Every finding on record at Blue Ash Health & Rehab

Based on medical record review, and staff interview, this facility failed to ensure documentation of medication being administered was charted in residents' electronic medication administration record. (Emar). This affected 11 residents (Resident #60, #62, #64, #66, #68, #70, #72, #74, #76, #78, and #80) of the 12 residents reviewed for medication administration. The facility census was 35. Findings include:Review of the medical records for Resident #60, #62, #64, #66, #68, #70, #72, #74, #76, #78, and #80 revealed each resident had physician orders to receive nighttime or evening medications. Continued review of each resident's electronic medication administration record revealed medication was not documented as being administered for the evening of 05/26/2026. Attempted contact on 05/29/2026 at 2:10 P.M. and again at 3:20 P.M. with Licensed Practical Nurse (LPN) #131 who was the nurse noted to have worked the evening of 05/26/2026 with no success. A voice message could not be left due to the voice mail box not being set up at that time. Attempted to contacted LPN #116 on 05/29/2026 at 2:15 P.M. and again at 3:15 P.M. with no success. LPN #116 was noted to be the nurse who was scheduled to work the evening of 05/26/2026 but was noted to be a no call, no show. Interview on 05/29/2026 with Registered Nurse (RN) #113 at 4:40 P.M. and LPN #76 at 4:45 P.M. revealed when a medication is administered to a resident, the electronic medication record will display a check mark in the box for that medication along with a time and the initials of who administered the medication. If the medication was refused it will have a R or REF marked in the box for that medication along with the time the medication was refused and the initials of who attempted to administer the medication. When the electronic medication record had a blank for a medication, it indicates that the medication was not given as per order or that the medication was not documented as being given even if it was administered. Interview via email on 06/01/2026 at 5:21 A.M. with the Director of Nursing (DON) revealed, When reviewing a medication administration record, if a medication has been administered, a check mark will be noted. When a medication has been refused, RD is noted in the box. When the box is empty/blank, the nurse may have not signed off on the medication, or the medication was not administered. Further interview with DON revealed she could not verify if Resident #60, #62, #64, #66, #68, #70, #72, #74, #76, #78, and #80 received their medication or LPN #131 forgot to sign off the medications on the Emar.

Based on observation, interview, and record review, the facility failed to ensure the facility had hot water in resident areas per resident preferences. This affected 18 residents (#02, #06, #08, #09, #10, #11, #12, #17, #18, #19, #23, #24, #25, #32, #33, #34, #35, and #36) out of 36 residents residing in the facility. The facility census was 36.Interview with Resident #08 on 03/12/26 at 8:17 A.M. revealed the water did not get hot at the facility. Resident #08 stated the water was also cold during bathing.Interview with Resident #11 on 03/12/26 at 8:19 A.M. revealed the water was cold at the facility and did not get hot. Resident #11 stated the water had been cold for approximately two months. Interview with Resident #17 on 03/12/26 at 8:39 A.M. revealed one side of the building had cold water for a long time. Observation of Maintenance Director #70 taking the water temperatures in the facility on 03/12/26 at 9:00 A.M. revealed the water temperature in Resident #02's bathroom was 135.9 degrees Fahrenheit, the water temperature in Resident #06 and Resident #07's bathroom was 69.7 degrees Fahrenheit, the water temperature in Resident #08's bathroom was 60.9 degrees Fahrenheit, the water temperature in Resident #09 and Resident #10's bathroom was 92.2 degrees Fahrenheit, the water temperature in Resident #11 and Resident #12's bathroom was 82.4 degrees Fahrenheit, the water temperature in Resident #17's bathroom was 95.8 degrees Fahrenheit, the water temperature in Resident #18's bathroom was 77.8 degrees Fahrenheit, the water temperature in Resident #19's bathroom was 93.2 degrees Fahrenheit, the water temperature in Resident #23, Resident #24 and #25's bathroom was 125.8 degrees Fahrenheit, the water temperature in Resident #32 and #33's bathroom was 82 degrees Fahrenheit and the water temperature in Resident #34, Resident #35 and #36's bathroom was 87.7 degrees Fahrenheit. The shower room on the A hallway was 120.8 degrees Fahrenheit, and the laundry room located on the A hallway had no water pressure in the sink and the sink was leaking. The water temperature in the laundry room was not able to be taken due to there being no water pressure. Maintenance Director #70 verified the observations. Maintenance Director #70 stated he had only worked at the facility for three weeks and he had never had a plumber come to the facility since he started working at the facility. Interview with Resident #18 on 03/12/26 at 9:05 A.M. revealed the water did not get hot in his room and he had no water pressure. Interview with Resident #09 on 03/12/26 at 9:20 A.M. revealed the water never got hot in his room or on his hallway.Observation of the boiler rooms on 03/12/26 between 11:00 A.M. and 11:30 A.M. revealed the water lines in both boiler rooms were very difficult to follow. In the C/D boiler room there was a outlet line coming from one hot water heater and going into another hot water heater. There were thermometers attached to two of the water lines but neither thermometer appeared to be working. Further observation found that in the C/D boiler room there were several orange tags hanging from the water lines. One of the tags had the number seven on it with text reading Cold supply to kitchen valve is not working. Another tag had the number nine on it and text reading kitchen hot water, valve not working.Interview with Maintenance Director #70 on 03/12/26 at 11:30 A.M. revealed Maintenance Director #70 was unsure which lines were which and he had only been there for three weeks. Maintenance Director #70 verified there were thermometers attached to two of the water lines in the C/D boiler room that were not functioning correctly and that two of the tags hanging from the water line read Cold supply to kitchen valve is not working and kitchen hot water, valve not working. Interview with Resident #07 on 03/12/26 at 3:57 P.M. revealed the water temperature in Resident #07's bathroom had been cold for months. Review of the facility's undated safe and homelike environment policy revealed the facility will provide a safe, clean and comfortable environment. This deficiency represents non-compliance investigated under Complaint Number 2702201.

Based on observation, staff interview, resident interview, record review, and facility policy review, the facility failed to maintain mechanical equipment to heat residents' rooms. This affected four Residents (#33, #34, #35, and #36) out of four Residents reviewed. The facility census was 40. Findings include:Medical record review for Resident #34 revealed he was admitted to the facility on [DATE]. Diagnoses included quadriplegia, chronic obstructive pulmonary disease (COPD), essential primary hypertension, gastro-esophageal reflux disease (GERD), hyperlipidemia, insomnia, major depressive disorder, diabetes mellitus (DM), and anxiety disorder.Review of the Minimum Data Set (MDS) assessment for Resident #34 dated 11/20/25, revealed he was cognitively intact.Medical record review for Resident #35 revealed he was admitted to the facility on [DATE]. Diagnoses included essential primary hypertension, asthma, intermittent explosive disorder, heart failure, anemia, major depressive disorder, generalized anxiety disorder, COPD, GERD, and morbid obesity.Review of the MDS assessment dated [DATE] for Resident #35 revealed he was cognitively intact.Observation on 12/11/25 at 9:49 A.M. revealed Resident #34 was seated in the hallway with a blanket on his head and shoulders. Resident #24 appeared to be shivering under the blanket.Interview with Resident #34 at the same time stated he was seated in the hallway with a blanket on his head and shoulders because his room was freezing. Resident #34 stated he was in the hallway because he was trying to get warm. Resident #34 stated no staff member asked him if he wanted to change rooms. Observation on 12/11/25 at 9:51 A.M. revealed Resident #35 could be heard yelling into the hallway from his room that he was cold and needed someone to fix his heat. Interview with Resident #35 at the same time revealed he was in his room yelling out the doorway that he was cold and needed someone to fix the heat in his room. Resident #35 stated he was aware of the heat not working in his room and denied being asked by staff if he wanted to move to another room.Interview on 12/11/25 at 9:55 A.M. Maintenance Supervisor (MS) #150 verified Residents' #33, #34, #35, and #36's room did not have any heat. MS #150 confirmed the heat had not worked in Residents' #33, #34, #35, and #36's room for several months. MS #150 stated he was not aware of any documentation where Residents' #33, #34, #35 and #36 were asked to move rooms because the heat was not working in their rooms. Observation revealed MS #150 obtained the following temperatures from the four rooms: Resident #33's room temperature was 66.5 degrees Fahrenheit (F), Resident #34's room temperature was 69.7 degrees F, Resident #35's room temperature was 67.7 degrees F, and Resident #36's room temperature was 68.4 degrees F. MS #150 stated room [ROOM NUMBER] did not have a current resident; however, the room does not have heat and the temperature was 64.8 degrees F. MS #150 confirmed he had obtained two quotes to have the heating system replaced. One was dated 10/30/25, and the other was dated 11/11/25. MS #150 stated the reason the replacement unit took so long was for corporate approval.Review of the facility policy titled Safe and Homelike Environment dated 2023 confirmed the facility will provide a safe, clean, comfortable, and homelike environment. Maintenance services will provide as necessary to maintain a comfortable environment. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep room temperatures between 71 degrees F and 81 degrees F.Review of the facility policy titled Resident Rights dated 2024 confirmed the Residents have the right to a safe, clean, comfortable, and homelike environment.This deficiency represents non-compliance investigated under Master Complaint Number 2687930.

Based on record review, staff interview, and facility policy review the facility failed to thoroughly investigate an allegation of abuse. This affected one (Resident #21) of three residents reviewed for abuse. The facility census was 40.Medical record review for Resident #19 revealed she was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, seizure, malignant neoplasm of the intrathoracic lymph node, delusional disorder, atrial fibrillation, essential primary hypertension, and multiple sclerosis.Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 had impaired cognition. Resident #19 was dependent on staff for activities of daily living (ADL).Review of the SRI (control number 266147) created on 10/08/25 at 1:41 P.M. related to an injury of unknown origin identified on 10/08/25. Resident #19 alleged Licensed Practical Nurse (LPN) #97 grabbed her arms during a disagreement and left discoloration. The facility collected statements from LPN #97 and Resident #19. The SRI indicated LPN #97 was providing personal care to Resident #19 who was upset with her sister at the time of personal care. LPN #97 attempted to change Resident #19's brief and moved the call light from underneath Resident #19, when the resident became angry and grabbed the call light. After Resident #19 grabbed the call light, it swung and hit the resident in the arm and the refrigerator near the bed. LPN #97 stated she saw the call light hit Resident #19's arm which could have caused the discoloration on the arm. The facility closed the investigation on 10/08/25 at 2:12 P.M. and unsubstantiated the allegation of abuse. Review of the October 2025 progress notes for Resident #19 revealed no documented information related to the allegations of abuse.Review of the facility investigation on 12/11/25 at 1:115 P.M., revealed one witness statement collected from LPN #97. No other information was documented in the facility investigation.Interview on 12/11/25 at 1:30 P.M. the Administrator confirmed the facility failed to complete a thorough investigation related to abuse allegations involving Resident #19 and LPN #97. The Administrator stated he would have expected the facility staff to complete a thorough investigation. Review of the facility policy titled Abuse Neglect and Exploitation dated 2025 revealed an immediate investigation was warranted when suspicion of abuse, neglect, or exploitation or reports of abuse occur. The facility was expected to interview all involved people, including the alleged victim, alleged perpetrator, and others who may have knowledge of the alleged incident. The facility would complete a thorough investigation including all documentation of the investigation.

Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to provide a safe environment related to residents smoking. This affected one (Resident #36) of the one resident observed for smoking. The facility census was 40.Findings include:Medical record review for Resident #36 revealed he was admitted to the facility on [DATE]. Diagnoses included nontraumatic intracerebral hemorrhage, dysphagia, essential primary hypertension, major depressive disorder, hyperlipidemia, congestive heart failure, and diabetes mellitus (DM).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. Resident #36 was dependent on staff for medication administration. Resident #36 required set up assistance from staff with eating, oral hygiene, toilet use, and supervision with bathing. He was independent with upper body dressing, lower body dressing, and personal hygiene.Review of the active care plan for Resident #36 revealed the resident was a supervised smoker. The interventions included Resident #36 was a supervised smoker in a designated smoking areas and smoking materials were to be stored in a designated area.Review of the smoking assessment for Resident #36 dated 11/11/25 revealed Resident #36 was listed as an independent smoker.Observation on 12/10/25 at 9:25 A.M. revealed Resident #36 was smoking while seated in his wheelchair inside the facility but in the doorway which exited to the courtyard. Resident #36 acknowledged he was smoking unsupervised inside the facility. Resident #36 would not say how he was able to obtain a cigarette and lighter. Interview on 12/10/25 at 9:26 A.M. MDS Nurse #77 verified Resident #36 was smoking inside the facility and in the doorway which led to the courtyard. MDS #77 confirmed the facility had designated smoking times and it was not a designated smoking time. MDS #77 verified the facility does not allow independent or dependent smokers to keep smoking items and could not say how Resident #36 had access to his smoking items. MDS #77 stated Resident #26 was non-compliant with following smoking rules. Interview with the Director of Nursing (DON) on 12/10/25 at 9:44 A.M. stated the Courtyard was designated smoking area and there were scheduled smoking times. The DON stated all smoking items were supposed to be kept at the nurse's station and the staff were to assist all smokers. The DON verified Residents should be outside of the facility when smoking and supervised by staff.Review of the facility smoking policy titled Resident Smoking dated 2025 confirmed the facility would provide a safe and healthy environment for residents, visitors, and employees, including safety related to smoking. Smoking was prohibited in all areas except the resident's designated smoking area. Signage identifying the designated smoking area will be prominently displayed. Safety measures for designated smoking areas would include protection from weather conditions, provision of ash trays, and located the required distance, at a minimum from public exits and common space.

Based on observation, staff interview, and policy review, the facility failed to ensure a sanitary environment for preparing and serving food and failed to ensure staff wore hair restraints while in the kitchen. This had the potential to affect all 53 residents who resided in the facility as the facility identified all residents received food from the kitchen. Findings include: Observation on 06/29/25 at 9:36 A.M., of the steam table in the kitchen with Dietary Supervisor (DS) #354, revealed a wooden panel of compressed wood, nailed to the side of the steam table. The top of the wooden panel, located even with the surface of the steam table, and extending the depth of the steam table, was observed to be significantly deteriorated and porous, with a beige fibrous material. Interview with DS #354 at the same time, verified the wooden panel was deteriorated, porous, and was not able to be cleaned. DS #354 stated the wooden panel had been in the stated condition when he started approximately three months prior. Observation on 06/30/25 at 10:26 A.M. with DS #354, revealed a fan, which was powered on, and blowing, facing the steam table. The fan was observed coated in a gray and fuzzy substance. Interview with DS #354 at the same time, verified the fan was coated in a gray and fuzzy substance and facing the food that was on the steam table. DS #354 stated the fan needed to be cleaned. Observation on 06/30/25 at 10:30 A.M. with DS #354, revealed the steam table wells contained brown debris floating in the water and had dark brown stains. Interview at the same time with DS #354, verified the steam table wells contained brown debris and dark brown stains. DS #354 stated the steam table wells should be cleaned daily and were last cleaned approximately two nights prior. Interview on 06/30/25 at 10:48 A.M., the Administrator, verified the steam table wells did not appear clean. The Administrator stated DS #354 spent a lot of time trying to clean them; however, he felt the steam table just needed to be replaced. Observation on 06/30/25 at 10:34 A.M. with DS #354, revealed a vent, measuring approximately 18 inches by 18 inches, above the coffee maker, facing toward the steam table, was coated in a dark gray and fuzzy substance. The vent was observed blowing air into the kitchen. Interview with DS #354 at the same time, verified the vent was coated in a dark gray and fuzzy substance and blowing air toward the steam table and needed to be cleaned. Observation on 06/30/25 between 10:25 A.M. and 10:32 A.M., revealed DS #354 making pureed green beans for the lunch meal. DS #354 had a beard, and it was not covered by a hair restraint. Observation on 06/30/25 at 11:50 A.M., revealed DS #354 plating food from the steam table for the lunch meal. DS #354's beard remained uncovered. Concurrent observation revealed [NAME] #307 was taking the plated food, covering it, and placing it on meal trays. [NAME] #307 was observed with facial hair that was not restrained. Continuous observation on 06/30/25 from 11:50 A.M. to 12:08 P.M., revealed DS #354 continued to plate food from the steam table without a facial hair restraint and [NAME] #307 continued to cover the plated food and place it on the meal trays without his facial hair being restrained. Interview on 06/30/25 at 12:08 P.M., DS #354, verified neither he nor [NAME] #307 wore facial hair restraints while in the kitchen and preparing food. DS #354 stated he did have facial hair restraints. Observation on 06/30/25 at approximately 12:22 P.M., revealed the last meal tray was made and added to the cart for delivery. DS #354 and [NAME] #307 remained without facial hair restraints. Review of the facility policy titled, Maintaining a Sanitary Tray Line, undated, revealed, hair restraints would be worn when preparing or handling food.

Based on staff interview and record review, the facility failed to maintain a facility Tuberculosis (TB) Risk Assessment. This had the potential to affect all 53 residents who resided in the facility. The facility also failed to ensure all newly hired employees were tested for TB and employees employed by the facility for more than a year were screened annually for TB. This affected four (Business Office Manager [BOM] #410, Licensed Practical Nurse [LPN] #305, Certified Nursing Assistant [CNA] #361, and CNA #332) of the five personnel files reviewed. This had the potential to affect all 53 residents of the facility. Findings Include: 1. Interview on 07/01/25 at 2:58 P.M. with the Administrator revealed the facility does not do a Tuberculosis Risk Assessment. Review of the facility provided documentation at the same time with the Administrator, revealed the facility had TB Risk Assessment. Review of the facility policy titled Tuberculosis Risk Assessment (not dated) states a Tuberculosis Risk Assessment shall be conducted annually. 2. Review of BOM #410's personnel file revealed BOM #410 was hired on 12/16/24. Further review of BOM #410's personnel file revealed BOM #410 did not receive a first or second step TB test upon hire. Review of LPN #305's personnel file revealed LPN #305 was hired on 01/29/20. Further review of LPN #305's personnel file revealed LPN #305 did not have an annual TB screen for 2024 or 2025. The last annual TB screen was completed on 01/26/23. Review of CNA #361's personnel file revealed CNA #361 was hired 11/17/23. Further review of CNA #361's personnel file revealed CNA #361 did not have an annual TB screen during 2024 or 2025. Review of CNA #332's personnel file revealed CNA #332 was hired 11/02/24. Further review of CNA #332's personnel file revealed CNA #332 did not receive a first or second step TB test upon hire. Interview on 07/01/25 at 2:30 P.M., BOM #451 verified BOM #410, and CNA #332 did not receive first or second step TB tests upon hire and LPN #305 and CNA #361 did not complete an annual TB screening. BOM #451 verified all employees should receive a first and second step TB test upon hire and complete annual TB screens thereafter. Interview on 07/01/25 at 3:52 P.M., the Administrator verified all employees should receive a first and second step TB test upon hire and complete annual TB screens thereafter.

Based on observation, staff interview, resident interview, review of facility documents, and review of the facility policy, the facility failed to ensure comfortable and safe temperatures were maintained throughout the facility in resident rooms and common areas. This had the potential to affect the 10 residents residing on the facility's A-hall (#03, #04, #07, #13, #16, #26, #36, #52, #204, and #206), the 13 residents residing on the facility's B-hall (#01, #02, #10, #17, #19, #24, #29, #35, #37, #39, #43, #47, and #50. The facility identified 16 residents who routinely ate meals in the dining room (#01, #02, #06, #11, #12, #15, #16, #20, #27, #30, #36, #37, #39, #40, #46, and #47). The facility census was 53 residents. Findings include: Observation on 06/29/25 at 10:35 A.M. revealed the Administrator was taking air temperatures with an infrared laser digital thermometer with the following results: 86.9 degrees Fahrenheit (F) at the beginning of A-hall, closest to the entrance of the building, 81.7 degrees in the second half of A-hall adjacent to the nurses' station, 84.9 degrees F to the front of the nurses' station, 81.9 degrees F in the beginning of B-hall closest to the nurses' station, 83.1 degrees F in the back half of B-hall, 83.8 degrees F in Resident #24's room, 84.6 degrees F in the dining room, 86 degrees F in the television room. Interview 06/29/25 at 10:45 A.M. with the Administrator confirmed the air temperatures taken exceeded 81 degrees F. Interview on 06/29/25 at 9:15 A.M. with Resident #03 confirmed the building had been without air conditioning for a long time. Interview on 06/29/25 at 9:51 A.M. with Resident #204 reported he had been at the facility for two weeks, and although his room was quiet and private, the heat was unbearable. Interview on 06/29/25 at 10:04 A.M. Resident #19 confirmed the building was too hot and had been so for several days. Interview on 06/29/25 at 4:02 P.M. with Resident #24 confirmed it was too hot in the building, and the facility had provided her with a fan, but all the fan did was blow the hot air around. Interview on 06/30/25 at 8:21 A.M. with Resident #47 confirmed she spent more time in the dining room during the day because the air conditioning wasn't working and she thought it was slightly cooler in the dining room. Observation on 06/29/25 at 1:39 P.M. revealed the Administrator was taking air temperatures with an infrared laser digital thermometer with the following results: 82.9 degrees F in Resident #03's room, 84.9 degrees F in Resident #204's room. Interview on 06/29/25 at 1:45 P.M. with the Administrator confirmed the air temperatures in Resident #03 and #204's room exceeded 81 degrees F. Interview on 06/29/25 at 2:08 P.M. with the Administrator confirmed he air conditioning had stopped working approximately two weeks prior. The Administrator confirmed the facility rented portable air conditioning units and utilized two units on the A-hall, two units on the B-hall, and one unit in the dining area. The Administrator confirmed the portable air conditioning units on the A-hall did not seem to be cooling the areas as desired and the facility staff was checking air temperatures on a random basis. Observation on 06/30/25 at 11:09 A.M. revealed the Administrator was taking air temperatures with an infrared laser digital thermometer with the following results: 85.9 degrees F in the dining room, 84.9 degrees F in the television room, 84.6 degrees F in Resident #03's room, 83.8 degrees F in Resident #204's room, 82.9 degrees F in Resident #07's room, 84.7 degrees F in Resident #16's room, 85.3 degrees F in Resident #26's room, 83.1 degrees F in Resident #206's room. The facility's air conditioning was not working and the facility had portable air conditioning units in the hallways and fans in all resident rooms. Interview on 06/30/25 at 11:29 A.M. with the Administrator confirmed the air temperatures taken on 06/30/25 exceeded 81 degrees F. The Administrator stated the air conditioning had been out for approximately one week and he had no idea when the compressor would be delivered. Review of a local heating and cooling vendor estimate dated 05/21/25 revealed the compressor needed to be replaced with an estimated cost of $7,467.84. The estimate was signed on 06/24/25. Handwritten information on the estimate indicated the part was ordered 06/26/25 and a delivery date was not known. Review of the facility plan titled Plan for Extreme Heat undated revealed the facility had taken the following actions as a response to the air conditioning outage in the facility: rented portable air conditioning units and placed throughout the facility to aid in cooling of the halls, admissions were halted until all resident rooms could maintain a consistent temperature within the compliance range of 71-81 degrees F, contacted vendors were to obtain quotes for repair, offered room changes to all residents on the A-hall and B-hall to C-hall and D-hall or to another facility with some residents accepting room changes, provide fans to residents, monitored residents for signs and symptoms of heat-related illness, add hydration stations and routine ice pass were added, passed out popsicles to residents twice per day, added water to all meal trays, encouraged residents to drink more water during medication administration, altered the menu to include more cold foods, restricted opening of windows to aid in maintaining temperatures, encouraged residents to keep blinds closed and wear lighter clothing, provide lighter clothing if residents did not have such items). Review of the facility policy titled Extreme Heat dated 2024 revealed if indoor temperatures increased and sustained at 81 degrees F or greater, leadership would determine the possibility of moving residents to alternate locations within the facility or outside of the facility.

Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility failed to provide residents with information regarding how to apply for Medicaid benefits. This affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53. Findings include: Review of the medical record for Resident #53 revealed an admission date of 11/20/24 with diagnoses including chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), opioid dependence, cocaine abuse, pulmonary hypertension, bipolar disorder and post-traumatic stress disorder and a discharge date of 04/02/25. Review of a notice of adverse determination from the Medicaid provider for Resident #53 dated 03/28/25 revealed the resident no longer needed daily nursing care and her care needs could be met in a lower level of care. The document also included information for the resident with the opportunity to file a grievance against the decision or appeal the decision. Review of a social services progress note for Resident #53 dated 04/01/25 at 2:34 P.M. and created 04/02/25 at 2:38 P.M. per Social Services Director (SSD) #343 revealed she and the Director of Nursing (DON) spoke with Resident #53 about immediate discharge due to non-payment. The resident was in her room packing saying she would be discharging with her brother. This note was struck out on 04/08/25 with the reason cited as inaccurate documentation. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 04/02/25 revealed the resident had intact cognition and had an unplanned discharge Interview on 06/30/25 at 10:08 A.M. with Business Office Manager (BOM) #450 confirmed Resident #53 had a skilled care Medicaid payor and payment was stopped because the resident no longer required a skilled nursing service. The BOM verified the facility had the opportunity to assist the resident in applying for long-term Medicaid services but did not do so. She had no explanation as to why the facility did not do so. Follow up interview on 06/30/25 at 10:51 A.M. with BOM #450 verified the facility did not provide Resident #53 the opportunity or assistance to apply for long-term Medicaid. Phone interview on 06/30/25 at 3:00 P.M. with Resident #53 verified she was not offered the opportunity or assistance to apply for long-term Medicaid. Review of the policy titled Transfer and discharge date d 10/17/22 revealed a facility-initiated transfer or discharge was a transfer or discharge to which the resident objects or did not originate through a resident's verbal or written request, and/or was not in alignment with the resident's stated goals for care and preferences. The facility would not initiate the discharge of a resident based solely on resident's payment source or change in the resident's payment source. If the resident continued to need long-term care services, the facility would offer the resident the ability to remain in the facility by providing the Medicaid-eligible residents with the necessary assistance to apply for Medicaid coverage. This deficiency represents noncompliance investigated under Complaint Number OH00164494.

Based on review of Self-Reported Incidents (SRIs), review of personnel files, review of the Bureau of Criminal Investigation (BCI) background check logs, staff interview, and review of the facility policy, the facility failed to implement their policy by failing to conduct criminal background checks. This affected two (Residents #08 and #156) of three residents reviewed for abuse. The facility census was 53 residents. Findings include: Review of the facility SRI dated 01/31/25 revealed the facility substantiated an allegation of misappropriation of funds from Resident #08 and #156's resident fund accounts per Business Office Manager (BOM) #410. The facility contacted the local police who investigated the allegation, BOM #410, was terminated, and the facility replaced the residents' funds. Review of the personnel file for BOM #410 revealed a hire date of 12/16/24 and a termination date of 02/03/25. The file did not include a criminal background check completed upon hire for BOM #410. Review of the facility BCI log revealed BOM #410 was hired on 12/16/24, but BCI checks were not obtained. Interview on 07/01/25 at 2:10 P.M. with BOM #451 confirmed BOM #410's personnel file did not contain a criminal background check. BOM #451 confirmed newly hired employees were expected to complete a criminal background check within five days of hire. Interview on 07/01/25 at 2:58 P.M. with the Administrator confirmed the facility did not ensure a background check was completed for BOM #410. The Administrator further confirmed BOM #410 had informed him she had a clear record. Review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property dated 2016 revealed the facility would conduct criminal background checks in accordance with state law and facility policy and retain on file the applicable records of employees regarding such checks.

Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility failed to ensure a safe and orderly discharge. The affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53 residents. Findings include: Review of the medical record for Resident #53 revealed an admission date of 11/20/24 with diagnoses including chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cocaine abuse, pulmonary hypertension, bipolar disorder and post-traumatic stress disorder. The resident was discharged from the facility on 04/02/25. Review of the physician's orders for Resident #53 revealed an order dated 01/27/25 for oxygen at three liters per minute via nasal cannula every shift. Review of a notice of adverse determination from the Medicaid provider for Resident #53 dated 03/28/25 revealed the resident no longer needed daily nursing care and that her care needs could be met at a lower level of care. The document also provided the resident with the opportunity to file a grievance against the decision or appeal the decision. Review of a social services progress note for Resident #53 dated 04/01/25 at 2:34 P.M. and created 04/02/25 at 2:38 P.M. per Social Services Director (SSD) #343 revealed she and the Director of Nursing (DON) spoke with Resident #53 about immediate discharge due to non-payment. The resident was in her room packing saying she would be discharging with her brother. This note was struck out on 04/08/25 with the reason cited as inaccurate documentation. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 04/02/25 revealed the resident had an unplanned discharge. Resident #53 had intact cognition, was always continent of bowel and bladder was independent for eating, required supervision for oral and personal hygiene, bed mobility and toileting, and required moderate assistance for bathing, dressing and transfers. Interview on 06/30/25 at 10:14 A.M. with SSD #343 confirmed Resident #53 was discharged to the community without home health and oxygen services in place and the exact location of the discharge was unknown. Interview on 06/30/25 at 10:27 A.M. with the DON confirmed she was involved in the discharge of Resident #53 and the resident was not offered the opportunity to appeal the noncoverage of services decision. The DON confirmed the facility had not made arrangements for home health or oxygen services for Resident #53 prior to discharge and these services should have been arranged at the time of discharge. Phone interview on 06/30/25 at 3:00 P.M. with Resident #53 confirmed the SSD and the DON told her she had to leave the facility because Medicaid stopped paying. Resident #53 confirmed the facility staff told her she had 12 hours to leave, or they would call the police. Resident #53 confirmed the facility did not offer home health services or ongoing oxygen services. Resident #53 confirmed the facility discharged her with a four-hour oxygen tank and she had to take the oxygen nasal cannula she used while at the facility to receive the oxygen from the tank. Resident #53 confirmed after the oxygen tank ran out, she went to the hospital and remained there for 24 hours. After the hospitalization Resident #53 confirmed she was living on the street. Resident #53 confirmed she was currently staying with her mother and was trying to be admitted to a local homeless shelter. Phone interview on 06/30/25 at 4:30 P.M. with the Ombudsman confirmed there was a meeting with Resident #53 at the hospital discussing the resident's discharge. The Ombudsman confirmed Resident #53 did not want to remain a resident of the facility long-term, but the facility did not make the proper arrangements needed for a safe discharge such as a safe destination and provision of home health and oxygen services. Phone interview on 07/01/25 at 10:13 A.M. with Medical Director (MD) #405 for Resident #53 confirmed she was not involved in Resident 53's discharge and had no knowledge of where the resident's discharge location. MD #405 confirmed Resident #53 needed continuous oxygen due to her compromised respiratory status and should never have been discharged without home health services and an adequate supply of oxygen and oxygen supplies. Review of the facility policy titled Transfer and discharge date d 10/17/22 revealed a facility-initiated transfer or discharge was a transfer or discharge to which the resident objects or which did not originate through a resident's verbal or written request and/or was not in alignment with the resident's stated goals for care and preferences. Orientation for transfer or discharge would be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident could understand. Depending on the circumstances, the orientation might be provided by various members of the interdisciplinary team. This deficiency represents noncompliance investigated under Complaint Number OH00164494.

Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility provide an accurate notice of discharge to a resident before discharge and failed to provide a copy of the discharge notice to the Ombudsman. This affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53 residents. Findings include: Review of the medical record for Resident #53 revealed an admission date of 11/20/24 with diagnoses including chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cocaine abuse, pulmonary hypertension, bipolar disorder and post-traumatic stress disorder. The resident was discharged from the facility on 04/02/25. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 04/02/25 revealed the resident had an unplanned discharge. Resident #53 had intact cognition, was always continent of bowel and bladder was independent for eating, required supervision for oral and personal hygiene, bed mobility and toileting, and required moderate assistance for bathing, dressing and transfers. Review of the medical record for Resident #53 revealed the record did not include information regarding a formal discharge from the facility and there was no documentation per the physician regarding the resident's discharge. Interview on 06/30/25 at 10:27 A.M. with the Director of Nursing (DON) confirmed Resident #53 was discharged from the facility to the community on 04/02/25, and the facility did not provide the resident with a written discharge notice. Interview on 06/30/25 at 10:39 A.M. with Social Services Director (SSD) #343 confirmed Resident #53 was discharged to the community on 04/02/25 without home health and oxygen services in place and the exact location of the discharge was unknown. SSD #343 verified Resident #53 was not provided with a thirty-day discharge notice. Phone interview on 06/30/25 at 3:00 P.M. with Resident #53 confirmed the SSD and the DON told her she had to leave the facility because Medicaid stopped paying. Resident #53 confirmed the facility staff told her she had 12 hours to leave, or the police would be called. The resident said the facility did not offer her the opportunity to appeal the decision, and she did not learn about the appeal process until she met with the Ombudsman at the hospital on [DATE]. Resident #53 confirmed the facility did not issue her a written discharge notice. Phone interview on 06/30/25 at 4:30 P.M. with the Ombudsman confirmed there was a meeting with Resident #53 at the hospital discussing the resident's discharge and the facility did not provide a notice of the resident's discharge to the Ombudsman's office. Phone interview on 07/01/25 at 10:13 A.M. with Medical Director (MD) #405 confirmed she was not involved with the facility's decision to discharge Resident #53 and had no knowledge of the resident's discharge location. MD #405 confirmed did not sign a written discharge notice nor did she document in the resident's medical record regarding the discharge. Review of the policy titled Transfer and discharge date d 10/17/22 revealed the facility's transfer/discharge notice would be provided to the resident and the resident's representative in a language and manner in which the resident could understand. Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident. Exceptions to the 30-day requirement applied when the transfer or discharge was affected because the health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident, resident's health improved sufficiently to allow a more immediate transfer or discharge, an immediate transfer or discharge was required by the resident's urgent medical needs, or the resident had not resided in the facility for 30 days. A written discharge notice must be provided to the resident, resident's representative if appropriate, and the Ombudsman as soon as practicable before the transfer or discharge. The facility would maintain evidence that the notice was sent to the Ombudsman. This deficiency represents noncompliance investigated under Complaint Number OH00164494.

Based on observation, staff, resident and physician interviews and record review, the facility failed to conduct pain assessments and administer pain medication as ordered. This affected one (#36) of the two residents reviewed for pain medication administration. The facility census was 53. Findings include: Review of the medical record for Resident #36 revealed the resident was admitted on [DATE]. Diagnoses included anxiety disorder, type two diabetes mellitus with diabetic peripheral angiopathy, hypertension, arthritis and schizophrenia. Review of the care plan for Resident #36 dated 04/28/25, revealed the resident was at risk for increase in behaviors of irritability, agitation, restlessness, grimacing, hyperventilation, groaning or crying without relief of pain. Interventions included administering medication as ordered and notify the physician if interventions were unsuccessful or unable to be fulfilled. Review of the Minimum Data Set (MDS) assessment for Resident #36 dated 06/10/25, revealed the resident had intact cognition, was independent with toileting and transfers, and required only moderate assistance with bathing and dressing. Review of a physician order for Resident #36 dated 06/26/25, revealed the resident was ordered to receive oxycodone with Acetaminophen tablet 7.5-325 milligrams (mgs) four times a day routinely for pain and an order for Tylenol 325 mgs ordered to give one tablet by mouth every eight hours as needed (PRN) for pain. Review of June 2025 medication administration record (MAR) for Resident #26, revealed no documented evidence of any pain assessments completed from 06/27/25 through 06/30/25. There was also no documented evidence oxycodone with Tylenol was administered to the resident on 06/27/25 through 06/30/25. The July 2025 MAR could not be provided to the surveyor for review. Observation of Resident #36 on 07/01/25 at 11:00 A.M., revealed the resident was lying on his side with his legs up on his wheelchair grimacing and moaning I am not happy. Interview at the same time with the resident stated he was unhappy. The resident stated he had not received his pain medicine for two days, and reported he was having pain all over. Interview with Licensed Practical Nurse (LPN) #326 on 07/01/25 at 11:02 A.M., verified Resident #36 had not been given Oxycodone with Tylenol yesterday or today because it was not supplied to the facility during the pharmacy supplier transition which took place on 06/30/25. LPN #326 also stated she had not informed the Director of Nursing (DON), the prescribing physician, or the new pharmacy vendor about the missing order. Interview with the DON on 07/01/25 at 11:29 A.M., revealed she had just been informed by Resident #36 he has not gotten his oxycodone with Tylenol the last few days. The DON reported she reached out to the prescribing physician and the pharmacy. A subsequent interview with LPN #326 on 07/01/25 at 11:52 A.M., revealed conflicting information. LPN #326 now stated she informed the DON first thing this morning that Resident #36's oxycodone with Tylenol was missing and LPN #326 also shared the information in report yesterday evening with LPN #311. Interview with Assistant Director of Nursing (ADON) #359 on 07/01/25 at 12:28 P.M., revealed oxycodone with Tylenol 7.5-325 mg was not available in the emergency supply box (E-box). Interview via telephone with Physician #405 on 07/01/25 at 12:30 P.M., revealed she was notified today at 11:00 A.M. by the DON regarding the missing medication for Resident #36. She verified she had no knowledge of a call being made to her regarding the missing oxycodone with Tylenol for Resident #36. Interview via phone with LPN #311 on 07/01/25 at 2:15 P.M., revealed she did not receive information regarding the missing medication for Resident #36 during shift change report from LPN #326 on 06/30/25. LPN #311 stated she was unable to check in the E-box supply because there were no keys to get into it. She also confirmed she did not notify the physician or the DON during her overnight shift about the resident's missing oxycodone with Tylenol. LPN #311 stated she reported the information about the missing medications to the DON and LPN #326 when they arrived around 07:00 A.M. LPN #311 also verified she did not make a progress notes regarding the missing medications and document Resident #36's pain. Interview with the DON on 07/01/25 at 2:35 P.M., verified Resident #326 was missing pain assessments from 06/27/25 through 06/30/25 and Resident #36 did not receive his ordered oxycodone with Tylenol 7.5-325 mg from 06/27/25 through 06/30/25. The DON stated she was unable to provide a July 2025 MAR. Review of a facility policy titled Unavailable Medications, revealed the facility shall use uniform guidelines for unavailable medications. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn and emergency medications. A STAT (immediate need) supply of commonly used medications will be maintained in-house for the timely initiation of medications. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. Medications may be unavailable to a number of reasons; however the staff shall take immediate action when it is known that the medication is unavailable by determining the reason for the unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or the pharmacy to obtain the medication, notify the physician, obtain an alternative treatment orders and or specific orders for monitoring the resident while the medication is on hold and if the facility allows, determine if resident has a home supply and obtain orders to use the home supply. If a resident misses a scheduled dose of the medication, staff shall follow procedure for medication errors, including physician/family notification, completion of a medication error report and monitoring the resident for adverse reactions to the omission of the medication.

Based on medical record review, observation, staff interviews, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected one (#29) of the five residents who received Insulin stored in the A/B medication cart and of the 24 residents with medications stored in the A/B medication cart. The facility census was 53. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, cerebral infarction and atrial fibrillation. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #29 had moderate cognitive impairment and was dependent on staff for medications. Review of physician orders for Resident #29 revealed an order dated 05/22/25 for Lantus SoloStar subcutaneous solution pen-injector 100 unit/milliliter (ml) inject 10 units subcutaneously at bedtime related to diabetes mellitus type II with hyperglycemia. Review of the May 2025 and June 2025 Medication Administration Records (MARs) for Resident #29, revealed Lantus Solostar was administered daily as ordered. Observation on 07/01/25 at 9:29 A.M. of the A/B medication cart with Licensed Practical Nurse (LPN) #326 revealed the Lantus SoloStar subcutaneous solution pen-injector for Resident #29 to be undated. Interview on 07/01/25 at 9:29 A.M. with LPN #326 verified the Lantus SoloStar pen-injector for Resident #29 was undated and should have been dated when removed from refrigerated storage and placed in the medication cart. Interview on 07/01/25 at 4:26 P.M. with the Director of Nursing (DON) verified insulin, in any form, is to be dated when removed from refrigerated storage and placed in the medication cart. The DON reported there was no policy and procedure for Medication Storage and Labeling. Review of the Manufacture's Insulin Products Expiration Guidelines revealed insulin products are to be labeled with the date when taken from the refrigerator or put into the medication cart.

Based on observations, staff interview, and review of facility policy, the facility failed to provide clean, sanitary kitchen. This had the potential to affect all 55 residents residing in the facility who receive food from the kitchen. Findings include: During an observations of the kitchen on 03/25/25 at 11:08 A.M., the floor was dirty with food crumbs scattered on floor, cracks on the floor, dirt was smeared all over the floor, the trash can which was full of trash had no lid. A hair net was lying on the floor next to the trash can. There was a dirty bath blanket and four towels with black unknown substance on them in a pile under the kitchen sink next to prep table. Interview on 03/25/25 at 11:30 A.M. with [NAME] #134 verified there was a blanket and towels under the sink. [NAME] #234 stated there was a big accident in the kitchen and there was spillage on the floor. Review of the policy titled Dietary Food Preparation Area, undated, revealed the facility will maintain a clean, sanitary and safe food preparation area. The facility was to have a sink hot water and soap disposable, hand towel rack, and step-on trash can. This deficiency represents non-compliance investigated under Complaint Number OH00162245.

Based on record review, interview, and policy review, the facility failed to ensure a resident was provided the correct diet texture. This affected one (Resident #52) of three residents reviewed. The facility census was 55. Findings include: Review of the medical record for Resident #52 revealed admitted [DATE]. Diagnoses included pneumonitis, anxiety disorder, type two diabetes, hemiplegia, and hemiparesis. Review of plan of care dated 12/10/24 revealed Resident #52 was at risk for nutrition and hydration problems related to diabetes mellitus, schizoaffective disorder, bipolar, need for nutritional supplements, supervision for all meals, nosey cup with drinks, and need for mechanically altered diet and thickened liquids. Interventions include allowing residents to make choices, or preferences, observe any signs and symptoms of choking, provide assisted devices with meals, obtain weights as ordered, speech therapy screen as need, and weekly weights. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/04/25, revealed that Resident #52 was severely cognitively impaired and required partial to moderate assistance meal assistance. Review of progress note dated 02/01/25 at 6:40 P.M. by unknown nurse stated another resident notified this nurse that the resident was choking. The nurse and another nurse ran to Resident #52 and noted her unable to make any noise, no coughing, no talking, and showing signs and symptoms of choking. Both nurses initiated the Heimlich Maneuver to Resident #52. Resident #52 coughed up the food and was able to speak. 911 arrived but did not take Resident #52 because she was responsive. Review of progress note dated 02/01/25 at 7:01 P.M. by unknown nurse stated Resident #52 was assessed and vitals as follows: blood pressure 136/78, heart rate 78 beats per minute, oxygen saturation 97 percent, blood sugar was 111, and temperature was 97.8 degrees Fahrenheit. Resident #52 was assessed for pain. Resident #52 stated she had not had pain or hurting at any time in the last five days. Review of progress note 02/01/25 at 7:21 P.M. by unknown nurse stated she notified the on call physician of choking event. The physician gave orders to assess her vitals once a shift until seen by physician next week. Review of the facility incident document dated 02/01/25 revealed Resident #52 was choking on a food item in the dining room. Agency Licensed Practical Nurse (LPN) #330 and another nurse administered the Heimlich Maneuver to Resident #52, who was coughing. Resident #52 coughed up an item and began to speak. Resident #52 denied pain or discomfort. Resident #52 stated she was trying to eat a sweet cake. Resident #52 had vitals assessed, assessed for pain. LPN #330 helped Resident #52 change her clothes. Resident #52's diet was reviewed. Resident #52 was to eat meals in the dining room with assistance. There was an order for consultation with speech therapy. A respiratory assessment was completed and a new order for a chest X-ray. LPN #330 stated there were no signs and symptoms of respiratory distress. LPN #330 notified the Director of Nursing (DON), guardian, and medical director. Resident #52 refused to be taken to the hospital. The predisposing environmental factor that affected Resident #52 was crowding. No injuries observed post incident of choking. Review of physician order dated 02/03/25 revealed Resident #52 had an order for a regular pureed diet with nectar thick liquids and a STAT chest X-ray for two views. Review of the facility chest X-ray result dated 02/03/25 revealed that Resident #52 had a chest x-ray impression that stated with comparison study from prior chest -ray done on date 10/28/24, Resident #52 had right basilar infiltrate developed since last X-ray. Review of physician order dated 02/05/25 revealed Resident #52 had an upgraded diet to mechanical textures, regular diet, nectar thick liquids, with ordered staff supervision during meals. Review of physician order dated 02/05/25 revealed Resident #52 was to have a speech evaluation. Review of physician order dated 02/17/25 revealed Resident #52 to have consistent carbohydrate diet, pureed texture, and nectar thick liquids. During an interview on 03/24/25 at 11:48 A.M., the Director of Nursing (DON) stated Resident #52 was aware she was on an altered diet. She took the corn bread from the resident sitting next to her. Resident #52 asked Nurse Supervisor (NS) #202 to open the corn bread, which was wrapped. NS #202 educated Resident #52 her diet, that she was a puree diet and could not have the corn bread. Resident #52 then found another piece of corn bread from another resident's food plate and asked Agency LPN #330 to open it for her. LPN #330 opened for Resident #30 and gave it to her without checking her diet. DON stated that Resident #52 ate it, and she began to choke. Nurse Supervisor (NS) #202 and LPN #330 performed the Heimlich maneuver on Resident #52. The emergency medical service arrived, and Resident #52 refused to be evaluated at the hospital. Resident #52's guardian was told she refused, and the guardian was ok with the resident's refusal to go out to the hospital. The DON stated Resident #52 was noncompliant in her diet and had since made her a one on one with all her meals. At this time, Resident #52 was compliant with the one-on-one staff at meals. During an interview on 03/25/25 at 5:50 P.M., LPN #330 stated she did give Resident #52 corn bread and did not look up or ask what Resident #52's diet was. Ten minutes later Resident #30 was in her wheelchair choking. LPN #330 tried to give her Heimlich, then another nurse assisted to help and the choking was resolved. LPN #52 stated she had never taken care of Resident #52 before and should have looked up her diet. Review of facility document titled Dietary Supervision of Resident's Nutrition, undated, revealed the facility personnel are responsible for assuring the Residents' are served the correct food tray. Prior to serving the food tray, the nurse aid must check the diet card to assure that the correct food tray was being served to the Resident. If there was doubt, the nurse supervisor or charge nurse will check the written physician's order. If an error has been made, report it to the dietary supervisor so that a new food tray can be issued. Residents needing assistance in eating must be promptly assisted upon being served. Self-help devices must be provided to those who need this assistance. The food and fluid intake must be observed by nursing personnel at each meal. The amount eaten must be recorded and or reported to the charge nurse. Deviations from the normal patterns must be recorded in the Resident's chart. The Director of Nursing and the Dietary Manager, with input from the consultant dietician, must review the Resident's nutritional problem and coordinate all resolutions. Recommendations must be presented to the attending physician for his or her approval. This deficiency represents non-compliance investigated under Complaint Number OH00162245.

Based on record review, observations, interview, and policy review, the facility failed to implement fall prevention interventions for residents. This affected one (Resident #46) of three residents reviewed for falls. The facility census was 55. Findings include: Record review revealed Resident #46 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, Schizophrenia disorder, disturbance psychotic disorder, anxiety disorder, irritable bowel syndrome, dementia, and pseudobulbar affect. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/18/24, revealed that Resident #46 was cognitively impaired. Resident #46 required maximal assistance for meals, oral care, personal hygiene, and dressing upper body. Resident #46 was dependent for dressing lower body, bathing, placing shoes on and off, and toileting hygiene. Review of the plan of care dated 02/07/25 revealed Resident #46 was at risk for falls related to Alzheimer's disease, impaired gait balance, impaired vision, schizophrenia, and seizure disorder. Interventions included floor mat placed to open side of bed while bed was occupied, close supervision by staff, encourage residents to lie down after lunch, fall risk assessment, ensure resident was wearing nonskid footwear, and left side of bed against the wall. Review of non-compliance that was resistant to assistance with care revealed that Resident #46 interventions was encouraged to keep call light in reach and encouraged to use assistance. During an observation on 03/24/25 at 3:54 P.M., Resident #46 was in bed, and had no call light in reach. Resident #46's call light was under the bed, at the wall. Resident #46 did not have his bedside table near him with personal items. There was no floor mat next to the bed. During an interview on 03/24/25 at 3:58 P.M., Nurse Supervisor (NS) #202 verified that Resident #46's call light was out of reach, that his personal items were out of reach and no fall mat was next to the bed. Review of facility document titled Call Light Policy and Procedure dated 12/2020 revealed the policy of the facility was to ensure timely response to resident call light to ensure needs are met. The call light was used by a resident to notify staff of the nursing facility that the resident had a need that he would like addressed. Staff will ensure that the resident was in a comfortable position and that the call light was within reach of the resident before leaving the resident's room. This deficiency represents non-compliance investigated under Complaint Number OH00163300.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure oxygen was administered as ordered by a physician and in accordance with professional standards of practice for respiratory care. This affected three (Residents #3, #14, and #18) of three residents reviewed for oxygen administration. The facility census was 51 residents. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including acute infarction of intestine due to gunshot wound, cocaine abuse, opioid dependence, bipolar disorder, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, severe protein-calorie malnutrition and pulmonary hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 12/01/24 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs). Review of the plan of care for Resident #14 dated 12/18/24 revealed the resident had altered respiratory status related to COPD with a goal to maintain a normal breathing pattern. The primary interventions included administration of inhaler as ordered, medications as ordered, and oxygen as ordered. Review of physician's orders for Resident #14 revealed an order dated 11/21/24 for the resident to receive oxygen at two to four liters per minute (LPM) per nasal cannula (NC) to keep oxygenation levels above 92 percent (%) and for the oxygen tubing to be changed every week and dated. Observation on 01/13/25 at 8:45 A.M. revealed Resident #14 was in bed and receiving oxygen via NC at two LPM. The tubing and NC were dated 01/03/25 and there was no signage on the door that indicated oxygen was in use. Interview on 01/13/25 at 8:45 A.M. with Registered Nurse (RN) #77 confirmed Resident #14's oxygen tubing and NC were outdated and there was no signage on the door indicating oxygen was in use. 2. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including COPD, hypertension, alcohol dependence and depression. Review of the MDS assessment for Resident #18 dated 11/18/24 revealed the resident had moderate cognitive impairment and required supervision and assistance with ADLs. Review of the care plan for Resident #18 dated 11/14/24 revealed the resident was at risk due to altered respiratory status related to COPD with a goal to maintain normal a breathing pattern. The primary interventions included administration of medications as ordered, elevated head of bed as needed for shortness of breath, observe for signs and symptoms of respiratory distress and notify the physician as needed, and teach resident relaxation techniques. Review of physician's orders for Resident #18 revealed an order dated 01/02/25 for the resident to receive oxygen at two LPM per nasal cannula. There was no order to change the oxygen tubing and nasal cannula. Observation on 01/13/25 at 9:00 A.M. revealed Resident #18 was receiving oxygen at two LPM and oxygen tubing and nasal cannula were undated. There was no sign on the door that indicated oxygen was in use. Interview on 01/13/25 at 9:00 A.M. with RN #77 confirmed Resident #18 did not have a physician order for the tubing and nasal cannula to be changed every seven days. RN #77 confirmed Resident #18's tubing and nasal cannula were undated and she was unsure when they were due to be changed and there was no signage on the door indicating oxygen was in use. 3. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including osteoarthritis, morbid obesity, hypertension, congestive heart failure, hyperlipidemia, asthma and chronic viral hepatitis C. Review of the MDS assessment for Resident #3 dated 10/27/24 revealed the resident was cognitively intact and required supervision with ADLs. Review of the care plan for Resident #3 dated 05/18/23 revealed the resident was at risk due to altered cardiac output related to congestive heart failure, hypertension and hyperlipidemia with a goal to be free of signs and symptoms of cardiac complications. The primary interventions were to administer medications and oxygen as ordered. Review of physician's orders for Resident #3 revealed the resident did not have an order for the administration of oxygen nor did the resident have an order to have the tubing and NC changed every seven days. Observation on 01/13/25 at 9:10 A.M. revealed Resident #3 was in his room in his wheelchair and was receiving oxygen via an oxygen concentrator at four LPM with oxygen tubing and NC dated 11/29/24. There was no sign on the door that indicated oxygen was in use. Interview on 01/13/25 at 9:05 A.M. with Registered Nurse (RN) #77 confirmed Resident #3 did not have physician orders for the administration of oxygen or for the oxygen tubing and NC to be changed. RN #77 confirmed Resident #3 was receiving oxygen at four LPM and the tubing was outdated and there was no signage on the door that indicated oxygen was in use. Interview on 01/14/25 at 3:55 P.M. with the Director of Nursing (DON) confirmed oxygen tubing and nasal cannula are to be changed and dated every seven days. Review of the facility policy titled Oxygen Administration revised October 2010 revealed the facility would provide safe oxygen administration which included to verify there was a physician's order in place for oxygen administration and to place an oxygen in use sign outside the resident's door.

Based on medical record review, resident representative interview, staff interview, and review of the facility policy, the facility discharged a resident from the facility without a physician's order or proper documentation of a rationale for the facility-initiated discharge. This affected one (Resident #42) of two residents reviewed for transfer or discharge. The facility census was 51 residents. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including unspecified encephalopathy, dementia, mood affective disorder and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 10/03/24 revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living (ADLs.) Review of the progress notes for Resident #42 dated 08/18/24 to 01/10/25 revealed they did not include documentation of a discharge notice from the facility to the resident nor did they include any documentation of a reason for discharge. Review of the physician's orders for Resident #42 dated 08/18/24 to 01/10/25 revealed there was no discharge order for the resident. Review of social services progress note for Resident #42 dated 01/10/25 per Social Service Director (SSD) #31 revealed the resident was transferred on 01/10/25 to another facility. Resident #42 was picked up by receiving facility transport and the resident's responsible party was notified. Review of the facility initiated thirty-day discharge notice for Resident #42 dated 01/10/25 revealed the notice was sent to Resident #42 and Resident #42's responsible party via certified mail on 01/13/25. Review of the notice revealed Resident #42 was being discharged immediately because the safety of other individuals in the facility was endangered. Interview on 01/13/25 at 9:46 A.M. with Resident #42's responsible party revealed SSD #31 called the resident's brother on 01/08/25 and told him the facility was discharging the resident to another nursing home immediately. Resident #42's responsible party confirmed he did not speak directly with anyone from the facility but received a text message from the resident's brother on 01/08/25 indicating the facility informed him the resident would be discharged to another local nursing facility on 01/10/25. Resident #42's responsible party confirmed the facility did not provide any written notice the resident would be discharged . Interview on 01/13/25 at 11:00 A.M. with the Administrator confirmed the facility sent a 30-day discharge notice via certified mail to Resident #42's responsible party on 01/13/25 after the resident had already been discharged from the facility. Interview on 01/15/25 at 9:20 A.M. with the Medical Director (MD) confirmed the either the Administrator or the Director of Nursing (DON) had called her the week prior and notified her of Resident #42's discharge. The MD confirmed she did not make a note in the resident's medical record stating the basis for the resident's discharge from the facility nor did she write a discharge order. Review of the facility policy titled Transfer and Discharge revised 01/13/25 revealed the facility would permit each resident to remain in the facility and would not initiate transfers or discharges for the residents from the facility, except in limited circumstances. For non-emergency transfers or discharges the facility would document the reasons for the transfer or discharge in the resident's medical record. The facility staff would document any danger to the health or safety of the resident or other individuals that failure to transfer or discharge would pose. The physician should document medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge was for any reason other than nonpayment of the stay or the facility ceasing to operate. A copy of the physician's order for the discharge should be attached to the discharge notice.

Based on medical record review, resident representative interview, staff interview, and review of the facility policy, the facility discharged a resident from the facility and failed to a written notice of discharge to the resident and resident representative before the discharge. This affected one (Resident #42) of two residents reviewed for transfer or discharge. The facility census was 51 residents. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including unspecified encephalopathy, dementia, mood affective disorder and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 10/03/24 revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living (ADLs.) Review of the progress notes for Resident #42 dated 08/18/24 to 01/10/25 revealed they did not include documentation of a discharge notice from the facility to the resident nor did they include any documentation of a reason for discharge. Review of the physician's orders for Resident #42 dated 08/18/24 to 01/10/25 revealed there was no discharge order for the resident. Review of social services progress note for Resident #42 dated 01/10/25 per Social Service Director (SSD) #31 revealed the resident was transferred on 01/10/25 to another facility. Resident #42 was picked up by receiving facility transport and the resident's responsible party was notified. Review of the facility initiated thirty-day discharge notice for Resident #42 dated 01/10/25 revealed the notice was sent to Resident #42 and Resident #42's responsible party via certified mail on 01/13/25. Review of the notice revealed Resident #42 was being discharged immediately because the safety of other individuals in the facility was endangered. Interview on 01/13/25 at 9:46 A.M. with Resident #42's responsible party revealed SSD #31 called the resident's brother on 01/08/25 and told him the facility was discharging the resident to another nursing home immediately. Resident #42's responsible party confirmed he did not speak directly with anyone from the facility but received a text message from the resident's brother on 01/08/25 indicating the facility informed him the resident would be discharged to another local nursing facility on 01/10/25. Resident #42's responsible party confirmed the facility did not provide any written notice the resident would be discharged . Interview on 01/13/25 at 11:00 A.M. with the Administrator confirmed the facility sent a 30-day discharge notice via certified mail to Resident #42's responsible party on 01/13/25 after the resident had already been discharged from the facility. Interview on 01/15/25 at 9:20 A.M. with the Medical Director (MD) confirmed the either the Administrator or the Director of Nursing (DON) had called her the week prior and notified her of Resident #42's discharge. The MD confirmed she did not make a note in the resident's medical record stating the basis for the resident's discharge from the facility nor did she write a discharge order. Review of the facility policy titled Transfer and Discharge revised 01/13/25 revealed the facility would provide written notice of the discharge to the resident and the resident's representative of the discharge as soon as practicable before the discharge.

Based on medical record review, review of hospital records, and resident and staff interviews the facility failed to provide adequate care and services to prevent constipation. This resulted in harm on 08/22/2024 when Resident #15 was sent to the hospital and received treatment for a large fecal impaction. This affected one of three resident sampled for constipation. The facility census was 51. Findings include: Review of the medical record revealed Resident #15, was admitted to the facility on [DATE]. Diagnoses included unspecified neuromuscular dysfunction of the bladder, stage IV sacral pressure ulcer, unstageable pressure ulcer to the left heel, generalized anxiety disorder, unspecified major depressive disorder, and hemiplegia with hemiparesis following cerebral infarction affecting the left non-dominant side. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, occasionally rejected care, and did not wander. Resident #15 had an indwelling catheter. Urinary continence was not rated. Resident #15 was frequently incontinent of bowel and was not on a toileting program. Resident #15 required maximum assist with toileting. Review of care plan dated 08/21/2024 revealed Resident #15 was at risk for constipation related to decreased mobility and medication side effects. Interventions included administer medications as ordered, encourage consumption of high fiber foods, monitor and record bowel movements, monitor /report signs of constipation, and auscultate bowel sounds as needed. Review of task documentation dated August 2024 revealed Resident #15 had a medium formed bowel movement on 08/13/2024. Resident #15 had documentation stating she had no bowel movements from 08/14/2024 to 08/19/2024. Resident #15 had a small bowel movement documented on first shift on 08/20/2024 at 1:58 P.M. and documentation which specified No bowel movement from 08/20 on night shift to 08/23/2024 on day shift. Resident #15 had a small bowel movement documented on 08/23/2024 on night shift and had specific documentation indicating No bowel movement from 08/24/2024 to 08/26/2026. Review of hospital documentation dated 08/22/2024 revealed Resident #15 presented to the hospital emergency room for evaluation and treatment on 08/21/2024 at 2:15 P.M. The resident stated she was concerns she had a urinary tract infection (UTI) related to not having her catheter changed in 37 days, fevers, chills, general malaise, and lower abdominal pain. Additionally, the resident complained she had not had a bowel movement in 11 days. Upon physical examination she had a large fecal impaction, and a large amount of hard, brown stool was disimpacted. The resident was discharged back to the facility on [DATE] at 2:41 A.M. During an interview on 08/26/2024 at 3:06 P.M. Regional Registered Nurse (RN) #120 stated the facility did not have a policy for constipation or tracking bowel movements. Regional RN #120 stated if a resident had not had a bowel movement in three days, it would pop up on the electronic health record as a clinical alert, and the nurse would follow up with PRN orders or contact the provider for new orders. During an interview on 08/26/2024 at 3:06 P.M. Assistant Director of Nursing (ADON) #176 verified Resident #15 had not had a bowel movement from 08/14/to 08/20/2024. The ADON stated when a resident had no bowel movements for three days, it should have triggered a clinical alert for the nurse to administer PRN's or call the doctor for new orders. ADON #176 verified there had been no clinical alert in response to Resident #15 not having bowel movements, Resident #15 had no PRN orders for constipation, and there was no provider notification. This deficiency represents noncompliance investigated under complaint #OH00157088.

Based on medical record review, observation, staff interviews, local police employee interviews, review of the facility investigation, review of the witness statements, review of the 15-minute check documentation, review of the local police report, review of a local police records screen shot for times the local police received the call, review of the policy on elopement and review of the policy on missing residents, the facility failed to provide adequate supervision to prevent one resident (#47), with severe cognitive impairment, from eloping from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death when on 11/15/21 at approximately 2:30 A.M., Resident #47 exited the facility, without staff knowledge, and staff failed to complete scheduled 15-minute checks to verify his location. Resident #47 left the facility and walked approximately two feet across the post office parking lot and into the street in front of the library in the middle of the night in 35-degree Fahrenheit (F) weather wearing dark pants, a shirt and a light rain type jacket. The road in front of the library was a two-lane road divided by a turn lane. Staff were unaware the resident was gone until the police returned him to the facility at approximately 2:55 A.M. This affected one (#47) of three residents reviewed for elopement risk. The facility census was 47. On 12/01/21 at 3:23 P.M., the Administrator was notified Immediate Jeopardy began on 11/15/21 at approximately 2:30 A.M. when Resident #47, who had diagnoses including [CONDITION(S)], hypertension, and seizures, and was severely cognitively impaired, eloped from the facility and was found approximately 250 feet away from the facility in the road across from the library. Resident #47 was seen wandering in the post office parking lot and a postal carrier called the local sheriff department. The local sheriff transported Resident #47 back to the facility at approximately 2:55 A.M. Staff were unaware the resident was gone until the police returned him to the facility. The facility reported being unaware of how Resident #47 exited the facility despite him being on 15-minute checks and six staff on duty. The Immediate Jeopardy was removed on 11/16/21 when the facility implemented the following corrective actions: · On 11/15/21 at 2:49 A.M., a progress note written by facility staff documented Resident #47 was returned to the facility by the police and agency Registered Nurse (RN) #213 immediately notified the Administrator, Director of Nursing (DON) and left a message for the physician/medical director. The Administrator notified the medical directors Certified Nurse Practitioner (CNP) #217 at 3:00 A.M. · On 11/15/21 at 2:50 A.M., the Administrator increased Resident #47 ' s supervision from 15-minute checks to one-on-one. · On 11/15/21 by 3:00 A.M., the agency RN #213 assessed Resident #47 with no negative findings. · On 11/15/21, an agency Licensed Practical Nurse (LPN) #206 completed a head count for every resident in the facility and all residents were present at 3:00 A.M. · On 11/15/21 at 8:00 A.M., the QAA Committee held a conference call to review and discuss Resident #47 leaving the facility without anyone ' s knowledge and being returned to the facility by police. Those who were on the meeting included Regional Director of Clinical Services #222, Vice President of Clinical #220, Vice President of Operations #221, the DON, ADON #216, Social Worker #70 and the facility Administrator who had spoken with CNP #217 for the Medical Director. · On 11/15/21, the DON reviewed and revised Resident #47 ' s Elopement Risk Assessment and Care Plan. · On 11/15/21, the Administrator and Interdisciplinary Team, after having a conversation with Resident #47 and his son, arranged for a transfer to a secured facility. Resident #47 was transferred on 11/15/21 by 2:00 P.M. · On 11/15/21, the DON reviewed and revised all 47 residents Elopement Risk Assessments. The DON revised the eight residents (#18, #20, #23, #26, #27, #28, #31 and #39) in the Elopement Book who were identified as being at risk for elopement. · On 11/15/21, the DON reviewed and revised all residents Elopement Risk Care Plans. None of the care plans were revised as they were deemed to be appropriate with no need for changes following the Elopement Risk Assessment reviews. · On 11/15/21, the DON reviewed and revised the Elopement Book. Resident #14 was removed from the Elopement Book as the resident was no longer assessed as being at risk. · On 11/15/21, Maintenance Director (MD) #204 ensured proper functioning of all exit doors and changed the code to the door at the end of B hall and this was completed by 11:00 P.M. · On 11/15/21, the DON and Assistant Director of Nursing (ADON) #216 educated 48 of 48 staff members on the Elopement Prevention and Missing Resident policy in person or by telephone. · By 11/16/21 at 11:00 P.M., MD #204 conducted an Elopement Drill on every shift to ensure staff knowledge of the Elopement Prevention and Missing Resident policy. All staff responded appropriately to the elopement drill and followed procedure. · Beginning 11/16/21, the DON and ADON #216 would complete a headcount on every resident daily for 30 days and then as determined by the Quality Assessment and Assurance (QAA) committee. · Beginning 11/16/21, MD #204 would conduct a randomly timed elopement drill on each shift weekly for four weeks and then as determined by the QAA committee. · Beginning 11/16/21, MD #204 would conduct audits of all secured doors to ensure they were secured five times weekly for four weeks and then as determined by the QAA committee. The secured doors were monitored monthly prior to Resident #47 ' s elopement. · Interviews on 12/01/21 between the hours of 4:33 P.M. and 5:00 P.M. with State tested Nurse Aides (STNAs) #74, #85, #91, and #93 and LPNs #49 and #84, verified education had been conducted by the DON and ADON #216 for all staff. · Observation on 12/01/21 from 4:30 P.M. to 5:00 P.M., verified the five residents identified in the Elopement Book (#08, #14, #16, #17, and #33) were all present in the building and provided with the required level of supervision. Although the Immediate Jeopardy was removed on 11/16/21, the deficiency remained at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident #47 was admitted to the facility on [DATE]. The resident was sent out to the local psychiatric hospital on 11/05/21 for agitation and wandering in and out of other resident rooms. The resident re-entered the facility on 11/10/21 and had diagnoses including [CONDITION(S)], hypertension, and seizures. Review of the elopement risk admission assessment dated [DATE] revealed documentation indicating Resident #47 was not physically capable of leaving the facility, he was confused as to time and place, wandered, and paced and should be monitored every two hours. Review of the care plan dated 11/05/21 revealed Resident #47 had a behavior problem related to wandering aimlessly, pacing at times, and wandering into other resident rooms. Interventions included providing medication as ordered, allowing him to discuss his feelings, speaking in a calm voice, encouraging him to attend activities, referring for psychiatric and counseling services as needed, anticipating his needs, and redirecting as able. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. Resident #47 was able to walk with no device, although his gait was unsteady, he was able to stabilize without staff assistance. Review of the progress notes dated 11/15/21 at 2:49 A.M. documented Resident #47 was brought back to the facility by police officers who found him wandering near the post office. Staff members were unaware how he got out of the facility. Resident #47 was confused with vitals within normal limits (No actual vital signs were recorded in the medical record for review). Review of the local police report dated 11/15/21 with no time noted revealed the local police received a call from the post office reporting a suspicious person was walking in the rear lot in 35-degree Fahrenheit weather with no coat. The police observed the subject standing in the middle of a two-lane road near the local library. The local police approached the subject who was shivering and unable to provide his information. The subject stated he was out on a pass and trying to get to the local Chili restaurant. The police notified him it was closed and offered to return him to the nursing home where staff were unaware, he had been missing. Review of the 15-minute checks documentation dated 11/15/21 revealed documentation was completed for checks at 2:15 A.M., 2:30 A.M. and 3:00 A.M. The check for 2:45 A.M. was not documented as completed. Review of the Elopement Risk Assessment updated on 11/15/21 for Resident #47 revealed he was physically capable of leaving the facility, wandered, and had a history of elopement. One-on-one supervision was initiated and discharge to another nursing facility was pending. Review of the written witness statement dated 11/15/21 revealed agency LPN #206 documented she observed the police come into the facility about 2:10 A.M. with Resident #47. The police reported he saw Resident #47 at the post office. Review of the written statement (undated) revealed STNA #83 did not know how Resident #47 escaped as no alarm went off and she was changing residents. Review of the facility investigation revealed no evidence of interviews for the other staff who were present at the time Resident #47 eloped. According to the time sheet documentation for 11/14/21 third shift, there was one other facility aide, two agency aides and one agency Registered Nurse also present on shift the night Resident #47 eloped. Review of the screen shot sent by the police records department revealed a call was received on 11/15/21 at 2:30 A.M., an officer found the subject in the two-lane roadway in front of the library at 2:32 A.M. and he was transported back to the facility at 2:55 A.M. During an interview on 11/30/21 at 10:41 A.M. with the Administrator and the DON they reported Resident #47 had a history of wandering since admission to the facility on [DATE]. His agitation increased on 11/13/21, and 15-minute checks were initiated and discharge planning to a more secure facility was initiated. On 11/15/21, the police brought Resident #47 back to the facility stating he was near the post office and reported he was going to a local Chili ' s restaurant. They reported the facility did not know he had been missing, he was not gone more than 15 minutes and he was placed on one-on-one until discharged to a more secure facility later that same date. As all outside doors are coded and an alarm did not sound, the Administrator and DON reported they suspected Resident #47 had entered the exit code when he left the facility. During an interview with STNA #203 on 11/30/21 at 4:45 P.M., she reported she was completing 15-minute checks on Resident #47 every 15 minutes and was not sure how he was able to exit the facility. She stated Resident #47 would pace but didn ' t try the doors and she had never seen him look at the code pad or try to enter codes. She reported they used redirection for his wandering, and he was placed on one-on-one supervision when he returned to the facility following his elopement. STNA #203 reported she had been providing care and missed the 2:45 A.M. check for Resident #47. During an interview with Maintenance Director (MD) #204 on 11/30/21 at 4:52 P.M., he reported he changed the codes about one month ago and instructed staff to cover the code when entering it when he revealed the new code. He stated when he changed the codes, he had verified all doors and alarms were working. During an interview with STNA #83 on 11/30/21 at 9:30 P.M., she reported she was tending to other residents when the police brought Resident #47 back and he was placed on one-on-one supervision until he was discharged . She stated Resident #47 was generally confused and would push on doors in the facility but never saw him try to put in codes for the door. During an interview with LPN #206 on 11/30/21 at 9:44 P.M., he reported he was unaware a resident was missing until the police returned him to the facility. He stated he was working the other unit and was unsure of how Resident #47 got out. During an interview on 11/30/21 at 10:34 P.M. with Officer #207 he stated they received a call reporting a suspicious person dressed all in black trying to get into the back lot of the post office. They responded, and while in route, saw the resident laying in the two-lane road. When they put on their lights he went to the sidewalk. Officer #207 reported it was very cold out and the resident was in a shirt, pants, shoes, and a light rain type jacket with snot running down his face and he was cold to the touch. He reported the resident was disoriented and stated he was trying to get to another local town where he lived and wanted to go to the local Chili ' s restaurant. Officer #207 stated when they took him back to the facility the staff were not aware, he had been gone. During an interview on 12/01/21 at 12:15 P.M. with Records Staff #210 of the police department, reported dispatch was contacted at 2:30 A.M. by a mail carrier reporting someone walking in their parking lot. The local police responded at 2:32 A.M. and returned Resident #47 to the facility at 2:55 A.M. Review of the facility policy titled Elopement Prevention (undated) revealed it was the policy to ensure the resident environment was safe while using the least restrictive measures possible. Residents were assessed for elopement upon admission and with any changes. If a resident was identified as an elopement risk, an individualized plan would be implemented to prevent elopement and their picture would be placed in an elopement binder. Staff should promptly report any incident of a resident trying to leave the facility. If an employee observed a resident leaving, they should stay with the resident and attempt to prevent them from leaving. If a resident did depart, they should examine the resident for injuries upon their return and notify the doctor and the resident ' s family. Review of the facility policy titled Missing Resident revised 09/23/19, revealed the facility would engage in timely measures to locate a missing resident and to ensure the incident did not reoccur. If a staff discovered a resident missing from the facility, they would determine if they had been signed out. A search would be completed of the facility and the grounds, the Administrator and Director of Nursing notified and if the resident was not located within 15 minutes, the police would be contacted. This violation substantiates Complaint Numbers OH 577 and OH 326. B. Based on record review, interview and policy review, the facility failed to ensure residents were supervised during smoking and failed to ensure residents were not keeping smoking materials on their person. This affected three (Residents #35, #13 and #26) of three residents reviewed for smoking. The facility identified 17 residents who smoked in the facility. The census was 47. Findings include: 1. Record review revealed Resident #35 was admitted on [DATE]. Review of the admission Minimum Data Set (MDS) assessment, dated 11/19/21, revealed Resident #35 was cognitively intact. Review of the smoking assessment for Resident #35, dated 11/24/21, revealed she did not have cognitive loss and she could light her cigarette, but required supervision to smoke. She needed to store her cigarettes and lighter with the facility. Review of the care plan, dated 11/24/21, revealed Resident #35 was at risk for injury related to smoking. The interventions included supervision for smoking, inform of smoking policy and designated smoking times, and staff were to keep cigarettes, lighter, and matches in designated areas. 2. Record review revealed Resident #13 was admitted on [DATE]. Review of the admission MDS assessment, dated 10/08/21, revealed Resident #13 was moderately cognitively impaired. Review of the smoking assessment for Resident #13, dated 11/24/21, revealed she did not have cognitive loss and she could light her cigarette, but required supervision. She needed to store her cigarettes and lighter with the facility. Review of the care plan, dated 11/24/21, revealed Resident #13 was at risk for injury related to smoking. Interventions included supervision for smoking, inform of smoking policy and designated smoking times, and staff were to keep cigarettes, lighter, and matches in designated areas. 3. Record review revealed Resident #26 was admitted on [DATE]. Review of the smoking assessment for Resident #26, dated 11/10/21, revealed he had cognitive loss, he could not light his own cigarette and he required supervision for smoking. The resident needed the facility to store his lighter and cigarettes. Review of the admission MDS assessment, dated 11/18/21, revealed Resident #26 was cognitively intact. Review of the care plan dated 11/24/21 revealed Resident #26 was at risk for injury related to smoking. Interventions included supervision for smoking, inform of smoking policy and designated smoking times, and staff were to keep cigarettes, lighter, and matches in designated areas. 4. During observation on 12/19/21 at 7:22 P.M., Resident #35 had a lighter that she used to light a cigarette. Residents #13 and #26 leaned into Resident #35 with cigarettes in their mouth and she lit their cigarettes with her lighter. There was not a staff member outside at the time. During interview at the time of the observation, Resident #35 stated she did not know if she was supposed to have her smoking materials on her person or not. Residents #13 and #26 also stated they did not know if they were to have smoking materials on their person. During interview on 12/19/21 at 7:23 P.M., the Director of Nursing (DON) confirmed Residents 335, #13 and #26 were outside smoking unsupervised. The DON stated residents were not to have smoking materials on their person, it was against the facility policy. Review of the facility policy titled Smoking, revised 08/22/19, revealed the facility would make best effort to establish and maintain safe resident smoking practices. The facility would inform on admission the facility's smoking policy. Any resident who has restricted smoking privileges will have the supervision that was needed. Residents must store all smoking materials with staff except if they are under supervision. Residents are not permitted to supervise, assist other residents with smoking, or give smoking materials to other residents. This is an incidental deficiency discovered during the course of this complaint investigation, and is an example of continued noncompliance from the survey dated 09/23/21.

Based on observation, record review, resident and staff interviews, and policy review, the facility failed to ensure suctioning equipment was available at the bedside to provide suctioning to a resident with a [CONDITION(S)] to maintain an open airway. This resulted in Immediate Jeopardy for one (Resident #22) resident when staff could not locate the suctioning equipment, the resident went into respiratory distress and 911 had to be called to treat the resident. Resident #22 was admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#22) of two residents reviewed for [CONDITION(S)] care of three residents reviewed for respiratory care. The facility identified two residents (#22 and #37) with tracheostomies. The facility census was 47. On 12/07/21 at 3:18 P.M., the Administrator, the Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #222, and Assistant Director of Nursing (ADON) #216 were notified Immediate Jeopardy began on 11/29/21 at 10:45 P.M. when Licensed Practical Nurse (LPN) #90 couldn't locate any suctioning equipment to clear Resident #22's airway. Resident #22 went into respiratory distress and 911 had to be called to suction the resident. Resident #22 was then transported to the emergency room for further treatment. The Immediate Jeopardy was removed on 12/07/21 at 11:00 P.M. when the facility implemented the following corrective action: · On 12/07/21, the Administrator, who is also a Respiratory Therapist (RT), assessed Residents #22 and #37, who had tracheostomies, to ensure the two residents had orders for suctioning in place, and comprehensive care plans in place for the use of suctioning as needed and ensured the two residents had a suctioning machine and suction equipment available for use at the bedside. · On 12/07/21 by 11:00 P.M., RDCS #222 educated nine of nine licensed nurses on the [CONDITION(S)] Care Policy including ensuring orders are in place for suctioning, a comprehensive care plan for suctioning is in place, and suctioning equipment and supplies needed are available at the bedside. · On 12/07/21 at 11:00 P.M., the DON will audit current residents identified who have a [CONDITION(S)] daily times 30 days to ensure suctioning machine and suction equipment are available for use at the resident's bedside. · On 12/07/21 at 11:00 P.M., the DON will audit current residents identified to have a [CONDITION(S)] daily times 30 days to ensure the medical records contain documentation for suctioning as ordered. · After 30 days of audits, the Quality Assurance Committee will determine the needed frequency of continued audits. Although the Immediate Jeopardy was removed on 12/07/21 at 11:00 P.M., the facility remained out of compliance at a Severity level 2 (no actual harm with a potential with more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE]. His medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders dated 10/04/21 revealed [CONDITION(S)] care to be provided every day and night shift. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan dated 10/05/21 revealed Resident #22 was at risk for altered respiratory status related to shortness of breath while lying flat and has a [CONDITION(S)]. Interventions were to obtain oxygen saturations, vital signs, suctioning and [CONDITION(S)] care as ordered and as needed. Review of the care plan dated 10/11/21 for Resident #22 revealed he had a [CONDITION(S)] related to cancer of the Larynx and upper lobe of the left lung. Interventions were to ensure [CONDITION(S)] ties are always secured, give humidified oxygen as prescribed, monitor for restlessness, agitation, confusion, increased heart rate and [CONDITION(S)]. Monitor and document respiratory rate, depth, and quality and document every shift. Suction as necessary. Review of the admission Minimum Data Set (MDS) assessment, dated 10/11/21, revealed Resident #22 was cognitively intact. He required limited assistance for bed mobility and supervision for transfers and eating. He used oxygen, required suctioning, and needed [CONDITION(S)] care. Review of a progress note dated 11/29/21 at 6:23 A.M. revealed Resident #22 was alert and oriented and able to make needs known. His oxygen saturation was 78 percent and he had difficulty breathing. He removed his [CONDITION(S)] on his own, multiple times. The hospice nurse was notified, and Resident #22 was sent to the emergency room for suctioning. Resident #22 was then sent back to the facility. Review of the emergency squad report, dated 11/29/21, revealed they were dispatched to the facility at 10:42 P.M. for trouble breathing for Resident #22. Upon arrival at 10:45 P.M., the resident was lying in his bed and was writing things down on a notepad to try to communicate with the emergency medical technicians (EMT) and it was hard to understand and read what he was writing. There was a nurse from hospice in the room also and she stated that she was called to help with the patient. When she arrived, the facility did not have a portable suction unit to remove the secretions from his [CONDITION(S)]. The resident had obvious rales in both lungs and was having significant trouble breathing. After the initial assessment was completed, the resident was transferred to the ambulance. Once in the ambulance, EMT's immediately started suctioning thick white sputum out of Resident #22's [CONDITION(S)]. During the transport the resident's vital signs were monitored as followed: 10:56 P.M. heart rate 60 beats per minute; respirations 16 breaths per minute; and oxygen saturation 76 percent. At 11:01 P.M., Resident #22's heart rate was 90 beats per minute; respirations 16 breaths per minute; oxygen saturation was 82 percent; and blood pressure was 114/71 mm/Hg. At 11:02 P.M., Resident #22's heart rate was 99 beats per minute; respirations 30 breaths per minute; oxygen saturation 90 percent; and his blood pressure was 114/71 mm/Hg. Review of the hospital report, dated 11/30/21 at 9:04 A.M., documented the date of admission was 11/29/21. The resident was seen and examined and the expected stay for two midnights due to medical therapy required for pneumonia and [CONDITION(S)]. The resident was currently under the care of hospice at his long-term care facility from where he was sent in overnight for increased secretion from laryngectomy tube, at which point the hospice care was revoked and it was agreed to get the resident's infection treated. The resident was confused and poor historian, so the history was obtained from chart review and emergency room as follows: he presented to the emergency room for feeling unwell. The resident was seen earlier today for difficulty in breathing and required suctioning from his [CONDITION(S)]. He was discharged back to the long-term care facility with improvement to his breathing after suctioning. The hospice nurse saw the resident earlier today at the facility and he continued to have difficulty breathing with copious secretions from his [CONDITION(S)] and she recommended sending him to the emergency room for further evaluation. Upon review of the resident's chest X-ray obtained last night [11/29/21] revealed left sided pneumonia. On examination the resident reports improvement in his breathing since he was suctioned at the emergency room . He was discharged back to the facility on [DATE]. During an interview on 12/06/21 at 8:46 A.M., Lieutenant #201 revealed he was the medic on the night of the dispatch call to the facility. He stated it was the night of 11/29/21 and when he entered the facility, Resident #22's [CONDITION(S)] was in place, but he had increased work of breathing. The staff told him Resident #22 had been sitting for a time that evening before they called for the squad. They didn't have any suctioning equipment such as the power unit and disposable equipment to be able to suction him. He said Resident #22 was trying to communicate with the team by writing down the information on his tablet that was hard to read or understand. He stated he did not know the names of the staff who worked that night. He said when he placed the resident in the squad, he removed the [CONDITION(S)], and he had a moderate amount of thick sputum that needed to be cleared to maintain a clear airway. During interview on 12/06/21 at 9:33 A.M., the DON stated there was suctioning equipment on the crash cart. Staff check the cart daily and check off if the supplies were present. During interview on 12/06/21 at 1:30 P.M., ADON #600 stated the crash cart would be checked daily to check to see if there is anything that needed to be replaced. During an interview on 12/06/21 at 1:49 P.M., State tested Nursing Assistant (STNA) #202 stated Resident #22 went out a couple of times for his [CONDITION(S)] that week because of his anxiety and he felt like he was drowning. She said the nurse told her there wasn't any suctioning equipment to be able to suction the resident but didn't know who the nurse was that told her this. During an interview on 12/06/21 at 4:38 P.M. with Licensed Practical Nurse (LPN) #90 revealed she worked the night of 11/29/21. She stated Resident #22 said he couldn't breathe, but when she assessed him, he was breathing, but he continued to say he couldn't breathe. Observation of his [CONDITION(S)] revealed there was thick secretions. She looked in his room and in the supply rooms for equipment to suction him but couldn't find any. She said she didn't look on the crash cart because when she had checked before, there weren't any supplies on it. The crash cart used to be behind the nursing station, and it had been moved and she didn't know where it was. She stated the resident didn't require suctioning before and didn't know if he came with his own equipment. She knew how to suction the residents but couldn't find the equipment to perform the task. She didn't want to send him out since the suctioning was something she could do, but she couldn't find any equipment. She said the resident had been sent out on 11/29/21 when he required suctioning for not breathing and there wasn't any equipment to do the suctioning. She said she received this in report by an agency nurse but didn't know the name of the nurse. She called the hospice nurse, but the nurse didn't come into the facility but told her to send him to the emergency room for treatment. She said later the hospice nurse came in and they searched for suctioning equipment, but only found bits and pieces and when they looked on the crash cart, it was there. She said when there is an emergency, there was little time to go around the building to search for equipment when it should have been in the room at the bedside. During observation and interview on 12/06/21 at 9:06 P.M., Resident #22 stated he had to go to the hospital for his [CONDITION(S)] a few days ago. He said there were a couple of episodes when he couldn't breathe, and the staff couldn't find any suctioning equipment to suction him. He said he had to go to the hospital to be suctioned. He said when he can't breathe, he felt a lot of anxiety. At this time there was a box observed on the floor in Resident #22's room. It contained a suction machine, suction catheter, tubing, and a canister. Review of the policy titled Suctioning the [CONDITION(S)], dated 10/01/10, revealed the purpose of the procedure was to remove secretions, maintain a patent airway and prevent infection of the lower respiratory tract. This deficiency substantiates Complaint Number OH 989.

Based on record review, observation, interview and policy review, the facility failed to ensure a resident's pain was managed. This resulted in actual harm to Resident #22 who had uncontrolled pain because his [MEDICATION(S)] patches were not changed in a timely manner and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #22) of one resident reviewed for pain management. The facility identified ten residents on a pain management program. The census was 47. Finding include: Record review for Resident #22 revealed an admitted [DATE]. His medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no pain assessment was completed for Resident #22 from admission to present. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/21 there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan for Resident #22, dated 10/04/21, revealed he was at risk for pain related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify the physician as needed. Observe for signs and symptoms of non-verbal pain grunting, moaning, groaning, yelling out, crying, clenched teeth, grimacing, rocking, holding, and rubbing the area. Review of the admission Minimum Data Set (MDS) assessment, dated 10/11/21, revealed Resident #22 was cognitively intact. He required oxygen, suctioning, and [CONDITION(S)] care. He received scheduled and as needed pain medication. The MDS documented no pain assessment interview was done with Resident #22. Review of physician orders, dated 10/16/21, revealed [MEDICATION(S)] 10 milligrams (mg) every two hours for chronic pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain levels were documented as ten of ten three times and eight of ten two times, on a one to ten scale, with ten being the worst pain. Review of the MAR from 12/02/21 through 12/06/21 revealed he received [MEDICATION(S)] five times. Pain levels were documented as ten out of ten one time and eight out of ten three times. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR from 11/25/21 through 11/29/21 revealed the resident received [MEDICATION(S)] 12 [NAME]. Pain levels were documented ten out of ten two times; nine out of ten one time; and eight out of ten three times. Review of the MAR from 12/02/21 through 12/06/21 revealed Resident #22 received [MEDICATION(S)] 13 times. His pain levels were documented as ten out of ten five times and eight out of ten two times. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #22. Review of the MAR from 11/25/21 through 11/29/21 for the [MEDICATION(S)] revealed out of nine opportunities, his pain level was ten out of ten three times and eight out of ten two times. From 12/01/21 through 12/06/21 out of nine opportunities for pain levels, the resident's pain was documented as a ten out of ten three times and eight out of ten two times. Review of the progress notes dated 11/29/21 at 6:23 A.M. revealed the resident was in severe pain and the nurse called hospice and he was sent out to the emergency room . He returned to the facility at 2:03 P.M. with no new orders. Review of the Narcotic Sheets for [MEDICATION(S)] from 11/25/21 through 12/06/21 revealed the only time the [MEDICATION(S)] patch was applied was on 11/25/21. Review of progress note dated 11/29/21 at 6:23 A.M. revealed Resident #22 was sent out to the hospital with complaints of severe pain. Further review of the progress notes revealed he returned to the facility at 2:03 P.M. with no new orders. Review of the squad report dated 11/29/21 for Resident #22 revealed he went out of the facility again for labored breathing at 10:47 P.M. Review of the progress note dated 12/02/21 at 2:00 A.M. revealed Resident #22 returned to the facility from the hospital at approximately 1:55 A.M. Review of progress note dated 12/04/21 at 10:14 A.M. revealed the resident was agitated but easily redirected. At 1:16 P.M., the hospice nurse was into see the resident and stated he did not have his [MEDICATION(S)] patches currently and he reported pain in his legs. An agency nurse will follow-up with the pharmacy. At 1:23 P.M. the pharmacy called and stated they needed a new prescription to refill the [MEDICATION(S)]. During observation on 12/06/21 at 9:06 A.M., Resident #22 was lying in bed. Licensed Practical Nurse (LPN) #84 checked the [MEDICATION(S)] patches on the resident. There was only one patch on the resident and it was dated 11/25/21. The nurse called another staff member to help her to turn the resident and he moaned, grimaced and winced when moved up in the bed. He said he was in pain and rated it a ten out of ten. Resident #22 stated his pain was not controlled and the pain was due to cancer in his back. During interview on 12/06/21 at 9:20 A.M., LPN #84 confirmed there was only one [MEDICATION(S)] patch on the resident and it was dated 11/25/21, two weeks ago. She stated she had received the new [MEDICATION(S)] patches and would be applying them. On 12/06/21 at 12:41 P.M. the resident complained of pain continuously. Authorization was provided to remove the old [MEDICATION(S)] patch and apply new [MEDICATION(S)] patches. During interview on 12/06/21 at 4:38 P.M., LPN #90 stated she was the nurse who sent Resident #22 out to the hospital on 11/29/21 related to severe pain. She confirmed his pain wasn't relieved and he was asking for pain medication at least every two hours. She said at the beginning of admission, the staff were applying two [MEDICATION(S)] patches. She said there were times when she would go to place a patch on him and there wasn't two on him. She said she called the nurse practitioner and told them he was in pain. Review of the facility titled Pain Management, dated 03/01/15, revealed the purpose of policy was to help staff identify pain in the resident and develop interventions that are consistent with the resident's goals and needs and that address the underlying causes for pain. The pain management program is a facility-wide commitment to the resident's comfort. Pain management is 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 and established treatment goals. Conduct a comprehensive pain assessment upon admission to the facility. Monitor the resident's response to interventions and level of comfort over time, cause of the pain, and the adverse consequences to treatment. This was an incidental deficiency discovered during the course of this complaint investigation.

Based on closed medical record review, hospital record review and staff interviews, the facility failed to ensure one resident with an indwelling urinary catheter upon admission was assessed for removal of the catheter as soon as possible and failed to provide care and services to prevent Catheter Associated Urinary Tract Infection (CAUTI). This resulted in Immediate Jeopardy and serious life-threatening harm when one resident (Resident #20) suffered an acute change in condition and was sent to the hospital for evaluation and treatment. The resident was admitted to the hospital with diagnoses of [CONDITION(S)], severe [CONDITION(S)] with a urinary source, and pyuria (pus in the urine). This affected one (Resident #20) of two residents identified with indwelling urinary catheters. The facility census was 34. On 04/23/21 at 2:07 P.M., the Administrator, Interim Director of Nursing (DON) and Regional Registered Nurse (RRN) #25 were notified Immediate Jeopardy began on 11/10/20 when Resident #20 was admitted to the facility from the hospital with an indwelling urinary catheter. The facility failed to assess for catheter removal, and failed to provide consistent daily catheter care and monthly catheter replacement as ordered by the physician. Consequently, Resident #20 was sent to the hospital emergency roiagnom on [DATE] at 9:13 A.M. with abnormal laboratory values and altered mental status. Review of the hospital discharge summary dated 03/19/21 at 3:04 P.M. revealed Resident #20 was immediately treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was removed on 04/23/21 when the facility implemented the following corrective actions: · On 04/23/21, the DON/Designee assessed one (Resident #41) of one resident identified to have an indwelling urinary catheter for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated catheterization was necessary, assessed the medical record to ensure the record contained documentation of the clinical indication for continued catheter use, ensured the resident's record had a comprehensive care plan for catheter use, and ensured the catheter was changed as ordered by the physician. · On 04/23/21, all licensed nursing staff were educated by the Regional Director of Clinical Services on the Urinary Catheter Care policy including assessing for catheter removal as soon as possible unless the resident's clinical condition demonstrated catheterization was necessary, ensuring the medical record contained documentation for the clinical indication for continued use, ensuring the catheter is changed according to physician orders and ensuring the catheter care is provided and documented according to physician orders. · On 04/23/21, the facility initiated daily audits performed by the DON/Designee for 30 days to ensure all current residents and new admissions had assessment for removal of the indwelling urinary catheter as soon as possible unless the resident's clinical condition demonstrated catheterization was necessary, assessed the medical record to ensure the record contained documentation of the clinical indication for continued catheter use, ensured the resident's record had a comprehensive care plan for catheter use, and ensured the catheter was changed as ordered by the physician. · On 04/23/21, the facility initiated a review of 30-day audits by the Quality Assurance Committee to determine the needed frequency of continued audits. Although the Immediate Jeopardy was removed, the facility remains 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 still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included acute kidney failure, history of rhabdomyolysis, End Stage [CONDITION(S)] (ESRD) with dependence on renal [CONDITION(S)], hypertension, and Type II Diabetes Mellitus. Review of the most recent Minimum Data Set (MDS) assessment, dated 01/05/21, revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #20 was a one-person physical assist, required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene, supervision for eating, and locomotion did not occur. The resident had and indwelling urinary catheter, had no trial of a toileting program attempted since admission and was not rated for urinary incontinence. Review of the care plans, dated 11/06/20, revealed Resident #20 had no plan of care for the care and maintenance of an indwelling urinary catheter. Review of the hospital after visit summary, dated 11/10/20, revealed Resident #20 was discharged with an indwelling urinary catheter related to new onset gross hematuria related to traumatic injury to the prostate and was to follow up with the urologist one week after discharge. Review of physician orders revealed on 11/10/20, Resident #20 was given orders for urinary catheter care every shift and to record urine output every shift. On 01/27/21, Resident #20 was ordered to have the urinary catheter changed monthly on the 28th day. Review of Medication Administration Records (MAR) dated January 2021 and February 2021 revealed no evidence that the catheter was changed as ordered. Review of Treatment Administration Records (TAR) dated January 2021 revealed no evidence that catheter care was provided for 23 of 31 day shifts and 28 of 31 night shifts. Review of the TAR dated February 2021 revealed no evidence that catheter care was provided 22 of 28 day shifts or 25 of 28 night shifts. Review of the TAR dated March 2021 revealed no evidence that catheter care was provided three of nine day shifts and seven of nine night shifts while the resident was in the facility. Review of nursing notes revealed on 03/08/21, Resident #20 had an elevated temperature of 100.2 degrees Fahrenheit (F) and diarrhea. The nurse practitioner was notified, and the resident was given an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/09/21, the resident was afebrile and had hematuria. There was no documented physician notification. A nursing note dated 03/10/21 documented Resident #20 continue(d) to show altered mental status and decline and listed laboratory results as of 03/10/21 which revealed an elevated blood urea [MEDICATION(S)] (BUN) of 36 milligrams per deciliter (mg/dL), normal 7 to 25 mg/dL; elevated creatinine of 5.81 mg/dL, normal 0.8 to 1.3 mg/dL; and a low sodium of 131 millimeters of osmolality per liter (mmol/L), normal 133 to 146 mmol/L. The physician was notified, and Resident #20 was sent to the hospital emergency room for revaluation and treatment. Review of the hospital records revealed Resident #20 was admitted on [DATE] for [CONDITION(S)], severe [CONDITION(S)], and pyuria. Review of the history and physical revealed Resident #20 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital laboratory values revealed Resident #20 had blood and urine cultures on 03/10/21 which were positive for MRSA. The tunneled [CONDITION(S)] catheter was removed and replaced due to purulent drainage. The discharge summary physician note dated 03/19/21 documented there was concern for neglect from the nursing home due to disheveled appearance, malodorous, with an infected tunneled [CONDITION(S)] catheter and an indwelling urinary catheter that appeared not to have been changed in some time. Interview on 04/14/21 at 6:02 P.M. with Licensed Practical Nurse (LPN) #05 revealed on 03/10/21 LPN #05 noticed Resident #20's family had arrived for a window visit. When LPN #05 went to inform the resident, she noticed the resident didn't seem right. LPN #05 reported to the agency nurse (unidentified) in charge of Resident #20's care that the resident did not seem as mentally sharp as usual. During an interview on 04/23/21 at 9:02 A.M., State tested Nursing Assistant (STNA) #04 stated the last time she worked with Resident #20, date unknown, she helped the resident dress for [CONDITION(S)], and the resident was able to make his needs known. STNA #04 stated Resident #20 had an indwelling urinary catheter but had very little output with no hematuria noted. STNA #04 stated the STNA's emptied the drainage bag and provided catheter care to residents with indwelling catheters. They reported to the nurse on duty to document the amount of output and any unusual color or smell of urine, skin irritation, or change in mental status observed. During a telephone interview on 04/23/21 at 12:07 P.M., Nurse Practitioner (NP) #01 stated she did not recall if Resident #20 was ever assessed for indwelling catheter removal or bladder training. NP #01 stated she seemed to recall a nurse calling and reporting Resident #20 had hematuria, but that was not uncommon. She stated she could not remember exactly what happened during the time Resident #20 was sent out of the facility in March 2021. She was able to review on her phone that she had received a fax of Resident #20's laboratory results obtained 03/09/21 at 10:23 P.M. and stated it would have had to have been a STAT (immediate) laboratory order for laboratory values to have been obtained at that time of night. NP #01 stated she was contacted on 03/10/21, no time specified, and was informed Resident #20 had a mental status change and a white blood cell count (WBC) of 2.5 units per liter (uL) normal 3.8 to 10.8 uL, and ordered the resident be sent to the hospital for evaluation and treatment. During an interview on 04/23/21 at 1:50 P.M., RRN #25 revealed Resident #20 had no plan of care for indwelling urinary catheter, no assessment for removal of an indwelling urinary catheter, no evidence of follow-up with the recommended urologist after the hospital visit on 11/10/20, no evidence of monthly catheter replacement as ordered, and no evidence of catheter care provided as ordered by the physician. During a telephone interview on 04/27/21 at 12:32 P.M., Medical Director #01 stated he was aware of Resident #20's history of hematuria and continued to monitor the resident's condition. Medical Director #01 did not recall if Resident #20 had followed up with the urologist as directed after the indwelling urinary catheter was placed at the hospital in November 2020. Medical Director #01 stated it was good practice to remove an indwelling urinary catheter unless there was clinical indication not to and stated the medical team would have followed the urologist's recommendations for treatment as it was left to the urologist to determine continued use for an indwelling urinary catheter. Medical Director #01 stated NP #01 co-managed resident care at the facility and was contacted regarding Resident #20's change of condition. Review of the facility policy titled, Catheter Care, Urinary, dated September 2014, revealed preparation for urinary catheter care included checking the care plan to assess for resident-specific care needs. Procedure steps instructed the care provider to refer to the care plan regarding safe positioning of the resident during catheter care treatment. This deficiency substantiates Complaint Number OH 356.

Based on clinical record review, observation and interview, the facility failed to ensure a resident received adequate wound assessment, treatments to promote healing and prevent further infection of three pressure ulcers present on admission and to prevent the formation of additional pressure ulcers identified on 10/13/10. This resulted in harm to one former Resident (#61) of three sampled residents as evidenced by documentation of wound infection and maggots in the wound when Resident #61 was sent to the hospital emergency room . Three residents were identified with pressure ulcers. Findings include: Review of the clinical record for Resident #61 revealed that he was admitted on [DATE] from another facility. He had [DIAGNOSES REDACTED]. His admission assessment completed on 09/17/10 revealed on page two of four that Resident #61 had open wounds involving the bilateral posterior trochanter, bilateral gluteus muscles, the posterior scrotum and the posterior right thigh. There were no measurements of the areas on the form. A plan of care was noted that was initiated on 09/29/10 acknowledging the presence of pressure ulcers. An intervention stated to document skin condition every week on the skin grid and the treatment administration record. The first documented wound assessment completed 09/17/10 indicated that Resident #61 had chronic, partial thickness wounds, with heavy green exudate and yellow slough exposing the subcutaneous tissues. The wound measured 54 centimeters (cm) from hip to hip, 45 cm from the top of the gluteus to the folds, and varied in depth from 0.5 cm to 1.0 cm with tunneling. A treatment order was noted on that date. The next wound assessment documented by the facility was dated 09/22/10. It detailed three wounds to the right buttock, left buttock and right posterior thigh. The wounds to the left and right buttocks were measured individually instead of as one wound and a new area had been noted on the right posterior thigh. A physician's orders [REDACTED]. The last wound assessment documented by the facility was dated 10/13/10. Nine wounds were documented at that time numbered one through ten with number six not documented. These included the initial left and right buttocks, the subsequent right posterior thigh, and new wounds including the left hip, right heel, base of right great toenail, left heel, left great toe, and the left great toenail. These entries included measurements and the areas were noted to be open or necrotic as indicated by a black color. A psychiatric consult was completed on 10/13/10 and Resident #61 agreed to have wound assessments completed on that date. The consult note refers to a behavioral plan to improve compliance. No documentation of a behavioral plan was noted in the record and was not provided by the facility upon request. Resident #61 was discharged to the hospital for a 72 hour psychiatric hold on 10/15/10 with readmission on 10/17/10. There was no documentation of wound assessment upon readmission to the facility. The nurse's notes did not have any documentation of the wound treatment clinic. The surveyor requested the information from the clinic and received an assessment dated [DATE]. The note documented the wound measurements as buttock/ischial/sacral/coccyx 24.9 cm by 32 cm unstageable, left hip 0.5 cm by 0.5 cm by 0.1 , right heel 8.2 cm by 6.4 cm unstagable and left heel 4.2 cm by 3.6 cm by 0.1 cm. A review of the Treatment Administration Record revealed the treatment was not completed on the right poster leg wound on any day in November. No additional wound assessments were documented by the facility prior to Resident #61's discharge to the emergency room at his request on 11/19/10. Documentation regarding the condition of Resident #61 on arrival to the emergency roiagnom on [DATE] revealed that when emergency room nurses turned the resident over, maggots were coming from his decubitus wounds on his buttocks. The physician documented on the emergency room Admit Resident #61 had the most severe decubitus he had ever seen on his buttocks, legs, and heels. The buttocks decubitus had maggots crawling out of them. Interview of the Director of Nursing (DON) on 12/03/10 at 10:00 A.M. revealed that Resident #61 was non compliant with care. The facility did not provide facility policies for wound care. The DON stated they follow the recommendations of the wound consultant. He verified that the facility protocol included assessment of wounds on a weekly basis and affirmed this had not been done. The DON affirmed an order had been received to send Resident #61 for treatment at the wound clinic. He confirmed that Resident #61 had not been sent to the emergency room or to the wound clinic on a regular basis for wound assessments. The DON stated that he was seen in the wound clinic one time on 10/22/10. He verified that Resident #61 had entered a behavior contract for smoking behaviors to ensure compliance and there was no behavior contract for wound assessment to try and ensure compliance with treatments. The DON verified the hospital stay on 10/15/10 and the 30 day notice of discharge date d 10/18/10 had been initiated because of non compliance with the smoking policy and not because of non compliance with wound treatment. The DON verified the wounds had been assessed by the facility three times in 60 days and were documented in the clinical record on 09/17/10, 09/22/10 and 10/13/10. He stated the wounds were worse and the number of wounds had increased. He verified that the Resident's room was noted to be in deplorable condition after he had been discharged from the facility. The linens were noted to have urine, feces and maggots in them. Maggots were on the floor behind the bed, an intact suprapubic catheter and bag full of urine was also on the floor. Two full urinals were noted in the drawer of the bed side table. The facility linens had to be discarded. This certification deficiency substantiates Complaint Number OH 540.