what they were. The light above the sink was also missing the cover.b. Observation and interview on 01/13/26 at 9:24 A.M with Resident #22 who was in bed in room [ROOM NUMBER] revealed the sink did not have hot water. The wall around the sink had a two-inch strip around the side and the back of the sink that was unpainted. The resident wasn't sure why they didn't have a chair in the room anymore either, but they wanted one.c. room [ROOM NUMBER] was missing drywall on the corner by the sink and the trim was loose. There was paint missing across the length of the bed. The front door had significant scuff marks.d. In the common area outside of room [ROOM NUMBER], there were chunks of wall missing by the bookcase, the hallway railing was marred for the length of the railing and spots of paint were missing on the wall. On 01/13/26 between 10:12 P.M. and 11:28 A.M. the Maintenance Director #258, the Regional Maintenance Director #605 and the Regional [NAME] President of Plant Operations #511 toured the areas mentioned and verified the described areas had not been maintained.6. Observations on 12/30/25 at 12:10 P.M. in the front lobby and hallway areas, there was approximately two inches of dark grime along the edge of the flooring by the walls in the main lobby and hallway by the elevator to the resident's rooms. This grime was observed to be present on the floor each day until 01/12/26 09:58 A.M. when the housekeeper was observed to be scraping the floor.Interview on 01/12/26 at 9:58 A.M. with Housekeeper #232 confirmed the grime along the edge of the floor in the lobby and adjacent hallways. He said it was buildup of wax accumulation and that it hadn't been there long.7. Observation and interview on 01/12/26 at 10:10 A.M. of the shower room in the memory care area revealed there was an approximately two foot by 5 inch area on the wall with white paint in the corner of a tan wall and an overhead fan covered in dust. Certified Nursing Assistant #337 verified both. She said she didn't know who was responsible for cleaning the fan dust.Observation and interview on 01/13/26 at 9:40 A.M. in shower room on the third floor revealed there were five wet towels piled on the floor in the shower area. Certified Nursing Assistant (CNA) #248 confirmed the towels were there. She said a resident must have taken a shower overnight. She said the staff normally would remove them if they were told about them.Observation and interview on 01/22/26 at 1:05 P.M. in the shower room on the third floor there was a pile of wet towels in the room. Certified Nursing Assistant (CNA) #248 confirmed the towels were there. She said she didn't know who was covering the area.These deficiencies represent non-compliance investigated under Master Complaint Number 2699666, 2591930, 1295681, and 1295679.

Based on observation, interview and review of work orders, the facility failed to maintain an environment free from a pest's infestation. This had potential to affect all 82 residents.Findings include:Observation on 12/30/25 at 12:26 P.M. in the first-floor dining room of multiple dead insects (a variety of insects including insects that resembled spiders and cockroaches (roaches)) along the walls near the windows.Interview on 12/31/25 at 8:59 A.M. with Resident #88 who said the roaches aren't living with us, we are living with them. She said they put roach traps around and are trying to [eradicate the cockroaches]. She said the roaches come out when the housekeeper mops. She said she sees the roaches climbing up the walls and she has fears they will fall down on her.Interview on 12/31/25 at 9:34 A.M. with Maintenance Director #258 revealed they had an issue with cockroaches, but he felt it was getting better. He said they switched [pest] companies three months ago and now he no longer had cockroaches running across his desk.Observation on 12/31/25 at 9:35 A.M. of the second-floor common area revealed multiple dead insects (a variety of insects including insects that resembled spiders and cockroaches (roaches)) on the windowsill by the entrance to memory care. Interview on 01/05/26 at 9:27 A.M. with Resident #87 revealed she saw the cockroaches in her room and in the hallways and she saw them come out of the kitchen. She said she was killing half a dozen a day. She said it had slowed down some, but she wished they would have fumigated the whole place.Interview on 01/05/26 at 7:22 A.M. with Resident #56 revealed he would have one or two cockroaches in his room but mostly he saw them in the hallways.Interview on 01/05/26 at 2:48 P.M. with Resident #90 revealed she felt the insect issues were bad, but they had gotten better.Interview on 01/05/26 at 4:10 P.M. with Regional Maintenance Director #605 revealed the resident in room [ROOM NUMBER] was a hoarder. He said when the resident was away from his room, they went in to get rid of the trash including empty shampoo bottles and empty grocery bags and he said they found a cockroach infestation in there and brought the exterminators in on this day for that room. He said they were German cockroaches.Observation and interview on 01/06/26 at 10:36 A.M. revealed a cockroach crawling up the wall in the third-floor shower room. Regional Maintenance Director #605 was present and confirmed that it was a German cockroach.Interview on 01/07/26 at 11:45 A.M. with Resident #74 revealed she didn't have too many bug issues where she was on the third floor. She said on the first and second floors they [cockroaches] were everywhere.Observation and interview on 01/08/25 at 8:29 A.M. revealed two cockroach traps in the kitchen by the door. Dietary Supervisor #238 said they had issues with cockroaches, but he felt it had gotten better.Interview on 01/12/26 at 10:36 A.M. with Resident #50 revealed she didn't want housekeeping to come in her room because she believed they brought the insects in with their mops.Interview on 01/12/26 at 2:39 P.M. with Resident #27 revealed the place was roached out. He elaborated and stated they were everywhere and they came out at night. He noted he saw one two days ago. Interview on 01/12/26 at 3:04 P.M. with Resident #268 revealed she saw roaches come out from under her bed.Interview on 01/12/26 at 3:25 P.M. with Resident #35 revealed his biggest complaint was the cockroaches because they were repulsive.Observation on 01/13/26 at 11:07 A.M. revealed the exterminator approaching maintenance managers and asking them where he should focus.Review of pest control work orders dated 09/09/25, 09/29/25, 10/06/25, 10/17/25, 10/22/25, 10/29/25, 12/08/25, 12/16/25 and 01/05/26 revealed they were treating both individual rooms and common areas and the primary issue and focus on the visits were the eradication of cockroaches. This deficiency represents non-compliance investigated under Master Complaint Number 2699666, 2593662, 2591930, 1295681, and 1295679.

Based on medical record reviews and interview the facility failed to ensure physician's orders were followed when administering medications. This affected two (Residents # 56 and # 94) of five residents reviewed for medication administration. Facility census was 82.Findings include: 1. Review of Resident # 56's medical record revealed an admission date of 05/01/25 with diagnoses including vertebral fracture (thoracic) T11-T12, vertebral fracture (lumbar) L1, radiculopathy, idiopathic peripheral autonomic neuropathy, low back pain and right shoulder pain, and right rotator cuff repair. Review of Resident # 56's care plans dated 05/15/25 revealed a care plan for chronic pain related to neuropathy, low back pain and thoracic and lumbar fractures; interventions include to administer medications as ordered. Review of Resident # 56's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 and he required assistance from staff with hygiene, dressing and transfers. Review of Resident # 56's physician's orders dated December 2025 revealed the following orders: Aspercreme Lidocaine Patch 4% (Lidocaine), apply to posterior right shoulder topically one time a day for pain, one patch and remove per schedule; Percocet (opioid) Oral Tablet 7.5-325 mg (milligrams), give one tablet by mouth every six hours as needed for pain. Further review revealed the order for Percocet started on 12/23/25 and ended on 12/29/25. Review of Resident # 56's prescription from Orthopedic Surgeons dated 12/23/25 revealed order and instructions for Percocet 7.5-325 mg per tablet, take one tablet by mouth every six hours as needed for pain (Days supply per fill: 10). Review of Resident # 56's Medication Administration Record (MAR) for December 2025 revealed Percocet 7.5-325 mg was administered daily from 12/24/25 to 12/29/25. Review of Resident # 56's progress notes dated 12/29/25 revealed DON received orders from NP # 705 to discontinue Percocet 7.5-325 mg. Review of Resident # 56's Percocet 7.5-325 mg individual patient-controlled substance administration record dated 12/24/25, revealed the medication was administered at least daily from 12/24/25 to 12/30/25. Interview on 12/31/25 at 8:39 A.M. with Resident # 56 revealed he received a prescription on 12/23/25 from the Orthopedic Surgeon for Percocet for 10 days for his shoulder. He confirmed he received the medication as requested until 12/31/25 when RN # 256 stated his order was discontinued. Interview on 12/31/25 at 8:45 A.M. with RN # 256 confirmed the order for Percocet 7.5-325 mg was discontinued on 12/29/25. Interview on 12/31/25 at 9:15 A.M. with DON revealed the resident had multiple narcotic medication changes handled by Orthopedic provider since his recent shoulder surgery. Stated NP # 705 reviewed orders and on 12/29/25 ordered to discontinue current Percocet due to resident's drug seeking history. Interview on 12/31/25 at 9:20 A.M. DON verified Resident # 56 received Percocet 7.5-325 mg until 12/30/25 with no physician's order. 2. Review of Resident # 94's medical record revealed he was admitted on [DATE] with diagnoses including insomnia, epilepsy, schizophrenia, anxiety and senile degeneration of the brain. Review of Resident # 94's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively impaired with a Brief Interview for Mental Status (BIMS) of 4. He required assistance from staff with hygiene, dressing and transfers. Review of Resident # 94's progress notes dated 08/01/25 revealed resident was sent out to hospital # 700 for evaluation due to a medication error of resident receiving excessive dose of Melatonin. Review of Resident # 94's hospital emergency department (ED) note dated 08/01/25 revealed resident was evaluated for drug overdose after he was accidentally administered approximately 22 mg (milligrams) of Melatonin at the facility. Further review revealed MD noted Melatonin was not expected to cause concern based on his discussion with the poison center, stated resident was asymptomatic and he returned the facility on 08/01/25 with no orders. Review of Resident # 94's Physician's Orders dated 07/15/25 to 8/13/25 revealed no orders for the medication Melatonin. Interview on 01/08/26 at 12:20 P.M. with DON confirmed Resident # 94 was sent to the hospital after nurse administered approximately seven, melatonin three mg. Stated resident was at the hospital for a few hours for observation and was sent back to the facility with no new orders. Review of policy titled Administering Medications dated December 2012 revealed medications must be administered in accordance with the orders, including any required time frame, the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones and the individual administering the medication must check the label three times to verify the right resident, right medication, right dose, right time and right route of administration before giving the medication.

Based on observation, interview, sanitizing instructions, and policy review, the facility failed to ensure the staff were properly trained on how to check the sanitization level in the dishwasher. This had the potential to affect all 90 residents. Facility census was 90. Findings include: Review of the dishwasher chemical log from 06/01/25 through 06/22/25 revealed the chemical reading was 200 parts per million (ppm) three times a day every day. Observation on 06/23/25 at 8:20 A.M. revealed Dietary Supervisor #296 used a test strip to check the chemical reading in the dishwasher. Dietary Supervisor #296 stated the dishwasher was a low temperature and used chemicals to sanitize the dishes. Dietary Supervisor #296 was unsure if the chemical level had been checked on 06/23/25. Dietary Supervisor #296 stated the bleach container was low and needed replaced. Dietary Supervisor #296 instructed the staff to rewash the dishes that had been done that morning. The bleach container was replaced and Dietary Supervisor #296 ran the dishwasher five times and dipped a test strip each time and the test strip did not turn a color (purple) that could be compared to the color chart provided. An observation at this time also revealed Dietary Aide #264 was scraping plates and putting the dishes on the racks to go through the dishwasher. An interview with Dietary Aide #264 revealed she was hired in May and was not trained on how to check the chemicals in the dishwasher. An interview on 06/23/25 at 9:54 A.M. Regional Director of Operations #602 stated the dishwasher was working correctly but Dietary Supervisor #296 was nervous and was dipping the test strips at the wrong time. An interview on 06/25/25 at 11:57 A.M. Dietary Supervisor #296 verified he was dipping the chemical strip on the rinse cycle instead of the sanitizing cycle. Review of the instructions to test chlorine levels in a dishwasher using test strips revealed a test load of dishes should be ran and then a sample collected of the final rinse water. The test strip should be dipped into the water and for a few seconds and then the color of the strip should be compared to the color chart provided with the test kit. The color on the strip indicated the chlorine concentration in ppm. The target concentration was typically 50 to 100 ppm for chlorine-based sanitizers. A more detailed breakdown included to run a test load to ensure the sanitizer concentration being tested was the same in a typical load. After the cycle was complete, a sample of the final rinse water should be collected. A good place to collect from was a cup or other item that had been in the final rinse cycle. Generally, the test strip was dipped into the water for a few seconds, ensuring the strip was fully submerged. The test strip should be immediately compared to the color chart provided with the test kit. The closest matching color indicated the chlorine concentration in ppm. If the concentration was within the recommended range (usually 50-100 ppm for chlorine) you could be confident the dishwasher was sanitizing properly. If the concentration was too low, you may need to adjust the sanitizer dispenser or add more sanitizer. If it was too high, you may need to dilute the solution. Sanitizer solutions can lose effectiveness over time, so it is important to retest the solution regularly, especially if using chlorine-based sanitizers. Retesting every two hours is a good practice. Review of the Dishwashing Machine Use policy (no date) revealed food service staff required to operate the dishwashing machine will be trained in all steps of dishwasher machine use by the supervisor or designee proficient in all aspects of proper use and sanitation. Dishwashing machine chemical sanitizer concentration and contact times for chlorine was 50-100 ppm for 10 seconds. A supervisor will check the dishwashing machine for proper concentration of sanitizer solution after filling the dishwashing machine and once a week thereafter. Concentration will be recorded in a facility approved log.

Based on review of the facility's antibiotic stewardship program and staff interviews the facility failed to ensure the facility's antibiotic stewardship program was completed by a certified infection control preventionist (ICP). This had the potential to affect all residents residing in the facility. The facility's census was 90. Findings Include: A review of the facility's antibiotic stewardship program dated 05/01/25 to 06/30/25 revealed the monthly tracking logs, trending maps, and the antibiotic criteria forms (McGeers) being completed by the facility's Director of Nursing (DON). There was no signatures on the monthly tracking logs to reflect an ICP was monitoring the program. A review of the facility's infection control program revealed the facility's ICP is the Regional Director of Clinical Services (RDCS) #601. RDCS #601's ICP certification was received in 12/21/19. There was no ICP certification on file for the DON. An interview on 07/01/25 at 2:53 P.M. with the DON revealed the antibiotic stewardship program required monthly tracking, trending, and completion of the antibiotic criteria forms were being completed by the DON. The DON does not have an ICP certification. RDCS #601 monitors the facility's antibiotic stewardship program with the DON actually completing the required documentation. An interview on 07/01/25 at 3:03 P.M. with RDCS #601 confirmed the facility's DON was completing the monthly documentation including the trending, tracking and completion of the antibiotic criteria forms for the facility's antibiotic stewardship program, even though the DON does not have an ICP certification.

Based on observation, work orders, policy and interview, the facility failed to ensure cool air temperatures, functional sinks, functional shower rooms, maintenance of ceilings, walls, floors, window seals and vanities, furniture, mattress, toilet paper holders, and functional hand sanitizer dispensers. This affected 24 (Resident's #24, #26, #27, #28, #32, #37, #38. #39, #40, #49, #52, #53, #56, #57, #58, #59, #60, #68, #73, #75, #76, #78, #185, and #285) of 90 residents in the facility. Findings include: 1. Review of quote dated 04/22/25 from heating, ventilation, and air conditioning (HVAC) company revealed cooling tower repairs due to coil froze and burst due to being shut off over the winter. The coil would need replaced for a total of $79,990. A quote dated 04/24/25 was received from the same HVAC company for temporary cooling tower, temporary pump, piping, electric, and breakers as needed for a total of $48,659.00. The work was completed and paid for sometime in May. Review of temperature logs from 04/28/25 to 06/12/25 revealed temperatures from 74 degrees to 82 degrees. The temperatures for resident rooms at 80 degrees or above had notation of air conditioner unit being off and/or windows open. A work order dated 06/06/25 revealed the air unit on the second floor (Blue) was not working. On 06/11/25 a work order was placed for a problem with air conditioning in Resident #57's room. On 06/13/25 a work order was placed for air conditioning not working for Resident #60. A timeline of events revealed on 06/22/25 maintenance reported to the facility to assist with elevated temperatures. HVAC company was contacted when complaints were received on increased temperatures. Residents were offered extra fans and portable air conditioning units. On 06/23/25 the facility implemented the Extreme Heat Policy. All residents were monitored for signs and symptoms of heat exhaustion every shift. Residents were offered to transfer to another facility, residents were offered an extra fan and/or portable air conditioner to use, and were educated on hydration, wearing light clothing, and turning off lights in their room. The facility attempted to obtain commercial portable air conditioner units but was unsuccessful due to multiple company's being out of stock. A email dated 06/23/25 at 3:46 P.M. from the HVAC company to [NAME] President of Plant Operations #600 revealed on 06/22/25 a technician arrived on site. An air bleeder on the building loop at the cooling tower was spraying out water. The bleeder was valved off and water was added. The power to the heat pumps on the second and third floor were cycled. A new air bleeder will need to be installed. Observations and interviews on 06/23/25 from 10:25 A.M. to 1:22 P.M. Residents #26, #28, #38, #60, #73, and #75 stated it was hot in the facility. Resident rooms and common areas were warm and multiple fans and portable air conditioners were noted. An observation on 06/23/25 at 1:11 P.M. of the thermostat at the nurses station on the third floor near the elevator showed 84 degrees. An observation on 06/23/25 at 1:12 P.M. of the nurses station on the back unit on the third floor had an electronic thermometer that showed 85 degrees. On 06/23/25 at 1:47 P.M. weather.com revealed the temperature in Columbus, Ohio, was 94 degrees. On 06/23/25 room temperatures were conducted with [NAME] President of Plant Operations #600 revealed the following temperatures: At 1:50 P.M. Resident #78's room was 81.8 degrees At 1:51 P.M. Resident #76's room was 82.9 degrees At 1:52 P.M. Resident #59's room was 82.2 degrees At 1:52 P.M. Resident #40's room was 82 degrees At 1:56 P.M. Resident #52's room was 81.1 degrees At 1:57 P.M. the common area on the locked unit was 81.8 degrees At 2:14 P.M. Resident #68's room was 83.3 degrees At 2:15 P.M. Resident #75's room was 84.2 degrees At 2:16 P.M. Resident #38's room was 84 degrees At 2:17 P.M. Resident #73's room was 81.1 degrees At 2:23 P.M. the nurses station on the third floor near the elevators was 85 degrees At 2:24 P.M. Resident #57's room was 85 degrees At 2:31 P.M. the therapy room was 84 degrees An interview on 06/23/25 at 3:50 P.M. [NAME] President of Plant Operations #600 revealed the cooling tower fan was running backwards and caused breakers to trip which resulted in the air conditioning not working properly. An interview on 06/24/24 at 10:19 A.M. Occupational Therapist #501 verified therapy was being completed in resident rooms because the therapy room was hot. An interview on 06/24/24 at 10:22 A.M. Therapy Director #505 verified therapy was only done in the therapy room if residents wanted therapy done there because the therapy room was hot. Therapy Director #505 stated a portable air conditioner and two fan were placed in the therapy room to help with the heat. An additional interview on 06/30/25 at 8:47 A.M. [NAME] President of Plant Operations #600 verified in April a temporary chiller was used until a part could be made. The end of May the part was available and the cooling tower was fixed. On 06/22/25 there were complaints of the air conditioning not working properly. The HVAC company was called and it was discovered the high voltage was wired wrong and caused the units to trip and an air bleeder was found. Excessive heat policy dated 11/30/14 revealed air conditioning will be utilized. If air conditioning was not appropriate or feasible, fans would be utilized to provide air circulation. Fluid hydration would be encouraged and cool fluids would be passed to residents on a regular basis. Window treatments would be closed to block out the sun where appropriate, residents would be encouraged to relocate and spend time in the cooler sections of the building, residents would be monitored closely for signs of dehydration, respiratory difficulties, and transferred to appropriate facilities if indicated. The facility must maintain temperature range of 71 to 81 degrees. 2. Observations 06/23/25 between 10:33 A.M. and 2:13 P.M. revealed the following: Resident's #53 and #58's bathroom did not have a roller to hold their toilet paper. Resident's Resident #37 and #49's bathroom did not have a roller to hold their toilet paper. One third of the vanity surrounding Resident #49's sink was missing. Resident #39's recliner was heavily worn with the fabric off on the headrest, arms and seat. Resident #24's sink had a note on it that it was out of order. The resident's had [NAME] and [NAME] bathrooms and a sink in their room. There was no evidence of hand sanitizer in the room in lieu of the sink being out of order. Three of four wall mounted hand sanitizers in the Behavior Unit did not dispense sanitizer when activated. Resident's #32 and #56's bathroom floor had 14 damaged, discolored floor tiles. Resident #27's overbed table and sink vanity were delaminating. The air conditioner was not working. Resident #52's sink and window seal were delaminating and chipped. The air conditioner was frozen and not cooling the room. The hall window outside room [ROOM NUMBER] had approximately two feet of the window seal missing. The Behavior Unit's shower room was patched and not painted near the corner of the sink over an approximately three feet in length and one foot in width area. Resident #185's overbed table was delaminating. Resident #78's room sink had laminate broken off leaving jagged edges. There were holes in the linoleum of the bathroom floor. The bedroom and bathroom doors were heavily scraped and damaged. The paint was scraped off the thresholds of the bedroom and bathroom doors. The air conditioner was not working. The knobs were off the air conditioner controls. The bedroom ceiling had an approximate four foot by two foot area damaged yellowish in color. The sink bowl was rusty colored. The temperature in the second floor lounge was 85 degrees at 11:40 A.M. The paint of the front of the second floor nurse station was scraped and dirty. There was a yellow stain in the ceiling tile of the between the elevator and second floor nurse station. The activity room had flooring missing in an approximate one and one half foot by one foot area and an approximate two inch by three inch corner. The activity room bathroom toilet had a black mold looking color around the water line. The floor was visibly dark, dirty. The walls were patched and not painted and the molding was off the wall. The bottom half of the elevator under the handrail was heavily scraped with the paint off. The back wall of the elevator above the handrail had large areas of plaster missing and was not painted. The hall wall from the dining room to the lobby below the handrails was heavily marred with dark scraped areas and damaged drywall. On 06/25/25 at 9:55 A.M. the Regional Director of Operations #602 and [NAME] President of Plant Operations #600 toured the above areas and verified the described areas had not been maintained. Observation 06/30/25 at 02:55 P.M. revealed there was a hole in the ceiling of Resident #78's room approximately eight inches by three inches. The ceiling had a liquid dripping into a fracture pan below. Interview 06/30/25 at 02:55 P.M. with Resident #78 revealed his ceiling started to leak on Saturday 06/28/25. He revealed there was also a leak in the middle of the room over the weekend. He put a Styrofoam cup on a table to catch the drips however, it was next to his bed which made it difficult to get out of bed. Interview 06/30/25 at 02:59 P.M. with Regional Director of Maintenance #702 verified the leak, He came in the room and started to pull the wet loose ceiling down. He opened an approximate one foot by one foot in the ceiling and stated the resident would need to be moved to another room. Interview 06/30/25 at 03:10 P.M. with Certified Nurse Assistant #244 revealed Resident #24 who's sink was out of order goes to the bathroom himself. She included he needs help wiping. She verified the resident did not have hand sanitizer or wipes in his room and verified his sink was not working. She did not know how he was washing his hands. 3) An observation on 06/25/25 at 4:30 P.M. of the large shower room located on the unit 3-Out revealed the toilet and sink were covered with plastic sheeting to prevent use. There was a hole in the tile surrounding the shower handle approximately three inches long by two inches wide to the left of the handle with wall material exposed. There was a dark substance noted to the bottom of the walls in the front corners of the shower and along the top part of the rubber kick plate behind the sink and the toilet. An interview on 06/26/25 at 2:05 P.M. with the [NAME] President of Maintenance (VPM) #600 revealed the facility had notified him on 06/16/25 concerning the large shower room on 3-Out was out of order related to ruptured water pipe. VPM #600 was unsure of how long the shower had been out of order before the facility had notified him. An interview on 06/26/25 at 4:25 P.M. with LPN #240 confirmed the plastic sheeting on the toilet and sink, the hole in the tile by the shower handle and the dark substance in the corners of the shower and behind the sink and toilet. LPN #240 stated this shower room had been out of use for several months due to a water pipe that had leaked and ruptured. 4) A review of Resident #285's medical record revealed admission date 06/18/25 with the following diagnoses including but not limited to aftercare following joint replacement of left hip, high blood pressure, and depression. Resident #285 was cognitively intact and required standby assist by staff to complete activities of daily living (ADL) tasks including transfers and bed mobility. An observation on 06/23/25 12:49 P.M. of Resident #285's bed revealed the bed frame was too long for the mattress. The mattress was touching the footboard which allowed for an approximately two-foot-wide gap between the headboard and the top of the mattress. Further observations on 06/24/25 at 10:00 A.M., 06/25/25 at 1:10 P.M., 06/26/25 at 9:15 A.M. and on 06/30/25 at 3:25 P.M revealed Resident #285's mattress continued to be too short for the bed frame. An interview on 07/01/25 at 8:15 A.M. with LPN #240 confirmed Resident #285's mattress was too short for the bedframe which resulted in a large gap between the headboard and the top of the mattress. LPN #240 stated either the housekeeping staff, or the clinical staff will notify central supply concerning mattresses that need replaced. These deficiencies represents non-compliance investigated under Master Complaint Number OH00166595, OH00166200, OH00165971, and OH00165933.

Based on observation, interviews, work orders, and policy review, the facility failed to ensure temperatures in the facility were at a comfortable level. This had the potential to affect all 90 residents. Facility census was 90. Finding include: Review of quote dated 04/22/25 from heating, ventilation, and air conditioning (HVAC) company revealed cooling tower repairs due to coil froze and burst due to being shut off over the winter. The coil would need replaced for a total of $79,990. A quote dated 04/24/25 was received from the same HVAC company for temporary cooling tower, temporary pump, piping, electric, and breakers as needed for a total of $48,659.00. The work was completed and paid for sometime in May. Review of temperature logs from 04/28/25 to 06/12/25 revealed temperatures from 74 degrees to 82 degrees. The temperatures for resident rooms at 80 degrees or above had notation of air conditioner unit being off and/or windows open. A work order dated 06/06/25 revealed the air unit on the second floor (Blue) was not working. On 06/11/25 a work order was placed for a problem with air conditioning in Resident #57's room. On 06/13/25 a work order was placed for air conditioning not working for Resident #60. A timeline of events revealed on 06/22/25 maintenance reported to the facility to assist with elevated temperatures. HVAC company was contacted when complaints were received on increased temperatures. Residents were offered extra fans and portable air conditioning units. Observations and interviews on 06/23/25 from 10:25 A.M. to 1:22 P.M. Residents #26, #28, #38, #60, #73, and #75 stated it was hot in the facility. Resident rooms and common areas were warm and multiple fans and portable air conditioners were noted. An observation on 06/23/25 at 1:11 P.M. of the thermostat at the nurses station on the third floor near the elevator showed 84 degrees. An observation on 06/23/25 at 1:12 P.M. of the nurses station on the back unit on the third floor had an electronic thermometer that showed 85 degrees. On 06/23/25 at 1:47 P.M. weather.com revealed the temperature in Columbus, Ohio, was 94 degrees. On 06/23/25 room temperatures were conducted with [NAME] President of Plant Operations #600 revealed the following temperatures: At 1:50 P.M. Resident #78's room was 81.8 degrees At 1:51 P.M. Resident #76's room was 82.9 degrees At 1:52 P.M. Resident #59's room was 82.2 degrees At 1:52 P.M. Resident #40's room was 82 degrees At 1:56 P.M. Resident #52's room was 81.1 degrees At 1:57 P.M. the common area on the locked unit was 81.8 degrees At 2:14 P.M. Resident #68's room was 83.3 degrees At 2:15 P.M. Resident #75's room was 84.2 degrees At 2:16 P.M. Resident #38's room was 84 degrees At 2:17 P.M. Resident #73's room was 81.1 degrees At 2:23 P.M. the nurses station on the third floor near the elevators was 85 degrees At 2:24 P.M. Resident #57's room was 85 degrees At 2:31 P.M. the therapy room was 84 degrees An interview on 06/23/25 at 3:50 P.M. [NAME] President of Plant Operations #600 revealed the cooling tower fan was running backwards and caused breakers to trip which resulted in the air conditioning not working properly. An interview on 06/24/24 at 10:19 A.M. Occupational Therapist #501 verified therapy was being completed in resident rooms because the therapy room was hot. An interview on 06/24/24 at 10:22 A.M. Therapy Director #505 verified therapy was only done in the therapy room if residents wanted therapy done there because the therapy room was hot. Therapy Director #505 stated a portable air conditioner and two fan were placed in the therapy room to help with the heat. An additional interview on 06/30/25 at 8:47 A.M. [NAME] President of Plant Operations #600 verified in April a temporary chiller was used until a part could be made. The end of May the part was available and the cooling tower was fixed. On 06/22/25 there were complaints of the air conditioning not working properly. The HVAC company was called and it was discovered the high voltage was wired wrong and caused the units to trip and an air bleeder was found. Excessive heat policy dated 11/30/14 revealed air conditioning will be utilized. If air conditioning was not appropriate or feasible, fans would be utilized to provide air circulation. Fluid hydration would be encouraged and cool fluids would be passed to residents on a regular basis. Window treatments would be closed to block out the sun where appropriate, residents would be encouraged to relocate and spend time in the cooler sections of the building, residents would be monitored closely for signs of dehydration, respiratory difficulties, and transferred to appropriate facilities if indicated. The facility must maintain temperature range of 71 to 81 degrees. This deficiency represents non-compliance investigated under Master Complaint Number OH00166971 and Complaint Number OH00165933

Based on observation, record review and interview, the facility failed to develop a dental plan of care and identify triggers for Post Traumatic Stress Disorder (PTSD). This affected two (Resident #10 and #40) of 27 residents reviewed. The census was 90. Findings include: 1. Review of Resident #10's medical record revealed a 05/21/24 admission with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, asthma, epileptic seizures, mood disorder, dysthymic disorder, post-traumatic stress disorder, major depressive disorder, malignant neoplasm of lung and bronchus, history of malignant neoplasm of pancreas, insomnia, and nicotine dependence. Review of the 05/23/25 Quarterly Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision making. Review of the residents' plans of care revealed two plans of care related to Post Traumatic Stress Disorder. A 06/23/25 plan of care revealed the resident had a past traumatic event of transportation accident (car accident/boat accident/train wreck/plane crash) related to a transportation accident. The problem did not include what type of transportation accident traumatized the resident. The problem did not include what triggers would elicit a PTSD reaction. Further review revealed a 06/23/25 plan of care revealed the resident had a past traumatic event of abuse from step father. The problem did not include what type of abuse the resident endured from her step father. The problem did not include what triggers would elicit a PTSD reaction. Interview on 07/02/25 at 9:48 A.M. with Resident #10 revealed her triggers for PTSD were yelling, slamming doors, and loud pops. She revealed her Mom and step-dad would shoot at her, put guns to her head, and break her favorite things. She went to live with an uncle when she was nine trying to get away from her parents. She shared she was molested by her uncle. He was also abusive and would drag her by her hair. Lastly, the resident shared she had a couple car accidents where she was hit in the front and back of the vehicle and totaled (wrecked beyond repair) two cars. Interview 07/02/25 at 2:20 P.M. with the Director of Nursing verified the plan of care needed to include what triggers would elicit a PTSD response so staff were aware to avoid triggers. 2. Review of the medical record for Resident #40 revealed an admission date of 10/18/23 with diagnosis that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, sickle-cell disease, pain, anxiety disorder, dysphagia and hypertension. Review of the medial record for Resident #40 revealed an oral assessment indicating Resident #40 had their own teeth and broken or carious teeth. Review of the medical revealed no dental/oral care plan was implemented. Interview on 07/01/25 at 4:25 P.M. with Regional MDS #703 verified no dental/oral care plan was implemented for Resident #40. Review of facility policy titled Care Plans, Comprehensive Person- Centered Revised December 2016 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to provide barber services for Resident #38. This affected one resident (#38) of four residents reviewed for activities of daily living. Facility census was 90. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, depression, and adjustment disorder with anxiety. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively intact. An interview on 06/23/25 at 10:59 A.M. Resident #38 stated he had not had a haircut since he was admitted to the facility, and he wanted his hair cut. Observation of Resident #38 revealed his hair was below his shoulders. An interview on 06/26/25 at 9:11 A.M. Licensed Nursing Home Administrator (LNHA) verified the facility had not had a beauty shop license since 2021. LNHA verified residents could not receive haircuts or beauty salon services at the facility. The LNHA stated he was currently looking into possibly taking residents to a local barber school and/or cosmetology school to receive haircuts. This deficiency represents non-compliance investigated under Complaint Number OH00165933.

Based on record review, policy review, and interview, the facility failed to ensure medical records contained accurate advance directives. This affected two residents (#39, #61) of 24 residents reviewed. Findings include: 1. Review of Resident #39's medical record revealed a [DATE] admission and [DATE] readmission with diagnoses including Alzheimer's disease, diabetes, dementia, delusional disorders, anxiety disorder, hyperlipidemia, chronic stage three kidney disease, morbid obesity, hypertension, and atherosclerotic heart disease. Review of the paper chart revealed there was a Do-Not-Resuscitate Comfort Care (DNRCC) advanced directive (a medical order that instructs healthcare professionals to not perform cardiopulmonary resuscitation (CPR) if a resident's heart or breathing stops, but to focus on providing comfort care) page. On the next page in the paper medical record, there was a signed advanced directive for a DNRCC-A (Do-Not-Resuscitate Comfort Care-Arrest, a type of Do-Not-Resuscitate (DNR) order that specifies that resuscitation efforts (like CPR) should not be initiated if a person experiences cardiac or respiratory arrest. However, until that point, the individual will receive standard medical care for any other illnesses or injuries). The electronic medical record contained an order for the resident to be a DNRCC-A. Interview on [DATE] at 3:46 P.M. with Licensed Practical Nurse (LPN) #230 verified it would be confusing as to what code status the resident was when the chart was opened. A yellow DNRCC page was the first advanced directive seen with the resident's name on the name line at the bottom and on the next page of the paper medical record, a DNRCC-A signed [DATE]. 2. Review of Resident #61's medical record revealed a [DATE] admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the resident's code status revealed when the hard chart was opened there was a blank full code sheet and a blank DNRCC sheet. The electronic record had an order for the resident to be a full code. Interview on [DATE] at 3:46 P.M. with LPN #230 verified the resident had a blank Full Code sheet followed by a blank DNRCC directive. LPN #230 verified it would be confusing as to what code status the resident was when the chart was opened. Interview on [DATE] at 4:52 P.M. with the Director of Nursing revealed they get the signed code status and upload them on the electric chart. They removed them all from the hard chart. The DON acknowledged the code status sheets were found on the hard chart and had not been removed from the hard chart. She indicated they did not have a policy that said the code status was in the electronic record not the hard chart. The advanced directive policy included information about whether or not the resident had executed an advance directive and shall be displayed prominently in the medical record.

Based on record review and interview, the facility failed to ensure an accurate assessment was completed for Resident #68. This affected one (Resident #68) out of 28 resident record reviews. Facility census was 90. Findings include: Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The admission/readmit form dated 03/12/25 revealed Resident #68 had impaired vision, wore glasses, and was deaf. The admission Minimum Data Set (MDS) date 03/15/25 revealed Resident #68 had cognitive impairment, had highly impaired hearing, impaired vision, and did not wear glasses. The quarterly MDS dated [DATE] revealed Resident #68 had adequate hearing, impaired vision, and did not wear glasses. An observation on 06/23/25 at 1:15 P.M. revealed Resident #68 had glasses with one lens on the right and tape on the right side of the glasses and the nose area. An interview on 06/24/25 at 9:07 A.M. with Resident #68's family member revealed Resident #68 was deaf and read lips or read what was written on paper to communicate. An interview on 06/25/25 at 8:51 A.M. Licensed Practical Nurse (LPN) #353 verified Resident #68 was deaf and read lips or used a communication board. An interview on 06/26/25 at 8:10 A.M. Regional Nurse #601 verified Resident #68 was admitted to the facility with broken glasses. An additional interview on 06/26/25 at 9:35 A.M. Regional Nurse #601 verified the MDS's completed on 03/15/25 and 06/14/25 were incorrectly coded to reveal Resident #68 did not wear glasses. Regional Nurse #601 also verified the 06/14/25 MDS was incorrectly coded to reveal Resident #68 had adequate hearing.

Based on medical record review, staff interview and review of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) manual the facility failed to complete a significant change MDS required for a resident admitted to hospice services. This affected one resident (Resident #2) of two residents reviewed for hospice services. The facility census was 90. Findings Include: A review of Resident #2's medical record revealed admission date 12/05/23 with the following diagnoses including but not limited to depression, high blood pressure, heart failure, anxiety, and schizoaffective disorder. Resident #2 had impaired cognition and required assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #2's physician orders revealed a revised order dated 03/13/25 to be admitted to Hospice with the diagnosis of metabolic encephalopathy. A review of Resident #2's hospice admission paperwork revealed an admission date of 01/30/25 to Hospice for metabolic encephalopathy. A review of Resident #2's completed MDS listing revealed an entry MDS was completed on 01/12/25, a quarterly MDS was completed on 01/15/25, and a quarterly MDS was completed on 04/14/25. A review of the MDS RAI manual dated 10/01/24 revealed in Chapter 2 - Assessments for the Resident Assessment Instrument (RAI) section 2.6 - Required Assessments for the MDS, A significant change in status assessment (SCSA) is required to be performed when a terminally ill resident enrolls in hospice program or changes hospice providers and remains in the nursing home. The assessment reference date (ARD) must be within 14 days from the effective date of the hospice election. An interview on 06/26/25 at 2:39 P.M. with Regional MDS Nurse #703 confirmed Resident #2 did not have a significant change MDS completed when hospice services were initiated on 01/15/25. Regional MDS Nurse #703 stated there should have been a significant change MDS completed within 14 days of Resident #2 being admitted to hospice on 01/15/25.

Based on record review and interview the facility failed to ensure assessments were accurately completed. This affected two (Resident #5 and Residents #40 ) of twenty eight residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 90. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included generalized idiopathic epilepsy and epileptic syndromes, schizophrenia, hypertension, anxiety disorder, disruptive mood dysregulation disorder, repeated falls, restlessness and agitation, senile degeneration of brain and glaucoma. Review of the Annual MDS 3.0 assessment dated [DATE] for Section J1800 revealed Resident #5 did not have any falls since admission/entry or prior assessment. Review of facility fall investigations revealed Resident #5 had falls on 12/16/24, 12/21/24, 03/11/25, 03/21/25, and 03/26/25. Interview on 06/30/25 at 01:52 PM with Regional MDS #703 verified MDS did not reflect the residents falls and it was coded incorrectly. 2. Review of the medical record for Resident #40 revealed an admission date of 10/18/23 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, sickle-cell disease, pain, anxiety disorder, dysphagia and hypertension. Review of the medial record revealed an oral assessment indicating Resident #40 had his own teeth and broken or carious teeth. Review of the Annual MDS 3.0 assessment dated [DATE] for section L0200 revealed No for natural teeth and No for broken natural teeth. Interview on 07/01/25 at 4:25 P.M. with Regional MDS #703 verified the MDS was coded incorrectly.

Based on record review, policy review and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) review was completed with a new psychiatric diagnosis. This affected one (Resident #61) of two residents reviewed for PASARR. The census was 90. Findings include: Review of Resident #61's medical record revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review revealed the last PASARR submitted for the resident was a 01/13/24 Significant Change for the addition of Post Traumatic Stress Disorder (PTSD) diagnosis. Record review revealed on 08/12/24 Resident #61 had a diagnosis of psychosis not due to a substance or known pathological condition added to her list of diagnoses. Review revealed there was no evidence of a subsequent PASARR submission, for a Level II consideration, to the state agency that included the new psychiatric diagnosis. Interview 06/26/25 at 5:03 P.M. with the Director of Nursing verified there was not a PASARR submitted to the state agency for Level II consideration after the addition of the psychosis diagnosis. Review of the facility's admission Criteria policy revised 12/2016 included nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable.

Based on observation, record review, policy and interview, the facility failed to ensure nail care was provided to dependent residents. This affected two (Resident #61 and #78) of four residents reviewed for activities of daily living. The census was 90. Findings include: 1. Review of Resident #78 revealed a 05/01/25 admission with diagnoses including fracture of T11-T12 vertebra, protein calorie malnutrition, fracture of first lumbar vertebra, valve endocarditis, lumbosacral radiculopathy, lumbar spondylosis, muscle wasting and atrophy, difficulty walking, cognitive communication deficit, low back pain, and mood disorder Review of the 05/06/25 admission Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision. The resident had no functional impairment and was in need of partial/moderate assistance with personal hygiene. Interview and observation on 06/24/25 at 12:20 P.M. with Resident #78 revealed he asked staff for fingernail clippers and did not get them. He said he had ripped off his fingernails and they were jagged. He showed that his thumb nails were long because they were too thick to tear off. Further observation of the resident's fingernails revealed the nails were jagged with sharp edges and dark debris under the nails. The resident also had long toenails. Interview 06/24/25 at 4:43 P.M. with Certified Nurse Aide #244 revealed she provided the resident a bed bath. She verified she has never cut or cleaned his nails. Observation of Resident #78 06/24/25 at 4:48 P.M. with Licensed Practical Nurse (LPN) #353 verified Resident #78's thumb nails and toe nails were long. He showed her where he has ripped them off and they were jagged and had debris under the nails. The resident said no one had cleaned his nails or cut them since he arrived. LPN #353 stated activities will do nails in the activity room but they do not go to individual rooms unless the residents are on the locked unit. Interview 06/24/25 at 4:55 P.M. with the Director of Nursing verified the facility has shower aides who are to do nail care with showers. Review of the facilities Care of Fingernails/Toenails policy revised October 2010 included the purpose of this procedure are to clean the nail bed to keep nails trimmed and to prevent infections. Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Notify the supervisor if the resident refuses the care. The following information should be recorded on the residents medical record. The date and time the nail care was given, the name and title of the individual who administered the nail care. The condition of the resident nails and nailbeds including redness or irritation of the skin of hands and feet, breaks or cracks in skin especially between toes, pale bluish or gray discoloration of feet, bluish or dark colored nail beds, corns or calluses, ingrown nails, bleeding and/or pain or any difficulties in cutting the residents' nails. If the resident refused the treatment the reason why should be documented an the intervention taken along with the signature and title of the person recording the data. Notify the supervisor if the resident refuses the care. 2. Review of Resident #61 revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the 02/10/23 Activity of Daily Living (ADL) plan of care included the resident had an ADL self-care performance deficit. Interventions included a 05/16/24 intervention with bathing and showering to check nail length and trim and clean on bath day and as necessary. Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making with no behaviors. She sometimes felt socially isolated. She has minimal difficulty hearing with no hearing aide. Has the ability to understand. Clear speech, and is understood. She had adequate vision without corrective lenses. She had trouble concentrating and falling asleep, feeling down, depressed or hopeless, with little pleasure in doing things. She had no functional impairment. The resident was supervision/ touch assistance for personal hygiene. Medications included antipsychotic, antidepressant, anticonvulsant. Receives antipsychotic on routine basis and no gradual dose reduction (GDR) had been attempted. The physician indicated a GDR was clinically contraindicated. Observation 06/24/25 at 10:35 A.M. revealed the resident had very long toe nails on her great toes bilaterally. Interview 06/24/25 at 10:35 A.M. with the resident revealed she had not been seen by a podiatrist to have her toenails cut since she was admitted . Review of the 04/23/25 podiatry list revealed the resident was not on the list to be seen. Interview 06/26/25 at 9:27 A.M. with Guardian #700 revealed Resident #61 is eligible for Veteran's benefits. She included she had asked in the past for the resident to take advantage of the veteran benefits for ancillary services. Interview 06/26/25 at 9:49 A.M. with the Director of Nursing verified the resident had not had ancillary services since admission. This deficiency represents non-compliance investigated under Complaint Number OH00166595 and OH00165933.

Based on record review, observation, interview, and policy review, the facility failed to ensure Resident #60, #68, and #72 had comprehensive care plans addressing preferences. This affected three (Residents #60, #68, and #72) out of 28 records reviewed. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #60 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included tracheostomy, paralysis of vocal cords and larynx, and anxiety. A care plan dated 05/24/23 revealed Resident #60 had a tracheostomy. Interventions included tracheostomy care as ordered. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #60 was cognitively intact. An interview on 06/23/25 at 1:20 P.M. Resident #60 stated he did his own tracheostomy care except for suctioning. An observation on 06/25/25 at 3:32 P.M. tracheostomy care was provided by Registered Nurse #228. The Director of Nursing was present and stated Resident #60 had been educated and provided his own tracheostomy care. Resident #60 declined to do tracheostomy care for the surveyor. A revised care plan dated 06/25/25 revealed Resident #60 had a tracheostomy. Interventions included tracheostomy care as ordered and Resident #60 preferred to complete tracheostomy care himself. Resident #60 had been educated on completing tracheostomy care. An interview on 06/26/25 at 2:30 P.M. Director of Nursing verified Resident #60's care plan had been updated with an intervention for Resident #60 to provide his own tracheostomy care. Director of Nursing also verified there was no documentation of Resident #60 being educated on how to complete tracheostomy care prior to 06/25/25. Review of Care Plans, Comprehensive Person-Centered policy (no date) revealed care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The resident will be informed of his or her right to participate in his or her treatment. The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. 2. Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The admission/readmit form dated 03/12/25 revealed Resident #68 had impaired vision and wore glasses. The admission Minimum Data Set (MDS) date 03/15/25 revealed Resident #68 had cognitive impairment, impaired vision, and did not wear glasses. The quarterly MDS dated [DATE] revealed Resident #68 had impaired vision, and did not wear glasses. An observation on 06/23/25 at 1:15 P.M. revealed Resident #68 had glasses with one lens on the right and tape on the right side of the glasses and the nose area. An interview on 06/24/25 at 9:07 A.M. with Resident #68's family member revealed Resident #68 was deaf and read lips or read what was written on paper to communicate. An interview on 06/25/25 at 8:51 A.M. Licensed Practical Nurse (LPN) #353 verified Resident #68 was deaf and read lips or used a communication board. An interview on 06/26/25 at 8:10 A.M. Regional Nurse #601 verified Resident #68 was admitted to the facility with broken glasses. An additional interview on 06/26/25 at 9:35 A.M. Regional Nurse #601 verified there was not a care plan for Resident #68's impaired vision. Review of Care Plans, Comprehensive Person-Centered policy (no date) revealed care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The resident will be informed of his or her right to participate in his or her treatment. The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. 3. Review of medical record for Resident #72 revealed an initial admission date of 06/01/25 and readmitted on [DATE] with diagnosis including periprosthetic fracture around internal prosthetic right hip joint, other mechanical complication of other internal joint prosthesis, fibromyalgia, protein-calorie malnutrition, repeated falls, major depressive disorder, chronic pain and opioid use. Review of activities care plan created 03/18/25 revised on 06/01/25 revealed interventions to provide the resident with materials for individual activities as desired. The resident likes the following independent activities: writing paper/pens. The resident's preferred activities was writing books. Observations on 06/23/25, 06/24/25, and 06/25/25 revealed Resident #72 did not attend activities outside of her room and had no writing paper/pens. Interview on 06/25/25 at 3:19 P.M. with Activity Director #216 revealed the resident cannot tell her what she likes to do. The AD stated the resident is scared and did not want to come out of her room to attend activities but the AD offers her crayons to color and the resident will accept coffee. Interview on 06/26/25 2:18 P.M. with Activity Director #216 verified the resident's care plan was not revised to reflect refusals to attend activities and activity preferences. Review of Care Plans, Comprehensive Person-Centered policy (no date) revealed care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The resident will be informed of his or her right to participate in his or her treatment. The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process.

Based on record review, policy and interview, the facility also failed to remove a resident's surgical staples and administer antibiotics to meet professional standards. This affected two residents (#134 and #234) out of 29 residents reviewed for appropriate care and services. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #234 was admitted on [DATE] with diagnoses that included staphylococcal arthritis right hip, osteomyelitis of vertebra, type 2 diabetes, protein-calorie malnutrition, asthma, hypertension, major depressive disorder, and anxiety disorder. The quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #234 was cognitively intact. Review of the after visit summary (AVS) from the hospital dated 06/16/25 revealed Resident #234's surgical staples would be removed at the skilled nursing facility two weeks post operative on 06/20/25. An interview on 06/23/25 at 11:58 A.M. Resident #234 stated he recently had surgery and needed staples removed. Resident #234 was unsure when the appointment for the staple removal was. An interview on 06/25/25 at 3:50 P.M. the director of nursing (DON) stated Resident #234 probably would not allow the skilled nursing facility staff to remove the staples. The DON was not aware the AVS revealed Resident #234's staples were to be removed by the facility staff on 06/20/25. An additional interview on 06/26/25 at 2:38 P.M. the DON verified there was an order on the AVS for the skilled nursing facility to remove Resident #234's staples. The DON stated Resident #234 permitted staff to remove the staples on 06/25/25. 2. A review of the medical record for Resident #134 revealed an admission date 05/21/25 with diagnoses including osteomyelitis of right foot, congestive heart failure (CHF), and type two diabetes. Resident #134 was discharged from the facility on 05/25/25. A review of Resident #134's physician orders revealed an order dated 05/21/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 14.5 milliliter (ml) per hour (hr) intravenously at bedtime for wound until 06/22/25, order was discontinued on 05/23/25. An order dated 05/23/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/22/25, order was discontinued on 05/25/25, and an order dated 05/25/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/25/25, order was discontinued on 05/27/25. A review of Resident #134's Medication Administration Record (MAR) dated 05/21/25 to 05/25/25 revealed the order for antibiotic Daptomycin Intravenous Solution Reconstituted use 14.5 milliliter (ml) per hour (hr) intravenously at bedtime for wound until 06/22/25 was marked on 05/21/25 as not administered with no reason documented and marked on 05/22/25 as not administered due to being in the care of the pharmacy. Further review revealed the order for antibiotic Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/22/25 was marked as being administered on 05/23/25 and 05/24/25. On 05/25/25 and 05/26/25 the order for Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/22/25 was marked as being not administered due to Resident #134 not being at the facility. A review of Resident #134's progress notes dated 05/21/25 to 05/25/25 revealed no notifications to the physician concerning the required clarification of the order dated 05/21/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 14.5 milliliter (ml) per hour (hr) intravenously at bedtime for wound until 06/22/25, and there were no entries in the progress notes to reflect the physician was notified of the two dose of antibiotic not being administered to Resident #134. An interview on 06/30/25 at 1:43 P.M. with the Director of Nursing (DON) confirmed Resident #134 was not administered the antibiotic Daptomycin on 05/21/25 and 05/22/25, and there were no notifications to the physician reflecting the need for the order clarification or the missed doses of the antibiotic. A review of the facility's policy titled Change in a Resident's Condition or Status dated 05/17 revealed the nurse will notify the resident's Attending Physician or Physician on call when there is a need to alter the resident's medical treatment. This deficiency represents non-compliance investigated under Complaint Number OH00166200.

2. Review of Resident #61 revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making with no behaviors. She has minimal difficulty hearing with no hearing aide, had the ability to understand. Clear speech, and is understood. She had adequate vision without corrective lenses. Interview 06/24/25 at 10:34 A.M. with Resident #61 revealed she wore glasses for distance vision but had not seen an eye doctor since she was admitted to the facility. The resident indicated she wore glasses while driving and for distance vision before admission. The resident was unable to find her glasses in her room. Review of the record revealed no evidence of the resident having an optometry consult while a resident in the facility. Interview 06/26/25 at 9:27 A.M. with Guardian #700 revealed Resident #61 was eligible for Veteran's benefits. She included she had asked staff, in the past, for the resident to take advantage of the veteran benefits for ancillary services. Interview 06/26/25 at 9:49 A.M. with the Director of Nursing verified the resident had not had ancillary services including optometry care since admission. This deficiency represents non-compliance investigated under Complaint Number OH00166595 and OH00165933. Based on observation, record review, and interview, the facility failed to provide Resident #61 and #68 with adequate and timely vision care. This affected two (Resident #61 and #68) of three residents reviewed for vision care. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The admission/readmit form dated 03/12/25 revealed Resident #68 had impaired vision, wore glasses, and was deaf. The admission Minimum Data Set (MDS) date 03/15/25 revealed Resident #68 had cognitive impairment, had highly impaired hearing, impaired vision, and did not wear glasses. The quarterly MDS dated [DATE] revealed Resident #68 had impaired vision, and did not wear glasses. A list of residents with vision appointments at the facility on 06/04/25 revealed Resident #68 was not on the list of residents seen. An observation on 06/23/25 at 1:15 P.M. revealed Resident #68 had glasses with one lens on the right side, no lens on the left side and tape on the right side of the glasses and the nose area. An interview on 06/24/25 at 9:07 A.M. with Resident #68's family member revealed Resident #68 was deaf and read lips or read what was written on paper to communicate. An interview on 06/25/25 at 8:51 A.M. Licensed Practical Nurse (LPN) #353 verified Resident #68 was deaf and read lips or used a communication board. An interview on 06/26/25 at 8:10 A.M. Regional Nurse #601 verified Resident #68 was admitted to the facility with broken glasses. A follow-up interview on 06/26/25 at 9:35 A.M. with Regional Nurse #601 verified Resident #68 had not seen the eye doctor and was unaware Resident #68 had glasses that only had one lens and the frame and lens were taped together.

Based on record review, policy review, and interview, the facility failed to ensure resident representatives were invited to care conferences. This affected two residents (#56, #61) of two residents reviewed for care planning. Findings include: 1. Review of Resident #56's medical record revealed a 06/01/23 admission with diagnoses including hemiplegia, hemiparesis, altered mental status, occlusion and stenosis of left carotid artery, dysphagia, cerebral infarction, chronic viral hepatitis C, major depressive disorder, contracture of right hand and hypertension. Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was severely impaired for daily decision making. The resident resided on the locked behavior unit. Review of the care conferences included a 06/09/25 electronic care conference entry by Social Services documented in the electronic record. There was no one listed in attendance. The nursing section was not signed by a nurse from any shift when the form indicated input from all shifts was required. The dietary section did not include oral intake, current weight, body mass index (BMI), weight history, bowel pattern, relevant medication, laboratory reports, or nutritional risk. The section was not signed by dietary staff. The pharmacy section was not completed. The code status was not marked. Social Services was the only department to sign the care conference. There was no evidence of the family being notified of the conference. There was a 03/13/25 and 12/05/24 care conference documented on paper. There was no evidence the resident's wife attended or was invited to the care conferences. There was no documentation of the wife being invited by phone. The surveyor attempted to contact Resident #56's wife at the listed phone number in the medical record for her office and the phone was answered by a female who indicated they did not have the name listed as the resident's wife. The mobile number had a recording the mailbox was full. Interview on 06/24/25 at 9:58 A.M. with Resident #56's wife revealed she did not know anything about quarterly meetings. She indicated the staff does not meet with her to discuss her husband's care. She had no knowledge of receiving care conference letters or phone calls to inform her of meetings. Interview on 06/24/25 at 5:24 P.M. during interview Social Services Staff #355 indicated she went to electronic care conference documentation in February (2025). Prior to that they were on paper filed in her office. She indicated she would call and leave messages with the family or guardian to inform them of the care conference. Families and guardians do not answer when she calls. She never received calls back. She said she would document if she called the family or guardian. She never sent a letter to families. Social Services Staff #355 indicated there was a message we send out to the staff to tell them when the meetings are. Social Services Staff #355 verified there was no evidence of families and guardians being invited or at the meetings. Interview on 06/25/25 at 1:49 P.M. with Admissions Staff #385 revealed she gets with Social Services Staff #355 in the morning meeting and learns what care conferences are coming up. If they have a family or a guardian she sends them a letter. Admissions Staff #385 presented letters with Resident #56's name and the time and date of the care conference. There was not a name or address on the letter of who the letter was sent to. Admissions Staff #385 said the name and address would be on the envelope. Admissions Staff #385 verified she had no evidence of care conference letters being sent. She verified they were not sent certified or with a signature page to respond to the letter. Admissions Staff #385 had no explanation as to why family and guardians did not receive the letter. Review of the facility policy Resident Participation- Assessment/Care Plans (revised December 2016) included spouses and other members of the family may participate in the resident assessment and development of the person centered care plan with the residents permission. For the purposes of this and other policies family includes spouse which is defined as an individual has been lawfully married to the resident regardless of the state or local laws of the jurisdiction of the facility. The resident resident representatives right to participate in the development and implementation of his or her plan of care. The care planning process will facilitate the inclusion of the resident and/or representative. The resident has the right to be fully informed in a language that he or she can understand of his or her total health status including but not limited to his or her medical condition the right to be informed in advance of changes to the plan of care the facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. An advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. The Social Service Director or designee is responsible for notifying the resident/representative. Notices include: the date, time and location of the conference. The method of contact (e.g., mail, telephone, email, etc.) 2. Review of Resident #61's medical record revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the care conferences included a 06/11/25 electronic care conference entry by Social Services documented in the electronic record. There was no one listed in attendance. The nursing section was not signed by a nurse from any shift when the form indicated input from all shifts was required. The dietary section did not include oral intake, current weight, BMI, weight history, bowel pattern, relevant medication, laboratory reports, or nutritional risk. The section was not signed by dietary staff. The pharmacy section was not completed. The code status was not marked. Social Services was the only department to sign the care conference. There was no evidence of the guardian being notified of the conference. There was a 04/14/25 and 01/16/25 care conference documented on paper. There was no evidence of the resident's guardian attending the care conferences. There was no evidence the guardian was invited to the care conferences. There was no documentation of the guardian being invited by phone. Interview 06/24/25 at 10:31 A.M. with Resident #61's guardian, Guardian #700 revealed they do not have care conferences including her. She indicated she has asked for care conferences and the staff does not arrange them. She does not get notified of meetings. The resident's guardian was not listed in the resident's medical record. There was a different name listed as the resident's guardian. Guardian #700 who answered the phone at the number listed for the guardian said she had been the resident's guardian for about two and a half years. Guardian #700 verified the name listed in the medical record was not correct. Interview on 06/24/25 at 5:24 P.M. of Social Services Staff #355 verified there was no evidence of Resident #61's guardian being invited or at the meetings. Interview on 06/26/25 at 12:47 P.M. with the Regional Director of Operations #602 verified there was no evidence of the guardians/families being notified of upcoming care conferences.

Based on record review, resident and staff interviews, review of hospital records, and facility policy review, the facility failed to timely treat and assess a pressure ulcer and prevent the pressure ulcer from worsening for one resident (Resident #234). Actual Harm occurred on 08/01/23 when Resident #234 was admitted to the facility with a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) pressure wound to her left proximal (back) upper thigh that worsened to a Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcer without evidence of routine skin assessments or timely treatments. This affected one resident (Resident #234) out of two residents reviewed for pressure ulcers. The facility census was 82. Findings Include: Review of the medical record for Resident #234 revealed an admitted on 08/01/23. Medical diagnoses included cardiomyopathy, morbid obesity, type II diabetes mellitus with diabetic neuropathy, unspecified mood (affective) disorder, hypertension, venous insufficiency (chronic) (peripheral), and hyperlipidemia. There was no evidence of a pressure ulcer being listed as a diagnosis for the resident. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #234 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #234 required limited assistance from one staff to complete bed mobility, transfers, and toileting. Resident #234 was ambulatory but was unsteady and required staff assistance to stabilize. The assessment did not note any skin impairments or wounds for Resident #234. Review of the hospital records dated 07/24/23 revealed Resident #234 was admitted on [DATE] and discharged on [DATE] to the facility. A wound to Resident #234's left proximal, posterior, upper leg was noted with a start date of 05/03/23 and had been present for 83 days. The wound was a Stage II decubitus ulcer and was present on admission. The hospital provided wound care and offloading. A picture of the wound dated 07/25/23 at 3:37 P.M. revealed Resident #234 had a Stage II pressure ulcer to the back of her left thigh. The wound measured four centimeters (cm) long by 1.5 cm wide by 0.1 cm deep. The primary dressing was a bordered foam dressing (Mepilex). Review of the Admit/Readmit Screener dated 08/01/23 and completed by Licensed Practical Nurse (LPN) #189 revealed there were no skin areas noted on the skin grid in the assessment. However, LPN #189 indicated pressure ulcer present under the oral/nutritional section of the assessment. Review of the Interim Care Plan dated 08/01/23 revealed Resident #234 had impaired skin integrity at admission. Review of Skilled Charting dated 08/04/23 at 4:05 A.M. revealed Resident #234 had treatable wounds. Review of Skilled Charting dated 08/05/23 at 4:20 A.M. revealed Resident #234 had treatable wounds to the buttock/sacrum area. Review of progress notes dated from 08/01/23 to 08/22/23 revealed no documentation of Resident #234's pressure ulcer wound until 08/20/23 at 11:17 A.M. Review of the physician's orders dated for August 2023 revealed no evidence the physician was notified of Resident #234's admission or of any wound treatments being implemented for Resident #234 until 08/20/23 (19 days after admission). Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August 2023 revealed Resident #234 did not receive any wound treatments until 08/20/23. Review of the Skin Observation task dated from 08/01/23 to 08/28/23 revealed an open area was noted for Resident #234 on 08/12/23 at 6:53 P.M. Review of the Skin Grid-Pressure assessment dated [DATE] at 4:56 P.M. revealed documentation of an initial assessment of a wound located on Resident #234's left posterior upper thigh. The assessment noted the wound as a Stage III pressure ulcer. The wound measured 4.2 cm long by 2.2 cm wide by 0.1 cm deep. The wound had a moderate amount of serous (clear to yellow fluid that leaks out of a wound) drainage. The physician, resident representative, and dietitian were notified of the presence of the wound on 08/21/23. A new wound treatment was ordered to cleanse with normal saline, pack wound with alginate, and cover with an absorbent dressing. The dressing was to be changed daily and as needed. Interview on 08/22/23 at 9:39 A.M. with Resident #234 revealed the resident had a pressure ulcer wound to the back of her left thigh when she was admitted to the facility. Resident #234 stated the facility staff did not assess or treat the wound until recently (about three times since admission). Resident #234 stated the wound bled sometimes and left soiled areas on the sheets. Resident #234 stated she experienced an increase in pain from that area since admission but is not able to see the area herself. Interviews on 08/23/23 at 10:31 A.M. and 10:55 A.M. with Unit Manager (UM) #175 and Regional Nurse (RGN) #210 revealed staff used the After Visit Summary (AVS) to determine medications and treatment orders and did not review the hospital records upon admission. Staff should contact the physician to reconcile the orders. It is up to the physician to review the hospital records and have knowledge of what the resident was in the hospital for and what treatment was provided. RGN #210 stated the facility initiated a new directive to complete two skin assessments and record reviews upon admission to ensure nothing was missed. Interview on 08/23/23 at 4:48 P.M. with Registered Nurse (RN) #121 revealed she worked on 08/20/23 and assessed Resident #234's pressure wound. RN #121 stated Licensed Practical Nurse (LPN) #192 asked her how a resident could be added to wound rounds. RN #121 and LPN #192 reviewed Resident #234's admission assessment and the skin grid in the assessment noted a wound to the resident's left gluteal area. RN #121 confirmed there was not a wound treatment in place, or any wound measurements completed at the time she assessed Resident #234 on 08/20/23. RN #121 stated Resident #234 reported she had pain in that area when she sat down and had asked LPN #192 to put something on it on 08/19/23 and 08/20/23. RN #121 pulled up the Admit/Readmit Screener assessment dated [DATE] and stated it was the assessment that she had reviewed prior to assessing the resident. RN #121 stated the Skin Integrity section of the assessment noted the area when she reviewed it, however, it was blank when reviewed today, 08/23/23. RN #121 stated, I promise you; it was there. Interview on 08/24/23 at 12:23 P.M. with LPN #192 via telephone revealed she worked during night shift on 08/19/23 and 08/20/23 and assessed Resident #234's wound area. LPN #192 confirmed Resident #234 was admitted with a wound to her left gluteal area on 08/01/23 and the area was noted on the skin grid in the Admit/Readmit Screener assessment dated [DATE]. LPN #192 stated she became aware of the wound when Resident #234 told her about it and that the area was draining and was uncomfortable. LPN #192 stated she checked for a treatment order and there was no order in place. LPN #192 placed a dry dressing on the wound on 08/19/23. Resident #234 requested to have the dressing changed again on 08/20/23 and at that time, LPN #192 decided she needed to confirm an appropriate treatment for the wound. LPN #192 notified RN #121 and they assessed the wound together and took measurements. The nurses placed a clean dry dressing on the wound and notified the physician. Resident #234 was also added to the list to be seen by the wound team. LPN #192 confirmed from 08/01/23 to 08/20/23, Resident #234 did not have a wound treatment in place and the pressure ulcer was not monitored appropriately. Interview on 08/25/23 at 5:20 P.M. with LPN #189 via telephone revealed he completed Resident #234's admission on 08/01/23. LPN #189 confirmed he did see Resident #234's wound on her buttocks area and noted it in the skin grid of the Admit/Readmit Screener assessment. LPN #189 stated the Unit Manager was supposed to double check the assessment and pass the information on to the wound team to have Resident #234 seen but I guess that didn't happen. LPN #189 stated he also noted the presence of a wound in the dietary section of the admission assessment to ensure Resident #234 received enough protein in her diet. Follow-up interview on 08/28/23 at 2:25 P.M. with Resident #234 in her room confirmed again she had been admitted with an open wound on the back of her left upper thigh/buttock area. Resident #234 stated she informed the staff a couple of times about the wound but the staff wouldn't listen. Resident #234 confirmed she did not receive any treatment to the wound until recently. Review of the facility policy, Prevention of Pressure Ulcers/Injuries, revised 07/2017, revealed the policy instructed staff to assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat as needed and upon any changes in condition. Conduct a comprehensive skin assessment upon admission, including skin integrity-any evidence of existing or developing pressure ulcers or injuries. Evaluate, report, and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on medical record review, staff interview, hospital record review, and facility policy review, the facility failed to complete comprehensive blood glucose monitoring for Resident #65 to ensure insulin was administered per physician order and to meet the resident's total care needs. Actual Harm occurred when the lack of blood glucose monitoring (beginning in June 2023 and continuing through August 2023) and evaluation and/or administration of insulin resulted in ongoing episodes of hyperglycemia. On 08/12/23 Resident #65 had a blood glucose reading above 500 milligrams per deciliter (mg/dL) and was admitted to the hospital with hyperglycemia and acute kidney injury. This affected one resident (#65) of four residents reviewed for quality of care. The facility census was 82. Findings include: Review of the medical record for Resident #65 revealed an initial admitted [DATE] and latest re-entry date of 08/15/23. Resident #65 had diagnoses including mild protein-calorie malnutrition, muscle wasting and atrophy, and type two diabetes mellitus. Review of the plan of care for Resident #65 dated 06/13/22 and revised on 05/08/23 revealed Resident #65 had a diagnosis of diabetes mellitus. Interventions included administering medication as ordered, monitor and document for side effects and effectiveness of medications, complete dietary consult for nutritional regimen and ongoing monitoring, complete fasting serum blood sugar as ordered, monitor, document and report as needed any signs or symptoms of hyperglycemia including increased thirst and appetitive, frequent urination, weight loss, fatigue, and dry skin. Review of Resident #65's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating the resident had moderately impaired cognition for daily decision-making. Record review revealed Resident #65 had a hospitalization from [DATE] to 06/13/23. Prior to the hospitalization the resident had a physician's order to check blood glucose level in the morning, record in the electronic medical record and notify the physician if the resident's blood glucose was greater than 400. The orders also included to monitor resident for signs or symptoms of hypo/hyperglycemia and notify the physician of blood glucose readings less than 60 or greater than 400 every shift. The resident had an order for insulin medication, Glargine (Lantus) 100 units/milliliter-solution 14 units subcutaneously at bedtime for diabetes mellitus. Review of Resident #65's after hospital visit summary dated 06/13/23 revealed to stop taking the prescribed Insulin Glargine (Lantus)100 units/ml and continue taking Insulin Lispro 100 units/ml solution per sliding scale. The sliding scale revealed for a blood glucose level of 100 to 150 give two units of Lispro, for a blood glucose of 151 to 200 give three units of Lispro, blood glucose of 210 to 300 give four units Lispro, blood glucose of 301 to 400 give six units of Lispro and for a blood glucose reading greater than 400 give 10 units of Lispro and then call the physician. The blood glucose monitoring and sliding scale coverage was ordered to be completed four times a day. Review of the physician's orders for Resident #65 revealed upon re-admission (06/13/23) the order for the Lantus insulin had been discontinued. However, the new order for the Lispro sliding scale insulin with blood glucose monitoring four times a day had not been written/implemented. There was an order for the resident's blood glucose to be monitored daily in the morning and to notify the physician of any reading less than 60 or greater than 400 (which was the order that had been in place prior to the 06/05/23 hospitalization ). Review of Resident #65's medication administration record (MAR) and treatment administration record (TAR) for June 2023 revealed an actual blood glucose reading was only obtained and recorded twice during the month for the resident. On 06/14/23 the resident's blood glucose was elevated at 325.0 mg/dL and on 06/22/23 it was elevated at 325.0 mg/dL. Based on the hospital visit summary, the resident should have received six units of insulin (Lispro) for the blood glucose readings of 325 of these dates. However, there was no evidence of any insulin being administered to the resident. Review of Resident #65's MAR and TAR for July 2023 revealed no evidence staff had checked or documented any blood glucose readings for the resident during the month of July 2023. Review of Resident #65's MAR and TAR for August 2023 revealed staff had only checked the resident's blood glucose levels twice; on 08/04/23 the resident's blood glucose level was 371.0 mg/dL (elevated) and on 08/12/23 the resident's blood glucose level was elevated at 549.0 mg/dL. There was no evidence the resident was administered any insulin on 08/04/23 related to the elevated blood glucose level of 371. Review of a physician note dated 08/10/23 at 1:38 P.M. created by Certified Nurse Practitioner (CNP) #500 revealed the CNP was asked to see the resident by staff due to increased confusion, type two diabetes mellitus, dementia, and chronic kidney disease. The CNP note reflected the resident was seen in the hospital from 06/06/23 through 06/13/23 for worsening shortness of breath, volume overload and elevated troponin. Hospital course included a left heart catheterization without intervention. The note revealed to monitor blood glucose and adjust regimen as needed, check HgbA1C and basic metabolic panel (BMP) periodically, order to check blood glucose daily in morning in place in electronic record. Accu check (blood glucose results) trends not available for review, will discuss with nursing. A1C ordered next lab day and every six months. Review of the nursing note dated 08/10/23 at 3:38 P.M. created by Licensed Practical Nurse (LPN) #114 revealed, laboratory orders obtained, stat complete blood count (CBC) and basic metabolic panel (BMP). Aspirin to be discontinued per CNP #500. Review of a nursing note dated 08/12/23 at 12:30 P.M. created by LPN #118 revealed received phone call from CNP #500. Resident's glucose level was 550 (critical). Called and spoke with physician concerning resident's lab work. New orders (1) Accu-check done and registers Hi. (2) Give Lispro 10 Units now. Re-check (blood) sugar in an hour. Call back if sugars were in the 400's. (3) collect urine and an A1C/ call lab. Resident says he's tired, did eat breakfast. Refusing lunch (just sleeping). There was no indication why the laboratory testing, ordered on 08/10/23 was not addressed until 08/12/23 (two days later). Review of the nursing note dated 08/12/23 at 2:00 P.M. created by LPN #118 revealed the nurse re-checked resident's blood glucose which was 549 (hyperglycemic). The resident still remained in bed sleeping, did not eat lunch. Called physician and explained the resident's condition and received new orders to send to emergency room due to status change. Review of Resident #65's hospital after visit summary for the hospitalization from [DATE] through 08/15/23 revealed the resident's primary diagnoses included hyperglycemia. The visit summary noted the resident was noted with a glucose reading in the 500's at the extended care facility. Hyperglycemia on admission likely secondary to lack of basal coverage. HgbA1C reading of 13% (elevated) which indicated the resident had an average blood sugar/glucose reading of 326 mg/dL in the last 90 days. Restarted Lantus insulin, titrated up to 24 units daily at bedtime with improvement in glucose in the 200's. Interview on 08/24/23 at 3:00 P.M. with Regional Nurse #210 confirmed Resident #65's blood glucose levels were not being monitored for the month of June 2023, July 2023, or August 2023 as per orders following the resident's re-admission in June 2023. Regional Nurse #210 also verified the hospital discharge instructions from the hospital stay dated 06/05/23 through 06/13/23 indicated for the resident to continue the insulin medication Lispro and if there any questions regarding this order, the admitting nurse should have called for clarification. Review of facility policy titled Obtaining a Fingerstick Glucose Level, dated 10/2011 revealed under Documentation, the person performing this procedure should record the following information in the resident's medical record: The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions needed to adjust insulin or oral medication dosages. No additional policy/procedures were provided for review related to diabetic monitoring and/or diabetic care/treatment.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, resident interview, review of hospital records, review of a medication error incident report, review of the facility medication administration policy, review of employee disciplinary records, and review of facility quality assurance documents, the facility failed to ensure Resident #16 was free from a significant medication error. Actual Harm occurred to Resident #16 on 05/24/23 when Registered Nurse #100 administered 500 milligrams (mg) of Methadone (a narcotic medication used for pain or to treat drug addiction) instead of the 100 mg that was ordered resulting in an opioid overdose requiring multiple doses of Narcan (medication used to treat narcotic overdose) with a nine day hospital stay. This affected one (Resident #16) of two residents reviewed for medication errors. The facility census was 83. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, long term opiate use, and spinal stenosis. Review of the Minimum Data Set (MDS) 3.0 assessment completed 03/30/23 documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of physician's orders revealed an order, dated 03/25/23 for Methadone 10 mg/5 milliliters (ml)- give 100 mg once daily for pain at 9:00 A.M. The order/medication record did not specify how many milliliters to give; however, 50 milliliters would have equaled 100 mg when the ratio of the medication solution was 10 mg/5 ml. Review of the Medication Administration Record (MAR) revealed on 05/24/23 at 9:00 A.M. the Methadone was administered by Registered Nurse (RN) #100. Review of a physician progress note on 05/24/23 at 9:10 A.M. revealed the physician was called to Resident #16's room because he had an acute alteration in mental status. The note stated the physician had seen the resident approximately 15 minutes earlier in the room and he had been awake, alert, and talkative. On arrival to the room the resident was lethargic and only responding to sternal rub. He was noted to have oxygen saturations in the 60's. He was emergently placed on supplemental oxygen per nasal cannula but was not breathing appropriately so changed to face mask (for oxygen). The resident was then given Narcan (two doses). The resident originally did not respond well to the Narcan. However, approximately five minutes later he started to become more awake, alert, responsive, and talkative. Physical exam: temperature 98.1, pulse 131, respirations 25, blood pressure 134/81. Generally resident was lethargic but now responsive. In mild respiratory distress with oxygen saturation of 96 percent on 100 percent face mask. Impression: Acute encephalopathy etiology unknown. Suspected related to opioid use. The resident had been on Methadone for years and had been on the same dose full time since he had been here (in facility). Is unclear whether he actually got into something else that could have caused him to become more lethargic. He did, however, respond well to Narcan. Because of concerns about mental status and airway protection, the resident was emergently transported to an acute care hospital. A nurse's note by Registered Nurse (RN) #100 on 05/24/23 at 11:26 A.M. revealed Resident #16 was noted by staff sitting on the side of his bed leaning forward and when staff called his name, he was not responding. Staff tried to sit him up but he kept falling forward. He was not responding at all to staff but he did respond briefly to a sternal rub. When oxygen saturation was taken it was 65 percent. He was put on oxygen immediately. Physician was in facility and aware of situation. He also advised Narcan as resident was on daily Methadone. When Narcan given, he did start to come around but still not at baseline. Per physician, sent out to hospital for evaluation and treatment. Medics in at 9:40 A.M. to transport resident to hospital. Review of a medication error incident report dated 05/24/23 revealed Resident #16 was given 50 ml of Methadone per order. Per physician, he sent a prescription to pharmacy on 05/23/23 changing the dose of the medication and that he spoke with the nurse working with the resident about changing the order in the computer system. The order was not changed and the resident received the incorrect dosage. The physician advised Narcan be administered and the resident was sent to the hospital for evaluation and treatment. The report was written by Registered Nurse #100. Review of a concern form dated 05/24/23 revealed Resident #16's daughter reported a concern to the Administrator. The daughter stated the resident had to have received the wrong medication, hence his admission to the hospital. The form stated the Director of Nursing (DON) investigated the occurrence to determine what happened. The form stated Resident #16 received 50 ml of Methadone instead of 10 ml due to a communication error regarding pharmacy and physician verbal order. Interview with the Director of Nursing (DON) on 06/27/23 at 10:00 A.M. revealed that when the physician provided a new prescription to the pharmacy on 05/23/23 for Resident #16's Methadone, the concentration of the medication was changed. It had previously been 10 mg of medication to five ml of solution and was now 10 mg of medication to one ml of solution. However, this change was not made to the medication order or the medication administration record. The order to give 100 mg of Methadone remained the same. But due to the change in concentration of the medication, the resident would now receive 10 ml of the medication instead of 50 ml to equal 100 mg. During the interview, the DON revealed Licensed Practical Nurse (LPN) #101 did not change the concentration level of the Methadone on the physician's order or medication administration record and Registered Nurse (RN) #100 did not follow the physician's order for 100 milligrams of medication. She confirmed Resident #16 received 50 ml of medications (500 mg of Methadone) on 05/24/23 at 9:00 A.M. instead of 10 ml (100 mg of Methadone) as ordered. Interview with Physician #102 on 06/27/23 at 10:05 A.M. confirmed Resident #16 received 500 mg of Methadone instead of 100 mg as ordered on 05/24/23, due to a change in the concentration level of the medication provided by the pharmacy. Review of an employee disciplinary action report revealed Registered Nurse #100 received a written warning on 05/26/23 for failure to read and check order before administration of any medication resulting in medication error. Review of an employee disciplinary action report revealed Licensed Practical Nurse #101 received a written warning on 05/26/23 for not following through with medication order causing a medication error. Review of hospital records for Resident #16 revealed he was admitted to the hospital on 05/24/23 with a diagnosis of opioid overdose. Review of the emergency room report revealed a chief complaint of drug overdose. States resident normally takes 100 mg of Methadone liquid and the facility overdosed me. Patient was apneic (temporarily stops breathing) and had to be given Narcan. Unknown amount of Narcan and unknown dose of Methadone. Complaining of shortness of breath, diaphoretic. Presents with accidental and possibly iatrogenic opioid overdose. The resident does remember receiving his Methadone at around 9:15 A.M. this morning but was unsure what dose it was. IV fluids were initially administered for tachycardia (elevated heart rate). He required an additional dose of Narcan in the emergency department after recurrent respiratory insufficiency and increased oxygen requirement, 0.2 mg was administered with very appropriate increase in alertness and respiratory drive. Narcan drip ordered. The resident was admitted to the hospital for further treatment. Review of the hospital discharge summary for 06/02/23 revealed addiction medicine restarted his Methadone on 05/26/23 with similar somnolent results and a Narcan infusion was restarted. Overnight he became agitated, requiring the use of restraints. Was restarted on Methadone 20 mg twice daily on 05/31/23. Resident #16 returned to the facility on [DATE]. Review of the facility policy dated 2001 and revised December 2012 titled Administering Medications revealed medications must be administered in accordance with the orders. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Interview with Pharmacist #103 on 06/28/23 at 9:30 A.M. revealed there is no maximum dose of Methadone. He stated he would definitely question a dose of 500 mg as that was an outrageous dose which would cause overdose symptoms, if not death. He stated Methadone dosages were titrated upward based on the person's tolerance. Interview with Resident #16 on 06/28/23 at 1:25 P.M. revealed on 05/24/23 he had received his medications (including Methadone) between 9:00-9:30 A.M. He was then found slumped over in his room. He stated he did not remember anything until after he was in the hospital. He stated he was there 11 days. He stated there had been no further issues with his medications. He stated that the vision in his right eye became blurry while in the hospital, after the overdose, and has remained blurry since. The deficient practice was corrected on 05/26/23 when the facility implemented the following corrective actions: On 05/24/23 Resident #16 was sent to the hospital for evaluation and treatment. He returned to the facility on [DATE]. On 05/24/23 the Administrator, Director of Nursing, and Physician had a quality assurance meeting to investigate and discuss medication error for Resident #16. A root cause analysis determined a verbal physician's order for change in concentration level was not carried out by LPN #101 and verification of medication prior to administration was not completed by RN #100. A whole house audit was completed on 05/24/23 to ensure no other medication errors (none noted). Both nurses (RN #100 and LPN #101) were disciplined and educated on 05/26/23. All nursing staff were educated on Medication Administration on 05/26/23. Weekly audits of medication administration by the Director of Nursing occurred following the incident through 06/26/23 with no errors noted. Daily audits by Administrator for any medication errors or issues with medications occurred following the incident through 06/24/23 with no issues noted. This deficiency represents non-compliance investigated under Complaint Number OH00143386, and OH00143892.

Based on medical record review, resident and staff interviews, review of hospital records, and review of facility policy, the facility failed to ensure Resident #68 was properly secured in her wheelchair in the facility's transport van to prevent a fall and failed to contact Emergency Medical Services (EMS) timely upon request from the resident's representative following the incident. Actual Harm occurred on 05/03/23 when Resident #68's wheelchair tipped backwards during transport and the resident hit her head on the transport van's floor. Resident #68's husband (Resident #67) called 911 to have Resident #68 transported to the hospital for an evaluation where the resident was diagnosed with a three millimeter (mm) subdural hemorrhage (brain bleed between the brain and skull), a small right parietal subgaleal hematoma (bleeding between the skull and scalp), and remote right rib fractures. Resident #68 was admitted to the hospital for three days for treatment and monitoring before being discharged back to the facility. This affected one resident (#68) of three residents reviewed for accidents during transportation. Findings include: Review of the medical record for Resident #68 revealed an admitted [DATE]. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II Diabetes Mellitus, cirrhosis of liver with ascites, congestive heart failure (CHF), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and peripheral vascular disease (PVD). Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #68 required limited assistance from one staff member to complete Activities of Daily Living (ADLs). Further review revealed the resident utilized a wheelchair. On 05/03/23 at 10:52 A.M., an Interdisciplinary Team (IDT) note revealed Resident #68 was being transferred from an appointment back to the facility. While being transported, as the van picked up speed, Resident #68's wheelchair tipped backwards. Resident #68 stated she hit her head and left shoulder when she fell . The driver and the resident's husband assisted Resident #68 back up and the driver brought the resident back to the facility to be examined by the nurse. Nuerochecks were started and Resident #68 complained of pain rated an eight on a scale of one to 10. The resident was offered medication for pain. X-rays were ordered but were not completed due to Resident #68 agreeing to be sent to the hospital. Interventions included Resident #68 was helped back into her wheelchair, the straps in the wheelchair were assessed, and the driver was educated. On 05/03/23 at 12:58 P.M., Resident #68 reported while being transported in the facility's van, her wheelchair tipped over and she hit her head and left shoulder. Vital signs were obtained and within normal limits. No injuries were noted. Pain was reported at an eight out of ten with ten being the worst pain level. Medications were administered to treat the resident's pain. The Certified Nurse Practitioner (CNP) was notified who stated to continue to monitor. On 05/03/23 at 1:57 P.M., a change of condition note revealed Resident #68's vitals documented were dated 04/24/23, except for the resident's weight and blood glucose levels. The resident's pain level was not indicated. The nursing observations, evaluation, and recommendations included: patient had a fall while being transported from an outside appointment. Resident #68 did not want to go to the hospital however, the resident's husband was adamant. There was no indication the facility called EMS to transport Resident #68 to the hospital when Resident #68 agreed to be transported to the hospital or when the resident's husband requested the resident be transported to the hospital. Review of Resident #68's physician orders for May 2023 revealed an order dated 05/03/23 at 2:15 P.M. to send the patient to the emergency room (ER) for treatment and evaluation one time only for fall. Review of the Pain assessment dated [DATE] revealed Resident #68 reported frequent pain at a level of eight out of ten on a scale where ten is the worst pain level. Resident #68 had vocal complaints of pain as well noted. The assessment did not clarify where the pain was located. Review of the hospital records dated 05/03/23 revealed Resident #68 was admitted to the hospital at 2:30 P.M. The resident presented to the emergency department after a fall backwards from wheelchair. Resident #68 complained of posterior head, neck, and mid back pain. A chest x-ray revealed remote right rib fractures, no acute displaced fracture was noted. A non-contrast Computed Tomography (CT) scan of the head revealed a small, three millimeter (mm) subdural hemorrhage (brain bleed between the brain and the skull) and a small right parietal subgaleal hematoma (bleeding between the skull and scalp). Resident #68 was transferred to another local hospital to be monitored and treated by neurosurgery. Resident #68 was admitted to the hospital from 05/03/23 to 05/06/23 (three days). Interview on 05/10/23 at 10:30 A.M. with Resident #68 and the resident's husband (Resident #67) confirmed Resident #68 was in the hospital for three days from 05/03/23 to 05/06/23 due to a brain bleed. Resident #68 stated she was on the facility's transport van returning from an outside appointment when her wheelchair tipped backwards, and she hit her head very hard on the van floor. Resident #68 reported she requested the driver call an ambulance to transport her to the hospital, but the driver did not comply. The driver moved Resident #68 back into her wheelchair (she reported she had slid up in the chair and her bottom was resting on the back rest after the chair tipped), proceeded to pick up another resident (Resident #31) from another appointment, and then returned to the facility. Resident #68 stated the facility staff did not examine the back of her head where she hit the floor for any injuries. Upon arriving to the facility, Resident #67 stated he requested x-rays be ordered and Resident #68 be transported to the hospital to be evaluated due to hitting her head. Resident #67 stated the facility staff would not call 911 to have Resident #68 transported so he called 911 himself from his cell phone while standing at the nurse's station. Resident #67 reported Licensed Practical Nurse (LPN) #205 and LPN #207 were both standing at the nurse's station when the call was made. Resident #67 pushed Resident #68 in her wheelchair to the elevator that took them to the first floor where they waited for the ambulance to arrive to take Resident #68 to the hospital. Interview on 05/10/23 at 1:35 P.M. with Licensed Practical Nurse (LPN) #205 revealed she was one of the nurses who cared for Resident #68 on 05/03/23. LPN #205 stated Resident #68 informed her upon arriving on the floor from the elevator that her wheelchair had tipped in the transport van, and she hit her head and left shoulder. LPN #205 stated she completed nuerochecks with no negative findings. The resident's husband (Resident #67) requested Resident #68 be transferred to the hospital and an order was obtained from the CNP, but the LPN stated Resident #68 refused to go to the hospital at that time. LPN #205 stated she assessed Resident #68, including her head, and did not find any injuries. LPN #205 stated Resident #68 complained of pain to her head, neck, and left shoulder. LPN #205 stated EMS did not come to the facility to transport Resident #68 to the hospital, the resident's husband (Resident #67) pushed her in her wheelchair across the street to the local hospital. LPN #205 confirmed she did not call 911 to have Resident #68 transported to the hospital. Interview on 05/10/23 at 2:18 P.M. with LPN #207 revealed she was the other nurse who cared for Resident #68 on 05/03/23. LPN #207 stated LPN #205 notified her Resident #68 had a fall in the facility's transport van and hit her head and shoulder. LPN #207 stated LPN #205 notified the CNP and offered to send Resident #68 to the hospital, but stated the resident had refused at that time. However, the resident's husband (Resident #67) was adamant Resident #68 needed to go to the hospital. X-rays were ordered but when the x-ray tech arrived, about an hour or two later, Resident #67 had called 911 to have Resident #68 transported to the hospital. Residents #67 and #68 went to the first floor but LPN #207 was not sure if EMS arrived to transport Resident #68 because she (LPN #207) remained on the second floor. LPN #207 confirmed she did not call 911 to have Resident #68 transported to the hospital. Interview on 05/10/23 at 3:47 P.M. with Transport Staff #200 revealed he was the driver who transported Resident #68 and her husband (Resident #67) on 05/03/23. Transport Staff #200 confirmed after picking the residents up from their appointment and enroute to pick up Resident #31, Resident #68's wheelchair tipped backwards, and Resident #68 hit her head. Transport Staff #200 revealed he did not properly strap Resident #68's wheelchair with four straps and only used three because he was rushing to pick up Resident #31. Transport Staff #200 stated, Had I properly done four straps, it would not have happened. Transport Staff #200 revealed Resident #68 requested he call an ambulance at the time of the incident to take her to the hospital but stated the resident's husband (Resident #67) said not to and to take Resident #68 back to the facility to be assessed. Transport Staff #200 confirmed he did not call EMS to have Resident #68 transported to the hospital as the resident had initially requested. Interview on 05/10/23 at 4:45 P.M. with the Administrator, LPN #205, and LPN #207 revealed per the Administrator (who spoke on behalf of the two nurses) the facility staff were not aware Resident #68's husband (Resident #67) had called 911 until after Resident #68 had been admitted to the hospital and Resident #67 returned to the facility to pick up some belongings and return to the hospital to stay with Resident #68. Review of the care plan, revised on 05/11/23, revealed Resident #68 had pain related to complaints of left shoulder pain and recent subdural hematoma. Interventions included administering medications as ordered, monitor for signs and symptoms of pain, and notify the physician of any significant changes or if interventions were unsuccessful. A facility policy related to transportation was requested during the entrance conference on 05/10/23 at 9:40 A.M. but a policy was not provided. Review of the facility policy, Falls-Clinical Protocol, revised 09/2012, revealed the policy indicated staff, with the physician's guidance, would follow up on any fall with associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. The deficiency represents non-compliance investigated under Complaint Number OH00142668.

Based on observation, closed medical record review, staff interview, family interview, United Health Care (UHC) transportation representative interviews, review of accuweahter.com information and review of the facility policy and procedures titled Discharge Summary and Plan and Discharge Medications, the facility failed to ensure a safe and orderly discharge for one resident (Resident #76), who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy, on 06/07/22 at approximately 5:00 P.M. when the facility arranged for transportation for Resident #76 to be taken to another long-term care facility for long term care placement. Prior to the resident's pick-up, there was no written evidence facility staff had communicated the specific details of Resident #76's transfer, his care needs or medication status to the receiving facility. Information obtained from the receiving facility revealed on 06/07/22 at approximately 6:15 P.M. Housekeeping Supervisor (HS) #139, whose shift had ended and who was leaving the facility, found Resident #76 in the facility parking lot without any staff present and without identification or discharge paperwork. The resident was able to state his name and was taken into the facility. Resident #76 was found to have 20 to 30 Suboxene strip medications (opioid medication for sublingual administration), alcohol and illegal drug paraphernalia, including a burning spoon and torch on his person. The risk for actual harm, injury or death occurred as Resident #76 had the potential to wander from the premises without staff knowledge, the resident had access to the medication Suboxene, which could have been self-administered or due to the effects of being left outside with a weather temperature of 78 degrees with rain on that date. This affected one resident (#76) of three residents reviewed for transfer/discharge. On 06/27/22 at 5:02 P.M. Regional Director of Operations #165, Administrator #145 and Vice President of Clinical Operations #220 were notified Immediate Jeopardy began on 06/07/22 when the facility failed to provide a safe and orderly discharge to another skilled nursing facility for Resident #76, who was transferred and left in the parking lot of the receiving skilled nursing facility with no evidence the resident's discharge and care needs/medication status were communicated by the discharging facility to the receiving facility. The Immediate Jeopardy was removed on 06/29/22 when the facility implemented the following corrective actions: · On 6/27/22 at 6:45 P.M. Vice President of Clinical Operations (VPCO) #220 in-serviced all department heads, including Director of Nursing (DON) #150, Receptionist #346, Dietary Director #336, Unit Managers #329, #344 and #362 Admissions Director #334, Administrator #145, Maintenance Director #323, Staff Scheduler #375, Social Service Director #160, Human Resource Director #310, Activity Director #348 and Housekeeping Supervisor #337 on the requirements for a safe and orderly resident discharge, including discharge medications, the Discharge Summary and Plan policy and also on the need to ensure when a resident was picked up by transport, the receiving facility was to be notified so they knew when to expect the resident. · On 06/27/22 at 6:45 P.M. Admissions Director #334 reviewed all resident discharges from 06/08/22 to 06/27/22 to ensure safe and orderly discharge was completed. No concerns were identified by the facility. Resident #61 was identified as the only resident discharged during this time period. · On 06/27/22 at 6:51 P.M. Regional Clinical Consultant #460 reviewed resident records related to discharges to ensure the discharges were safe and orderly. Residents #3, #50, #52, #59, #61, #64, #67 and #72 were reviewed with no concerns identified by the facility. · On 6/28/22 at 10:00 A.M., Social Service #485, Regional Director of Operations #165 and Regional Director of Business Development #210 provided additional in-service training to all department heads on the requirements for a safe and orderly discharge, including discharge medications, the Discharge Summary and Plan policy and on the need to ensure that when resident was picked up by transport, the receiving facility was notified so they know when to expect the resident. · On 06/28/22 by 10:05 A.M. the facility Interdisciplinary Team (IDT), including DON #150, Receptionist #346, Dietary Director #336, Unit Managers #329, #344 and #362 Admissions Director #334, Administrator #145, Maintenance Director #323, Staff Scheduler #375, Social Service Director #160, Human Resource Director #310, Activity Director #348, Housekeeping Supervisor #337 and Medical Director #450 reviewed the records of eight residents (Resident #3, #50, #52, #59, #61, #64, #67, and #72) who had been discharged or were pending discharges (as of this date) to ensure discharge planning and paperwork was complete/up to date to ensure a safe and proper discharge occurred for each resident. · On 06/28/22 by 10:30 A.M. Vice President of Clinical Operations #220 and Department Heads (DON #150, Receptionist #346, Dietary Director #336, Unit Managers #329, #344 and #362 Admissions Director #334, Administrator #145, Maintenance Director #323, Staff Scheduler #375, Social Service Director #160, Human Resource Director #310, Activity Director #348 and Housekeeping Supervisor #337) in serviced all nursing staff on safe and orderly discharges, including discharge medications, discharge summary, report to receiving facility/location and also on need to ensure that when resident was picked up by transport, the receiving facility was notified so they knew when to expect the resident. The training included three registered nurses (RNs), 23 licensed practical nurses (LPNs) and 38 state tested nursing assistants (STNAs) and was done either one on one, verbally in group or via telephone. As of 06/28/22 all nursing staff had been educated. · On 06/28/22 by 12:00 P.M. Regional Clinical Consultant #460 contacted the transport company used to transport Resident #76 on 06/07/22, regarding the procedure for transporting a resident from the facility. The facility requested all transportation from this company now include a safe handoff to the receiving location, and that if that cannot be accomplished for some reason, to immediately contact the transferring facility. · Beginning on 06/28/22 the facility implemented a plan for Administrator #145, DON #150, Regional Director of Operations #165, or Vice President of Clinical Operations #220 to review all discharges for the next 30 days prior to the resident leaving the facility to ensure discharge planning was completed, and the receiving location was aware and expecting the resident. Findings will be reported to the QAPI Committee (RDO #165, VPCO #220, Social Service #485, RCC #465, Regional Director of Business Development #210, DON #150, UM #329 and #362, MD #450, Vice Present of Operations #500, Director of Rehabilitation #510 and Admissions #334). If any concerns are identified during the 30 days, the review will continue for a longer period of time. · On 06/28/22, an ad HOC QAPI meeting was held with the Medical Director #450 and above QAPI committee members to discuss the issue and the above plan. · On 06/29/22 VPCO #220 provided a newly created document tool for staff to enter information regarding resident transfers including the name/date/time of staff contacted (at the receiving facility), the date/time the resident left the facility and any pertinent communication regarding the specifics of the transfer. The document will be reviewed daily by DON #150 and/or designee and will become part of the resident's permanent electronic medical record. · On 06/29/22 from 11:45 A.M. to 12:08 P.M. interviews with Licensed Practical Nurse (LPN) #306, #313, #362 and State Test Nursing Assistant (STNA) #322 and #361 revealed the staff interviewed had been educated and were knowledgeable on the newly implemented facility discharge procedures. Although the Immediate Jeopardy was removed on 06/29/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings Include: Review of Resident #76's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] to a sister skilled nursing facility. Resident #76 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #76 resided on the secured/locked unit of the facility. Record review revealed the resident was admitted for long term care placement. Review of the resident's plan of care revealed no discharge plan of care had been developed for the resident. Review of the resident's physician medication orders revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 05/30/22 revealed Resident #76 had clear speech, usually understood others, usually made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12 (out of 15). The assessment indicated the resident had not displayed any behaviors during the review period and required staff supervision for bed mobility, transfers and ambulation. Review of the plan of care, dated 06/03/22 revealed the resident resided on a secure unit related to exit seeking behaviors, dementia and poor decision-making skills. Interventions included encourage to attend activities of interest, monitor for exit seeking behavior and document occurrences, provide activities of interest and secure unit as physician ordered. Review of the plan of care, dated 06/03/22 revealed the resident had impaired cognitive function/dementia or impaired thought process related to difficulty making decisions and head injury. Interventions included administer medications as ordered and observe for side effects and effectiveness, use the resident's preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact and reduce any distractions. The plan of care revealed the resident understands consistent, simple directive sentences and to monitor/document/report any changes in cognitive function. Review of a progress note dated 06/01/22 at 7:10 P.M. revealed Resident #76 went out of the building and per staff the resident was found in Franklin Park (approximately one block away) without injury. The note revealed the Director of Nursing (DON), Administrator and physician were made aware. A facility investigation of the incident documented a staff member was present with the resident during the time he was out of the facility and at the park on this date. Review of a progress note dated 06/06/22 at 4:15 P.M. revealed Resident #76 was found spray painting his bedroom floor. The note indicated spray paint and a bottle of alcohol was confiscated from the resident at that time. The resident was educated on the facility's policy regarding alcohol and the resident voiced understanding. A facility investigation revealed the facility believed the spray paint and alcohol were brought into the resident from a visitor. Review of the progress note dated 06/07/22 at 2:25 P.M. and authored by Administrator #145 revealed she spoke with Resident #76's father and informed him the resident would be transferring to another skilled nursing facility within the company today (06/07/22) due to behaviors. The entry documented the resident's father was agreeable to transfer. Review of a progress note dated 06/07/22 at 5:59 P.M. and authored by Agency Nurse #205 revealed Resident #76 was discharged to another facility. The note failed to contain any additional information regarding the discharge/transfer. There was no documentation related to the actual time the resident left the facility, no documentation of communication to the receiving facility, no documentation related to transportation and no documentation of what information/belongings were transferred with the resident. Review of a late entry progress note, dated 06/09/22 at 3:00 P.M. (effective for 06/07/22 at 8:56 P.M.) and authored by DON #150 revealed the patient's medications were taken to the receiving facility this evening, report was given to accepting nurse. Review of Resident #76's physician's orders revealed no order to transfer/discharge the resident was obtained prior the resident's discharge. Review of a document titled Discharge Plan of Care and Recapitulation, dated 06/07/22 at 12:56 P.M. and authored by Social Service Director (SSD) #160 revealed under the nursing services section was a handwritten entry, personally took medications from facility to facility 06/07/22. The section was signed by DON #150. Further review revealed the document was incomplete of the recapitulation of the resident's stay at the facility. On 06/27/22 at 9:38 A.M. interview with Administrator #145 revealed Resident #76 resided on the facility secured care unit (due to cognitive impairment and behaviors). The Administrator verified the resident had walked off from the facility on 06/01/22 and the decision was made, following that incident, to discharge/transfer the resident to a sister facility that was more secure. On 06/27/22 at 10:55 A.M. interview Administrator #145 revealed SSD #160 had spoken with the unit manager (UM) and Former Administrator (FA) #140 of the receiving facility to inform them Resident #76 was being transferred to their facility. Administrator #145 indicated the communication was done verbally and denied having any written documentation of the specific details of the transfer or communication that occurred. On 06/27/22 at 11:24 A.M. interview with Regional Director of Operations (RDO) #165 revealed on 06/07/22 he called Former Administrator #140 (of the receiving facility) and verbally informed him Resident #76 was being transferred to the facility but did not have an estimated time of arrival. RDO #165 revealed Former Administrator #140 later contacted him, alerting him the resident was dropped off in the parking lot and had home medications including Suboxene strips and drug paraphernalia on his person. RDO #165 revealed they used the resident's insurance company transportation service and to his knowledge the company provided medically trained staff for transportation. On 06/27/22 at 1:17 P.M. interview with UHC Transportation Representative #200 (a representative from the resident's insurance company) revealed Resident #76 was transported from the facility on 06/07/22 by their contracted transportation company. The representative revealed the resident's pick-up time was scheduled for 5:00 P.M. and indicated the driver would have called the facility approximately 15 minutes within the actual scheduled pick-up time to confirm the pick-up, but denied the driver was required to call the facility the resident was being dropped off to (as they provided non-emergency medical transportation). The representative revealed unless specifically indicated or if the facility had reported the resident was cognitively impaired when transportation was booked, the resident would simply be dropped off and the transportation company would not provide door to door or hand to hand assistance during transport. The representative revealed there would be no way for the transportation driver to walk the resident to the door or alert the receiving facility the resident was there. The driver would go by any notes entered at the time of the booking. No specific notes of the booking were provided during the call. However, the representative revealed she had no indication Resident #76 needed anything more than dropped off. On 06/27/22 at 3:12 P.M. telephone interview with Resident #76's father revealed he was agreeable with the resident's transfer as he felt the new facility would be more secure and prevent the resident from leaving without staff knowledge. However, the resident's father revealed he was unaware of when his son was actually going to be moved to the new facility as this had not been communicated to him. On 06/28/22 at 12:45 P.M., interview with DON #150 verified on 06/07/22 a discharge summary had not been sent with Resident #76 to the receiving facility nor was there any evidence of report being called or the specifics of Resident #76's transfer being completed/documented prior to or at the time of discharge. DON #150 revealed she personally transported the resident's prescription medications, at approximately 9:00 P.M. that evening to the receiving facility as written on the resident's discharge summary. She said at that time she also provided the receiving facility with a copy of the discharge summary, the resident's history and physical and physician's orders. On 06/28/22 at 1:28 P.M. interview with Agency Nurse #205 revealed she was on duty on 06/07/22 and participated in discharging Resident #76 to the receiving facility. She indicated the resident was sent with his belongings and she had been told by Administrator #145 all required paperwork had been faxed to the receiving facility. Agency Nurse #205 revealed she had been notified on 06/07/22 about an hour or two before the resident left the facility of the transfer and indicated multiple staff members and the resident were packing the resident's belongings. Agency Nurse #205 revealed the resident had a lot of belongings and staff did not go through all of the belongings. Review of accuweather.com information revealed on 06/07/22 a weather temperature of 78 degrees with rain on that date. On 06/29/22 at 9:05 A.M. telephone interview with Representative #460 from the UHC contracted transportation company verified Resident #76 was transported by their company on 06/07/22 from the facility to another long-term care facility. Representative #460 revealed Resident #76 was picked up at the facility by a Dodge Grand Caravan at 4:29 P.M. and dropped off at the receiving facility at 5:41 P.M. Representative #460 revealed the transportation company provided non-emergency medical transport and the drivers had no formal medical training. Representative #460 revealed the company does not alert the receiving facility of the member being dropped off, especially if they were ambulatory because they just provide transportation. Representative #460 revealed the driver who transported Resident #76 was no longer employed by the company (last date worked 06/15/22), the representative did not provide a reason for the driver no longer being employed. Review of the facility policy titled, Discharge Summary and Plan, dated 12/2016 revealed when a resident discharge was anticipated, a discharge summary and post-discharge plan would be developed to assist the resident to adjust to his/her new living environment. The discharge summary would include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's current diagnoses, medical history, course of illness, treatment and/or therapy since entering the facility, current laboratory, radiology, consultation and diagnostic test results, physical and mental functional status, sensory and physical impairments, nutritional status and requirements, special treatments and procedures, mental and psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status and medication therapy. A copy of an evaluation of the resident's discharge needs, post discharge plan and the discharge summary would be provided to the resident and receiving facility. Review of the facility policy titled, Discharge Medication, dated 12/2016 revealed unless otherwise specified by facility policy, or contrary to current law or regulations, medications shall be sent with the resident upon discharge. Controlled substances may not be released to the resident upon discharge. Prior to the above onsite investigation, on 06/24/22 an onsite complaint investigation was conducted at the receiving facility, Country Lane Gardens Rehab and Nursing Center in regards to the status and admission of Resident #76 on 06/07/22. The following information was obtained on 06/24/22: On 06/24/22 at 9:10 A.M. interview with the receiving facility's Director of Nursing (DON), DON #157 revealed on 06/07/22 the facility received an admission (identified to be Resident #76) from the above/discharging facility. DON #157 revealed the discharging facility, [NAME] Terrace Rehabilitation and Nursing Center arranged for the resident's transportation and had the resident dropped off. DON #157 revealed Resident #76 was found in the facility parking lot (time not provided) with no communication to them of the transfer or the resident's care or medication needs. She said Resident #76 was subsequently admitted to the facility secure care unit on the second floor due to cognitive impairment and exit seeking behaviors. On 06/24/22 at 9:27 A.M. interview with receiving Unit Manager (UM) #128 (the UM of the secure care unit) revealed Former Administrator #140 notified her Housekeeping Supervisor (HS) #139 found Resident #76 outside the facility when she was leaving her shift. UM #128 revealed whoever transported the resident just unloaded him and left. UM #128 revealed the facility was aware the resident was going to be admitted but were not aware of the actual date/time of when the resident was coming or of any actual transportation arrangements being made. During the interview, UM #128 revealed the resident had a spoon that had been bent and a torch (used for illegal drug use) and Suboxene medications in his belongings when they went through them after his arrival. UM #128 revealed the resident was very confused and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/24/22 at 10:33 A.M. a call was placed to [NAME] Terrace Rehabilitation and Nursing Center to obtain additional information regarding the transfer of Resident #76. The discharging facility's DON, DON #150 verified Resident #76 had been transferred but stated she was unaware of any details related to the transfer. DON #150 revealed Administrator #145 and SSD #160 made all arrangements for the discharge. She said SSD #160 arranged for transportation for Resident #76. DON #150 revealed she transported the resident's medications to the receiving facility after she left work on 06/07/22 (time not provided). DON #150 revealed at that time, she had been notified (by staff at the receiving facility), Resident #76 had medications (Suboxene) on his person when he arrived. DON #150 verified medications were not to be given to confused residents and that was why she transported the resident's (facility prescribed) medications to the receiving facility. DON #150 revealed she had also been notified, at that time that Resident #76 had been left in the parking lot by the transportation service and in addition to the medication, he had drug paraphernalia. On 06/24/22 at 10:48 A.M. interview with Licensed Practical Nurse (LPN) #144, who was employed by the receiving facility revealed she came to work on 06/07/22 at approximately 7:00 P.M. LPN #144 revealed at approximately 6:15 P.M. that day, Resident #76 was found outside the facility, standing with bags and boxes of his belongings. The LPN revealed HS #139 had brought the resident in the facility because the resident told her he was supposed to live at the facility. LPN #144 revealed the discharging facility just did a drive by and dropped him off. The LPN revealed the resident had 20 to 30 Suboxene strips, a torch, burning spoon and marijuana with tobacco mixed in it found in his personal belongings. The LPN said Resident #76 had no discharge instructions or identification. LPN #144 revealed she immediately contacted the Administrator (Former Administrator #140) and asked him to come to the facility (he had left for the day) to address the medications that were found with the resident. LPN #144 revealed DON #150 arrived at the facility later that night, around 11:00 P.M. with the resident's prescription medications. On 06/24/22 at 11:09 A.M. interview with the [NAME] Terrace Rehabilitation and Nursing Center Administrator, Administrator #145 revealed on 06/07/22 Resident #76 was discharged from the facility and transported by United Health Care (UHC) transportation service to Country Lane Gardens Rehab and Nursing Center. Administrator #145 denied knowledge the resident was dropped off in the parking lot or of the receiving facility being unaware of his arrival. Administrator #145 denied knowledge of the resident being transferred with Suboxene or illegal drugs/paraphernalia on his person. Administrator #145 revealed Social Service Director (SSD) #160 had been in communication with the receiving facility. Resident #76 was being transferred from the facility due to extensive behaviors and finding spray paint and alcohol in his room during room sweeps. On 06/24/22 at 11:38 A.M. interview with the receiving facility's Admission Coordinator, (AC) #101 revealed on 06/07/22 at 10:12 A.M. she received an email correspondence from the discharging facility indicating Resident #76 was pending authorization for transfer. AC #101 revealed she received a second email from corporate office approving the transfer pending the insurance authorization. AC #101 revealed there was never a specific date or time for the resident's transfer received from the discharging facility. On 06/24/22 at 12:09 P.M. interview with Housekeeping Supervisor (HS) #139 revealed on 06/07/22 after 6:00 P.M. at the end of her shift when she was leaving the facility, she noticed a man standing at the edge of the parking lot with his belongings. HS #139 revealed she was being picked up by her husband and her husband reported to her a (personal type) vehicle had pulled up, got the man and his stuff out of it and then drove off. HS #139 revealed her husband reported no one, neither the transportation driver or man himself, went to the door or into the facility. HS #139 revealed the man (later identified to be Resident #76) did not have any identification on him and she immediately contacted AC #101 and Former Administrator #140. HS #139 revealed she saw medications in the resident's belongings but did not know what they were. On 06/24/22 at 12:29 P.M. interview with discharging facility SSD #160 revealed he contacted Resident #76's insurance company on 06/07/22 at approximately 3:30 P.M. and then set up transportation to the receiving facility. SSD #160 revealed he spoke with a unit manager (UM) regarding a transfer for Resident #76, but could not recall the name of the UM he spoke to. SSD #160 revealed transportation was arranged through the resident's insurance and he assumed the transportation company would make sure the resident got to where he needed to go. SSD #160 revealed the DON took the resident's prescription medications to the receiving facility later that day (06/07/22). On 06/24/22 at 1:45 P.M. Resident #76 was observed sitting in a lounge area on the secured unit. An attempt to interview the resident was unsuccessful as the resident was focused on obtaining a cigarette to smoke and unable to be redirected to answer interview questions. On 06/24/22 at 2:22 P.M. interview with receiving facility Former Administrator (FA) #140 revealed he was driving home from work on 06/07/22 when the housekeeping supervisor called him and asked him if he knew about the guy standing in the parking lot with his boxes. FA #140 revealed he immediately thought of a referral from a sister facility that had been talked about but stated nothing had been confirmed and no date or time of transfer had been set-up. FA #140 revealed he then contacted Regional Director of Operations (RDO) #165 and Vice President of Clinical Operations (VPCO) #220 to inquire why the resident was left in the facility's parking lot. FA #140 again voiced, the transfer had been approved but no date or time of transfer had been arranged. FA #140 revealed LPN #144 then called him with concerns of the resident having Suboxene and drug paraphernalia found in his personal belongings. FA #140 revealed he returned to the facility and did take photographs of the items found in Resident #76's possession. On 06/29/22 at 8:52 A.M. observation of the pictures taken by FA #140 of the items found on Resident #76 on 06/07/22 revealed they included a baggie of marijuana, a medication planner with Suboxene strips, a torch (commonly used to heat/dissolve illegal substances), a bottle of Chloroseptic spray, an unlabeled pill bottle with a bent spoon in it with half of white pill on the spoon and a bottle of mouthwash. This deficiency substantiates Complaint Number OH 684.

Based on record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized behavioral health program, including the administration of the psychoactive medication, [MEDICATION(S)] for Resident #16, who had mental health diagnoses, to ensure the resident maintained his highest practicable physical, mental, emotional and psychosocial well-being. Actual Harm occurred on 02/11/22 when Resident #16, who had not received his scheduled [MEDICATION(S)] for multiple days was transferred and admitted to the hospital for increased agitation and self harm (banging head). The resident was hospitalized for five days. This affected one resident (#16) of two residents sampled for behavior health medications. The facility identified two residents who had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE]. Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The order was written for one 100 mg tablet, one 200 mg tablet and one 25 mg tablet to total the 325 mg ordered dose). Review of the plan of care, dated 01/08/22 revealed Resident #16 used [CONDITION(S)] medications related to [CONDITION(S)] disorder. The goal was for the resident to have improved mood state. Interventions include to administer [CONDITION(S)] medications as ordered by the physician and monitor for side effects and effectiveness. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 25 mg was marked unavailable on 01/3/22 through 01/18/22, 01/20/22 through 01/23/22 and 01/29/22. [MEDICATION(S)] 100 mg was marked unavailable on 01/13/22, 01/14/22, 01/17/22, 01/18,22, 01/20/22 through 01/22/22 and 01/29/22. Review of the MAR for February 2022 revealed [MEDICATION(S)] 200 mg was marked as unavailable on 02/04/21, 02/05/22, 02/06/22 and 02/07/22, administered on 02/08/22, marked unavailable on 02/09/22. [MEDICATION(S)] 100 mg was marked unavailable on 02/04/22 through 02/10/22, marked administered on 02/08/22. Review of the facility documentation revealed Resident #16 was hospitalized from 02/11/22 through 02/15/22. Review of the local hospital emergency notes revealed Resident #16 was admitted for agitation, banging head and threatening facility staff. The notes further revealed reported medication non-compliance. Review of the MAR for March 2022 revealed [MEDICATION(S)] 100 mg was marked unavailable from 03/01/22 through 03/07/22 and on 03/10/22. [MEDICATION(S)] 50 mg was marked unavailable from 03/01/22 through 03/03/22 and 03/05/22 through 03/06/22. On 03/31/22 at 11:19 A.M. interview with Licensed Practical Nurse (LPN) #124 revealed sometimes medications did not get delivered from the pharmacy timely and residents had to wait two to three days before the medication could be administered. On 04/04/22 at 12:06 P.M. interview with Resident #16 revealed some confusion and memory impairment by the resident during the interview. However, Resident #16 did confirm the facility did not always have his medications in the past. The resident could not remember how long he had been on the [MEDICATION(S)] medication and reported he had increased anxiety, without the medication. On 04/04/22 at 1:55 P.M. interview with the Director of Nursing (DON) confirmed the MAR for Resident #16 revealed the [MEDICATION(S)] medication was administered inconsistently and this could have contributed to increased psychiatric symptoms exhibited by the resident. The DON further confirmed the [MEDICATION(S)] was not administered as ordered for the seven days leading up to Resident #16's psychiatric hospitalization in February 2022. In addition, review of the nursing progress notes revealed no evidence of comprehensive behavior monitoring, no notes related to the resident being transferred to the hospital or behaviors being exhibited leading to the hospitalization and no documentation related to the medication not being available, why it was not available or what staff did to attempt to obtain the medication. Review of facility policy titled Medication Administration, revised 12/2012 revealed medications should be administered in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This deficiency substantiates Complaint Number OH 399.

Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #16 was free from a significant medication error when the resident was not administered the psychoactive medication, [MEDICATION(S)] to treat his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual Harm occurred on 02/11/22 when Resident #16, who had not received his scheduled [MEDICATION(S)] for multiple days was transferred and admitted to the hospital for increased agitation and self harm (banging head). The resident was hospitalized for five days. This affected one resident (#16) of two residents sampled for behavior health medications. The facility identified two residents who had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE]. Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The order was written for one 100 mg tablet, one 200 mg tablet and one 25 mg tablet to total the 325 mg ordered dose). Review of the plan of care, dated 01/08/22 revealed Resident #16 used [CONDITION(S)] medications related to [CONDITION(S)] disorder. The goal was for the resident to have improved mood state. Interventions include to administer [CONDITION(S)] medications as ordered by the physician and monitor for side effects and effectiveness. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 25 mg was marked unavailable on 01/3/22 through 01/18/22, 01/20/22 through 01/23/22 and 01/29/22. [MEDICATION(S)] 100 mg was marked unavailable on 01/13/22, 01/14/22, 01/17/22, 01/18,22, 01/20/22 through 01/22/22 and 01/29/22. Review of the MAR for February 2022 revealed [MEDICATION(S)] 200 mg was marked as unavailable on 02/04/21, 02/05/22, 02/06/22 and 02/07/22, administered on 02/08/22, marked unavailable on 02/09/22. [MEDICATION(S)] 100 mg was marked unavailable on 02/04/22 through 02/10/22, marked administered on 02/08/22. Review of the facility documentation revealed Resident #16 was hospitalized from 02/11/22 through 02/15/22. Review of the local hospital emergency notes revealed Resident #16 was admitted for agitation, banging head and threatening facility staff. The notes further revealed reported medication non-compliance. Review of the MAR for March 2022 revealed [MEDICATION(S)] 100 mg was marked unavailable from 03/01/22 through 03/07/22 and on 03/10/22. [MEDICATION(S)] 50 mg was marked unavailable from 03/01/22 through 03/03/22 and 03/05/22 through 03/06/22. On 03/31/22 at 11:19 A.M. interview with Licensed Practical Nurse (LPN) #124 revealed sometimes medications did not get delivered from the pharmacy timely and residents had to wait two to three days before the medication could be administered. On 04/04/22 at 12:06 P.M. interview with Resident #16 revealed some confusion and memory impairment by the resident during the interview. However, Resident #16 did confirm the facility did not always have his medications in the past. The resident could not remember how long he had been on the [MEDICATION(S)] medication and reported he had increased anxiety, without the medication. On 04/04/22 at 1:55 P.M. interview with the Director of Nursing (DON) confirmed the MAR for Resident #16 revealed the [MEDICATION(S)] medication was administered inconsistently and this could have contributed to increased psychiatric symptoms exhibited by the resident. The DON further confirmed the [MEDICATION(S)] was not administered as ordered for the seven days leading up to Resident #16's psychiatric hospitalization in February 2022. In addition, review of the nursing progress notes revealed no evidence of comprehensive behavior monitoring, no notes related to the resident being transferred to the hospital or behaviors being exhibited leading to the hospitalization and no documentation related to the medication not being available, why it was not available or what staff did to attempt to obtain the medication. Review of facility policy titled Medication Administration, revised 12/2012 revealed medications should be administered in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This deficiency substantiates Complaint Number OH 399.

Based on observation, interview, review of the facility policy and procedure for skin management, and record review the facility failed to implement a comprehensive and effective pressure ulcer prevention program to prevent and identify pressure ulcers in a timely manner. In addition, the facility failed to timely complete a pressure ulcer assessment upon discovery of a new pressure ulcer. This affected two residents (Resident #2 and #21) of two residents reviewed for pressure ulcers. The facility census was 58. Actual Harm occurred on 07/29/21 when Resident #21, who required extensive assist of two staff with bed mobility and transfers, was found to have two Stage IV pressure ulcers (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) pressure ulcers to the coccyx and right buttocks. Finding included: 1. Review of the medical record for Resident #21 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission/readmit screening form for Resident #21 dated 07/06/21 revealed the resident had a sacrum pressure ulcer Stage III, and interventions included for the resident to have an air mattress to his bed, Stage III sacral wound care, a peripherally inserted central catheter (PICC) line to his left upper extremity where he will receive intravenous antibiotics for this wound. Review of the nurses' notes dated 07/06/21 at 10:37 P.M. revealed Resident admitted to facility around 10:30 P.M. transported by local transport via cot with two attendants. Resident alert and oriented to person, place, time, and situation. Physician notified of admission. Denies pain at time of admission. Physician to send narcotic prescriptions to pharmacy. Stage III wound to sacral area upon admission. [CONDITION(S)] and 16 french Foley catheter. PICC line to left upper extremity. Call light within reach. Review of the pressure ulcer risk assessment dated [DATE] revealed a score of 13, indicating the resident at a moderate risk for the development of pressure ulcers. Review of the nutrition/dietary note dated 07/10/21 at 9:16 A.M. revealed Resident #21 had a Stage III sacral decubitus with [CONDITION(S)]. Supplements included, Ensure Active High Protein, 1 can daily which provided 16 grams of protein and 350 calories. Resident's energy/need includes 2225 calories/day, 85-90 grams of protein a day and 2200-2400 ml's of fluid a day. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/13/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating a moderately impaired cognition for daily decision making abilities. Resident #21 required extensive assistance from two staff members for bed mobility, and was totally dependent on two staff members for dressing, toilet use, personal hygiene, and bathing. Resident #21 was noted to have impairments to the bilateral upper and lower extremities. Resident #21 required the assistance of an indwelling catheter and ostomy for bowel and bladder elimination. Resident #21 was noted to have been admitted with one Stage III pressure ulcer and one Unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). Wound care included a pressure relieving device to the resident's bed, nutrition and hydration program, and pressure ulcer/injury care. Review of the plan of care dated 07/10/21 revealed Resident #21 had an increased need for protein, vitamins, and minerals related to [CONDITION(S)] and a sacral wound healing. Interventions include to administer vitamins, minerals, and liquid protein supplement as ordered, provide regular textured thin liquid diet with double entree portion. Review of the plan of care dated 07/12/21 and revised on 08/02/21 revealed Resident #21 has a Stage IV pressure ulcer to the sacrum. Interventions included to place an air mattress to promote wound healing, dietary consult as indicated, float heels in bed, reposition, treatments as ordered, weekly monitoring for measurements and wound bed assessment by nurse, and a wound doctor as indicated. Review of the plan of care dated 07/12/21 and revised on 07/27/21 revealed Resident #21 was on intravenous antibiotic related to [CONDITION(S)] of pressure ulcer of sacral region Stage III. Interventions included to monitor site for infection, infiltrate, issues, bleeding at site, and [CONDITION(S)]. Review of physician orders for July 2021, identified orders for: -Ensure active high protein 1 can daily for [CONDITION(S)], start on 07/07/21, and discontinue on 07/15/21 -Encourage turn and reposition as tolerated every day and night shift. Ordered on 07/07/21 -Multivitamin minerals tablet, one tablet daily for supplement, start on 07/07/21 -[MEDICATION(S)] (hcl) tablet 100 milligram (mg), daily for supplement, start on 07/07/21 -[MEDICATION(S)] tablet 220 mg, one tab daily for supplement start on 07/07/21 -[MEDICATION(S)] Tazobactam in [MEDICATION(S)] solution 4-0.5 gram (GM)/100 ml use 4.5 GM IV every 8 hours for [CONDITION(S)] start 07/07/21. -[MEDICATION(S)] tablet 20 mg, give one tablet 4 times a day for [CONDITION(S)] start on 07/07/21 stop on 07/31/21 -Cleanse sacral wound with normal saline, pat dry and apply a foam dressing every shift for wound care start 07/07/21 and discontinued on 07/22/21 --Encourage resident to float heels while in bed as tolerated every day and night shift, ordered on 07/08/21 -Cleanse sacral wound with normal saline, pat dry and apply mesalt and foam dressing every shift for wound care start 07/22/21 and end 07/29/21. -Cleanse sacral wound with normal saline, pat dry and apply mesalt and dry protective dressing daily for 10 days start 07/29/21 and end on 07/30/21 -Cleanse coccyx wound with normal saline, pat dry and apply mesalt and dry protective dressing. Apply once a day for 10 days. Started on 07/30/21. -Cleanse right buttocks wound with normal saline or wound cleanser, pat dry and apply mesalt and dry protective dressing apply once daily for 10 days. Start on 07/30/21 Review of Resident #21's treatment administration record (TAR) for July 2021 revealed ordered wound treatments were not completed on 07/09/21, 07/10/21, 07/12/21, 07/16/21, 07/20/21, 07/23/21, 07/27/21, during the day time shift. Ordered wound treatments were not completed on 07/16/21, 07/18/21, 07/19/21, 07/20/21, 07/21/21, 07/23/21, 07/24/21, 07/27/21, and 07/28/21 during the night time shift. Review of the skin observation tool dated 07/06/21 revealed Resident #21 had a sacrum pressure Stage III, had a [CONDITION(S)] and a Foley catheter and a PICC to the left upper extremity. Review of the skin observation tool completed on 07/13/21 and 07/25/21 revealed Resident #21 had no skin issues. Observation of Resident #21 on 07/29/21 at 2:30 P.M. with agency Registered Nurse (RN) #503 while completing a dressing change revealed RN #503 confirmed dressing change order which identified to cleanse the sacral wound with normal saline, pat dry, place Mesalt on the wound, then cover with a foam dressing. RN #503 was observed cleaning the resident's beside table and applying a barrier cloth to ensure a clean working station. RN #503 gathered all of the needed supplies for the dressing change. Upon removing the resident's incontinence brief it was revealed the resident had two pressure ulcers. One pressure ulcer on the coccyx and one pressure ulcer on the right buttocks. RN #503 proceed to notify the director of nursing (DON) of the observed pressure ulcers. The DON proceeded to contact the medical director right away. At the time of the observation, Resident #21 was complaining of discomfort from laying in his current position. RN #503 proceeded to cleanse both wounds, apply a padded dressing and ensure the resident was in a comfortable position until a new dressing treatment order could be obtained from the physician and the order could be put in place. Interview on 07/29/21 at 2:35 P.M. with RN #503 and the DON both staff confirmed they were not aware Resident #21 had two pressure ulcers. RN #503 revealed she is a nurse with an agency staff and had not completed a dressing change for this resident prior to today. The DON claimed she is new to the facility and is still unaware of all the wounds/pressure ulcers each resident had. The DON also confirmed Resident #21's orders only show a dressing change to be completed to a Stage III sacral wound, not two different pressure wounds which appeared to be more of a Stage IV. Review of the wound observation tool dated 07/29/21, revealed no assessments or observations completed until after wound care was observed with the surveyor on 07/29/21. The wound observation tool dated 07/29/21 revealed the resident had a coccyx wound pressure ulcer (Wound #1), Stage IV, which was noted to be improving. Noted was granulation tissue, and slough tissue present, 40% slough, 60% granulation, moderate amount of serous drainage. Measurements were 4 centimeters (cm) in length by 3.2 cm in width, by 0.4 cm in depth. Wound #2 was located on Resident #21's right buttock and was noted as a Stage IV; 20% slough tissue and 80% granulation tissue noted. There was noted to be a moderate amount of serous drainage. Measurements were 4 cm in length, by 3.6 cm in width, by 0.2 cm in depth. Interview with Resident #21 on 07/29/21 at 2:30 P.M., revealed the resident stated, My butt is hurting and they don't care. They don't change my dressing or anything. They say they will take care of it but they never come back. Review of facility policy titled Wound and Skin Care, (no date) noted that upon admission a skin care assessment will be completed. If a pressure area/ulcer area is noted, then the resident will be placed on a wound program and the area will be measured/traced weekly until the area is resolved or the resident discharges from the the facility. 2. Review of the medical record for Resident #2 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS 3.0 assessment completed on 07/17/21 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognition for daily decision making abilities. The resident required extensive assistance from two staff members for bed mobility and toilet use, and had total dependence on two staff member for transfers. Resident #2 was noted to have an indwelling catheter for bladder elimination and frequently incontinent of bowel elimination. Resident #2 was noted to have a Stage III pressure wound, which was present upon admission. Interventions for this pressure wound included a pressure reducing device for the bed and chair, nutrition and/or hydration program, application of ointments and/medication, and application of a non-surgical dressing. Review of Resident #2's physician treatment orders for August 2021 revealed: -Cleanse coccyx area with normal saline, pat dry and cover with foam dressing one time a day for wound care, start on 07/12/210 -Cleanse coccyx area with normal saline, pat dry and cover with foam dressing, daily start 07/12/21 discontinue (DC) on 07/11/21 -Encourage resident to float heels while in bed as tolerated every day and night shift -Encourage to turn and reposition Review of the plan of care for Resident #2 dated 07/14/21 revealed the resident had nutritional problem or potential nutritional problems related to impaired skin. Interventions included to provide diet and supplements as ordered. Review of the Braden Assessment (used for predicting pressure ulcer risk) for Resident #2 revealed a score of 12 indicating a high risk for pressure ulcers. Review of the hospital discharge note for Resident #2 dated 07/10/21 revealed the resident had a Stage III coccygeal wound. Review of the facility's skin observation and wound assessment form for Resident #2 revealed no assessment had been competed for this resident. Interview on 08/04/21 at 11:30 A.M. with the DON confirmed Resident #2 did not have a skin observation or wound assessment completed. This deficiency substantiates Complaint Number OH 465.

Based on staff interview, resident interview, observation, record review, and review of facility policy for Administering Medication, the facility failed to ensure residents were free from significant medication errors when physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition the facility failed to administer as needed sedative medication for a resident who was experiencing [CONDITION(S)] activity and also failed to ensure a resident received the correct binding medication. This affected three (Residents #10, #27, and #49) of the four residents reviewed for medication administration. The facility census was 58. Actual harm occurred when Resident #27 was admitted to the facility from the hospital on 11/09/20 with orders for a diuretic medication that was not correctly transcribed in the resident's medical record resulting in the resident not receiving the medication and requiring admission to the hospital for nine days for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE] and a re-entry date of 07/23/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/20/21, revealed the resident had impaired cognition. The resident required limited assistance with one-person assist for bed mobility, personal hygiene, and bathing. He required extensive assistance with one person for transfers and dressing, and extensive assistance with two-person for toileting. Review of Resident #27's plan of care dated 11/10/20 and revised on 02/17/21 revealed the resident had altered cardiovascular status related to atria fibrillation, hypertension, and [CONDITION(S)]. Interventions included to assess for shortness of breath, monitor pedal pulses, report any changes in lung sounds, [CONDITION(S)] and changes in weight. Review of Resident #27's hospital discharge notes dated 11/09/20 revealed discharge medication to include [MEDICATION(S)], [MEDICATION(S)] (a diuretic) 40 milligrams (mg) tablet, give daily for seven (7) days (from 10/27/20 to 11/03/20 while in the hospital) and then begin taking [MEDICATION(S)] 40 mg every other day. Review of Resident #27's physician medication order for November 2020 revealed to give the resident [MEDICATION(S)] 40 mg, one tablet every other day for 7 days for hypertension. No additional [MEDICATION(S)] orders were noted. There was no evidence the hospital discharge medication order of [MEDICATION(S)] 40 mg, one tab, every other day was carried over to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #27's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence the resident received any [MEDICATION(S)] after the 11/16/20 dose. Review of Resident #27's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's nurse's note dated 07/15/21 at 12:44 P.M. revealed the resident received new orders for [CONDITION(S)] that included [MEDICATION(S)] 20 mg twice daily, give at 9 A.M. and 2:00 P.M The note identified a basic metabolic panel (BMP) should be taken every Monday for four weeks. Record review revealed the resident was transferred to the hospital on 07/15/21 and admitted . The resident returned to the facility on [DATE]. Review of the hospital discharge summary list revealed the problem list included acute on chronic systolic heart failure and localized swelling of both lower legs. The discharge orders included [MEDICATION(S)] 40 mg tablet, one daily. Interview on 07/26/21 at 11:00 A.M. of family for Resident #27 revealed the resident was supposed to be on [MEDICATION(S)] the whole time he has been at the facility since his admission on 11/09/20. Resident #27's family claimed the resident's legs were swelling really bad and he ended up going to the hospital where they removed about 40 pounds of fluids from his body. When the resident returned to the facility he had an order in place to take [MEDICATION(S)] daily, but if he would have been getting it as ordered before he may not have needed to go to the hospital. Interview on 07/29/21 at 1:43 P.M. with the Director of Nursing (DON) confirmed the [MEDICATION(S)] order for Resident #27 was not transcribed correctly upon his admission to the facility on [DATE] and Resident #27 should have been on [MEDICATION(S)] 40 mg every other day since admission on 11/09/20. Review of the facility's policy titled Administering Medications, no date noted, revealed, Medications shall be administered in a safe and timely manner and as prescribed. 2. Review of the medical record for Resident #49 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 06/21/21, revealed the resident had intact cognition. The resident required supervision with set up assistance only for bed mobility. She required limited assistance with one person assist for transfers, dressing, eating, toileting, and personal hygiene. She required physical assistance with transfers with one person assist for bathing. Review of Resident #49's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 150 milligram (mg) tablet, give twice a day for seizures, -[MEDICATION(S)] 200 mg two tablets, three times a day for seizures, -[MEDICATION(S)] 2 mg/1 milliliter (ml) solution, inject 1 ml intramuscularly every 1 hours as needed for seizures. Review of Resident #49's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's nursing progress note dated 06/24/21 at 3:41 P.M. revealed, On this shift, this nurse was made aware of [CONDITION(S)] activity that was recorded starting at 12:55 (P.M.) and [MEDICATION(S)] for 2 minutes. Resident was on the floor for safety, turned on her side, she was placed in her bed with the call light in reach. As needed [MEDICATION(S)] was given by mouth for increased anxiety due to the [CONDITION(S)]. Review of Resident #49's nursing note for 07/08/21 at 4:38 P.M. revealed, Resident had a [CONDITION(S)] on this shift [MEDICATION(S)] for 5 minutes. No injuries noted at this time. Doctor notified. Review of Resident #49's physician notes from 06/22/21 through 07/29/21, revealed multiple reported episodes of the resident experiencing [CONDITION(S)] activity. Review of Resident#49's plan of care dated 06/15/21 revealed the resident has a [CONDITION(S)] disorder related to a previous stroke. Interventions included to provide [CONDITION(S)] medication as ordered by the doctor. Interview on 08/04/21 at 1:00 P.M. with Resident #49 revealed there had been many times she had not received her [CONDITION(S)] medication and she is known to have a lot of them. She also stated that she has an order to receive, as needed, intramuscularly (IM) [MEDICATION(S)] for any [CONDITION(S)] activity. The resident claimed she has had multiple [CONDITION(S)] while at the facility and has not received the as needed IM, [MEDICATION(S)] medication. Resident #49 also stated there are a lot of agency staffing working and if they can not locate the prescribed medication, then they will just mark it as refused or not available and refuse to get it out of the stock box. Resident #49 said one of the agency staff members did not give her the as needed IM [MEDICATION(S)] because the agency nurse said the resident didn't have any available. Observation on 08/04/21 at 12:00 P.M. of the facility's emergency medication stock box revealed the facility had four (4) bottles of [MEDICATION(S)] 2 mg/ml solution on hand to use as needed. Interview on 08/04/21 at 12:30 P.M. with the DON confirmed Resident #49 did not have any [MEDICATION(S)] 2 mg/ml solution for use but the facility did have this medication in the medication stock box for staff use if a resident should be out of a medication and need it. The DON confirmed Resident #49 did not receive her as needed [MEDICATION(S)] medication as per physician order. Review of the facility's policy titled Administering Medications, (no date), revealed, Medications shall be administered in a safe and timely manner and as prescribed. 3. Review of the medical record for Resident #10 revealed an initial admitted [DATE] and a re-entry date of 06/18/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's nursing notes dated 7/26/21 at 5:17 P.M. revealed Resident told this nurse that she was given the wrong medication. She was given another resident binder medication and a totally different dosage. She told that nurse it was the wrong medication. Doctor notified, no new orders just observe for any adverse reactions. Resident was educated to not take the medication the next time. Review of the facility incident log noted on 07/26/21, Resident #10 had received the incorrect medication The medication was noted to be in the same classification of medication but a different name and different dosage. A complete investigation was complete along with an assessment of the residents. Interview on 07/29/21 at 2:00 P.M. with the DON confirmed this medication error had been reported to the nurse the next day. No ill effects resulted from the error. The nurse who was on duty the night of the error was not able to be reached and was a agency nurse. This deficiency substantiates Complaint Number OH 278 and Complaint Number OH 214.

Based on observations, medical record review, review of the policy for Wandering Unsafe Residents, review of the facility investigation and staff interviews, the facility failed to provide adequate supervision to prevent one cognitively impaired resident (Resident #14) from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious injury when Resident #14, who was assessed as a moderate risk for wandering behaviors and early dementia, left the facility unknown to staff, out an unalarmed unlocked back door and was found in a neighboring State (Indiana), 18 hours later the following day. This affected one (#14) of three (#14, #30, and #06) residents reviewed for potential elopement. The facility identified 19 residents who were at risk for elopement. The facility census was 48. On 05/26/21 at 1:41 P.M., the Administrator, Director of Nursing (DON), and Vice President (VP) of Clinical Services were notified Immediate Jeopardy began on 05/17/21 at 10:51 P.M., when Resident #14, who was assessed as a moderate risk for wandering behaviors and early dementia, left the facility unknown to staff and was found in another State. Review of the facility security cameras revealed the resident exited the building through the unalarmed unlocked back door on 05/17/21 at 10:51 P.M. The facility was unaware Resident #14 was missing until staff from the neighboring state local hospital called the facility on 05/18/21 at 4:56 P.M. and spoke to Social Worker (SW) #301. The hospital staff member inquired about a resident who used a name that was familiar to the SW #301. It was determined through a physical description the resident was Resident #14. The Resident had used her sister's name. The facility was unaware Resident #14 was missing for 18 hours, until the hospital notified the facility. The Immediate Jeopardy was removed on 05/19/21 at 2:15 P.M., when the facility implemented the following corrective actions: · On 05/18/21 at 5:00 P.M., the Director of Nursing (DON) instructed all staff to complete a whole house head count and called all managers in the facility to assist with head count and began the investigation. · On 05/18/21 at 5:45 P.M., the DON confirmed all residents were accounted for except Resident #14. · On 05/18/21 at 6:00 P.M., the Administrator and disciplinary team reviewed the facility surveillance video. The video revealed the resident exited the back door on 05/17/21 at 10:51 P.M. At that time, an employee was placed at the unalarmed back door to watch for safety. · On 05/18/21 at 6:08 P.M. the DON notified the Medical Director of Resident #14 missing. · On 05/18/21 at 6:15 P.M., the resident's sister was contacted and informed of the resident's elopement. · On 05/18/21 at 6:15 P.M., maintenance staff and or designee completed a check of all exterior doors. Maintenance staff also changed all keypad codes. · On 05/18/21 at 6:15 P.M. and ending at 11:00 P.M., all facility staff including all disciplines were educated on the wandering policy, census policy, medication administrator and not leaving medication at bedside, tray passing and validation of residents every two hours, by the DON, Unit Manager and/or Human Resource Director. · On 05/18/21 at 7:50 P.M., the back door was engaged and activated with a coded keypad handle lock. The activated code handle required a code to exit and enter the door. · On 05/18/21 at 8:30 P.M., all residents were re-assessed for wandering/elopement risk and care plans updated as needed, this was completed by DON or designee. · On 05/18/21 at 8:45 P.M., Quality Assurance Performance Improvement meeting was held with the Interdisciplinary Team to address the resident leaving the facility without staff knowledge. · On 05/18/21 at 5:00 P.M. and on 05/19/21 at 2:15 P.M., Elopement Drills were completed. On 05/18/21, Regional Maintenance Director #289 conducted an elopement drill with all staff scheduled and management team on the premises. Review of the elopement drill documentation dated 05/18/21 at 5:00 P.M., revealed signatures of seven staff attending the drill and the drill was completed without problems. Review of the Elopement Drill dated 05/19/21 at 2:15 P.M., completed by the DON, revealed all staff, therapy, dietary and housekeeping staff that were present in the facility for the drill, participated without any problems. · On 05/19/21 at 12:03 A.M., Resident #14 returned to the facility via a facility vehicle accompanied by staff members. A head to toe assessment was refused by the resident. · On 05/19/21, an admission Wandering Risk Assessment was completed and revealed the resident was at a moderate risk for wandering. · On 05/19/21 at 11:35 A.M., Resident #14 was transported to Riverside Methodist Hospital for psychiatric evaluation per physician order. · Observation on 05/24/21 from 1:37 P.M. through 6:16 P.M., revealed a keypad code was required to exit the back doors without setting off the alarm. Residents were actively evacuated through the alarmed back door due to a heat emergency. Staff were present to code the alarm. · Phone interviews on 05/26/21 from 5:33 P.M. through 5:37 P.M., revealed Licensed Practical Nurse (LPN) #220 and Registered Nurse (RN) #280 verified they received the in-Service education related to elopement policy, midnight census, charting and documentation, smoking, and nutritional services. · Observation on 05/26/21 and 05/27/21, revealed no residents present in the facility. The facility evacuation with resident transfer was in effect related to heat. · Interview on 05/27/21 at 8:34 A.M., with the DON revealed all employees had received the mandatory education except two, one dietary aide and one LPN. She stated voice messages were left that the mandatory in-service must be completed before return to work. · Interview on 05/27/21 at 8:41 A.M. With State tested Nurse Aide (STNA) #401 verified she received education related to Code doors, elopement, where to locate binder to identify residents at risk for elopement, smoking policy and monitoring, monitoring residents are present in the facility, and meal tray pick up protocols. · Review of two additional medical records (#30 and #06) for elopement risk revealed no concerns. · Review of the facility action plan revealed when residents return to the facility, all residents will be considered re-admission for new elopement assessments to be completed by DON or designee. · Review of the facility action plan revealed when residents return to the facility, the DON and two Unit Managers will audit quarterly elopement assessments. Start every three-month quarterly assessment with re-admitted . DON and Unit Managers and Minimum Data Set (MDS) Nurse will complete assessments. · Review of the facility action plan revealed when residents return to the facility, the DON will monitor exterior doors to make sure they are secure three times a week for four weeks. · Review of the facility action plan revealed when residents return to the facility, Unit Managers and DON will complete tray audits three times a week for four weeks. Trays passed and picked up documentation. The purpose is to verify resident was present for meals. If resident did not consume food from tray pass, staff were to notify nursing. · Review of the facility action plan revealed when residents return to the facility, the DON will complete audits three times a week for four weeks, cigarettes available for residents and supervised smoking. · Review of the facility action plan revealed when residents return to the facility, the DON will audit daily headcount at 12:00 P.M. and 12:00 A.M. three times a week for four weeks. Although the Immediate Jeopardy was removed on 05/19/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy), as the facility was still in the process of implementing their corrective action plan and is unable to complete monitoring for ongoing compliance, due to there are no current resident in the facility. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including [CONDITION(S)] (COPD), chronic kidney disease, hypertension, traumatic subdural hemorrhage without loss of consciousness sequela, paranoid [CONDITION(S)], anxiety disorder, [CONDITION(S)] II disorder, pseudobulbar affect, unspecified dementia with behavioral disturbance, and [CONDITION(S)]. Review of Resident #14's wandering risk assessment dated [DATE] and 03/15/21, revealed the resident was at moderate risk for wandering. The resident was assessed as being independent with mobility, had early dementia and had forgetful/short attention span. Medications included antipsychotics, antidepressants, and narcotics. The resident was not identified as a known wanderer or history of wandering. Review of the plan of care dated 04/18/21 for wandering risk related to attempts to leave facility unattended revealed the resident was at elopement risk/wandering related to history of attempts to leave facility unattended. The resident's safety will be maintained through the review date. Interventions included: distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering. Intervene as appropriate. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE], revealed the resident had impaired cognition and no wandering behaviors exhibited during the assessment. The resident required supervision with set up help only for bed mobility, transfer, walking in room and corridor, locomotion on and off unit, personal hygiene, eating, dressing and toilet use. Review of the nursing note dated 05/18/21 at 12:07 A.M., documented by Licensed Practical Nurse (LPN) #402, revealed the resident was resting quietly in bed at this time. No complaints of shortness of breath this tour. Breathing even and unlabored. Review of the facility investigation revealed the hospital in Indiana called the facility on 05/18/21 at 4:56 P.M. and spoke to Social Worker (SW) #301. The hospital stated they had a resident by the name of (Resident #14's sister's name). The facility stated that they did not have a resident by that name. However, SW #301 was familiar with the name, as a family member of Resident #14. SW #301 asked the hospital if the resident had a mole on her face and the hospital confirmed that she did. SW #301 then sent a face sheet to the hospital to identify the resident. The hospital confirmed that the resident they had was Resident #14 and was giving the hospital the name of her sister. The surveillance video was reviewed by management team and revealed Resident #14 exited the facility through the back door on 05/17/21 at 10:51 P.M. Review of the nursing note dated 05/18/21 at 6:06 P.M., revealed the physician was notified the resident was not in the facility. Resident #14 was at the hospital Emergency Department for psychiatric evaluation and the resident will be returning to facility tonight. Review of the nursing notes dated 05/19/21 at 3:32 A.M., revealed Resident #14 returned to facility from the hospital in Indiana per facility vehicle and two staff members around 12:10 A.M. Registered Nurse (RN) Supervisor #280 took the resident upstairs to second floor and took the resident out for a smoke. Resident #14 attempted to leave the facility while in the smoking area and was redirected by staff members. The nurse updated the DON of the resident's return from the Indiana hospital at approximately 12:34 A.M. The nurse left a call back message with the resident's sister at 1:39 A.M. RN Supervisor #280 left a call back message with the physician at approximately 1:30 A.M. Resident #14 was very hostile with staff and very uncooperative with staff and was on one-on-one supervision with STNA #403. Resident #14 refused to allow the nurse to complete a head to toe assessment for injuries and accused this nurse of sexual impropriety in front of RN Supervisor #280 and STNA #403. Resident #14 denied any pain at this time and was in her room with an STNA nearby. Review of a communication note dated 05/19/21 at 1:30 P.M., revealed SW #301 spoke with the resident about why she left and where she went. Resident #14 stated she was upset do to not having any smokes. Resident #14 stated she walked out the back door and just kept going. She went to the bus station where she bought some smokes and a bus ticket. Resident #14 stated she wanted to go to Indiana because she was born there. She went to Indiana and walked until she couldn't walk any more. She then hitch-hiked with a lady to the police station. The police took her to the hospital. Resident #14 stated no one hurt her and she doesn't understand why she had to come back. She wanted to get her birth records from the hospital and was never given them. Interview on 05/26/21 at 11:10 A.M., with the DON revealed Resident #14 was ambulatory and told SW #301, that another resident had stated, if you don't like it here, just leave. The DON revealed the resident did not like scheduled, supervised smoking. The DON further stated the day shift nurse on 05/18/21, had stated she passed the resident's 8:00 A.M. scheduled medications but had left them sitting at the bedside. The DON stated the Medication Administration Record (MAR) had documentation that the medications were administered, but then was changed to document not given as Resident #14 was not available. The DON stated when she had gone to Resident #14's room on 05/18/21 between 5:30 P.M. and 6:00 P.M., she noted the resident's 8:00 A.M. medications were sitting at the bedside. Interview on 05/26/21 at 4:06 P.M., with the DON revealed she immediately assigned staff for one-on-one at the back door, beginning on 05/18/21 at 6:00 P.M., when the facility learned Resident #14 was off the premises, through 05/19/21 at 11:05 A.M. Interview on 05/27/21 at 2:15 P.M. with the DON and Human Resources Director (HR) #403 verified the back door opened to the parking lot. They stated the back door had never been used as a main entrance for staff, visitors, or residents. They stated it was a service door for trash take out and deliveries. They further stated the door had never had an inside lock or alarm to restrict exits from the building. Observation on 05/27/21 from 8:30 A.M. through 4:00 P.M., revealed the facility had two elevators. One elevator was near the front of the building (not in use) and currently under contract for repair. The second elevator was toward the back of the facility and opened in a hallway adjacent to the back door. Residents, without a wander guard, had free access to the elevator from the second and third floor. The back door was 17 steps from the back-elevator first floor landing. Interview on 06/01/21 at 9:06 A.M., with LPN #283 verified the residents only use the back elevator and the unlocked, unalarmed back door was 17 steps from the elevator. Interviews on 06/01/21 from 9:06 A.M. through 9:27 A.M., revealed LPNs #281 and #283 stated they had not seen Resident #14 exit seek, nor speak of leaving the facility. LPN #281 stated she was not aware Resident #14 was an elopement risk, the resident moved about the facility freely, and was independent with ambulation and care needs. Interview on 06/01/21 at 1:55 P.M., verified the nursing note dated 05/18/21 at 12:07 A.M., documented by LPN #402, was documented while the resident was not even in the facility and was false documentation. Review of the policy titled, Wandering, Unsafe Resident, revised date 10/13/20, indicated the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement or other risk due to judgement or cognition. This deficiency substantiates allegations in Complaint Numbers OH 572, OH 662, OH 721 and OH 885.

Based on medical record review, resident and staff interview, interview with the Local Fire Department, review of the hospital records and review of the facility's policy on pain, the facility failed to provide adequate pain management for one resident (Resident #1). This resulted in actual harm for Resident #1 who complained of pain throughout the night and requested pain medications several times. Resident #1 was not administered the medication resulting in the resident crying out in pain. Resident #1 called emergency services (911) six times throughout the night requesting help. This affected one of three residents reviewed for pain management. The facility identified eight residents on a pain management program. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] at 6:34 P.M. [DIAGNOSES REDACTED]. Review of the hospital discharge instructions, dated 05/23/20, revealed Resident #1 was to receive [MEDICATION NAME] (narcotic pain medication to treat severe pain) 10-325 mg., one tablet every four hours as needed (PRN) for pain. [MEDICATION NAME] 5-325 mg. was administered to the resident in the hospital at 5:24 P.M., prior to his discharge on 05/23/20. Review of the pain assessment, dated 05/24/20, revealed Resident #1 stated she had frequent pain or hurting over the past five days and it has made it hard for her to sleep at night and has limited her day-to-day activities because of pain. She described her pain as severe. Review of the undated plan of care revealed Resident #1 was on pain medication therapy to rule out [MEDICAL CONDITION] and [DIAGNOSES REDACTED], left buttock wound and post-laminectomy surgery. The goal was for the resident to be free of any discomfort or adverse effects from the pain medication. Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review Resident #1's medication administration records (MAR) revealed the resident did not receive [MEDICATION NAME] throughout the night shift of 05/23/20 to the morning of 05/24/20. The MAR indicated [REDACTED].M. on 05/24/20 and her pain level was a level nine out of ten on the pain scale (a scale indicating zero for no pain and ten being worse pain ever). Interview and observation with Resident #1 on 05/24/20 at 10:35 A.M. revealed the night nurse would not give her pain medication despite asking multiple times for it. She stated she was suffering, she was shaking because of withdrawals and was unable to sleep through the night. She reported her pain level was a ten out of ten on the pain scale. She said the nurse aides were trying to make her comfortable, but it didn't help. She was tearful during the interview and she said the nurse would just ignore her when she requested her pain medications. She said she had to call 911 three times during the night because she was hurting so bad and she didn't know what else to do if the nurse would not give her pain medications. She said the day shift nurse gave her pain medication right after she requested it around 8:00 A.M. She did say she was feeling better but would need to get back on track for pain management. She explained she had back surgery and it was painful. Interview with Licensed Practical Nurse (LPN) #23 on 05/24/20 at 10:44 A.M. revealed Resident #1 requested pain medications from her at 8:00 A.M. and she appeared in distressed. The resident stated her pain level was an eight or nine on the pain scale and reported the night nurse would not give her any pain medications. LPN #23 stated she called the pharmacy to get approval to pull four [MEDICATION NAME] pills from the facility's emergency drug supply and received permission to pull four so the resident didn't have to miss her next dose if she requested it in four hours. LPN #23 stated the pharmacy would drop-ship the medications today. Interview with the Administrator on 05/24/20 at 11:55 A.M. revealed the facility always has [MEDICATION NAME] in the facility's emergency drug kit so that would not be a reason to not administer a resident's request for [MEDICATION NAME]. Interview with the Local Fire Department Employee (FDE) #200 on 05/29/20 at 9:55 A.M. revealed Resident #1 called 911 six times during the night of 05/23/20 to the morning of 05/24/20. He said he was one of the team members that arrived at the facility the six times throughout the night. He said the resident's concern was not getting her pain medications. At 1:55 P.M., FDE #200 stated the resident did show physical signs of pain including sweating and bending over. He stated he spoke with a male nurse and told him the resident was complaining of pain and she called 911 several times due to her pain. Review of the facility's policy on administering pain medications, last revised 10/2010, revealed the pain management program is based on a facility-wide commitment to resident comfort. Pain management was defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition established treatment goals. This deficiency substantiates Complaint Number OH 814.

Based on medical record review, observations, review of hospital records, resident, staff and physician interviews and review of the Smoking and Substance Abuse Policy, the facility failed to implement an action plan when one resident (Resident #56), who had a history of [REDACTED]. Actual harm occurred on 06/01/18 when Resident #56 required hospitalization , and on 07/16/18 and 07/18/18, required the administration of [MEDICATION NAME] for the reversal of opioid overdose. This resulted in Immediate Jeopardy when the facility failed to act on the illicit drug use, implement the illicit drug contract, and implement a plan of supervision. This affected one of two residents reviewed for drug overdose. Additionally, the facility failed to ensure residents were appropriately assessed for supervised smoking and were not in possession of smoking materials. This resulted in Immediate Jeopardy when Residents #37 and #56 were found smoking in their room, and Resident #122 was discovered smoking with oxygen in use. This posed the threat for the likelihood of serious injury or death to the facility population of 71 residents. Lastly, one resident (Resident #30) sustained a fall from his wheelchair that had the armrests broken off and the facility refused to repair. This affected one of one resident reviewed for falls. On 08/09/18 at 3:21 P.M., the Licensed Nursing Home Administrator (LNHA), and Vice President of Clinical Operations (VPCO), also known as Registered Nurse (RN) #500 were notified Immediate Jeopardy began on 06/01/18 at 9:20 A.M., when facility staff smelled cigarette smoke and staff observed ashes on Resident #56's bedside table. Additionally, on 06/01/18 at 7:51 P.M., Resident #56 was found unresponsive and was sent to hospital, with the admitting [DIAGNOSES REDACTED]. The Immediate Jeopardy was removed on 08/14/18 when the facility implemented the following corrective actions: · Upon notification of Immediate Jeopardy, Resident #56 was placed on 1:1 supervision on 08/09/18 at 3:32 P.M., and would remain on 1:1 supervision until alternative placement was found. · The Medical Director was notified of the Immediate Jeopardy on 08/09/18 at 3:46 P.M., by RN #500. · A search of all facility resident rooms for unauthorized smoking materials and illegal substances began on 08/09/18 at 3:37 P.M., and was completed by 4:53 P.M., by the Director of Nursing (DON) or designee. All variances were corrected. · The facility will implement visual observation/rounding of the designated smoking areas by staff every two hours to ensure residents are safely smoking for one week, and will be reevaluated by the Quality Assurance (QA) team. · Education for licensed nursing staff and state tested nursing assistants (STNAs) began at 4:05 P.M., on 08/09/18 regarding facility smoking policy and substance abuse policy by the DON or designee. Employees who were not working were educated via telephone. Additional staff training was completed by 08/14/18. · An audit of all in house residents for history/risk of substance abuse was completed by DON or designee by 8/09/18 and residents identified at risk will receive a copy of substance abuse policy. Care plans will be reviewed and modified as needed. · An audit of all in house residents who smoke will be conducted by DON or designee by 8/09/18 and all residents identified will receive a copy of the facility smoking policy. The facility will update smoking assessments as needed and complete by 8/09/18. Care plans will be reviewed and modified as needed. · A random audit of resident's rooms will be conducted for smoking material storage daily for one week, then three times a week for two weeks, then weekly for one week. The results of the audits will be reviewed by the QA committee, and the duration will be continued as recommended by QA. · Interviews on 08/13/18 at 4:30 P.M., with six staff regarding the education/training of the smoking policy and illegal drugs revealed Licensed Practical Nurses (LPN) #144 and #120, STNAs #142, #147, and RN #143 all confirmed they had received the education/training. STNA #104 who worked on 08/11/18 and 08/13/18, denied receiving the education/training. STNA #104 received the education/training on 08/14/18. · Interviews continued on 08/14/18 at 6:20 A.M., with night shift staff regarding the education/training of smoking and illegal drugs. STNA #142 denied receiving the education/training, and confirmed he had worked on 08/11/18, 08/12/18, 08/13/18. STNA #144 denied receiving the education/training, and confirmed he had worked on 08/10/18, 08/11/18, 08/12/18 and 08/13/18. Staff who confirmed they had received education/training were, STNA #187, LPN #123, STNA #102, and LPN #102. STNA #142 and #144 received the education/training on 08/14/18. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of implementing their action plan to ensure ongoing compliance. Findings include: 1. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #56's most recent Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact, and required supervision to limited assistance for all activities of daily living (ADLs). Review of Resident #56's care plan dated 10/11/17 revealed the resident was at risk for addiction related to history of addiction to opioids. The two interventions were to provide the resident with drug rehabilitation services, if he requested, and random drug testing, as ordered by the physician. Review of the facility's controlled substance contract dated 12/07/17, revealed Resident #56 agreed not to obtain or use any controlled medications from any other physician, or illegal source. The contract further revealed if the contract was broken, the resident would be issued a 30 day discharge notice for not complying. The resident signed the contract on 12/18/17. The Medical Director, who was Resident #56's physician, also signed the contract. Review of Resident #56's care plan dated 01/23/18, revealed the resident was at risk for smoking injury. Goals included to maintain a safe smoking environment when smoking, follow the smoking policy and the resident's smoking would not put others at risk. Interventions included on 05/03/18 to keep smoking materials at the nursing station. Review of Resident #56's nursing note dated 04/17/18 revealed therapy staff reported to the nurse they had smelled, and saw smoke from the resident's room and the nurse witnessed the same. Resident #56 was educated on the smoking policy. Review of a nursing note on 05/03/18 revealed Resident #56 was in his room and the room smelled like smoke. The Resident confirmed he had smoked a half of a cigarette, and it smelled bad. The smoking policy was reviewed with the resident, and a smoking agreement was signed. Review of Resident #56's smoking assessment dated [DATE], revealed the resident smoked two to five times daily in the morning, afternoon and evening. Resident #56 required supervision while smoking, and the facility should keep the resident's cigarettes and lighter. Review of Resident #56's nursing note dated 06/01/18 at 9:20 A.M., revealed Resident #56 was found smoking in his room. The room smelled of cigarette smoke and the nurse noticed two areas of ashes on the bedside table. The resident confirmed he laid the cigarettes on the bedside table to put them out. At 7:51 P.M., the resident was found unresponsive and emergency medical services (911) was called. Resident #56 was sent to the hospital for evaluation and treatment. Review of the hospital record revealed Resident #56 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED].#56 was found by the facility on 06/01/18 in a frozen like statue, and was given [MEDICATION NAME]. The drug screen at the hospital revealed the resident tested positive for [MEDICATION NAME] (narcotic pain medication). Review of the hospital assessment dated [DATE] revealed the resident presented to the hospital following opioid overdose, and end stage [MEDICAL CONDITION], with chronic [MEDICAL CONDITION]. Review of Resident #56's physician orders [REDACTED]. Review of Resident #56's nursing note date 06/11/18 at 10:46 A.M., revealed the resident's room smelled of cigarette smoke. The resident revealed he could not walk very well, so he smoked in his room. There was a water cup noted on his bedside table containing ashes and cigarette butts. Resident #56 was re-educated that he could not smoke in his room. The resident refused to give staff his cigarettes and lighter. The resident agreed to use the call light to ask for help to the designated smoking area. Review of a nursing note dated 06/16/18 revealed Resident #56 was found smoking in his room again. Facility staff took the resident's cigarettes and lighter from him. It was noted the resident was an unsafe smoker and needed to be supervised. Review of Resident #56's nursing note dated 07/16/18 revealed maintenance personnel came to the nurse and said the resident was not responding when they knocked on the door. The nurse found the resident lying in bed with his head against the wall, his eyes fixed, and dilated. The resident's heart rate was 110 beats per minute (bpm), his blood pressure was 70/40 millimeters of mercury (mm HG), and his oxygenation level was 80%. At 12:05 P.M., Resident #56 was given 0.4 milligrams (mg) of [MEDICATION NAME] intramuscularly (IM). Review of Resident #56's nursing note dated 07/16/18 at 4:18 P.M., revealed the resident was discharged from Hospice, per the care agreement, due to the resident had obtained opioids from a source other than approved by Hospice. Review of Resident #56's physician (Medical Director) progress note dated 07/17/18 revealed Resident #56 did admit to ingesting something on 07/16/18, and it messed him up. Review of Resident #56's nursing note dated 07/18/18 at 10:18 A.M., revealed the resident was found lethargic, and was unable to answer questions. Multiple doses of Heroin (opioid) were noted to be laying on the bedside table. Resident #56 was given one dose of [MEDICATION NAME]. After the administration of [MEDICATION NAME], the resident opened his eyes and was answering one word questions. The note further revealed LPN #146 found a white powdery substance wrapped in a small piece of paper, and a cut straw was found in the resident's pocket. The police department was notified to come to the facility and pick up a substantial amount of a white, powdery substance that was found near the resident. LPN #146 told the staff nurse to administer [MEDICATION NAME], 0.4 mg, IM, to Resident #56. At 10:46 A.M., it was noted a police officer came to the facility and retrieved the white powdery substance from the nursing staff, and left the facility. Review of Certified Nurse Practitioner's (CNP) #1's progress note dated 07/18/18 revealed the reason of the visit was due to Resident #56's overdose. The note revealed Resident #56 was given [MEDICATION NAME] on 07/18/18, due to the probable overdose of illicit drugs. The resident's altered mental status was reversed after the first dose of [MEDICATION NAME], and the resident was discontinued from the Hospice program. The plan for the drug overdose was to hold all opiates for 24 hours, discontinue [MEDICATION NAME] (narcotic pain medication) 10/325 mg, every four hours as needed, and start every eight hours, as needed. The physician wrote the order as stated. Review of Resident #56's physician progress notes [REDACTED].#56 was informed if there were any further instances of his illicit drug use, he would discontinue his pain medication. Interview and observation with Resident #56 on 08/07/18 at 12:48 P.M., revealed there was a large amount of ashes in all the corners of his bedside table. Resident #56 stated he used a cardboard food box for an ash tray, and it had fallen over. He further revealed he smoked in his room, because he could not get to ashtrays outside in the smoking area, because too many residents were using them. Interview on 08/08/18 at 5:09 P.M., with LPN #125, confirmed Resident #56 required supervision for smoking, and she completed his assessment in 05/2018. She revealed the resident had been caught in his room smoking numerous times. LPN #125 further confirmed Resident #56 had been found unresponsive due to use of illicit drugs. She stated the last incident on 07/18/18 they found a substantial amount of drugs near him. The LPN revealed staff found five or six bubble gum wrappers which had a white powdery substance in them. Interview on 08/09/18 at 8:23 A.M., with Resident #56 confirmed he had smoked in his room at times, especially when he was having trouble walking. On the window sill there was a plastic cup, partially filled with water. There were ashes observed scattered on the window sill, and a large ash on top of the cup lid. The window was open. Resident #56 confirmed he had smoking materials on him, and pulled out a pack of cigarettes from his left flannel jacket pocket, and a lighter from the right chest pocket. Interview on 08/09/18 at 8:33 A.M., with STNA #148 revealed you could smell and see smoke coming from Resident #56's room every day. STNA #148 confirmed he had taken cigarettes from the resident at times, and ashes were usually observed in the resident's room. During the interview STNA#148 confirmed there were ashes on the window sill and plastic cup. Interview on 08/09/18 at 11:34 A.M., with LPN #121 revealed he had gone into Resident #56's room on multiple occasions and smelled a strong smell of smoke. He further revealed he had seen ashes on the resident's chest, and bed side table. Interview on 08/09/18 at 12:07 P.M., with Social Service Designee (SSD) #163, the LNHA, and RN #500 all confirmed Resident #56 was not given a 30 day discharge notice, as stated in the contract signed by the resident, and Medical Director for the use of illicit drugs. Interview on 08/09/18 at 2:08 P.M., with the LNHA revealed he was unaware of any suspected drug overdoses, or drugs being found at the facility. He stated normally he would be notified. The LNHA revealed he was unaware of any residents smoking in their rooms. The LNHA confirmed he would expect to be notified of such incidents. The LNHA confirmed the facility staff should be keeping Resident #56's smoking materials. Interview on 08/09/18 at 2:44 P.M., with RN #500 revealed Resident #56 was non-complaint with drug screens. RN #500 further revealed Resident #56 had the right to do drugs and confirmed the facility had illegal drug issues. RN #500 further revealed she was not aware the resident had been caught smoking in his room. RN #500 revealed the facility had attempted to store Resident #56's smoking materials, however the Resident tells the staff he does not have any. Interview on 08/14/18 at 8:24 A.M., with the Medical Director, who was also Resident #56's physician, revealed he was not made aware Resident #56 had been sent to the hospital on [DATE] due to a suspected drug overdose, and was positive for [MEDICATION NAME] use. He was also unaware the police were notified to retrieve drugs that were found on the bedside table after the incident on 07/18/18. The Medical Director further revealed it was impossible to watch all the residents regarding drug abuse. The Medical Director also revealed he had not been notified Resident #56 had been found smoking in his room. 2. Medical record review revealed Resident #122 was admitted to the facility on [DATE] from another long term care facility, with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident's cognition was moderately impaired. Review of Resident #122's initial smoking assessment dated [DATE] revealed the resident had no cognitive loss, had a visual deficit, dexterity problems, and smoked two to five times per day. The assessment further revealed there was no need to store the resident's lighter and cigarettes with nursing staff, or to supervise the resident's smoking. The assessment revealed there was no reason to develop a smoking care plan. Review of the smoking assessment dated [DATE] revealed the resident was changed to a supervised smoker with no reason in the nursing notes, or assessment as to why she was changed to a supervised smoker. The new assessment revealed nursing staff were to store her lighter and cigarettes. Interview with Resident #122 on 08/07/18 at 08:16 A.M., revealed she was kicked out of the previous nursing facility she was residing in related to smoking with her oxygen tank on. She further revealed on 08/09/18 at 4:09 P.M., she lost her independent smoking privileges a few days ago when she accidentally left her oxygen on, while smoking outside in the smoking area. Multiple observations of Resident #122 on 08/7/18 at 08:16 A.M., 08/09/18 at 04:09 P.M., and 08/10/18 at 08:06 A.M., revealed her oxygen was on, per nasal cannula, at three liters. Interview on 08/13/18 at 11:28 A.M., with LPN #120 confirmed Resident #122 was changed to a supervised smoker on 08/07/18 because an STNA, whom she was unable to identify, reported the resident left her oxygen on while she was smoking. Interview 08/13/18 at 02:00 P.M., with the LNHA and Director of Nursing (DON) confirmed Resident #122 was on continuous oxygen, was moderately impaired cognitively, and was not assessed as a supervised smoker until 08/07/18. They further confirmed the 08/07/18 and 08/09/18 smoking assessments did not state the reason the resident was changed to a supervised smoker. Additionally, they both confirmed the resident's care plan was not updated to reflect the supervised smoking until 08/09/18. 3. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #37's smoking assessment dated [DATE], revealed the resident smoked at night, and it was required for nursing to store her lighter and cigarettes. She was assessed as an unsupervised smoker. Review of the smoking care plan initiated on 06/01/18 revealed the resident refused to keep her cigarettes and lighters at the nursing station. Review of Resident #37's nursing note dated 07/03/18 revealed LPN #108 found the resident smoking in her room. The resident was educated regarding the smoking policy. LPN #108 was not available for an interview. Review of Resident #37's smoking assessment dated [DATE], revealed the resident smoked in the afternoon, and no longer needed the staff to store her lighter and cigarette. The resident continued to be an unsupervised smoker. Interview with the LNHA and DON on 08/13/18 at 2:00 P.M., verified after the 07/03/18 smoking incident in Resident #122's room, the smoking assessment should have been revised to require supervised smoking. They both agreed the smoking assessment completed 08/09/18 which revealed there was no need to store the resident's smoking materials was incorrect. Review of Resident Drug and Alcohol policy and procedure, dated 04/24/18, revealed the purpose of the policy was to ensure the safety of staff, visitors, and residents residing in the facility, the use and/or consumption of illegal drugs, illegal substances, and alcohol were strictly prohibited in the facility. Residents were prohibited from consuming illegal substances, alcohol, or medication not prescribed by a physician. Residents were prohibited from being in possession of illegal substances, alcohol, or medications not prescribed by a physician. The facility reserved the right to issue a notice of intent to discharge to any resident who violated the Drug and Alcohol policy. Review of Smoking Policy, dated 01/01/16, revealed residents who smoke will be assessed for needed assistance upon admission, quarterly, and with a significant change. The facility staff will supervise residents while smoking who are indicated to need supervision. Smoking is only allowed in areas of the facility that are designated smoking areas. All smoking materials will be kept in a secured area, and distributed by facility staff for residents who need supervision. The failure of any resident or visitor to comply with these rules places others at risk for injury. The facility may find it necessary to assist a resident and family in finding an alternative placement if smoking and safety rules are not followed. Review of the policy titled Oxygen Safety, (undated), revealed residents were not permitted to smoke with oxygen in use. 4. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment further revealed the resident's range of motion (ROM) was impaired on both sides of the lower extremities. A walker and wheelchair were listed as mobility devices. Observation on 08/06/18 at 2:30 P.M., of Resident #30's room revealed the wheelchair did not have any arms on it. The broken arms were observed to be hanging on the back of the wheelchair. Interview on 08/07/18 at 5:40 P.M., with LPN #125 confirmed Resident #30's arms of his wheelchair were broken off, and were hanging on the back of the wheelchair. LPN #125 revealed a work order was either sent to the maintenance department, or therapy to repair the wheelchair. Interview on 08/08/18 at 10:30 A.M., with the Physical Therapy Assistant (PTA) #1 revealed Resident #30 was not receiving services. He further revealed he had no record of a work order to repair Resident #30's wheelchair arms. Interview on 08/08/18 at 11:15 A.M., with the LNHA revealed the facility was not obligated to repair Resident #30's wheelchair. He stated the arms of the wheelchair were broken by the resident. He further revealed if the resident wanted his wheelchair repaired, he could privately pay to have it repaired. Observation of Resident #30 on 08/08/18 at 3:39 P.M., revealed the resident was on the floor at the second floor nursing station. LPNs #125 and #134, and STNA #154 assisted the resident back into his wheelchair. Interview on 08/08/18 with STNA #154 at the time of the observation revealed Resident #30 was on the phone, had a [MEDICAL CONDITION], and fell out of the right side of his wheelchair, which did not have an arm on it. Resident #30 was assessed by LPN #125, and denied any injury. Review of Resident #30's progress note dated 08/08/18 at 3:52 P.M., revealed the resident was offered to be sent to the emergency room , and he declined.

Based on review of the medical record, medication administration procedure and Medication Error Investigation Summary and staff, resident and Pharmacist interviews, the facility failed to ensure one resident (Resident #22) received the correct amount of [MEDICATION NAME] oral concentrate (narcotic pain medication), in accordance with the prescriber's order. Facility nurses failed to ensure the written physician's orders [REDACTED].#144, #160, and #180, failed to determine the correct dose prior to administering the [MEDICATION NAME]. This resulted in Immediate Jeopardy for Resident #22, who was administered 150 milligrams (mg), of [MEDICATION NAME] oral concentrate, instead of the 10 mg. ordered dose as documented on the Medication Administration Record (MAR) and/or Controlled Drug Use Record on 07/24/18 at 6:48 A.M., on 07/24/18 at 7:00 P.M., on 07/24/18 at 8:00 P.M., and on 07/25/18 at 5:00 A.M. Serious harm occurred when Resident #22 had a significant change in condition/level of consciousness after the administration of the [MEDICATION NAME] on 07/24/18 at 7:00 P. M., and required an injection of [MEDICATION NAME] (also referred to as [MEDICATION NAME], a prescription medicine used for the treatment of [REDACTED]. This affected one of three residents reviewed for liquid narcotic pain medication administration. The facility census was 71. The Administrator and Vice President of Clinical Operations (VPCO), Registered Nurse (RN) #500 were notified on 08/14/18 at 3:08 P.M., Immediate Jeopardy began on 07/24/18 when Resident #22 was administered [MEDICATION NAME] oral concentrate at fifteen times the correct dosage, on four separate occasions. In addition, LPN #160 who administered the [MEDICATION NAME] to Resident #22 confirmed she had never administered [MEDICATION NAME] before, had no proper training, or knowledge of the proper protocol to administer [MEDICATION NAME]. The Immediate Jeopardy was removed on 08/15/18 at 3:29 P.M., when the facility implemented the following corrective measures. · On 07/25/18 at 6:45 P.M., LPN #160 discontinued the incorrectly transcribed [MEDICATION NAME] oral concentrate order for Resident #22, and re-entered the correct physician's orders [REDACTED]. · On 08/14/18 at 3:29 P.M., the Medical Director was notified of the immediate jeopardy. · On 08/14/18 at 3:29 P.M., the DON and Unit Manager, LPN #125 began in-servicing all licensed nursing staff in person, or via telephone, on proper transcription and administration of opiate medications, and the administration of [MEDICATION NAME]. All nursing staff inservices were completed on 08/15/18. All nurses will complete a posttest prior to the start of their next shift. · On 08/14/18 at 5:40 P.M., RN #500 completed an audit of two additional residents, (Residents #12 and #15), who were identified as receiving liquid narcotics to ensure the correct dose was identified and administered. No similar dose discrepancies, or errors were found. · On 08/15/18 Certified Nurse Practitioner (CNP) #1 was educated on proper dosing of [MEDICATION NAME], and clarification of new orders by the physician. Interviews with LPNs #120 and #121 on 08/15/18 from 8:10 A.M., through 8:23 A.M., confirmed they both had received education and training on the administration of narcotics, clarifying orders, and the administration of [MEDICATION NAME]. They both confirmed they had also completed, and passed a post-test regarding the administration of [MEDICATION NAME]. · A random selection of residents receiving an opioid medication will be audited for correct orders, and dosing by the DON or designee, three times a week, for four weeks. Results of the audits will be forwarded to the Quality Assurance (QA) Committee for review. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their action plan to ensure ongoing compliance. Findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the Controlled Substance Prescription Form dated 07/23/18 at 12:04 P.M., revealed CNP #1 ordered Resident #22 [MEDICATION NAME] 20 mg, per 5 milliliter (ml), give 7.5 ml (30 mg) by mouth, every 12 hours for pain. Further review of the prescription form revealed a communication from Pharmacist #300, was sent to CNP #1 on 07/23/18 to clarify the [MEDICATION NAME] oral concentrate, as the pharmacy only carried the [MEDICATION NAME] concentrate in 20 mg, per ml. At 4:42 P.M., Pharmacist #300 documented the CNP would fax back a new prescription, and would speak to the Director of Nursing (DON) about the change. Review of the Controlled Substance Prescription form dated 07/23/18 at 5:26 P.M., revealed CNP #1 changed the order for Resident #22 to receive [MEDICATION NAME] 20 mg, give 0.5 ml (10 mg) every six hours, as needed for pain. Further review of the controlled prescription form revealed Pharmacists #300 documented at 7:40 P.M., the facility was called and the DON was notified of the new, clarified order. Review of the Facility Order Audit Report revealed on 07/23/18 at 7:37 P.M., LPN #121 entered into PCC, orders for Resident #22 to receive [MEDICATION NAME] Solution 20 mg/5 ml, give 7.5 ml (30 mg) every twelve hours for pain. This was the original order CNP #1 had prescribed, not the current order. Review of the Controlled Drug Use Record dated 07/23/18 delivered to the facility on [DATE] with the [MEDICATION NAME] medication for Resident #22, revealed physician orders [REDACTED]. The quantity delivered was 30 ml. Review of the Controlled Drug Use Record, revealed Resident #22 was administered the incorrect dose of [MEDICATION NAME] of 7.5 ml (150 mg) on 07/24/18 at 6:48 A.M., by LPN # 180, on 07/24/18 at 7:00 P.M., by LPN #160, on 07/24/18 at 8:00 P.M., by LPN #144, and on 07/25/18 at 5:00 A.M., by LPN #144. Review of Resident #22's July, (YEAR) Medication Administration Record (MAR) revealed Resident #22 was administered the incorrect dose of 7.5 ml (150 mg) of [MEDICATION NAME] by LPN's #180, #160 and #144 as documented on the Controlled Drug Use Record. The dose LPN #160 administered on 07/24/18 at 7:00PM and documented on the Controlled Drug Use Record was not documented on the MAR. Review of the nurse's notes dated 07/24/18 revealed LPN #160 observed Resident #22 sitting in the middle of the hallway, in the dining room area, on the second floor. The resident appeared to be lethargic, incoherent, and only slightly communicating. The resident was not fully responding, or able to follow commands, when spoken to. Respirations were 10 breaths per minute, his heart rate was 118 beats per minute, and oxygen saturation was 60 % on room air. LPN #160 administered [MEDICATION NAME] per intra-muscular injection (IM), in the resident's left deltoid (arm). The DON and CNP #1 were made aware. Review of the facility's Medication Error Summary dated 07/24/18, completed by RN #500, revealed Resident #22 was observed sitting in an electric wheel chair, in the dining room on the second floor of the facility. The resident appeared lethargic, incoherent, and was slightly communicating. The resident was not able to fully respond, or able to follow commands when spoken to. [MEDICATION NAME] was given IM in the resident's left deltoid. The Medication Error Summary further revealed Resident #22 had an order on 07/23/18 for [MEDICATION NAME] oral concentrate, 7.5 ml, every twelve hours, for pain. Upon clarification, a correct order was given for [MEDICATION NAME] oral concentrate, 0.5 ml, 10 mg, every twelve hours. The nurse administered [MEDICATION NAME] as a reversal due to the medication error, and Resident #22 responded. Resident #22 and his responsible party were made aware. CNP #1 was educated by RN #500 on accurate orders. The Medication Error Summary was absent of information related to the additional three medication errors on 07/24/18 at 6:48 A.M., at 8:00 P.M., and on 07/25/18 at 5:00 A.M. The incorrect doses given on 07/24/18 at 8:00 P.M., and 07/25/18 at 5:00 A.M., were given after the [MEDICATION NAME] was administered for the dose given on 07/24/18 at 7:00 P.M. Review of Resident #22's July, (YEAR) physician orders, and MAR revealed no documentation of the resident being ordered or being administered [MEDICATION NAME]. The MAR revealed Resident #22 received the incorrect dose, at 15 times the ordered dose, on four separate occasions. Two of the additional doses were given after the resident was administered [MEDICATION NAME] following the incorrect dose on 07/24/18 at 7:00 P.M. On 08/14/18 at 7:39 A.M., during an interview, Resident #22 revealed he did not remember being over medicated with the [MEDICATION NAME] oral concentrate four times. On 08/14/18 at 8:24 A.M., an interview with the Medical Director revealed Resident #22 was prescribed [MEDICATION NAME] for pain control, and the insurance stopped paying for it, so the pain medication was changed to [MEDICATION NAME]. CNP #1 wrote the first prescription and she was notified by the pharmacy it was not available in the concentration she ordered, so she changed the order. The Medical Director confirmed he was informed the resident was given the wrong dose, and was given [MEDICATION NAME] on one occasion. The Medical Director stated he was not aware of the other three occasions the resident received the wrong dose of [MEDICATION NAME]. The Medical Director confirmed the incorrect doses of [MEDICATION NAME] oral concentrate were significant medication errors. On 08/14/18 at 9:45 A.M., during an interview with RN #500 she confirmed the nurses should have called and verified the orders on the Controlled Drug Use Record, versus administering the incorrect dose of [MEDICATION NAME] which was on the MAR. RN #500 confirmed CNP #1 was notified by the pharmacy the [MEDICATION NAME] oral concentrate did not come in the concentration she requested, and the CNP changed the order to the correct dose. RN #500 further confirmed the Medication Summary Report was incorrect as to what the corrected order of Resident #22's [MEDICATION NAME] oral concentrate was changed to. She confirmed the correct dose was to be, [MEDICATION NAME] oral concentrate, give 0.5 ml (10 mg), every six hours, as needed for pain, not every 12 hours, as indicated in the Medication Summary Report. On 08/14/18 at 11:15 A.M., during an interview, LPN #121 confirmed on 07/23/18 he entered into PCC, as instructed by CNP #1, an order for [REDACTED]. LPN #121 stated he was not notified of any changes to the order. On 08/14/18 at 11:30 A.M., during an interview, LPN #160 revealed she administered the doses of [MEDICATION NAME] oral concentrate to Resident #22 as written on the MAR, and did not check the prescription on the Controlled Drug Use Record. LPN #160 confirmed she did not record the dose of [MEDICATION NAME] she administered on 07/24/18 at 7:00 P.M. LPN #160 also confirmed LPN #108 assisted her to administer [MEDICATION NAME] to Resident #22 on 07/24/18 because she had never administered the medication before, and the facility had never provided any teaching, or procedures to follow for the administration of [MEDICATION NAME]. LPN #160 stated she did not become aware of the medication error until 07/25/18 at 6:02 P.M., when she called the pharmacy requesting a refill for the [MEDICATION NAME] oral concentrate, and the pharmacist informed her it was too early for a refill. She revealed the pharmacist informed her of the correct dose that should have been given. On 08/14/18 at 2:35 P.M., a telephone interview with Pharmacist #330 revealed the pharmacy was contacted by the facility that a refill was needed for Resident #22's [MEDICATION NAME] oral concentrate. Pharmacist #300 indicated it was discovered at that time the nurses were giving the wrong dosage because the refill was being ordered too soon. Pharmacist #330 revealed no one should be given the amount of [MEDICATION NAME] Resident #22 was given four times. The Pharmacist further revealed it was a risk for respiratory arrest and death. On 08/14/18 at 3:00 P.M., during a telephone interview LPN #144 revealed on 07/24/18 she was not informed in the shift change report by LPN #160 that Resident #22 was given the 7:00 P.M. dose of [MEDICATION NAME], and it was not documented on the MAR. She further revealed she was not informed Resident #22 required the administration of [MEDICATION NAME] by LPN #160 on 07/24/18. She confirmed she did not check the Controlled Drug Use Record for the time the last dose was administered. LPN #144 confirmed she administered the incorrect dose of [MEDICATION NAME] to Resident #22 at 8:00 P.M., and on 07/25/18 at 5:00 A.M., according to the orders on the MAR, and not the Controlled Drug Use Record. On 08/14/18 at 5:18 P.M., during a telephone interview CNP #1 revealed on 07/23/18 she was notified by the pharmacy the concentration of [MEDICATION NAME] she had ordered for Resident #22 was not available. She stated a new order was submitted to the pharmacy, the DON and a nurse (could not recall the nurse's name) were notified of the new order for the resident's [MEDICATION NAME]. The medication, with the Controlled Drug Use Record with the new prescription printed on the sheet was delivered to the facility. CNP #1 stated she was not informed of the medication errors until 07/25/18 when LPN #160 informed her the pharmacy order conflicted with the MAR, and a new prescription was needed because the resident had no [MEDICATION NAME] left from the order delivered on 07/23/18. Review of the facility's Medication Administration Procedures, revised (MONTH) (YEAR), under Procedures, revealed to review the resident's five rights, three times prior to removing the medication package/container from the cart/drawer. Further review of the procedures revealed to check the label against the order on the MAR.

Based on record review and interview the facility failed to prevent a resident to resident altercation involving Resident #31 and #2 resulting in physical abuse to Resident #2. Actual Harm occurred when Resident #2 was pushed to the ground and then physically attacked by Resident #31 resulting in the resident requiring hospital treatment for [REDACTED]. This affected two residents (Resident #2 and #31) of three residents reviewed for physical abuse. Findings include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 07/30/18. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, used a wheelchair for locomotion and rarely ambulated. The assessment revealed the resident transferred independently and he was unsteady on his feet but able to stabilize without staff assistance. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 assessment, dated 07/25/18 revealed the resident had intact cognition and completed most activities of daily living independently including ambulation. Review of Resident #2's nursing note, dated 07/28/18 revealed the resident reported Resident #31 ran over his right foot with his wheelchair, grabbed his cane from him and pushed him to the ground. This resident called the police with no visible injury noted. The police spoke to the resident, then he went out for emergency services. Review of the hospital documentation dated 07/28/18 revealed the resident was an assault victim with a facial contusion and acromioclavicular right (AC) joint injury with no fracture. Record review revealed the facility submitted a self reported incident (SRI), tracking number 5 related to a physical altercation between Resident #2 and #31 on 07/27/18 with no ill effects noted. The conclusion of the SRI investigation, dated 08/06/18 revealed the facility unsubstantiated the allegation of physical abuse. There was no person listed as a witness on the SRI. However, review of the facility investigative notes revealed a statement from State tested Nursing Assistant (STNA) #141 who worked the night shift on the date of the incident. Review of the statement from STNA #141 completed on 07/30/18 revealed she observed Resident #31 run over Resident #2's foot with the wheelchair, push him to the ground and attack him. The investigation revealed Resident #31 was the aggressor and was placed on one to one supervision following the incident until his discharge back into community. Interview on 08/07/18 at 09:55 A.M. with Resident #2 regarding the incident on 07/27/18 revealed he did nothing to Resident #31 except asked him to stop urinating on the sidewalk outside next to the building in front of the women and other residents smoking. He stated Resident #31 started pushing him to the ground, grabbed his cane and hit him on the shoulder/face, then ran over his foot with his wheelchair. Resident #2 said he hit Resident #31 with his cane in self defense. He called the police and went to the emergency room because his shoulder and face hurt. The resident returned from the emergency room with no broken bones. He stated he felt physically abused by the other resident. Interview on 08/07/18 at 10:40 A.M. with Vice President (VP) Nurse #500 who completed the above SRI verified the conclusion dated 08/06/18 was not completed within the five working day required time frame for SRIs. The SRI should have been completed by 08/03/18. Nurse #500 verified there was no witness mentioned on the submitted SRI; however, there was a staff witness interviewed. Nurse #500 stated it was her belief that an incident of physical abuse did not occur related to the above incident because she did not believe the residents intended to harm each other. Interview on 08/08/18 at 06:48 A.M. with STNA #141 revealed on 07/27/18 at approximately 11:30 P.M. she observed Resident #31 run over Resident #2's foot with his wheelchair, push the resident to the ground and continued attacking/abusing Resident #2 while he was on the ground outside the facility. She stated she called for additional staff to get both residents back in the building and the nurse was informed. She stated she encouraged Resident #2 to call the police and go to the emergency room . The STNA identified Resident #10 who had also been witness to the incident. Interview on 08/08/18 at 8:32 A.M. with Resident #10 verified she had witnessed Resident #31 hitting Resident #2 when he was on the ground outside on 07/27/18 late at night. Review of the facility policy titled, Abuse: Abuse Reporting Policy and Procedure dated 01/01/18 revealed abuse included the willful infliction of injury resulting in physical harm. An incident report form was completed by the person witnessing or having knowledge of the alleged violation. The Administrator was responsible for assuring the results of a thorough investigation were reported to the state agency with five working days of the incident.

Based on medical record review, staff interviews, resident interviews, review of the facility's Self-Reported Incidents (SRI), and review of the facility's Abuse Prevention Policy and Procedure, Abuse Investigation Policy and Procedure and Abuse Reporting Policy and Procedure, the facility failed to ensure Resident #18 was protected from verbal abuse while receiving direct care by State tested Nursing Assistant (STNA) #20. Harm occurred as Resident #18 cried uncontrollably and began hyperventilating while STNA #20 continued to provide incontinence care. This affected two (Residents #18 and #68) of three residents reviewed for abuse as Resident #68 also told surveyors said STNA #20 was mean to her while providing care. The facility census was 83 residents. Findings include: Review of Resident #18's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had unclear speech, usually understands others, sometimes makes herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 11. The MDS 3.0 assessment indicated the resident required extensive assistance of one staff member for activities of daily living. On 01/22/18 at 12:20 P.M., interview with Physical Therapy Assistant (PTA) #30 revealed Speech Therapist (ST) #30, Occupational Therapy Assistant (OTA) #34 and Occupational Therapist (OT) #35 reported an incident of verbal abuse to Resident #18 by STNA #20, occurring on 01/09/18. She said she reported the incident to the DON immediately. She said the DON requested statements from those staff members who witnessed the verbal abuse, and two staff statements were provided to the DON on 01/09/18, and the final statement was provided on the morning of 01/10/18 to the DON. Review of the statement dated 01/09/18 from ST #30 revealed on 01/09/18 at approximately 9:10 A.M. she entered Resident #18's room to provide therapy services but the resident needed incontinence care. The resident activated her call light and ST #30 located STNA #20 and alerted her of the resident's need for incontinence care. STNA #20 told the ST she would provide the care and it would take 20 minutes. Upon returning to the resident's room Resident #18 told ST #30 she was not provided incontinence care, and STNA #20 did come into her room and was talking on her cell phone and left. ST #30 reported to the nurse on duty, LPN #9, that she had requested STNA #20 to provide incontinence care to Resident #18 which was not provided and the STNA was currently on the third floor of the facility. Upon return to the second floor STNA #20 walked past ST #30 and Occupational Therapist (OT) #35 and stated I went upstairs to get deodorant. Ya'll need to get ya'll facts straight. ST #30 documented STNA #20 entered the resident's room and said, Why are you lying? very loudly to the resident. ST #30 reported the incident of what STNA #20 said to the resident. LPN #9 requested a written statement from ST #30, which indicated OT #35 also heard someone yelling in Resident #18's room. LPN #9, ST #30, and OT #35 then entered the resident's room and STNA #20 stated, Just wait a minute all of ya'all in here crowding me and I'm trying to do patient care. ST #30 documented the resident was crying very loudly and could be heard through a closed door. The statement documented the resident kept pointing to STNA #20. ST #30 then went next door to Resident #68's room to provide therapy services. Resident #68 was visibly upset and reported STNA #20 kept yelling at Resident #18, and all Resident #18 could do was cry. Review of OTA #34's statement, dated 01/09/18, revealed she was in Resident #68's adjoining room to Resident #18, which was separated by a privacy curtain. The statement documented OTA #34 and Resident #68 heard STNA #20 yelling at Resident #18, you have to roll, roll, I can't clean you up if you don't roll, I said roll. Resident #18 was crying so hard she was not able to catch her breath. The statement documented someone was in the room telling Resident #18 to calm down as STNA #20 continued to yell. OTA #34 documented Resident #68 said I don't like her, she is so mean, very mean. She talks mean to me, lets me sit wet and always talks mean to Resident #18, is always mean to her. I hear it all the time. I open the curtain all the time and tell her when she's crying that it will be okay. I tell Resident #18 that all the time. She is so sweet; she doesn't bother nobody. That don't make sense. Review of OT #35's statement dated 01/10/18 revealed she was seated at the nurse's station when she heard STNA #20 enter Resident #18's room and slam the door behind her. STNA #20 was heard yelling at Resident #18, Don't you go telling stories on me. I just went to get you deodorant. You knew I would be right back. STNA #20 continued to yell at Resident #18 but the words were unintelligible. OT #35 entered the resident's room finding the resident heavily crying. The statement documented the resident's nurse and the DON were notified of the situation. Upon entry to the resident's room STNA #20 was in the middle of changing the resident, yelling roll at her while the resident cried. LPN #9 and ST #30 entered the room due to hearing the STNA yelling. OT #35 told STNA #20 she would finish changing the resident but the STNA proceeded to continue changing the resident while the resident was heavily crying and pointing to STNA #20 then to the door. OT #35 continued to ask the STNA to leave the room, stating she would assist the resident to dress, as she can dress herself. STNA #20 then yelled, you didn't tell me you could dress yourself! Why have you been having me do it? The statement documented the resident continued to cry and required extended time for ADL during therapy session due to continued crying and need for emotional support. On 01/22/18 at 12:35 P.M. interview with Resident #18 revealed she remembered the incident involving STNA #20. Resident #18 said yes when asked if a staff member had said mean things to her or made you feel afraid or degraded. Resident #18 said yes when ask if the DON spoke with her and if she reported the incident as abuse. On 01/22/18 at 12:50 P.M., interview with LPN #9 revealed she was the nurse on duty on 01/09/18. She said she was notified by ST #30 there was a problem in Resident #18's room. She said she was told ST #30 who was at the nurse's station, and a therapy employee in the adjacent room overheard STNA #20 yelling at Resident #18. She said she tried to get the STNA to leave the room but she said the STNA wanted to finish providing care. She said she stayed in the room while STNA #20 finished the resident's care. She said she immediately reported the situation to the DON, and was unsure what the DON did but she came back and told her STNA #20 was no longer allowed in the resident's room. However, STNA #20 remained at the facility and worked her normal shift and remained employed until 01/22/18. She said she reported the incident because she felt it was verbal abuse. On 01/22/18 at 1:20 P.M. interview with STNA #20 revealed on 01/09/18 she was working on the second floor but Resident #18 was not assigned to her. She said LPN #9 told her the resident needed changed. She said she was just coming back from her break and was talking to the cable company on her personal cell phone. She said she had to go to the third floor for linens and personal products because the second floor didn't have any. She said when she came back down and was headed back into the resident's room she was still talking to the cable company and she said, Why you want to lie to the person on the phone. She said she started cleansing the resident and she had stool all over her hands and she put them in her face. She said, I told her not to but her hands in my face. She said the resident then began to flip her off and crying. She said at that time LPN #9, ST #30, and OT #35 entered the room and got in her personal space. She said she told them they were in her space while she was trying to provide care. She said they tried to make her leave the resident's room but she told them she was going to finish the resident's care. She said the resident has always had a problem with her and doesn't know why. She said the DON told her she was not allowed in the resident's room any longer. On 01/22/18 at 2:00 P.M. interview with the DON revealed the bottom line of the matter was STNA #20 was written up for her being on her personal cell phone with the cable company. She said the STNA made the statement, Why you lie, referring to charges on her bill she did not make. She said therapy reported the incident and reported they heard her say why you lie going into the resident's room. She said therapy reported the situation verbally and she had to ask for the statements. She said she investigated the comment why you lie while walking into the resident's room. She said she began getting the statements on 01/09/18. She said LPN #9 did report some kind of issue in the resident's room. On 01/22/18 at 2:35 P.M., interview with OTA #34 revealed she was in Resident #68's room after giving the resident a shower. She said she heard STNA #20 saying roll over, in such a tone of voice that she looked at Resident #68 and said, I can't believe what I am hearing. She said Resident #68 said STNA #20 treated them both in this manner all the time. She said she would have cried too if she was talked to in that manner. She said another staff member entered the room and tried to calm the resident. On 01/22/18 at 2:45 P.M. interview with OT #35 revealed on 01/09/18 she was at the nurse's station located down the hall from the resident's room documenting when she heard ST #30 tell LPN #9, Resident #18 needs changed. She said she then seen STNA #20 enter the resident's room, slam the door and start yelling, why you telling lies. She said the STNA continued yelling but she was unable to make out what was being said. She said she alerted ST #30 and LPN #9 of the situation and upon entry into the resident's room she was sobbing uncontrollably, hyperventilating. She said she offered to finish providing the resident care but the STNA refused her assistance. She said she then offered to finish dressing her due to working with the resident on the task. She said the STNA became angry yelling at her, You didn't tell me you can dress yourself, why you making me do it for you. She said the resident continued to cry, pointed to STNA #20 and then pointing to the door. She said the DON did come into the room while she was providing treatment and ask if the resident was verbally abused. She said Resident #18 nodded her head up and down indicating yes. On 01/23/18 at 3:55 P.M. interview with Resident #68 revealed she recalled two separate occasions when STNA #20 was in Resident #18's room and she tried to calm Resident #18 when STNA #20 was yelling at her, and making her cry. She said Resident #18 has no problems with any of the aides but for some reason STNA #20 does not like her and yells at her to the point she cries. Resident #68 said STNA #20 was verbally abusive to her as well. She said STNA #20 told her she could do things for herself and she was just lazy. Resident #68 said she felt humiliated and degraded and felt abused by STNA #20. She said she did not report this to anyone. Review of STNA #20's timecard report from 01/09/18 to 01/22/18 revealed the STNA continued to work following the allegation of verbal abuse. STNA #20 worked on 01/10/18, 01/12/18, 01/14/18, 01/17/18, 01/18/18, 01/19/18, 01/20/18, 01/21/18, and 01/22/18. Review of STNA #20's employee file revealed a written warning on 10/03/17 for neglect when a resident (unspecified), complained that their call light was on for two hours, and on 01/09/18 was given a final written warning for poor customer service and being on her cell phone while at work. Review of the facility's Abuse Prevention Policy and Procedure dated 01/01/16 revealed the facility will follow state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse, sexual abuse or involuntary seclusion. The facility defined verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. This deficiency substantiates Complaint Number OH 628.

Based on observation, open and closed record review and interview the facility failed to administer narcotic, [MEDICAL CONDITION] and mood stabilizing medications as ordered for Resident #77 and Resident #106 resulting in significant medication errors. Actual Harm occurred to Resident #106 when the facility failed to administer [MEDICATION NAME] acid ([MEDICATION NAME]) and [MEDICATION NAME] as ordered resulting in the resident receiving double doses of the medications for a period of time. The resident experienced increased lethargy and an elevated [MEDICATION NAME] acid blood level which required medical intervention in the form of bolus intravenous fluid administration to flush the excessive medication from the resident's system. This affected two residents (Resident #77 and #106) of three residents review for unnecessary medication use. Findings include: 1. Review of Resident #106's closed medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the admission 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making. Review of Resident #106's admission physician orders, dated 01/27/17 revealed an order to administer [MEDICATION NAME], an atypical antipsychotic medication, 3.0 milligrams (mg) one-half tablet daily at bedtime and [MEDICATION NAME], a mood stabilizer 500 mg two tablets at bedtime. Review of the Medication Administration Record [REDACTED]. Review of the nurse's note dated 02/06/17 revealed Resident #106's sister went with him to an outside appointment and the resident returned with new orders. Review of an ambulatory care center laboratory result report, dated 02/06/17 revealed Resident #106 had an elevated [MEDICATION NAME] level of 115 (normal was 50 to 100 ug/mL). A [MEDICATION NAME] level evaluated the amount of [MEDICATION NAME] medication in the resident's blood. Review of the ambulatory care center record Discharge to Home Instructions dated 02/06/17 revealed Resident #106 was seen in the urgent care and diagnosed with [REDACTED]. The resident was administered 1,000 milliliters of normal saline bolus intravenously and the lethargy improved. New orders included to hold the resident's [MEDICATION NAME] on 02/06/17 and 02/07/17, and then start [MEDICATION NAME] 500 mg before bedtime. On 02/28/17 at 2:41 P.M., interview with the Director of Nursing (DON) verified Resident #106's medications were not administered as ordered as noted above. The DON verified the resident received double the doses of the ordered [MEDICATION NAME] and [MEDICATION NAME] which resulted in the resident being seen in an ambulatory urgent care center where the resident was diagnosed with [REDACTED]. 2. Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 was cognitively intact for daily decision-making, received scheduled and as needed (PRN) pain medication for complaints of frequent pain rated a seven out of 10 on a scale of one to 10. Review of the physician order, dated 10/25/16 revealed Resident #77 was ordered [MEDICATION NAME] (narcotic pain medication) 10 milligrams (mg) two tablets every six hours as needed for moderate pain. On 01/17/17 at 7:16 P.M., Resident #77's [MEDICATION NAME] 10 mg was discontinued. Review of the Controlled Drug Receipt/Record/Disposition Form dated January, 2017 revealed Resident #77 received two tablets of [MEDICATION NAME] 10 mg on 01/17/16 at 11:45 P.M. and on 01/21/17 at 6:00 A.M., one tablet was documented as an error, signed by two staff resulting in one tablet left in the card. Review of Resident #77's [MEDICATION NAME] 10 mg controlled drug card dated 01/13/17 revealed one of 28 tablets remained. Observation of Resident #77's [MEDICATION NAME] medication card revealed Resident #77 had one pill remaining. On 02/28/17 at 12:30 P.M., interview with Resident #77 revealed the facility had administered [MEDICATION NAME] after it was discontinued by the physician. On 02/28/17 3:05 P.M., interview with the Director of Nursing (DON) verified Resident #77 received at least two [MEDICATION NAME] 10 mg tablets in error and there was one missing [MEDICATION NAME] 10 mg tablet that was unaccounted for. The DON stated Resident #77's pain management and illicit drug use was being monitored by a physician, the resident had a positive drug screen for [MEDICATION NAME] recently and the resident had tried to blame the facility for it. The DON verified one pill was documented on the controlled substance form as being given on 01/21/17 which would leave two pills remaining in the medication card; however, only one pill remained. On 02/28/17 at 3:17 P.M., interview with Licensed Practical Nurse (LPN) #8 revealed Resident #77 had three [MEDICATION NAME] 10 mg tablets not accounted for and the last documented administration of [MEDICATION NAME] was on 01/16/17. LPN #8 stated if [MEDICATION NAME] had been pulled from the cart after it was discontinued it would not have been administered in error. The DON verified controlled medications were destructed when pharmacy came to the facility and verified she had not destroyed Resident #77's [MEDICATION NAME] as of 02/28/17. On 02/28/17 at 3:22 P.M., interview with the DON revealed medications should be removed from the medication cart when the physician discontinues the medication to reduce the risk of a medication error. Review of the Controlled Substances policy dated July, 2016 revealed the facility to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Nursing staff must count controlled drugs at the end of each shift. Any discrepancy was to be documented, reported to the Director of Nursing Services and investigated to determine the cause and identify any responsible parties. This deficiency substantiated Complaint Number OH 669 and Complaint Number OH 609.

Based on observation, staff and resident interviews and record reviews, the facility failed to provide care and services to a resident with a pressure sore, and failed to ensure that a resident did not develop pressure sores unless the clinical condition demonstrated they were unavoidable. This affected three of five residents reviewed with pressure sores (Resident #30, Resident #44, and Resident #74). The facility identified 10 residents residing in the facility with pressure sores. The facility census was 72. Harm occurred when Resident #44 developed a pressure ulcer on 05/20/15 that required a referral to a wound clinic and treatment with [MEDICATION NAME], an Intravenous (IV) Antibiotic after Resident #44 developed [DIAGNOSES REDACTED]. While Resident #44 was receiving the IV antibiotic, he did not receive laboratory studies as ordered to ensure the correct dosage of the medication to ensure appropriate treatment of [REDACTED].#44 also received [MEDICAL TREATMENT] three times a week. Harm occurred to Resident #74 when the facility failed to follow the interventions in the resident's plan of care resulting in the development and initial discovery of a Stage III pressure ulcer to the coccyx. Findings include: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/31/15 he was assessed as having a Brief Interview for Mental Status score of 12, which would indicate moderate cognitive impairment. The assessment dated [DATE] identified Resident #44 needed limited assistance with bed mobility and transfers, and supervision with locomotion via wheelchair while on the unit. Resident #44 was continent of bowel and bladder. He was not on a pain medication regimen and did not complain of pain. Review of the treatment administration record indicated Resident #44 was to have a skin assessment every week on Fridays. The assessment was completed 05/01/15, 05/08/15, 05/15/15 according to the treatment record. The facility was unable to produce any nursing documentation regarding the condition of Resident #44's skin on these dates. On 05/20/15, the medical record indicated that Resident #44 was to have a skin assessment today per Director of Nursing. There was no documentation regarding the reason for the assessment. The facility was unable to produce any documentation as to what was noted upon this assessment. A Physician order [REDACTED]. LPN #10 verified on 08/20/15 at 9:50 AM there was no assessment, measurements nor description regarding the wound noted on the right foot on 05/20/15. An ultrasound report dated 05/21/15 indicated no significant limitation of arterial flow in the right lower extremity. A review of the Physician record from vascular surgery consult indicated Resident #44 was to follow up with the Wound Center on 06/16/15 and to apply a dressing to the right foot; wet to dry normal saline and change twice daily. Review of physician information from wound center on 6/16/15 indicated to cleanse both wounds, right medial foot and right lateral foot daily with saline, apply santyl ointment and saline moist gauze, cover with dry dressing and the roll gauze daily. A follow up appointment was made for 06/23/15. The facility could not produce documentation that a follow up appointment was maintained for Resident #44. On 07/02/15, Resident #44 was seen at the Wound Care Center and was treated for [REDACTED].#44 was to receive a Vanco trough (laboratory report) before the third dose and to return to the wound clinic on 07/09/15. There was no further information from the wound clinic available for review. Interview on 08/19/15 at 3:57 PM with the Director Of Nursing (DON), RN#15, and LPN #10 confirmed there was no further information from the wound clinic regarding Resident #44. The last notation from the Certified Nurse Practitioner who conducted an in house assessment of wounds was 07/24/15. During an interview with Resident #44 on 08/19/15 at 4:59 PM he stated he did go to wound clinic at the Hospital and he had not been there for a good while. Resident #44 stated he had been going weekly but was unable to remember the last time he was there. A review of monthly physician progress notes [REDACTED].) #58 revealed no mention of a wound to Resident #44's right foot on 10/03/14, 11/04/14, 12/14/14, 01/03/15, 02/08/15, 03/07/15 and 04/04/15. Dr. #58's progress note on 06/07/15 stated the resident was evaluated at the wound center today and the wound to the right foot was not healing. Dr. #58's progress note on 07/03/15 stated to continue to follow up at the Wound Center for wound on the lower right extremity, and on 08/08/15 stated to continue to follow up at the wound center. During an interview with the DON and RN #15 on 08/19/15 at 11:12 A.M., they confirmed they were not aware of the intent for Resident #44 to follow up at the Wound Center. On 08/20/15 at 1:26 P.M., LPN #10 reported she talked to Dr. #58 regarding Resident #44 going to the wound clinic at the Hospital. LPN #10 stated Dr. #58 stated he was not sure if Resident #44 was still going to wound clinic and at this time would wait until the new wound practitioner started coming to the facility and would have Resident #44 evaluated. Review of weekly skin assessments revealed no skin assessment sheets were available before 06/05/15. This was confirmed by LPN #10 and RN #15 on 08/20/15 at 4:00 P.M Weekly Skin Assessments dated 06/05/15, 06/12/15, 06/19/15, 07/03/15 identified the previously identified pressure area, and previously identified non-pressure area were completed by LPN #60 and all were dated on 07/17/15. Weekly skin assessment dated [DATE] by RN #67 identified no pressure areas and no non-pressure areas. Weekly skin assessments dated 08/06/15 and 08/13/15 identified previously identified pressure and non pressure areas and were completed by LPN #10. On 08/20/15 at 4:00 PM, LPN #10 and RN #15 confirmed that the first pressure skin grid available for review was on 06/05/15. On 06/05/15, the weekly skin grid identified an area to the right lateral foot measuring 9.4 cm length by 5.5 cm width and questionable depth as a suspected deep tissue injury with minimal serous drainage and unknown duration. The second area identified on 06/05/15 identified a right medial foot area 7.5 cm in length, 6.9 cm in width and questionable depth of unknown duration with moderate serosanguineous drainage and odor. Skin assessment completed 06/19/15 identified the right lateral foot wound measured 10.0 cm in length, 6.0 cm in width and questionable depth, identified as pressure with vascular component and minimal serosanguineous drainage. Review of the assessment indicated the physician was notified of the decline in the wound at this time. The 06/19/15 assessment of the right medial foot identified an area 7.7 cm in length, 7.0 cm in width and unknown depth with moderate serosanguineous drainage with odor. Skin assessment indicated the physician was notified of the decline in the wound at this time. There was no assessment available for review from 06/19/15 to 07/03/15. The skin assessment dated [DATE] stated the right lateral wound was 9.8 cm in length, 5.4 cm in width and unknown depth with moderate serous drainage. There was no assessment of the right medial foot area. The next assessment was dated 08/06/15 and described the right medial foot wound as 4.8 cm in length, 4 cm in width, and 0.4 cm in depth, pressure area with vascular components and moderate serosanguineous drainage. The right lateral foot wound as 9.2 cm in length, 5.2 cm in width, and 0.3 cm in depth with minimal serous drainage. There was no documentation the physician was notified of the decline in the resident's condition on 08/06/15. On 08/20/15 at 4:00 P.M. interview with RN #15 and LPN #10 confirmed there was no weekly assessment available for review from 07/03/15 through 08/06/15. On 08/19/15 at 8:22 A.M. during interview, the surveyor confirmed with DON that all assessments would be on point click care and had not been completed weekly. Review of Resident #44's plan of care addressed potential/actual impairment to skin integrity related to an open area to the plantar aspect of the right foot. This plan of care was initiated 03/09/11 and had been updated through 06/18/15. On 08/20/15 at 4:00 P.M., the DON and RN #15 stated this was the current Plan of Care for Resident #44. The Plan of Care did not address the open area to the right medial aspect nor the right lateral aspect of Resident #44's foot. The Plan of Care also did not address the current physician's orders [REDACTED]. The physician's orders [REDACTED]. This was not included on Resident's #44 Plan of Care. 2. Review of Resident #74's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of weekly skin assessment for Resident # 74 dated 07/01/15 revealed no pressure ulcers were noted, and skin was intact. Review of skin grid pressure ulcer documentation dated 07/23/15 revealed Resident # 74 was found to have a Stage III pressure ulcer to the coccyx. Measurements of the pressure ulcer, completed by LPN #10, were 1.0 centimeter (cm) long by 1.0 cm wide by 1.6 cm in depth. A scant amount of bloody drainage with slight odor was present. Review of weekly skin assessments for Resident #74 revealed the weekly skin assessments were absent from the clinical record from 07/01/15 until 07/23/15. No documentation was found to indicate the status of Resident # 74's skin condition. Review of Resident # 74's most recent skin grid pressure ulcer measurement on 08/13/15 for the coccyx Stage III was 1.8 cm long x 0.8 cm wide x 1.6 cm depth. No drainage or odor was present. Review of Resident #74's Braden Scale for predicting pressure ulcer risk dated 06/01/15 revealed a score of 14 indicating high risk for pressure ulcers. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 74 was assessed for pressure ulcer risk, and did not have a Stage III pressure ulcer present. Review of Resident # 74's pressure ulcer care plan dated 6/25/15 revealed an intervention of weekly skin assessments. Review of facility policy titled Skin Risk Assessment dated February, 2013 and Skin Assessment - Monitoring and Healing dated February, 2014 revealed the facility would prevent acquired pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable. It further revealed the pressure ulcers were to be assessed by a nurse weekly with documentation of the location, staging, size and description. Interview on 08/19/15 at 11:55 A.M. with LPN # 10 verified there was no documentation for Resident # 74's skin assessment from 07/01/15 until 07/23/15 when she found the coccyx Stage III pressure ulcer and completed the skin grid measurements. Review of physician telephone orders for Resident #74 dated 07/31/15 revealed a new order to the coccyx Stage III pressure ulcer to irrigate with normal saline, apply santyl, pack with a hydrogel dressing, apply a border foam dressing, and change every day and as needed. Registered Nurse (RN) # 20 documented on 07/31/15 in the progress notes the new pressure ulcer treatment orders by the certified nurse practitioner (CNP). Review of Resident #74's August 2015 Treatment Administration Record (TAR) revealed orders to the coccyx pressure ulcer to irrigate with normal saline, pack with a hydrogel dressing, and cover with a dry dressing, and change daily and as needed. The physician order [REDACTED]. The new pressure ulcer order to the coccyx dated 07/31/15 was not reflected on the August 2015 TAR. Observation on 08/19/15 at 11:40 A.M. revealed LPN # 10 administered the treatment to Resident # 74's coccyx stage three pressure ulcer consisting of a normal saline irrigation, packed with a hydrogel dressing and covered with a dry dressing. Interview on 08/19/15 at 12:24 P.M. with LPN # 10 verified she did not follow the new pressure ulcer order dated 07/31/15 for Resident # 74's coccyx treatment. She further verified the new order was not documented on the August TAR for Resident # 74. She stated she would have to look into it to clarify. 3. Record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. She needed extensive assistance of one staff member for bed mobility, transfers, and did not walk in the room or in the corridor. She was totally dependent on staff for dressing, personal hygiene, and toilet use. She had functional limitation of both upper and lower extremities. She was always incontinent of bowel and bladder. Review of the care plan dated 06/09/14 revealed the resident was at high risk for pressure sores with a goal to remain free of open areas. The goal date was updated with a current goal date of 09/30/15. Interventions included to keep skin clean, dry, and free of body waste, perspiration, and wound drainage and to assess skin weekly. Interventions on Activities of Daily Living (ADL) care plan dated 06/09/14 included to turn and reposition every two hours as required and to provide assistance with toileting as required. The nutrition care plan updated 07/17/15 did not address impaired skin integrity. The impaired skin integrity care plan also updated 07/17/15 had a goal of skin will be free of breakdown. Interventions included provide incontinence care as needed, pericare after each incontinent episode, and barrier cream after each incontinent episodes. Nutrition assessment dated [DATE] indicated no pressure ulcers. Nurses progress notes did not indicate skin impairment until 07/23/15. Nurses Progress notes had no evidence of daily monitoring of the Stage II pressure ulcer. Review of physician order [REDACTED]. Skin Risk assessment dated [DATE] identified the resident as high risk for skin impairment. Skin grid dated 07/23/15 identified a new Stage II pressure ulcer to the left gluteal fold with a measurement of 1.8 cm x 1.3 cm x 0.1 cm. Pressure Ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Stage II indicates a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. Review of physician order [REDACTED]. Dietary progress note dated 07/28/15 new skin alteration to buttocks/ coccyx area stage II. The medical record did not indicate any open wounds to the left inner, upper thigh that were currently being monitored. Skin assessments were completed 07/23/2015, 08/06/2015, 08/13/2015, and 08/17/2015 each indicated a Stage II pressure ulcer to the left buttock originating on 07/23/15. The skin grid dated 08/06/15 showed no change in measurements or improvement since 07/23/15. Skin Grid Non pressure assessment dated [DATE] was initiated after the observed dressing change and identified a left gluteal fold excoriation that measured 0.5 cm x 0.7 cm x 0.1 cm. A Skin grid pressure assessment dated [DATE] was also completed for the Stage II pressure wound to left buttock. The Stage II wound measured 0.5 cm x 0.4 cm x 0.1 cm. The medical record indicated new physician orders [REDACTED]. Cleanse open area to coccyx with NSS, apply hydrogel to open area, cover with comfort foam dressing, change daily and PRN. Observation of Resident #30 on 08/19/15 at 7:56 A.M. revealed resident in bed on her back, dressed in a hospital gown with clothing protector on. The head of her bed was elevated 45 degrees. Her breakfast tray was in front of her and she was moving the spoon with left hand not eating. There was an air mattress on the bed in on position with the dial turned past the 360 pound indicator mark. Interview with Resident #30 at that time revealed she stated the mattress doesn't work and it was not comfortable. She indicated she felt sore on her bottom. Interview on 08/19/15 at 8:11 A.M. with LPN #25, RN #30, and the DON confirmed they were not familiar with air mattress or its settings and were not able to determine if the setting was correct. RN #30 stated she would get the maintenance man to find out about the mattress. Interview with LPN #25 on 08/19/2015 at 8:40 A.M. revealed she stated Resident #30 had a dressing ordered to her coccyx, the dressing was changed every five days, and the dressing should remain in place for five days before being changed. She was unable to verify in the record what date the dressing was last applied and stated she believed she saw the dressing in place yesterday when she applied cream to Resident #30's perineal area. Observation on 08/19/15 at 8:51 A.M. revealed RN #30 adjusted the setting on the air mattress. RN #30 turned the dial on the air mattress pump to between the 90 pound to 180 pound setting. Interview at that time confirmed Resident #30 weighed 158 pounds, the setting should be according to her body weight, and should have been set at 158 pounds not over 360 pounds. RN #30 stated Resident #30 needed a new mattress. Interview with Maintenance Director (MD) #35 on 08/19/15 at 8:52 A.M. stated the air mattress was old and the increments were identified on the dial in a weight range not by each specific pound. MD #35 stated the facility did not have another mattress and a mattress would have to be ordered. Observation of Resident #30 on 08/19/15 at 9:55 A.M. revealed she remained on her back with her head of bed elevated 45 degrees. STNA #11 began Resident #30's A.M. care. Resident #30 had on a white incontinence brief that had a blue stripe on it. STNA #11 indicated that meant the brief was wet. STNA #11 rolled resident toward the wall to expose her back side. There was an additional saturated incontinence brief under Resident #30. STNA #11 discarded two incontinence briefs that were saturated. There was an open wound to the left inner, upper thigh with red drainage and an open wound to the left coccyx area. STNA #11 verified there was no dressing in the incontinence briefs. She left the room to get the nurse and then returned. Interview with STNA #11 on 08/19/15 at 10:00 A.M. revealed she stated the night shift STNA (unidentified) had put the two pads on Resident #30. She stated she only used one pad and that was the first time Resident #30 had been changed since the night shift. She stated that breakfast time was always busy and she had to feed residents. Interview with LPN #25 on 08/19/15 at 10:14 A.M. verified the dressing that was ordered for Resident #30 was not in place and should have been because Resident #30 also had an as needed order. LPN #25 verified the wound was open to the left inner, upper thigh and there was a wound in the buttocks crease and a Stage II pressure ulcer to the left side of the coccyx. LPN #25 left the room and returned with RN #15. Interview with RN #15 on 08/19/15 at 10:20 A.M. verified the left inner, upper thigh had an open wound with red drainage. RN #15 confirmed the left side of the coccyx area was open and stated she believed the area in the crease of her buttocks was healed scar tissue. Observation of dressing change on 08/19/15 at 10:31 A.M. performed by LPN #25 on Resident #30 revealed she washed her hands, provided a barrier in the bed, put on gloves, cleansed the left inner, upper thigh, measured the wound to be 0.7 cm x 1.0 cm x 0.1 cm, and applied a water proof foam dressing. LPN #25 did not change her gloves or wash her hands prior to cleansing the Stage II pressure ulcer to Resident #30's left buttock/ coccyx area. LPN #25 measured the wound to be 0.5 cm x 0.4 cm x 0.1 cm, applied hydrogel and a foam dressing, removed her gloves, and then washed her hands. Interview with LPN #25 on 08/19/15 at 10:42 A.M. revealed LPN#25 stated that Resident #30's wounds were all in the peri area and it was not her practice to change her gloves or wash her hands between wound sites located in the same general area. LPN #25 confirmed the wound to the inner, upper thigh was a new area and LPN #25 initiated a new treatment. Interview with LPN #10 on 08/20/15 at 9:29 A.M. revealed she was the facility's wound nurse. LPN #10 stated it was the facility's expectation the nurse performing treatments would remove their gloves and wash their hands between cleansing individual wounds. LPN #10 confirmed that was a standard infection control practice. Interview with the DON on 08/19/15 at 3:27 P.M. verified the findings of the skin assessment, skin grids, and dates of assessments in the medical record. The DON confirmed that skin grids were documented in the computer, but was not aware of how often the assessments were completed. Interview with the DON on 08/20/15 at 8:52 A.M. revealed she stated incontinence care was expected to be provided every two to three hours or per resident's choice. The expectation and practice was that only one incontinence brief should be used at a time. The DON confirmed Resident #30 was at high risk for skin impairment and should not have two incontinence briefs used at the same time. Review of the facility's Skin: Dressings and Wound Care policy dated 04/2002, updated 07/2003 and 01/2005 revealed Ulcers would be treated according to physician's orders [REDACTED]. Review of the facility's policy Skin Assessment- Monitoring and Healing dated February 25, 2014 revealed a licensed nurse would monitor pressure ulcers daily. Daily monitoring of a pressure ulcer would be charted in the nurse's note and include: a) an evaluation of the ulcer if no dressing is present b) an evaluation of the status of the dressing (intact, drainage, leaking, etc.) c) the status of surrounding ulcer (observed without removing the dressing) d) the presence of possible complications (increased redness, swelling or drainage) e) whether pain, if present, is adequately controlled. A nurse would also assess ulcers and wounds at least weekly. The following would be documented on the appropriate skin grids: a) location and staging b) size, length, width, depth c) presence, location, and extent of any undermining or tunneling d) Exudate, if present: type (purulent, serous) color, odor, and approximate amount e) pain, if present, nature and frequency (episodic or continuous) f wound bed: color and type of tissue/ character including evidence of healing (granulation) g) description of wound edges and surrounding tissue (rolled edges, redness, hardness/ induration, maceration). The nurse will report failure of the wound to respond to the current treatment within two weeks. Review of the facility's policy Skin: Incontinence Care Protocol dated January 14, 2005 revealed the purpose was to maintain skin integrity, prevent skin breakdown, control odor and provide comfort and self- esteem for the resident. Review of the facility's Hand Washing policy dated 12/28/2013 revealed employees at a minimum should wash their hands after contact with any body fluids and after handling any contaminated items. This deficiency is a re-cite to the complaint survey completed 06/16/15.

Based on medical record review, observations, staff interview, review of the facility's policy regarding missing/wandering residents, review of the Elopement Risk Assessment policy, review of the facility's incident report, review of the facility's Self-Reported Incident (SRI) investigation, and review of the surveillance camera timeline, the facility failed to supervise one resident, (Resident #1) of eleven residents identified at risk of elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy for Resident #1 who successfully eloped from the facility's secure unit without staff knowledge and was found approximately 6 miles from the facility. Three additional residents identified at risk were reviewed for exit seeking behaviors, Residents #2, #3 and #4. On 07/28/15 at 8:45 A.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 07/17/15 at approximately 7:57 P.M., when Resident #1 exited the facility through an alarmed exit door which was de-energized (un-alarmed). The facility was not aware Resident #1 was missing until approximately 8:13 P.M. Resident #1 was independently mobile per his wheelchair. He propelled self an unknown distance to a nearby gas station where he was able to gain transportation to his family's residence approximately five to six miles away from the facility. Family members found Resident #1 circling the apartment parking lot in his wheelchair at approximately 9:30 P.M. The resident's family members then notified facility administration per telephone that Resident #1 was at his home residence at 9:52 P.M. Resident #1's spouse didn't want him in their home. Resident #1's psychiatrist was phoned and ordered a psychiatric examination. At the first evaluation, the Emergency Medical Services (EMS) was not willing to take Resident #1 to the hospital because of his refusal. The EMS felt Resident #1 was alert and oriented. However, during the course of the EMS assessment, Resident #1 exhibited increased agitation and was yelling and cursing. Resident #1 then agreed to be transported per EMS to the hospital for physical evaluation and treatment however he refused a psychiatric evaluation. Resident #1's spouse stated she was afraid of him. The Immediate Jeopardy was removed on 07/27/15 at 8:00 A.M. when the facility implemented the following corrective actions: · On 07/18/15 at 2:00 A.M. the Administrator and Director of Clinical Services (DCS) #80 began in-servicing for all facility staff working that night concerning all residents who resided on the secure care unit and the risk of elopement. · On 07/18/15 at 4:15 A.M., Resident #1 returned to the facility from the hospital without injury. A Wander-Guard bracelet ( a device that causes exit doors to alarm and alert staff when a resident is near an exit or actually exits) was immediately placed on the wheelchair frame of Resident #1's wheelchair as this was the resident's primary mode of transportation. At approximately 10:06 A.M., DCS #80 increased the staffing on the secured unit to two State-tested Nurse Aides (STNA) and began monitoring the secured unit assignment. · On 07/18/15, at approximately 11:10 A.M., an Elopement Reassessment was completed for Resident #1. Resident #1 was assessed by the facility physician #83 at 12:02 P.M. · On 07/18/15 through 07/23/15, review of facility in-service documentation revealed that 33 STNAs, eight Licensed Practical Nurses (LPN), five Registered Nurses (RN), two Maintenance employees, eight Housekeeping employees, two Laundry employees, eleven Dietary employees, and three Administration employees were provided education regarding facility elopement policies and procedures. This education was provided by the Administrator and DCS #80. Five employees remain to be educated. As per interview with the Administrator on 07/29/15 at 12:30 P.M., these five will receive the in-service training prior to working on the floor. · On 07/20/15 at 8:00 A.M., DCS #80 and Minimum Data Set (MDS) Nurse #9 reviewed the elopement assessments and care plans of the eleven residents who resided on the secure care unit. All eleven records were reviewed for accuracy. · On 07/20/15 at 9:45 A.M. Maintenance Supervisor #81 verified the alarm volume on the secured care unit exit doors was sounding loudly. Daily checks on all alarmed doors began at 9:00 A.M., and continued throughout the day at various times by Maintenance Director #81 and this process continues daily. · On 07/20/15 at 2:00 P.M. a notification sign was posted at the receptionist desk at the main lobby as a reminder to staff to activate the outer exit door burglar alarms (not part of the secured unit) for the courtyard exit at 5:00 P.M. each evening. · On 07/21/15 at 9:00 A.M. the Administrator and DCS #80 began to audit staff knowledge of residents off the secured care unit. The plan for elopement drills for missing resident was to be completed three to five times a week for four weeks and monthly thereafter. Two elopement drills were conducted on 07/21/15 at approximately 2:00 P.M. and 7:22 P.M. These drills were conducted with staff present on their individual shift and an unnamed volunteer resident who acted as an eloping resident. This resident was hidden in the facility with a member of Administration present, and a search was conducted to determine their whereabouts. As per interview with the Administrator revealed that during the audit of Maintenance Director #81 revealed he was conducting the alarm testing at the same time. The Administrator advised Maintenance Director #81 to randomly audit the alarm doors. · On 07/22/15 at 3:13 P.M., Geriatric Psychiatrist #82 conducted an onsite evaluation of Resident #1. · On 07/23/15 at 3:00 P.M., DCS #80 developed Elopement Kits which were kept at the main nursing station. This kit detailed exactly what to do in the event of a future elopement and provided specific assignments for each facility staff member present for that shift. · On 07/24/15 at 4:00 P.M. the secured care alarm company verified the alarms on the doors of the secured care unit were functional. There were two fire exit doors to stairwells on the secured unit. · On 07/27/15 at 3:00 P.M., a daily sign off sheet for activating the burglar alarms was implemented and posted at the receptionist desk. This posting was in addition to the notification sign that was posted on 07/20/15. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy), as the facility is in the process of implementing the new policy regarding exit door alarms being activated and assessing the appropriateness of staff response to the newly developed drills regarding missing persons. In addition, there were five additional staff members that had not received the inservice training. Findings Include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. This resident was not be assessed for cognition per MDS assessments due to multiple resident refusals on attempted assessments. The resident resided in the facility's secured unit. On 05/14/15, a Wandering Risk Assessment was completed for Resident #1 identifying him as a moderate risk for wandering with a score of 5 with 15 being without risk. This assessment identified Resident #1 as disoriented, severely agitated and combative. On 07/01/15, Resident #1 was assessed for an Elopement Risk. At the time of the assessment, Resident #1 was alert and oriented to person, place, and time; was dependent for wheelchair mobility; and had not made any attempts to exit the facility. No score was provided on the assessment. On 07/18/15, Resident #1 was assessed with [REDACTED]. This was reviewed by RN #79 on 07/18/15 and a Wander-Guard alarm bracelet was placed on the resident's wheelchair. This assessment revealed that Resident #1 presented with exit seeking behaviors, was alert to self only, and was mobile in his wheelchair. Review of nurse's notes revealed Resident #1 was admitted to the facility on [DATE] and the resident was admitted to the secured unit due to increased concerns for resident safety and behaviors. Resident #1 was also documented to display increased behaviors and combativeness, such as yelling, cursing and swinging at facility staff. There was no plan of care developed for Resident #1 for elopement or exit seeking behaviors until 07/20/15. No entries for any further attempted elopements were documented following the incident on 07/17/15. Review of Resident #1's plan of care dated 07/20/15 revealed the resident was not considered an elopement risk until 07/18/15. Interventions included staff intervention for unsafe decisions, give supervision for daily decision making, and monitoring the Wander-Guard bracelet every shift and daily for function. Review of the facility SRI investigation dated 07/18/15 revealed Resident #1 exited the building on 07/17/15 through an unalarmed door and gained transportation from a stranger at a local gas station to his family home approximately six miles away. The resident was transferred to the hospital emergency room and no injuries were identified. Observation of Resident #1 on 07/27/15 at 10:30 A.M. revealed the resident was resting in bed with his eyes closed and no acute distress. The call light was within reach and no concerns noted. A Wander-Guard bracelet was visible and attached to the frame of his wheelchair. An attempt was made to interview Resident #1 however; the resident would not answer any questions. Interview with the Administrator on 07/27/15 at 10:50 A.M. revealed that Resident #1 left the third floor alarmed unit on the evening of 07/17/15 at approximately 7:45 P.M. The Administrator stated that Resident #1 was able to enter the main elevator and proceed to the first floor of the facility. The Administrator stated that (STNAs #43 and #53 were actively looking for the resident, proceeded to the North exit doors and went outside in an attempt to locate him. The Administrator stated that while the two STNAs were outside, they were able to visualize Resident #1 still in the facility at the first floor dining room seated in his wheelchair. STNAs #43 and #53 were aware Resident #1 resided on the third floor secured unit and observed the resident unsupervised on the first floor. At approximately 8:05 P.M., STNA #60 used the main elevator and proceeded to the back door where STNAs #43 and #53 were positioned. The Administrator stated STNA #60 did not see the resident. It then was apparent the resident used an unalarmed side door on the first floor to gain access to the outside courtyard. The outside courtyard was located on the West side of the building. The Administrator stated the outside access door to the courtyard was to be locked and alarmed at approximately 5:00 P.M. each day and this was not completed on the day of the elopement. The courtyard was surrounded by a wooden fence, however there was a ' panic bar ' present that if pressed for 15 seconds, would unlock the wooden fence door. The Administrator also stated that Resident #1 was able to exit through this door undetected and proceed through the courtyard and exited the courtyard through an unlocked wooden gate gaining sidewalk access. Resident #1 was discovered by family members in the parking lot of his spouse's apartment complex at 9:52 P.M. According to the Administrator, this location was approximately six miles from the facility. Review of the facility's Video Surveillance Timeline on 07/27/15 at 11:00 A.M., revealed that at 7:57 P.M. on 07/17/15, STNA #43 and #53 were positioned outside of the glass exit door on the North side of the facility. At 7:58 P.M., visual contact was made by both STNAs of Resident #1 through the glass door. Resident #1 was seated in his wheelchair in the back section of the first floor dining area. At 8:03 P.M., Resident #1 moved into the adjacent hallway and proceeded outside through the West courtyard exit undetected at 8:05 P.M. At 8:06 P.M., STNA #60 walked past the courtyard door that Resident #1 had just exited, without making visual contact with the resident on the outside. STNA #60 exited the North exit door and spoke to STNA #43 and STNA #53 at 8:06 P.M. During that time, Resident #1 had gained access to the wooden courtyard door to the street. Interview with STNA #32 on 07/27/15 at 10:15 A.M. revealed that she currently worked on the 300 hall locked unit and Resident #1 had exhibited multiple wandering tendencies in the past. STNA #32 stated that on the night of 07/17/15, the resident was able to exit the locked unit and somehow managed to eventually exit the facility during the evening hours. STNA #32 stated at that time, a Wander-Guard bracelet was not in place to her knowledge and there was only one STNA working the floor on that night. STNA #32 also stated that she was not working during the time of the resident elopement, and that she had told facility administration that there was a possibility of resident escape due to a low number of facility staff on evening shifts prior to Resident #1's elopement. Interview with STNA #32 on 07/27/15 at 1:45 P.M. revealed that all residents on the secured unit were to always be with a staff member when out of the secured unit at any time for safety purposes. STNA #32 stated following Resident #1's elopement, in-services were held to educate staff regarding drills to locate a missing resident, notify the Administrator and DCS #80 and to notify family and the Police Department if the resident could not be found following an elopement. Telephone interview with STNA #53 on 07/27/15 at 2:15 P.M. revealed that when she began her shift on 07/17/15 at 7:00 P.M., Resident #1 was extremely agitated. STNA #53 stated that a dayshift nurse aide (unidentified) accompanied the resident to the vending machines in the basement and brought him back up to the third floor where he was allowed to sit near the birdcage/aviary. STNA #53 stated the resident disappeared from the area shortly after and was able to make his way to the elevator and down to the first floor dining room. STNA #53 stated she took the back elevator to the back entrance and positioned herself outside the back door with STNA #60 and watched Resident #1 through the glass doors. She stated that she then entered the building again and went back upstairs leaving the resident still sitting in his wheelchair in the back of the dining room. STNA #53 stated that shortly afterwards (no time noted), she was sitting in the nurse ' s station when Resident #1 ' s wife called stating that the resident was currently sitting in the parking lot of her apartment building. She stated that Resident #1 was extremely irritated and agitated throughout the entire evening, and had attempted to leave the unit several times the previous day. STNA #53 stated she was previously instructed by the Corporate Nurse (CN) #1 that the resident could sit off of the unit and watch the birds in the birdcage. Interview with STNA #43 on 07/27/15 at 2:30 P.M. revealed that on 07/16/15, CN #1 was called into the facility regarding Resident #1's exit seeking behaviors. She stated that around 8:00 P.M. on 07/17/15, she was working on the second floor when she was told that Resident #1 was attempting to leave the facility. STNA #43 also stated that she went to the back door and was able to watch Resident #1 move from the back door to the back of the dining area. STNA #43 stated the resident was able to gain access to the outside courtyard through the side door. STNA #43 stated that no alarms were heard. Interview with STNA #60 on 07/27/15 at 2:50 P.M. revealed he was assigned to work on the secured unit on the evening of 07/17/15 beginning at 7:00 P.M. The STNA stated that a dayshift STNA (unidentified) took Resident #1 to the basement area to the vending machines and brought him back shortly afterwards and left him on the secured unit. STNA #60 stated that shortly afterwards, he assisted another resident to bed and during that time, Resident #1 exited the secured unit and was observed by the birdcage/aviary. STNA #60 stated there was a nurse (unidentified) at the main nurses' station at that time, and the next thing that he knew, the resident was gone. Interview with Resident #1's spouse on 07/27/15 at 3:00 P.M. revealed that on the evening of 07/17/15, she received a knock on her door by an unnamed male that stated he provided her husband a ride to her apartment complex. She stated she saw Resident #1 riding his wheelchair in the parking lot and she became fearful that he was away from the facility. Resident #1's spouse stated that she immediately had her daughter call the facility and notify them Resident#1 was at her current residence. Resident #1's spouse stated that she had not been notified by the facility that Resident #1 had eloped. The first correspondence was made when the family placed their own call to the facility at around 9:30 P.M. Observation of the third floor exit areas on 07/28/15 at 8:00 A.M. revealed that both exit stairwell doors were alarmed and locked. Observation of the secured unit door revealed there was an audible alarm that sounded each time the secured unit door was opened. Observation of the outside courtyard access door revealed that this door remained unlocked from the inside at all times and was locked from outside entry each day at 5:00 P.M. and that an alarm would sound if exit was attempted. Observation of the third floor secured unit on 07/28/15 at 1:55 P.M. revealed all 14 residents who utilized Wander-Guard bracelets had the bracelets in place and functioning. Interview with STNA #76 on 07/28/15 at 1:25 P.M. revealed that she was a newly hired employee who had been in-serviced on the new elopement procedure on 07/27/15. She stated there was a new elopement box that gave instruction on how to deal with an attempted elopement and that it was located at the main nurse ' s station. Interview with LPN #7 on 07/28/15 at 1:35 P.M. revealed there were 11 residents on the secured unit. LPN #7 stated that all exit stairwells were locked and alarmed to prevent resident elopement. LPN #7 stated that a new procedure was being implemented regarding resident elopement and staff was educated on the new procedure. LPN #7 stated that additional STNA staffing was being implemented for the secured unit. Interview with STNA #30 on 07/27/15 at 1:55 P.M. revealed that if a resident was an elopement risk, that resident was to be accompanied by at least one facility staff member at all times when off of the unit. She also stated that in the event of an actual elopement, the resident ' s family, the Administrator, DCS #80 and police were to be notified for resident safety. Interview with RN #79 on 07/28/15 at 2:15 P.M. revealed that all employees have been in-serviced regarding new policies and procedures for elopement. There have been no other elopements from the secured unit since Resident #1 on 07/17/15. This deficiency substantiates Complaint Number OH 056 and is an example of continued non-compliance from the complaint survey completed 06/16/15.

Based on observation, medical record review, review of the facility's Abuse Policy, staff interview and review of the facility's Self-Reported Incidents, the facility failed to ensure a resident was free from physical abuse. This affected one of six residents reviewed related to abuse (Resident #3). The census was 75. Harm occurred when a resident was struck by a Stated tested Nurse Aide (STNA) causing a bloody, swollen lip. Findings include: Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the resident's Minimum Data Set (MDS) 30 day readmission assessment dated [DATE], he required extensive assistance with activities of daily living (ADL's) and was severely cognitively impaired. Review of documentation in the medical record of Resident #3 revealed there was an injury to the resident's mouth. Review of Progress Notes dated 11/26/13 at 1:28 A.M. (actual time not noted in the progress note regarding the actual time of the injury) under the section Change in Condition Note, Physician Phone Order: During PM (evening) rounds this nurse (Licensed Practical Nurse #11) entered Resident #3's room. The resident was sitting in his wheelchair and STNA #1 was standing beside the resident cleaning blood from the resident's mouth. Resident #3 stated that his mouth was swollen. This nurse assessed Resident #3's mouth and cleaned the area as much as possible with a wet towel and asked State tested Nurse Aide (STNA) #1 what happened? There was no documented reply to the question in the note. The nurse instructed STNA #1 to continue cleaning Resident #3's face and prepare him for bed. Vital signs assessed as temperature 98.3 degree's Fahrenheit (F), pulse 88, blood pressure 142/68 millimeters of mercury (mm/Hg) with respirations 18. Licensed Practical Nurse (LPN) #11 reported Resident #3's condition to the supervisor and called the physician for a stat (as soon as possible) X-ray. A message was left for the Power of Attorney (POA). According to Change in Condition Documentation: to monitor resident for signs/symptoms (s/s) of bleeding, change in level of consciousness (LOC), complain of pain to face /mouth. There was no documentation that evidenced the resident was in pain. There was no documentation in the resident's Progress Note section of the medical record regarding what occurred to Resident #3 on 11/25/13. Information documented in the facility investigation evidenced the documenting LPN, LPN #11 was aware regarding what happened to Resident #3. Resident #3 was physically abused by STNA #1 resulting in a laceration to the lip with bleeding and bruising as a result of being punched in the mouth by STNA #1 at approximately 7:30 P.M. on 11/25/13. Review of the Self Reported Incident (SRI) summary completed on 11/28/13 by the facility revealed on 11/25/13 at approximately 7:30 PM Resident #3 presented with a swollen bleeding lip. STNA #1 was providing care and stated to Registered Nurse (RN) #10 that Resident #3 fell while getting out of bed and hit his mouth on the siderail. STNA #2 stated that STNA #1 was rushing Resident #3 and grabbed his neck and choked him to the bed and punched him in the face. STNA #1 was sent home. Resident #3 stated that he got busted in the mouth. Resident #3 was cleaned up. The Guardian was notified of injury, the physician was notified and a stat X-ray was ordered and did not reveal any other injuries. The facility's Administrator was notified by RN #10 at approximately 7:53 P.M. The police were called at approximately 8:00 PM. The Administrator and RN #10 met the police officer at their arrival. Review of the police report indicated the investigation was for an assault to Resident #3 by STNA #1 which occurred on 11/25/13. STNA #1 was removed from the floor and sent home prior to the police arrival. Review of the written statement by STNA #2 completed on 11/25/13 at approximately 7:30 P.M., revealed STNA #2 went to see STNA #1 on the unit to talk about the schedule. STNA #1 was at the linen cart to get a gown for Resident #3. STNA #1 and STNA #2 headed toward Resident #3's room. Once at Resident #3's room STNA #1 rushed into the resident's room because Resident #3 was trying to get out the bed. While STNA #1 was rushing, she grabbed Resident #3's neck and choked him to the bed and slammed him down on the bed. STNA #1 then punched Resident #3 in the mouth. After seeing STNA #1 hit Resident #3, STNA #1 asked for a washcloth because he was bleeding. STNA #2 got some ice and a washcloth to help Resident #3. At that time, LPN #11 was making rounds and entered the unit and saw the two STNA's in Resident #3's room. LPN #11 saw his mouth was bleeding and asked what happened. STNA #1 stated that he fell . STNA #2 documented she was in shock and felt panicked and did not say anything and then she ran out of the unit down to the second floor. LPN #11 then left the unit and proceeded to the central nursing station to inform RN #10 that Resident #3 had fallen. RN #10 finished up what she was doing and was leaving. While STNA #2 was on the second floor, STNA #4 who stated that she was looking for RN #10 because Resident #3 said that STNA #1 busted him in the mouth. STNA #2 told STNA #4 that she witnessed Resident #3 getting hit in the mouth. STNA's #2 and #4 searched for RN #10 and found her at the backdoor getting ready to leave and informed her of the incident. RN #10 proceeded back to the third floor informed LPN #11 of the situation and instructed her to go back to the unit with her and get STNA #1 out of the building after she writes her statement. RN #10 proceeded to examine Resident #3 and asked him what happened. Resident #3 stated that she hit me in mouth. RN #10 then left the unit and called the facility Administrator. The Administrator instructed RN #10 to get STNA #1 out the building and call the police. Review of the written statement of STNA #1 denied striking Resident #3. Review of the facility's "Abuse Policy" dated 01/01/00 revealed the facility did follow procedure for investigation and reporting. However, the facility failed to meet the goal to achieve an abuse free environment for Resident #3. During the course of the complaint investigation on 12/02/13 and 12/03/13, interview with three licensed nursing staff, four STNA's, two housekeepers and the speech therapist (ST) revealed all were aware of the facility's abuse policy and immediate reporting. The ST reported she observed the swelling and bruising to the lip of Resident #3 and reported her observation to the nurse and was told it was already reported. These 10 staff members all worked 7:00 A.M. to 7:00 P.M. The abuse occurred on the 7:00 P.M. to 7:00 A.M. shift. Interview of the 7:00 P.M. to 7:00 A.M. staff was conducted on 12/03/13 beginning at 6:30 A.M. Seven night shift staff were interviewed to include six STNA's and the RN charge nurse. All staff were aware of the facility's Abuse Policy and to report abuse immediate to the nurse supervisor with any type of resident abuse. Observation of Resident #3 on 12/02/13 at 9:30 A.M. revealed the resident was seated in a wheelchair in the lounge. The resident's lower lip to the left side was bruised and swollen with a scabbed area. The resident was unable to tell the surveyor what happened to his lip that caused the bruising. Interview of the Director of Nursing (DON) on 12/02/13 at 9:35 A.M. verified the injury to Resident #3's lower lip was the result of being hit by STNA #1 on 11/25/13. STNA #2 was interviewed on 12/03/13 at 6:50 A.M. STNA #2 was asked to give an account of the incident which occurred on 11/25/13 with Resident #3. STNA #2 repeated the same story as her written statement. STNA #2 described the choking by the neck of Resident #3 when STNA #1 grabbed him by the neck and slammed him to the bed. STNA #2 stated STNA #1 took her fist and busted Resident #3 in the mouth. STNA #2 stated the resident yelled "Ouch, She hit me in the mouth". There was blood everywhere, a lot of blood. STNA #2 stated she left the room to get the nurse supervisor to report the incident because STNA #1 was lying to the floor nurse saying the resident fell out of bed. STNA #2 stated she found the nurse supervisor (RN #10) and reported the incident. The nurse supervisor went back to the third floor and told the floor nurse what had happened and STNA #1 was removed from the facility. Review of an additional SRI completed by the facility dated 09/06/13 also involved Resident #3 and STNA #1. The report indicated the resident had a black eye. The facility was unable to substantiate abuse but investigated as injury of unknown source with conclusion of the resident hit his face on the side rail. STNA #1 was the reporting staff member who discovered the black eye. Interview with the Administrator and President CEO of the facility on 12/18/13 between 8:30 and 9:30 A.M. revealed they felt the staff acted appropriately and as quickly as possible to address the situation of STNA #1 hitting Resident #3. They stated that STNA #2 left the room to report to the RN supervisor because STNA #1 was lying to the nurse that was in the room and she did not want to start a confrontation in front of the resident. Interview with RN #10 on 12/18/13 at 9:40 A.M. confirmed that STNA #2 reported the abuse to her and she immediately went to the unit and had STNA #1 removed from providing care to any resident. This deficiency substantiates Complaint Number OH 696.