Every finding on record at Canfield Healthcare Center

Based on record review, review of a facility self-reported incident (SRI), observation of recorded video, review of a police report, interviews and review of the facility abuse policy, the facility failed to protect Resident #66's right to be free from physical abuse by Housekeeper #582. This resulted in Immediate Jeopardy and Actual Harm on 09/16/25 at approximately 11:15 A.M. when Housekeeper #582 physically abused Resident #66. Housekeeper #582 pushed Resident #66 in his wheelchair causing the resident to fall out of the wheelchair and hit his head on the nurse's medication cart. Housekeeper #582 was then observed by (staff) witnesses and per the resident to put his hand around Resident #66's neck and punch the resident with a closed fist. Resident #66 was subsequently transferred to the emergency room (ER) for an evaluation. This affected one resident (#66) of three residents reviewed for abuse. The facility census was 67. On 09/23/25 at 5:27 P.M. the Administrator and Regional Director of Clinical Operations (RDCO) #578 were notified Immediate Jeopardy began on 09/16/25 at approximately 11:15 A.M. when Housekeeper #582 physical abused Resident #66. The Immediate Jeopardy was removed on 09/17/25 when the facility implemented the following corrective actions: On 09/16/25 at 11:15 A.M., Social Service Designee (SSD) #524 separated Housekeeper #582 and Resident #66 and provided for resident safety. On 09/16/25 at 11:15 A.M., Housekeeper #582 was suspended pending investigation by the Administrator. On 09/16/25 at 11:15 A.M., the Director of Nursing (DON) notified Medical Director #585 and Resident #66's emergency contact/brother of the incident. On 09/16/25 at 11:18 A.M., the Administrator notified the local police department. The police arrived and documented incident number 254043477. On 09/16/25 at 11:35 A.M., the Administrator collected witness statements from facility staff that observed the incident. On 09/16/25 at 11:40 A.M., the Administrator changed all of the door codes in the facility (to prevent unauthorized access to the building). On 09/16/25 at 11:41 A.M., the Administrator reviewed the facility abuse policy with no changes to the policy deemed necessary. On 09/16/25 at 11:45 A.M., the Administrator initiated training on the facility Abuse Policy, Aggressive and Combative Behavior Management Policy, and Resident Rights with all staff, including initiation of a posttest with a theme of Just Walk Away! The training was completed by 09/17/25 at 10:00 A.M. On 09/16/25 at 12:27 P.M., Resident #66 was transferred to the local ER for evaluation per his brother's request. The resident returned to the facility on [DATE] at 7:09 A.M. On 09/16/25 at 11:50 A.M., SSD #524 interviewed all interviewable residents in facility related to abuse. On 09/16/25 at 11:51 A.M., Registered Nurse (RN) #538 completed skin checks on residents unable to be interviewed related to abuse. On 09/16/25 at 1:56 P.M., RDCO #578 completed training on Abuse Policy with all staff via OnShift. On 09/16/25 at 2:00 P.M., RDCO #578 completed training on policy on Management of Combative and Aggressive Behavior with all staff via OnShift. On 09/16/25 at 2:04 P.M., RDCO #578 completed training related to Identifying, Preventing and Managing Aggressive Behaviors with all staff via OnShift. On 09/16/25 at 3:38 P.M., RDCO #578 completed training on resident rights policy with all staff via OnShift. On 09/17/25 at 10:49 A.M., SSD #524 assessed Resident #66's psychosocial status. at baseline psychosocial status. On 09/17/25 at 10:55 A.M., the Administrator in collaboration with Healthcare Services Group terminated Housekeeper #582's employment. On 09/17/25 at 10:56 A.M., the Administrator reiterated to Human Resources #587 to continue to ensure newly hired employees were educated on the abuse policy upon hire during orientation. Beginning on 09/22/25, the facility implemented a plan for SSD #524 to conduct interviews with five employees weekly related to abuse and five residents weekly related to abuse for four weeks, then monthly for two months. Compliance with the interviews would be overseen by the Administrator. Results of the interviews would be reviewed with the Quality Assurance and Performance improvement (QAPI) committee for additional recommendations as warranted. Although the Immediate Jeopardy was removed on 09/17/25, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of the medical record of Resident #66 revealed an admission date of 08/11/23 with diagnoses including displaced fracture of the base of the neck of the left femur, subsequent encounter for closed fracture with routine healing, diabetes mellitus type II, fracture of one rib, subsequent encounter for fracture with routine healing, repeated falls, alcohol dependence, cannabis dependence, bipolar disorder, nicotine dependence, cocaine dependence, major depressive disorder, insomnia and anxiety. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 15 indicating Resident #66 had intact cognition. The assessment revealed Resident #66 required (staff) supervision and set-up for all activities of daily living (ADLs) and used a wheelchair for mobility. Review of the care plan dated 08/14/25 revealed Resident #66 was at risk for disruptions in his mood due to diagnoses of bipolar disorder, depression, insomnia and anxiety. Interventions included behavioral consultations as needed, encouraging the resident to express his feelings, encouraging the resident to maintain as much independence and control/decision making as possible. The care plan also indicated Resident 66 was at risk for falls due to falls prior to admission with fractures and impaired mobility. Interventions included educating the resident regarding safety with transfers and ensuring the resident's room was free of potential visible hazards. Review of a nursing progress note dated 09/16/25 at 11:30 A.M. authored by RDCO #578 revealed an alleged staff-to-resident physical altercation. The progress note included Resident #66 declined assessment but had a BIMS of 15 and denied pain or injuries. Medical Director #585 and Resident #66's brother informed. The progress note also included staff member was suspended pending the investigation. Review of an additional nursing progress note dated 9/16/25 at 12:02 P.M. authored by the DON revealed social services (SSD #524) found this nurse and asked for assistance in a situation with the resident. This nurse was led to the 200 unit, where Resident #66 was seen sitting upright on the floor. The resident's left leg was straight out and the right leg was bent, with his right foot near his inner left leg. The resident's wheelchair was a few feet away from him. The nurse practitioner (NP) and this nurse attempted to assess the resident, and he refused stating, I want to gather myself. This nurse asked the resident what happened, and he stated, I was talking to that one girl (Housekeeper #583) about being in my room and we got upset talking to each other, heading down the hallway. The housekeeper told me to talk to her boss about being in my room. I thought that guy (Housekeeper #582) was her boss. Words got exchanged back and forth then he (Housekeeper #582) grabbed me by my neck and knocked me out the wheelchair, then he got on top of me. The housekeeper whooped my [expletive]. After several minutes, the aides assisted the resident back to his wheelchair. This nurse asked the resident if there was anything we could do for him at this time, and he stated that he didn't want us to do anything for him. The note included the resident refused to have his vital signs assessed as well. The resident was calling his brother and going to the hospital. Once his brother arrived, the resident allowed this nurse to perform a partial skin check. There was a small abrasion and a [NAME] on the resident's lower left back. The resident complained of pain rated an eight to nine on a pain scale of zero to 10 with 10 being the worst pain. Pain medications were offered; however, the resident decided he wanted to wait until he got to the hospital to take any medication. Review of a facility self-reported incident (SRI) tracking number 265294 dated 09/16/25 revealed the facility reported an incident of alleged abuse involving Resident #66 to the State agency. A witness statement from Certified Nursing Assistant (CNA) #570 reported Housekeeper #582 choked Resident #66 during a verbal confrontation. A witness statement from Licensed Practical Nurse (LPN) #526 stated she saw Housekeeper #582's hands around Resident #66's neck and saw Resident #66 hit his head on the nurse's cart and fall to the floor. A witness statement from LPN #561 stated Housekeeper #582 held Resident #66 with one hand and punched him twice with closed fist with the other hand. Review of a nursing progress note revealed Resident #66 was transferred to the ER on [DATE] at 12:27 P.M. and returned to the facility on [DATE] at 7:09 A.M. with no new orders. Review of a local police report incident number 25Y043477 dated 09/16/25 revealed upon arrival, three officers made contact with the facility staff who stated that a patient, later identified as Resident #66 and a staff member, later identified as Housekeeper #582, were engaged in a physical altercation. The staff then directed the officers to Resident #66's room where the resident stated that he and this staff member (Housekeeper #582) had gotten into a verbal argument in the hallway on the opposite side of the facility. Housekeeper #582 then pushed him (who is stationed in a wheelchair) against a wall and began punching him on the right side and left neck area. The resident stated he just had surgery as well and his left hip was also in pain, but he did not remember exactly where all Housekeeper #582 had made contact with him. He stated then Housekeeper #582 jumped on top of him and continued hitting him. Housekeeper #582 then left the facility. No noticeable injuries could be seen on Resident #66 at that time. A telephone interview on 09/22/25 at 10:52 A.M. with Resident #66's brother revealed he was not present in the facility at the time of the incident on 09/16/25 but had been made aware of the altercation that had occurred. The resident's brother did not provide any additional information related to the circumstances of the incident. Interview with Resident #66 on 09/22/25 at 10:59 A.M. revealed on 09/16/25, Housekeeper #583 had been in his room too much and he asked her to leave. She told him she was told to mop his floor, and he would have to talk to her boss about it. Resident #66 stated he became angry, and he and Housekeeper #583 started heading down the hall to talk to her boss when Housekeeper #582 showed up and started a verbal confrontation. Resident #66 stated the next thing he knew, Housekeeper #582's hand was around his neck choking him and punching him with a closed fist. Resident #66 stated Housekeeper #582 kneed him and kicked him in the side once or twice and banged him against the wall while still seated in his wheelchair. Resident #66 stated the two of them somehow ended up on floor during the scuffle. He stated staff called police to file report and press assault charges against the housekeeper. The resident said he was sent to hospital in an ambulance and then returned to the facility. The resident stated he had nothing broken but was still sore all over from the incident. Interview with CNA #570 on 09/22/25 at 11:26 A.M. revealed on 09/16/25 he was sitting in the hallway when he heard some commotion and overheard Resident #66 complaining that housekeepers were in his room too much. The CNA revealed an argument ensued between Resident #66 and Housekeeper #582, and he tried to resolve the issue but was ignored. He stated Resident #66 was swearing and being loud and when he turned around, Resident #66 and Housekeeper #582 were on floor, and Housekeeper #582 was choking Resident #66. Another staff member separated Resident #66 and Housekeeper #582 and asked Resident #66 if he needed help, but the resident wanted to stay on the floor for a minute. The police were called and then an ambulance was called. Interview with LPN #526 on 09/22/25 at 1:55 P.M. revealed she was sitting at the nurse's station on 09/16/25 when she witnessed Resident #66 following housekeeping staff down the hallway. Resident #66 wanted to speak to Housekeeping Supervisor #580 due to staff mopping his floor twice. LPN #526 stated Resident #66 was swearing at housekeeping staff. Housekeeper #582 tried to get Housekeeper #583 away from Resident #66 when Resident #66 got verbally aggressive toward Housekeeper #582. LPN #526 saw Housekeeper #582's hands around Resident #66's neck and then Resident #66 hit his head on nurse's cart and fell to floor. Staff came running and separated Housekeeper #582 and Resident #66. Resident #66 refused to be assessed and wanted to sit on the floor for a minute following the incident. LPN #526 stated the police were called and took statements, and Resident #66 then went to the hospital. Interview with LPN #561 on 09/22/25 at 2:02 P.M. revealed she was walking down hall on 09/16/25 when she saw Housekeeper #582 and Resident #66 in each other's faces. Housekeeper #582 started walking away but came back toward Resident #66 and grabbed him by the neck. Housekeeper #582 then pushed Resident #66 into the nursing cart when Resident #66's wheelchair tipped, and he ended up on ground with Housekeeper #582. Another staff member separated them. LPN #562 stated she saw hands flying and saw Housekeeper #582 holding Resident #66 with one hand and punching him twice with a closed fist with the other hand. LPN #561 further stated the police were called, Resident #66's brother was called and came to the facility. Then an ambulance was called and took Resident #66 to the hospital. Interview with the Administrator on 09/22/25 at 11:40 A.M. revealed she was in her office when this incident (on 09/16/25) occurred and staff had come to get her. When she arrived at the scene of the incident, everyone involved was clustered near the nurse's station. Resident #66 was on the floor and didn't want helped or assessed. Resident #66 wanted to wait until his brother came to the facility to go to the hospital and then went to hospital when his brother arrived. Resident #66 returned to the facility with no new orders and no reported injuries from the incident. She further stated Housekeeper #582 vanished after the incident. Staff called the police who came immediately and took statements from everyone involved. Housekeeper #582 and Housekeeper #583 were immediately suspended pending investigation, and all codes on all facility doors were immediately changed. Housekeeper #582 was subsequently fired. Observation of a video recording of the incident on 09/22/25 at 2:15 P.M. revealed the entire incident on 09/16/25 lasted approximately 16 seconds. Housekeeper #582 was seen approaching Resident #66 who was seated in his wheelchair. Housekeeper #582 placed both hands on Resident #66's neck/shoulder area and pushed him out of the frame. Several staff members were seen running towards the altercation. Resident #66's leg was seen on the floor from the upper right corner of frame but nothing else could be seen until Resident #66 was seen sitting up against a wall on the floor for several minutes following the incident. Housekeeper #582 was seen walking toward the camera until he walked out of frame. Interview with Police Detective #586 on 09/23/25 at 2:05 P.M. revealed a meeting with the City Prosecutor was scheduled for Friday 09/26/25 when he anticipated felony abuse charges would be filed against Housekeeper #582. Interview with the facility's Medical Director #585 via telephone on 09/23/25 at 2:29 P.M. revealed the facility notified him and all other appropriate parties in a timely manner after the incident involving Resident #66 on 09/16/25 occurred. Review of the facility policy titled Abuse, Neglect, and Exploitation, revised 09/20/22, revealed abuse was defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain, or mental anguish. Physical abuse was defined as including but was not limited to hitting, slapping, pinching, and kicking or flicking with fingers or striking with any manner that is demeaning. It also included controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Master Complaint Number 2621975 and Complaint Numbers 2621911 and 2617679 and is an example of continued noncompliance from the survey completed on 09/17/25.

Based on observation, record review, review of a facility self-report incident, facility investigation review, police report review, policy review and interviews, the facility failed to provide adequate supervision and/or intervention to prevent resident elopement. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 05/24/25 when Resident #13, who was assessed as an elopement risk, had exit seeking behaviors and was deemed incompetent by the court system, was permitted by staff to leave the facility unattended and without guardian consent. The resident's whereabouts were unknown until the resident was returned to the facility via police escort on this same date. The Immediate Jeopardy and potential for actual harm continued on 08/16/25 when staff allowed Resident #61, a moderately cognitively impaired resident to leave the facility unattended. The resident's whereabouts were unknown until the resident was found by police, on 08/17/25 a half mile from the facility sleeping on the ground behind a gas station. The resident was transported to the hospital for evaluation. In addition to the two incidents of elopement, the facility failed to have adequate systems in place to identify risks associated with its current practice of determining if residents could safely leave the facility unsupervised/unattended. In addition, concerns that did not rise to Immediate Jeopardy were identified when the facility failed to adequately supervise Resident #11, #37, #40 and #68 related to smoking and possession of smoking materials for safety/accidents. The facility also failed to ensure fall interventions were individualized and comprehensive to prevent falls for Residents #5 and #84. This affected two residents (#13 and #61) of three residents reviewed for wandering/elopement, four residents (#11, #37, #40 and #68) of 15 residents reviewed for smoking and two residents (#5 and #84) of three residents reviewed for falls. The facility identified three additional residents with guardianship in place (Resident #10, #51 and #55) and 21 additional residents with cognitive impairment (Resident #4, #8, #9, #11, #19, #22, #25, #31, #33, #34, #43, #44, #47, #51, #53, #61, #62, #63, #64, #66 and #72). The facility census was 72. On 08/28/25 at 2:04 P.M. the Administrator, Director of Nursing (DON) and Regional Registered Nurse (RN) #869 were notified Immediate Jeopardy began on 05/24/25 when the facility failed to have effective systems in place to prevent resident elopement (Resident #13 and #61) and to ensure residents' leaving the facility or with a desire to leave the facility were safe to be in the community independently and unsupervised. In addition, the facility failed to ensure adequate systems were in place to timely identify when residents were missing to ensure proper action was immediately taken. No changes in the facility's practice for determining if residents were able to leave the facility unattended was completed by the facility between 05/24/25 and 08/28/25. The Immediate Jeopardy was removed on 08/28/25 when the facility implemented the following corrective actions. On 08/17/25 the Administrator provided all staff education related to the facility elopement policy and procedures. On 08/18/25 Assistant Director of Nursing (ADON) #805 completed wandering assessments for all residents. On 08/18/25 the Administrator conducted a facility elopement drill. On 08/28/25 at 3:40 P.M. ADON #805 spoke with Resident #13's guardian, related to the resident's ability to leave the facility with supervision. On 08/28/25 by 6:00 P.M. the DON, Unit Manager #844 and ADON #805 re-assessed all residents for elopement risk. The results of the assessments revealed Resident #11, #13, #31, and #61 were identified as elopement risk. On 08/28/25 at 10:30 A.M., the door codes were changed by the door company. On 08/28/25 by 6:00 P.M., all residents were reviewed to determine if they were able to go on LOA supervised or unsupervised and orders were written to reflect the findings. On 08/28/25 the DON, ADON #805 and Unit Manager #844 consulted with resident families/guardians and physicians to determine resident LOA status. On 08/28/25 the DON/designee placed a list of residents (#4, #8, #9, #10, #11, #13, #22, #25, #31, #33, #34, #36, #43, #51, #53, #55, #61, and #66) who were not permitted to go on leave of absence (LOA) unsupervised at both nurses' stations and at the front receptionist area. On 08/28/25 Regional RN #869 reviewed and updated the elopement binders on all units. On 08/28/25, all staff were educated by Regional RN #869, LPN #865, Mobile Business Office Manager #890, Administrator, DON, ADON #805, Regional Director of Environmental Services #891, Dietary Manager #876, and Regional Dietary Manager #892 regarding all residents being required to have a physician order for LOA and if the LOA was required to be supervised or could be unsupervised. All staff were educated that nobody was to assist any resident out of the facility for any reason without consulting with the charge nurse who was assigned to that resident. Once a staff member confirmed with the nurse that a resident was permitted to go LOA, the staff member must enter the code without the resident seeing the code. At no time was it appropriate to give the code to a resident or family. Education included the facility door codes would be changed weekly. Education included not permitting residents to smoke in front of the facility and only permitting smoking in the designated courtyard. Beginning on 08/29/25 the DON/designee were assigned to review the LOA list daily in clinical meetings Monday through Friday and updates were to be completed if needed. A new list would be placed at both nursing stations and front desk on an ongoing basis. Beginning on 08/29/25 a process was initiated for the DON/designee to review new admissions in clinical meeting for LOA status on an ongoing basis. Beginning on 08/29/25 Human Resources (HR) #851/designee was assigned the duty to ensure all new hires were educated on the LOA process on an ongoing basis. Beginning on 08/29/25 the facility implemented a plan to conduct elopement drills by the DON/designee on a weekly basis each shift for four weeks then on an as needed basis. The drills were scheduled to begin the week of 09/01/25. Beginning on 08/29/25 the DON/designee was scheduled to interview five staff members on the LOA process weekly for four weeks then on an as needed basis. The interviews were scheduled to begin the week of 09/01/25. The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation. Beginning on 08/29/25 the Administrator/designee was to observe five smokers weekly for four weeks then on an as needed basis to ensure they were smoking in the appropriate areas. The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation. Although the Immediate Jeopardy was removed on 08/28/25, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:1. Review of Resident #13's medical record revealed an admission date of 05/23/25. Resident #13 had a letter of guardianship for person only for an indefinite time dated 04/30/25. Resident #13 had diagnoses including delusional disorders, anti-social personality disorder, anxiety disorder, apraxia (a neurological condition characterized by loss of the ability to perform activities that a person is physically able and willing to do), difficulty walking, and insomnia. Resident #13 had no physician orders regarding LOA. A nursing note by RN #847 dated 05/24/25 at 12:19 A.M. indicated Resident #13 arrived at the facility at 8:16 P.M., transported from the hospital. Resident #13 ambulated into the facility independently while carrying his personal belongings. Upon arrival, Resident #13 immediately expressed his intention to sign out and return home. Resident #13 was provided with education regarding his care plan and the importance of staying at the facility, but he remained insistent on leaving. Unit Manager #844 was made aware of the situation and advised that Resident #13 be re-educated, especially since he reportedly had no alternative place to go. Unit Manager #844 also sent the contact information of Resident #13's legal guardian to notify her of the situation. Resident #13's guardian was contacted, informed of Resident #13's desire to leave and advised that Resident #13 should remain at the facility as he has no safe discharge destination. Resident #13's guardian instructed staff to calm him and, if necessary, use the pink slip (involuntary psychiatric hold) process should he become aggressive. Resident #13 was encouraged to stay and agreed to watch television (TV) for a few minutes before making a final decision. Resident #13 was escorted to the TV lounge and made comfortable. After spending some time there, Resident #13 approached staff and requested to be taken to his room, stating he would remain at the facility for the night and reconsider leaving the following day. A nursing admission assessment dated [DATE] indicated Resident #13 was admitted with a cognitive disorder. Resident #13 was alert and oriented to person, place and time. It was unknown if Resident #13 had a history of exit seeking or wandering. The elopement part of the assessment indicated Resident #13 did not have a history of wandering and/or a pattern tied to Resident #13's past. Resident #13 was not accepting the new admission situation and Resident #13 had expressed anxiety/apprehension to leave the facility. Resident #13 was determined to be at risk for elopement or unsafe wandering. A baseline care plan indicated Resident #13 was at risk for elopement. Interventions included assessing for hunger, thirst, ambulation, and toileting needs. Wandering evaluations were to be completed upon admission/re-admission, quarterly and as necessary. Resident #13 was to be evaluated for need of a secure unit and the medical provider notified as needed. Interventions included providing diversionary activities as needed and redirecting Resident #13 when appropriate. A telehealth physician note by Physician #888 on 05/24/25 at 3:31 A.M. indicated Resident #13 was admitted after a psychiatric hospitalization. According to discharge papers, it appeared he had new onset delusions. A nursing note by LPN #861 dated 05/24/25 at 7:11 P.M. indicated Resident #13 signed out LOA around 3:45 P.M. stating he was going to the store. Resident #13 had not returned at that time. The note included all parties were aware. Review of a LOA sign out sheet dated 05/24/25 revealed Resident #13 signed out at 4:09 (did not indicate if A.M. or P.M. or include an anticipated return time) to go downtown. Sign in was at 8:24 or 8:29 (last number not completely legible) the same day. A nursing note by RN #846 dated 05/24/25 at 10:46 P.M. indicated Resident #13 was returned to the facility with police escorts at 8:10 P.M. No complaints were made. Record review revealed there was no evidence of further interventions or change in LOA process at this time for Resident #13. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was able to make himself understood and was able to understand others. A Brief Interview for Mental Status (BIMS) assessment indicated Resident #13 was cognitively intact with a score of 13 (out of 15 possible points). No signs of psychosis were noted. Wandering occurred daily. Wandering placed Resident #13 at significant risk of getting to a potentially dangerous place. Resident #13 was assessed as independent with walking 150 feet, once he was standing, in a corridor or similar space with no mobility devices. A nursing note by RN #805 dated 07/10/25 at 10:57 A.M. indicated Resident #13 began to exit seek. Resident #13 did not have clear directive as to where or why. A wanderguard device (a bracelet that alerts staff if a resident tries to leave a safe area) was applied. A voicemail was left for Resident #13's guardian. The resident's care plan was updated on 07/14/25 related to the wanderguard use and orders. A Nurse Practitioner (NP) note by NP #889 dated 07/31/25 indicated Resident #13 was hospitalized on [DATE] due to psychotic and cognitive disorders. Resident #13 was involuntarily probated by his sister for delusions involving Satan stealing his cigarettes and believing his sister was possessed by demons. Resident #13 exhibited poor hygiene, flight of ideas, paranoia and delusions. Review of the facility undated Resident Leave of Absence policy revealed a resident who was cognitively intact with independent decision making with a physician's order may sign themselves out for LOA. The procedure indicated a physician's order was to be obtained for the resident to leave the facility with or without supervision. The physician was to be alerted if the resident was at risk for elopement. Provide the resident or family/responsible party with the facility phone number as needed and instructions to contact the facility if return was delayed more than one hour from the anticipated return time. Contact the resident or family/responsible party if they had not returned within one hour of the anticipated return time. Notify the Executive Director if unable to contact the resident or responsible party, or if they refuse to return. On 08/27/25 at 8:15 A.M., the DON was interviewed regarding the facility LOA process. The DON indicated if a resident wanted to sign out LOA, nurses or herself checked a resident's BIMS score and expected it to be over 12 for a resident to leave unattended. Each resident had a LOA form in a notebook at their respective nursing station. Upon review of Resident #13's LOA form, the DON verified Resident #13 had not designated a planned return time when leaving in May 2025. The DON was asked about the rationale for Resident #13 being able to sign LOA when he had been assessed as an elopement risk and stated she would have to research it. On 08/27/25 at 10:58 A.M., the DON revealed Resident #13 was able to leave the facility on LOA by stating Resident #13 had been assessed as cognitively intact. The DON stated when the guardian was contacted the night of admission when Resident #13 wanted to leave, she had only indicated Resident #13 could not leave the facility to go home as he had no home or other alternate placement. The DON stated the guardian did not specifically state Resident #13 could not go out on LOA. During an interview on 08/27/25 at 10:13 A.M., LPN #859 stated if a resident wanted to go out LOA, they had to sign out on the LOA paper and nurses were to document it in the computer (recently started alert charting) that was accessible to the nurses and probably management, but she was not sure. The LPN revealed there was a list of residents who could not sign out LOA at the nursing station and front desk. LPN #859 was unable to identify who made the determination Resident #13 was able to be signed out LOA on 05/24/25. During an interview on 08/27/25 at 10:28 A.M., Resident #13 stated he continued to want to leave the facility and had spoken to everybody at the facility about wanting to leave. Resident #13 did not wish to speak about his LOA when police escorted him back to the facility. During an interview on 08/27/25 at 11:27 A.M., Resident #13's guardian stated Resident #13 had a long psychiatric stay prior to his admission to the facility. She stated when she was contacted by the facility the night Resident #13 was admitted , she did tell the facility Resident #13 was homeless and had nowhere to go and if he was unstable the facility should send him back to the psychiatric hospital. Resident #13's guardian stated she presumed staff would know with his history and wanting to leave the facility he should not be allowed to sign out LOA unless he was accompanied by family or someone from the facility. The guardian stated had staff consulted with her, Resident #13's guardian would have told them there were to be restrictions on Resident #13 signing himself out LOA. Resident #13's guardian stated she believed it was poor judgement on the facility's part if they let him sign himself out LOA. Resident #13's guardian stated she was not notified of Resident #13 leaving LOA and subsequently returning with police intervention. Resident #13's guardian stated Resident #13 had a son in Florida but was homeless for much of his life. Resident #13 was admitted to the psychiatric hospital after he became psychotic and tried to kill his sister who he was staying with. During an interview on 08/27/25 at 10:14 A.M., Certified Nursing Assistant (CNA) #835 stated nursing assistants could let residents sign out LOA if they were not on a list at the nursing station as not being permitted to go LOA. During an interview on 08/27/25 at 11:45 A.M., Regional RN #869 stated she did not know Resident #13 well enough to know if he should have been permitted to sign out LOA or if he should have been assessed as an elopement risk based on not wanting to be at the facility. RN #869 stated staff did not always have a resident's history when first admitted . Based on that, the facility probably should have waited until they were more familiar with Resident #13 to determine if he could safely leave the facility independently. RN #869 stated Resident #13 was assessed as cognitively intact on admission and was used to being homeless. During an interview on 08/27/25 at 5:10 P.M., the Administrator stated the facility had not notified the police when Resident #13 had not returned from LOA on 05/24/25, stating Resident #13 was known by the police in the community from past interactions. The Administrator revealed police had seen Resident #13 and stopped to inquire about what he was doing at an undisclosed location, and Resident #13 was able to inform them he was a resident of the facility. During an interview on 08/28/25 at 8:10 A.M., RN #846 stated she was unable to recall if the police indicated why they had picked up Resident #13 and returned him to the facility on [DATE]. RN #846 stated if a resident wished to sign out LOA they had to be independent and cognitively clear. Nurses have them sign a form saying when they expect to return and document. If a resident had a guardian, they were permitted to leave with the guardian. However, the RN revealed the facility allowed residents who met the criteria of cognitive abilities and independence to sign out for LOA without guardian input. During an interview on 08/28/25 at 8:18 A.M., LPN #861 stated the parties referred to in her progress note on 05/24/25 at 7:11 P.M. was the on-call unit manager (later identified as Unit Manager #844). LPN #861 stated for a resident to be able to sign out LOA she referred to a list or asked the DON or unit manager. During an interview on 08/28/25 at 8:23 A.M., the Administrator stated she had never been informed of Resident #13 leaving the facility on LOA until it was brought to her attention after questioning by the survey team. During an interview on 08/28/25 at 9:56 A.M., Unit Manager #844 stated when residents wanted to go out on LOA it was based largely on the cognitive scores on the BIMS interview. However, the facility tried not to let residents sign out on LOA for the first 24 hours after admission. A resident was permitted to leave the facility LOA if they had a guardian unless the guardian had provided specific instruction for them not to do so. Unit Manager #844 stated she was not aware of Resident #13 signing out LOA on 05/24/25 until staff called to report he had been returned to the facility by police. Unit Manager #844 stated it was her understanding Resident #13 wanted to go to the hospital to get personal items he believed were still there. Unit Manager #844 stated police were familiar with Resident #13 and simply gave him a ride to the facility, stating no police report had been filed. On 08/28/25, the local police department verified there was no police report involving Resident #13 on 05/24/25. During an interview on 08/28/25 at 12:47 P.M., RN #847 stated she assessed Resident #13 as an elopement risk on admission because he was very aggressive regarding his desire to want to leave and go home because there was nobody at his home to take care of it. RN #847 stated Resident #13 hovered at the front entrance for a long time, making attempts to leave but could not because he did not have the code to open the door. RN #847 stated Resident #13 was so upset he could not leave he made threatening moves toward her and only stopped when other residents placed themselves between her and Resident #13. On 08/28/25 at 4:25 P.M., ADON #805 spoke with Resident #13's guardian who indicated Resident #13 was to only go on supervised LOA with the guardian only. If anyone other than the guardian wanted to leave the facility with the resident, the guardian must be notified and give permission. During an interview on 09/02/25 at 11:21 A.M., LPN #858 stated she was not aware Resident #13 was unable to leave the facility on 05/24/25. Police had phoned the facility after her shift started (night shift) and told her Resident #13 was unsupervised downtown, maybe at the bus stop or the hospital, and they knew he should not be wandering around unaccompanied. Police offered to return Resident #13 to the facility. Once he arrived, Resident #13 was upset, and she explained to him he could not leave when he had a guardian. Resident #13 appeared to be confused and stated he did not know he had a guardian. During an interview on 09/02/25 at 4:18 P.M., the Medical Director stated he did review facility policies and provide input. However, regardless of how good a policy was, it was only effective upon staff implementing it. The Medical Director stated he had not been asked to provide input for LOA orders in the past three months. The facility had their own criteria for addressing LOA and would not necessarily involve guardian notification. Per the medical director, Resident #13's going LOA on 05/24/25 was not appropriate as Resident #13 had not been at the facility long enough to be assessed for health risks associated with him going LOA. 2. Record review revealed Resident #61 was admitted [DATE] with diagnoses of unspecified dementia, severe, with behavioral disturbance, unspecified mood disorder, alcohol dependence in remission, and cognitive communication deficit. Review of the Wandering Observation Tool dated 06/13/25 and 07/14/25 revealed Resident #61 was not at risk for wandering or eloping. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 was moderately cognitively impaired based on a score of eight out of 15 on the BIMS scale. The MDS revealed the resident was independent with all activities of daily living. Review of the progress note dated 08/17/25 at 2:57 A.M. by Curricular Practical Training (CPT) Intern RN #846 revealed Resident #61 was last seen (on 08/16/25) between 8:00 P.M. and 8:30 P.M. during medication administration. At regular night rounds, CPT Intern RN #846 noticed Resident #61 was not in his room. A facility and ground search was conducted, and Resident #61 was not found. The Nurse Supervisor LPN #858 was notified at 2:00 A.M. The Nurse Manager #844 contacted Resident #61's mother, the hospital, and various police stations, all of which were unaware of Resident #61's location. Review of the progress note dated 08/17/25 at 9:23 A.M. by Charge Nurse #842 revealed a call was received from the Local Police Department that Resident #61 was being transported to the hospital for an unknown reason. Review of the progress note dated 08/17/25 at 4:01 P.M. by RN Unit Manager #844 revealed Resident #61 was placed on 1:1 supervision upon return to the facility. Review of the physician orders revealed Resident #61 was placed on 1:1 supervision effective 08/17/25. Review of the progress note dated 08/17/25 at 4:04 P.M. by Charge Nurse #842 revealed Resident #61 returned to the facility (on 08/17/25) at 3:45 P.M. by ambulance with two staff and was alert and oriented to self. Resident #61 refused to have a wanderguard placed on his body. Review of a police report from the Local Police Department dated 08/17/25 revealed the facility reported a missing person incident on 08/17/25 at 2:53 A.M. The responding officer arrived at the facility at 4:15 A.M and spoke with healthcare worker CPT Intern RN #846 upon arrival. It was reported that Resident #61 had wandered away from the facility sometime after 8:30 P.M. on 08/16/25. CPT Intern RN #846 advised Resident #61suffered from depression, mood disorders, and alcoholism which caused him confusion at times. CPT Intern RN #846 advised she last gave the resident his medications on 08/16/25 at 8:30 P.M. at which time she watched him take a phone call and walk outside for a cigarette. She further stated that he had wandered from the facility before but not for this length of time. On 08/17/25 time unspecified, Youngstown Police Department received a message from Austintown Police Department stating Resident #61 was located by their officers and was being transported to the local emergency room. The facility was notified, and Resident #61 was removed from Law Enforcement Automated Data System (LEADS). Review of the Wandering Observation Tool dated 08/17/25 revealed Resident #61 was identified as a high risk for elopement or unsafe wandering. Review of the progress note dated 08/17/25 at 5:58 P.M. by LPN #858 revealed vital signs were obtained and a skin assessment was completed. There were no known injuries noted. There were no new orders from the emergency department, and Resident #61 continued to refuse a wanderguard. Review of the investigation of self-reported incident (SRI) tracking number 264129 revealed the following sequence of events: On 08/16/25 at 7:30 P.M. Certified Nursing Assistant (CNA) #817 observed Resident #61 in his room and was told a few hours later Resident #61 was gone. On 08/16/25 around 9:30 P.M. CNA #828 reported Resident #61 was seen by the front door attempting to put in door code to go outside and smoke. To not cause the door alarm to go off, CNA #828 entered the code and let Resident #61 out the front door to go smoke. CNA #828 observed Resident #61 walking towards the left side of the facility to sit at the table and chairs. CNA #828 revealed the resident did not have on a wanderguard and therefore, was not an elopement risk prior to letting him outside. On 08/16/25 at 9:30 P.M. CNA #809 reported seeing Resident #61 at the bus stop when she went to a store across the street on her break, but the resident was gone when she came back. Around 2:00 A.M. she noticed he was not in his room and notified the nurse at which time they began to look for him. On 08/16/25 at an unspecified time LPN #858 was notified by CNA #809 that Resident #61 was not in his room and unable to be found. LPN #858 initiated the facility's elopement action plan, and staff searched inside and outside the facility, but Resident #61was not accounted for. Management was notified during the search. On 08/17/25 at 2:35 A.M. LPN #858 contacted Resident #61's mom and determined Resident #61was not there. On 08/17/25 between 2:40 A.M. and 3:35 A.M. the police and hospital were contacted, but Resident #61 was still not located. A voice message was left with Resident #61's friend who was also listed as a contact. LPN #858 made multiple attempts to reach Resident #61 on his cell phone but was unsuccessful. As of 4:15 A.M. when LPN #858 left, Resident #61 had not been located. On 08/17/25 at 2:00 A.M. CNA #833 reported another aide approached her to say that Resident #61was missing and that she saw him at the bus stop (on 08/16/25) about 9:00 P.M. They then started looking for him. Review of the Police Dispatch Log revealed on 08/17/25 at 8:07 A.M. Resident #61 was found at a gas station which was one-half mile from facility and a 15-minute walk. Between 8:07 A.M. and 8:10 A.M. a male in the store notified police a man was sleeping behind the store. The responding officer noted Resident #61 was awake and breathing but was unable to focus or understand questions, had possible altered mental status, was very confused, and not aware of what happened last night. Review of the Ambulance Prehospital Care Report Summary dated 08/17/25 revealed Resident #61 was transported to a local emergency department. Resident #61 walked with assistance to stretcher. No drug use was suspected, he was psychologically impaired, with the chief complaint being altered mental status. Resident #61 was found asleep behind a gas station and had no idea how he got there, where he lived, or what happened prior to his arrival at the scene. On 08/27/25 the administrator provided a list of residents with wanderguards and required 1:1 supervision. The list identified Resident #13 and #31 with wanderguards and #61 with 1:1 supervision. Observation on 08/27/25 at 8:03 A.M. revealed Resident #61 in his room sleeping with an aide standing outside his door. Several attempts from 08/27/25 to 08/28/25 to interview CNA #828, who initially let Resident #61 out of the building were unsuccessful. Interview on 08/27/25 at 10:58 A.M. with the DON revealed one CNA was assigned to always supervise Resident #61 on all shifts. That CNA did not provide any care to any other residents, was not included in the count for the floor aides and was to keep eyes on Resident #61 at all times. Observation at the time of the interview revealed CNA #822 was assigned to Resident #61 and was seated in a chair on the left side of the doorway to his room. Resident #61's assigned 1:1 CNA was not included in the count for the floor aides. Interview on 08/27/25 at 2:07 P.M. with LPN #858 revealed she was not scheduled for the night of 08/16/25 but happened to be in the building because of a different event that occurred. Before she left, LPN #858 went to check on the 100 halls when she was informed by CNA #809 that Resident #61 was not in his room around 2:00 A.M. She reported the aides were supposed to be doing two-hour checks on the residents. All staff in the building, which consisted of three nurses including herself and six aides, assisted with the search. LPN #858 believed CPT Intern RN #846 was the nurse assigned to the unit Resident #61 resided on. LPN #858 left the building about 3:50 A.M. and drove around to see if she could find Resident #61 but was unable to locate him. Interview on 08/27/25 at 2:24 P.M. with CNA #809 revealed on 8/16/25 at 9:30 P.M. Resident #61 was observed at the bus stop while on her way to the store while on break. CNA #809 did not see Resident #61 when she came out the store but did not think anything of it because residents leave out the front door all the time and were allowed to stay out until midnight, so it was not unusual for residents to be out past 9:00 P.M. CNA #809 reported she worked the 200 hall the night of 08/16/25 but had to go to the 100 hall for something. CNA #809 walked past Resident #61's room about 2:00 A.M., noticed he was not there, and reported it to LPN #858. CNA #808 confirmed CNA #817 and CPT Intern RN #846 were the assigned staff to the 100 halls where Resident #61 resided. Interview on 08/27/25 at 3:11 P.M. with CNA #817 confirmed that she was assigned to the resident's hall the night he eloped. CNA #817 started her shift at 7:00 P.M. and stated she saw Resident #61 at 7:30 P.M. CNA #817 was unaware Resident #61 was missing until another staff member informed her. She was unable to recall the time she was notified. CNA #817 further confirmed that residents who were mostly independent with activities of daily living were not checked on routinely throughout the night. Interview on 08/27/25 at 3:29 P.M. with CPT Intern RN #846 c[TRUNCATED]

Based on observation, record review, review of a facility self-report incident, facility investigation review, police report review, policy review and interviews, the facility failed to provide adequate supervision and/or intervention to prevent resident elopement. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 05/24/25 when Resident #13, who was assessed as an elopement risk, had exit seeking behaviors and was deemed incompetent by the court system, was permitted by staff to leave the facility unattended and without guardian consent. The resident's whereabouts were unknown until the resident was returned to the facility via police escort on this same date. The Immediate Jeopardy and potential for actual harm continued on 08/16/25 when staff allowed Resident #61, a moderately cognitively impaired resident to leave the facility unattended. The resident's whereabouts were unknown until the resident was found by police, on 08/17/25 a half mile from the facility sleeping on the ground behind a gas station. The resident was transported to the hospital for evaluation. In addition to the two incidents of elopement, the facility failed to have adequate systems in place to identify risks associated with its current practice of determining if residents could safely leave the facility unsupervised/unattended. In addition, concerns that did not rise to Immediate Jeopardy were identified when the facility failed to adequately supervise Resident #11, #37, #40 and #68 related to smoking and possession of smoking materials for safety/accidents. The facility also failed to ensure fall interventions were individualized and comprehensive to prevent falls for Residents #5. This affected two residents (#13 and #61) of three residents reviewed for wandering/elopement, four residents (#11, #37, #40 and #68) of 15 residents reviewed for smoking and one resident (#5) of three residents reviewed for falls. The facility identified three additional residents with guardianship in place (Resident #10, #51 and #55) and 21 additional residents with cognitive impairment (Resident #4, #8, #9, #11, #19, #22, #25, #31, #33, #34, #43, #44, #47, #51, #53, #61, #62, #63, #64, #66 and #72). The facility census was 72. On 08/28/25 at 2:04 P.M. the Administrator, Director of Nursing (DON) and Regional Registered Nurse (RN) #869 were notified Immediate Jeopardy began on 05/24/25 when the facility failed to have effective systems in place to prevent resident elopement (Resident #13 and #61) and to ensure residents' leaving the facility or with a desire to leave the facility were safe to be in the community independently and unsupervised. In addition, the facility failed to ensure adequate systems were in place to timely identify when residents were missing to ensure proper action was immediately taken. No changes in the facility's practice for determining if residents were able to leave the facility unattended was completed by the facility between 05/24/25 and 08/28/25. The Immediate Jeopardy was removed on 08/28/25 when the facility implemented the following corrective actions. On 08/17/25 the Administrator provided all staff education related to the facility elopement policy and procedures. On 08/18/25 Assistant Director of Nursing (ADON) #805 completed wandering assessments for all residents. On 08/18/25 the Administrator conducted a facility elopement drill. On 08/28/25 at 3:40 P.M. ADON #805 spoke with Resident #13's guardian, related to the resident's ability to leave the facility with supervision. On 08/28/25 by 6:00 P.M. the DON, Unit Manager #844 and ADON #805 re-assessed all residents for elopement risk. The results of the assessments revealed Resident #11, #13, #31, and #61 were identified as elopement risk. On 08/28/25 at 10:30 A.M., the door codes were changed by the door company. On 08/28/25 by 6:00 P.M., all residents were reviewed to determine if they were able to go on LOA supervised or unsupervised and orders were written to reflect the findings. On 08/28/25 the DON, ADON #805 and Unit Manager #844 consulted with resident families/guardians and physicians to determine resident LOA status. On 08/28/25 the DON/designee placed a list of residents (#4, #8, #9, #10, #11, #13, #22, #25, #31, #33, #34, #36, #43, #51, #53, #55, #61, and #66) who were not permitted to go on leave of absence (LOA) unsupervised at both nurses' stations and at the front receptionist area. On 08/28/25 Regional RN #869 reviewed and updated the elopement binders on all units. On 08/28/25, all staff were educated by Regional RN #869, LPN #865, Mobile Business Office Manager #890, Administrator, DON, ADON #805, Regional Director of Environmental Services #891, Dietary Manager #876, and Regional Dietary Manager #892 regarding all residents being required to have a physician order for LOA and if the LOA was required to be supervised or could be unsupervised. All staff were educated that nobody was to assist any resident out of the facility for any reason without consulting with the charge nurse who was assigned to that resident. Once a staff member confirmed with the nurse that a resident was permitted to go LOA, the staff member must enter the code without the resident seeing the code. At no time was it appropriate to give the code to a resident or family. Education included the facility door codes would be changed weekly. Education included not permitting residents to smoke in front of the facility and only permitting smoking in the designated courtyard. Beginning on 08/29/25 the DON/designee were assigned to review the LOA list daily in clinical meetings Monday through Friday and updates were to be completed if needed. A new list would be placed at both nursing stations and front desk on an ongoing basis. Beginning on 08/29/25 a process was initiated for the DON/designee to review new admissions in clinical meeting for LOA status on an ongoing basis. Beginning on 08/29/25 Human Resources (HR) #851/designee was assigned the duty to ensure all new hires were educated on the LOA process on an ongoing basis. Beginning on 08/29/25 the facility implemented a plan to conduct elopement drills by the DON/designee on a weekly basis each shift for four weeks then on an as needed basis. The drills were scheduled to begin the week of 09/01/25. Beginning on 08/29/25 the DON/designee was scheduled to interview five staff members on the LOA process weekly for four weeks then on an as needed basis. The interviews were scheduled to begin the week of 09/01/25. The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation. Beginning on 08/29/25 the Administrator/designee was to observe five smokers weekly for four weeks then on an as needed basis to ensure they were smoking in the appropriate areas. The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation. Although the Immediate Jeopardy was removed on 08/28/25, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:1. Review of Resident #13's medical record revealed an admission date of 05/23/25. Resident #13 had a letter of guardianship for person only for an indefinite time dated 04/30/25. Resident #13 had diagnoses including delusional disorders, anti-social personality disorder, anxiety disorder, apraxia (a neurological condition characterized by loss of the ability to perform activities that a person is physically able and willing to do), difficulty walking, and insomnia. Resident #13 had no physician orders regarding LOA. A nursing note by RN #847 dated 05/24/25 at 12:19 A.M. indicated Resident #13 arrived at the facility at 8:16 P.M., transported from the hospital. Resident #13 ambulated into the facility independently while carrying his personal belongings. Upon arrival, Resident #13 immediately expressed his intention to sign out and return home. Resident #13 was provided with education regarding his care plan and the importance of staying at the facility, but he remained insistent on leaving. Unit Manager #844 was made aware of the situation and advised that Resident #13 be re-educated, especially since he reportedly had no alternative place to go. Unit Manager #844 also sent the contact information of Resident #13's legal guardian to notify her of the situation. Resident #13's guardian was contacted, informed of Resident #13's desire to leave and advised that Resident #13 should remain at the facility as he has no safe discharge destination. Resident #13's guardian instructed staff to calm him and, if necessary, use the pink slip (involuntary psychiatric hold) process should he become aggressive. Resident #13 was encouraged to stay and agreed to watch television (TV) for a few minutes before making a final decision. Resident #13 was escorted to the TV lounge and made comfortable. After spending some time there, Resident #13 approached staff and requested to be taken to his room, stating he would remain at the facility for the night and reconsider leaving the following day. A nursing admission assessment dated [DATE] indicated Resident #13 was admitted with a cognitive disorder. Resident #13 was alert and oriented to person, place and time. It was unknown if Resident #13 had a history of exit seeking or wandering. The elopement part of the assessment indicated Resident #13 did not have a history of wandering and/or a pattern tied to Resident #13's past. Resident #13 was not accepting the new admission situation and Resident #13 had expressed anxiety/apprehension to leave the facility. Resident #13 was determined to be at risk for elopement or unsafe wandering. A baseline care plan indicated Resident #13 was at risk for elopement. Interventions included assessing for hunger, thirst, ambulation, and toileting needs. Wandering evaluations were to be completed upon admission/re-admission, quarterly and as necessary. Resident #13 was to be evaluated for need of a secure unit and the medical provider notified as needed. Interventions included providing diversionary activities as needed and redirecting Resident #13 when appropriate. A telehealth physician note by Physician #888 on 05/24/25 at 3:31 A.M. indicated Resident #13 was admitted after a psychiatric hospitalization. According to discharge papers, it appeared he had new onset delusions. A nursing note by LPN #861 dated 05/24/25 at 7:11 P.M. indicated Resident #13 signed out LOA around 3:45 P.M. stating he was going to the store. Resident #13 had not returned at that time. The note included all parties were aware. Review of a LOA sign out sheet dated 05/24/25 revealed Resident #13 signed out at 4:09 (did not indicate if A.M. or P.M. or include an anticipated return time) to go downtown. Sign in was at 8:24 or 8:29 (last number not completely legible) the same day. A nursing note by RN #846 dated 05/24/25 at 10:46 P.M. indicated Resident #13 was returned to the facility with police escorts at 8:10 P.M. No complaints were made. Record review revealed there was no evidence of further interventions or change in LOA process at this time for Resident #13. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was able to make himself understood and was able to understand others. A Brief Interview for Mental Status (BIMS) assessment indicated Resident #13 was cognitively intact with a score of 13 (out of 15 possible points). No signs of psychosis were noted. Wandering occurred daily. Wandering placed Resident #13 at significant risk of getting to a potentially dangerous place. Resident #13 was assessed as independent with walking 150 feet, once he was standing, in a corridor or similar space with no mobility devices. A nursing note by RN #805 dated 07/10/25 at 10:57 A.M. indicated Resident #13 began to exit seek. Resident #13 did not have clear directive as to where or why. A wanderguard device (a bracelet that alerts staff if a resident tries to leave a safe area) was applied. A voicemail was left for Resident #13's guardian. The resident's care plan was updated on 07/14/25 related to the wanderguard use and orders. A Nurse Practitioner (NP) note by NP #889 dated 07/31/25 indicated Resident #13 was hospitalized on [DATE] due to psychotic and cognitive disorders. Resident #13 was involuntarily probated by his sister for delusions involving Satan stealing his cigarettes and believing his sister was possessed by demons. Resident #13 exhibited poor hygiene, flight of ideas, paranoia and delusions. Review of the facility undated Resident Leave of Absence policy revealed a resident who was cognitively intact with independent decision making with a physician's order may sign themselves out for LOA. The procedure indicated a physician's order was to be obtained for the resident to leave the facility with or without supervision. The physician was to be alerted if the resident was at risk for elopement. Provide the resident or family/responsible party with the facility phone number as needed and instructions to contact the facility if return was delayed more than one hour from the anticipated return time. Contact the resident or family/responsible party if they had not returned within one hour of the anticipated return time. Notify the Executive Director if unable to contact the resident or responsible party, or if they refuse to return. On 08/27/25 at 8:15 A.M., the DON was interviewed regarding the facility LOA process. The DON indicated if a resident wanted to sign out LOA, nurses or herself checked a resident's BIMS score and expected it to be over 12 for a resident to leave unattended. Each resident had a LOA form in a notebook at their respective nursing station. Upon review of Resident #13's LOA form, the DON verified Resident #13 had not designated a planned return time when leaving in May 2025. The DON was asked about the rationale for Resident #13 being able to sign LOA when he had been assessed as an elopement risk and stated she would have to research it. On 08/27/25 at 10:58 A.M., the DON revealed Resident #13 was able to leave the facility on LOA by stating Resident #13 had been assessed as cognitively intact. The DON stated when the guardian was contacted the night of admission when Resident #13 wanted to leave, she had only indicated Resident #13 could not leave the facility to go home as he had no home or other alternate placement. The DON stated the guardian did not specifically state Resident #13 could not go out on LOA. During an interview on 08/27/25 at 10:13 A.M., LPN #859 stated if a resident wanted to go out LOA, they had to sign out on the LOA paper and nurses were to document it in the computer (recently started alert charting) that was accessible to the nurses and probably management, but she was not sure. The LPN revealed there was a list of residents who could not sign out LOA at the nursing station and front desk. LPN #859 was unable to identify who made the determination Resident #13 was able to be signed out LOA on 05/24/25. During an interview on 08/27/25 at 10:28 A.M., Resident #13 stated he continued to want to leave the facility and had spoken to everybody at the facility about wanting to leave. Resident #13 did not wish to speak about his LOA when police escorted him back to the facility. During an interview on 08/27/25 at 11:27 A.M., Resident #13's guardian stated Resident #13 had a long psychiatric stay prior to his admission to the facility. She stated when she was contacted by the facility the night Resident #13 was admitted , she did tell the facility Resident #13 was homeless and had nowhere to go and if he was unstable the facility should send him back to the psychiatric hospital. Resident #13's guardian stated she presumed staff would know with his history and wanting to leave the facility he should not be allowed to sign out LOA unless he was accompanied by family or someone from the facility. The guardian stated had staff consulted with her, Resident #13's guardian would have told them there were to be restrictions on Resident #13 signing himself out LOA. Resident #13's guardian stated she believed it was poor judgement on the facility's part if they let him sign himself out LOA. Resident #13's guardian stated she was not notified of Resident #13 leaving LOA and subsequently returning with police intervention. Resident #13's guardian stated Resident #13 had a son in Florida but was homeless for much of his life. Resident #13 was admitted to the psychiatric hospital after he became psychotic and tried to kill his sister who he was staying with. During an interview on 08/27/25 at 10:14 A.M., Certified Nursing Assistant (CNA) #835 stated nursing assistants could let residents sign out LOA if they were not on a list at the nursing station as not being permitted to go LOA. During an interview on 08/27/25 at 11:45 A.M., Regional RN #869 stated she did not know Resident #13 well enough to know if he should have been permitted to sign out LOA or if he should have been assessed as an elopement risk based on not wanting to be at the facility. RN #869 stated staff did not always have a resident's history when first admitted . Based on that, the facility probably should have waited until they were more familiar with Resident #13 to determine if he could safely leave the facility independently. RN #869 stated Resident #13 was assessed as cognitively intact on admission and was used to being homeless. During an interview on 08/27/25 at 5:10 P.M., the Administrator stated the facility had not notified the police when Resident #13 had not returned from LOA on 05/24/25, stating Resident #13 was known by the police in the community from past interactions. The Administrator revealed police had seen Resident #13 and stopped to inquire about what he was doing at an undisclosed location, and Resident #13 was able to inform them he was a resident of the facility. During an interview on 08/28/25 at 8:10 A.M., RN #846 stated she was unable to recall if the police indicated why they had picked up Resident #13 and returned him to the facility on [DATE]. RN #846 stated if a resident wished to sign out LOA they had to be independent and cognitively clear. Nurses have them sign a form saying when they expect to return and document. If a resident had a guardian, they were permitted to leave with the guardian. However, the RN revealed the facility allowed residents who met the criteria of cognitive abilities and independence to sign out for LOA without guardian input. During an interview on 08/28/25 at 8:18 A.M., LPN #861 stated the parties referred to in her progress note on 05/24/25 at 7:11 P.M. was the on-call unit manager (later identified as Unit Manager #844). LPN #861 stated for a resident to be able to sign out LOA she referred to a list or asked the DON or unit manager. During an interview on 08/28/25 at 8:23 A.M., the Administrator stated she had never been informed of Resident #13 leaving the facility on LOA until it was brought to her attention after questioning by the survey team. During an interview on 08/28/25 at 9:56 A.M., Unit Manager #844 stated when residents wanted to go out on LOA it was based largely on the cognitive scores on the BIMS interview. However, the facility tried not to let residents sign out on LOA for the first 24 hours after admission. A resident was permitted to leave the facility LOA if they had a guardian unless the guardian had provided specific instruction for them not to do so. Unit Manager #844 stated she was not aware of Resident #13 signing out LOA on 05/24/25 until staff called to report he had been returned to the facility by police. Unit Manager #844 stated it was her understanding Resident #13 wanted to go to the hospital to get personal items he believed were still there. Unit Manager #844 stated police were familiar with Resident #13 and simply gave him a ride to the facility, stating no police report had been filed. On 08/28/25, the local police department verified there was no police report involving Resident #13 on 05/24/25. During an interview on 08/28/25 at 12:47 P.M., RN #847 stated she assessed Resident #13 as an elopement risk on admission because he was very aggressive regarding his desire to want to leave and go home because there was nobody at his home to take care of it. RN #847 stated Resident #13 hovered at the front entrance for a long time, making attempts to leave but could not because he did not have the code to open the door. RN #847 stated Resident #13 was so upset he could not leave he made threatening moves toward her and only stopped when other residents placed themselves between her and Resident #13. On 08/28/25 at 4:25 P.M., ADON #805 spoke with Resident #13's guardian who indicated Resident #13 was to only go on supervised LOA with the guardian only. If anyone other than the guardian wanted to leave the facility with the resident, the guardian must be notified and give permission. During an interview on 09/02/25 at 11:21 A.M., LPN #858 stated she was not aware Resident #13 was unable to leave the facility on 05/24/25. Police had phoned the facility after her shift started (night shift) and told her Resident #13 was unsupervised downtown, maybe at the bus stop or the hospital, and they knew he should not be wandering around unaccompanied. Police offered to return Resident #13 to the facility. Once he arrived, Resident #13 was upset, and she explained to him he could not leave when he had a guardian. Resident #13 appeared to be confused and stated he did not know he had a guardian. During an interview on 09/02/25 at 4:18 P.M., the Medical Director stated he did review facility policies and provide input. However, regardless of how good a policy was, it was only effective upon staff implementing it. The Medical Director stated he had not been asked to provide input for LOA orders in the past three months. The facility had their own criteria for addressing LOA and would not necessarily involve guardian notification. Per the medical director, Resident #13's going LOA on 05/24/25 was not appropriate as Resident #13 had not been at the facility long enough to be assessed for health risks associated with him going LOA. 2. Record review revealed Resident #61 was admitted [DATE] with diagnoses of unspecified dementia, severe, with behavioral disturbance, unspecified mood disorder, alcohol dependence in remission, and cognitive communication deficit. Review of the Wandering Observation Tool dated 06/13/25 and 07/14/25 revealed Resident #61 was not at risk for wandering or eloping. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 was moderately cognitively impaired based on a score of eight out of 15 on the BIMS scale. The MDS revealed the resident was independent with all activities of daily living. Review of the progress note dated 08/17/25 at 2:57 A.M. by Curricular Practical Training (CPT) Intern RN #846 revealed Resident #61 was last seen (on 08/16/25) between 8:00 P.M. and 8:30 P.M. during medication administration. At regular night rounds, CPT Intern RN #846 noticed Resident #61 was not in his room. A facility and ground search was conducted, and Resident #61 was not found. The Nurse Supervisor LPN #858 was notified at 2:00 A.M. The Nurse Manager #844 contacted Resident #61's mother, the hospital, and various police stations, all of which were unaware of Resident #61's location. Review of the progress note dated 08/17/25 at 9:23 A.M. by Charge Nurse #842 revealed a call was received from the Local Police Department that Resident #61 was being transported to the hospital for an unknown reason. Review of the progress note dated 08/17/25 at 4:01 P.M. by RN Unit Manager #844 revealed Resident #61 was placed on 1:1 supervision upon return to the facility. Review of the physician orders revealed Resident #61 was placed on 1:1 supervision effective 08/17/25. Review of the progress note dated 08/17/25 at 4:04 P.M. by Charge Nurse #842 revealed Resident #61 returned to the facility (on 08/17/25) at 3:45 P.M. by ambulance with two staff and was alert and oriented to self. Resident #61 refused to have a wanderguard placed on his body. Review of a police report from the Local Police Department dated 08/17/25 revealed the facility reported a missing person incident on 08/17/25 at 2:53 A.M. The responding officer arrived at the facility at 4:15 A.M and spoke with healthcare worker CPT Intern RN #846 upon arrival. It was reported that Resident #61 had wandered away from the facility sometime after 8:30 P.M. on 08/16/25. CPT Intern RN #846 advised Resident #61suffered from depression, mood disorders, and alcoholism which caused him confusion at times. CPT Intern RN #846 advised she last gave the resident his medications on 08/16/25 at 8:30 P.M. at which time she watched him take a phone call and walk outside for a cigarette. She further stated that he had wandered from the facility before but not for this length of time. On 08/17/25 time unspecified, Youngstown Police Department received a message from Austintown Police Department stating Resident #61 was located by their officers and was being transported to the local emergency room. The facility was notified, and Resident #61 was removed from Law Enforcement Automated Data System (LEADS). Review of the Wandering Observation Tool dated 08/17/25 revealed Resident #61 was identified as a high risk for elopement or unsafe wandering. Review of the progress note dated 08/17/25 at 5:58 P.M. by LPN #858 revealed vital signs were obtained and a skin assessment was completed. There were no known injuries noted. There were no new orders from the emergency department, and Resident #61 continued to refuse a wanderguard. Review of the investigation of self-reported incident (SRI) tracking number 264129 revealed the following sequence of events: · On 08/16/25 at 7:30 P.M. Certified Nursing Assistant (CNA) #817 observed Resident #61 in his room and was told “a few hours later” Resident #61 was gone. · On 08/16/25 around 9:30 P.M. CNA #828 reported Resident #61 was seen by the front door attempting to put in door code to go outside and smoke. To not cause the door alarm to go off, CNA #828 entered the code and let Resident #61 out the front door to go smoke. CNA #828 observed Resident #61 walking towards the left side of the facility to sit at the table and chairs. CNA #828 revealed the resident did not have on a wanderguard and therefore, was not an elopement risk prior to letting him outside. · On 08/16/25 at 9:30 P.M. CNA #809 reported seeing Resident #61 at the bus stop when she went to a store across the street on her break, but the resident “was gone” when she came back. Around 2:00 A.M. she noticed he was not in his room and notified the nurse at which time they began to look for him. · On 08/16/25 at an unspecified time LPN #858 was notified by CNA #809 that Resident #61 was not in his room and unable to be found. LPN #858 initiated the facility's elopement action plan, and staff searched inside and outside the facility, but Resident #61was not accounted for. Management was notified during the search. · On 08/17/25 at 2:35 A.M. LPN #858 contacted Resident #61's mom and determined Resident #61was not there. · On 08/17/25 between 2:40 A.M. and 3:35 A.M. the police and hospital were contacted, but Resident #61 was still not located. A voice message was left with Resident #61's friend who was also listed as a contact. LPN #858 made multiple attempts to reach Resident #61 on his cell phone but was unsuccessful. As of 4:15 A.M. when LPN #858 left, Resident #61 had not been located. · On 08/17/25 at 2:00 A.M. CNA #833 reported another aide approached her to say that Resident #61was missing and that she saw him at the bus stop (on 08/16/25) about 9:00 P.M. They then started looking for him. · Review of the Police Dispatch Log revealed on 08/17/25 at 8:07 A.M. Resident #61 was found at a gas station which was one-half mile from facility and a 15-minute walk. Between 8:07 A.M. and 8:10 A.M. a male in the store notified police a man was sleeping behind the store. The responding officer noted Resident #61 was awake and breathing but was unable to focus or understand questions, had possible altered mental status, was very confused, and not aware of what happened last night. · Review of the Ambulance Prehospital Care Report Summary dated 08/17/25 revealed Resident #61 was transported to a local emergency department. Resident #61 walked with assistance to stretcher. No drug use was suspected, he was psychologically impaired, with the chief complaint being altered mental status. Resident #61 was found asleep behind a gas station and had no idea how he got there, where he lived, or what happened prior to his arrival at the scene. On 08/27/25 the administrator provided a list of residents with wanderguards and required 1:1 supervision. The list identified Resident #13 and #31 with wanderguards and #61 with 1:1 supervision. Observation on 08/27/25 at 8:03 A.M. revealed Resident #61 in his room sleeping with an aide standing outside his door. Several attempts from 08/27/25 to 08/28/25 to interview CNA #828, who initially let Resident #61 out of the building were unsuccessful. Interview on 08/27/25 at 10:58 A.M. with the DON revealed one CNA was assigned to always supervise Resident #61 on all shifts. That CNA did not provide any care to any other residents, was not included in the count for the floor aides and was to keep eyes on Resident #61 at all times. Observation at the time of the interview revealed CNA #822 was assigned to Resident #61 and was seated in a chair on the left side of the doorway to his room. Resident #61's assigned 1:1 CNA was not included in the count for the floor aides. Interview on 08/27/25 at 2:07 P.M. with LPN #858 revealed she was not schedul

Based on review of schedules, review of time punches, and interviews, the facility failed to ensure eight consecutive hours of registered nurse (RN) coverage was provided every day. This had the potential to affect all 72 residents. Findings include:Review of the schedule and time punches for the period between 01/01/25 and 01/07/25 revealed on 01/01/25 one RN was scheduled and worked between 7:30 P.M. and 12:30 A.M. On 01/02/25, an RN worked day shift for 7.75 consecutive hours, leaving at 3:26 P.M. Another RN clocked in at 6:54 P.M., resulting in a lack of RN coverage for eight consecutive hours. The schedules and time sheets revealed on 01/04/25 there were 4.5 hours of RN coverage. On 01/05/25 RN coverage started at 6:40 P.M. On 09/04/25 at 11:57 A.M., Unit Manager #844 stated during the reviewed week of 01/01/25 to 01/07/25 the facility had three RNs, including the Director of Nursing (DON). All three of the RNs were trying to provide RN coverage for the facility, along with their already assigned duties. The findings above were discussed with the Administrator on 09/08/25 at 2:15 P.M. The Administrator stated the DON covered the floor some of those days, acknowledging the census was over 60. The Administrator acknowledged the nights the DON covered the floor she came in and worked night shift but was still waiting on times the DON worked as a charge nurse. No time sheet was provided indicating what hours the DON worked on the unit as a charge nurse.

Based on medical record review, review of job descriptions and personnel files, and interviews, facility administrative staff failed to identify deficient practices and failed to notify the Administrator of known non-compliance in an attempt to increase compliance. This had the potential to affect all 72 residents residing in the facility. Findings include:1. On [DATE] at 12:12 P.M., Activity Director #800 was heard explaining in front of the Administrator that getting activity assistants to consistently document activities had been an ongoing issue. On [DATE] at 12:12 P.M., the Administrator stated she had not been made aware of the non-compliance with documentation. Had she been made aware, she could have intervened. 2. While reviewing the personnel files and criminal background check log with the Administrator on [DATE] at 10:58 A.M., the Administrator verified there were employees whose criminal background check results had not been received in the time frame specified by the state regulations but were permitted to continue working. The Administrator stated the previous Human Resource Director had not made her aware or action could have been taken. 3. On [DATE] at 9:25 A.M., the Administrator stated when she started at the facility in [DATE], the current Director of Nursing (DON) was working as a unit manager. The Administrator stated she was unsure of what training the DON received prior or when accepting the position. Review of the DON's employee file revealed she was originally licensed as a registered nurse (RN) on [DATE]. The application revealed past work history from [DATE] to [DATE] as a RN at a different long term care facility then from [DATE] until hired as a medical supervisor at a plasma center. The file revealed a hire date of [DATE] as a charge nurse. The DON was promoted to Unit Manager on [DATE] then to the DON position [DATE]. The DON's nursing license expired [DATE] with no Board action documented. On [DATE] at 10:30 A.M., the Administrator stated Regional RN #869 trained the DON to job responsibilities but did not know what the training consisted of. Review of the facility's DON job description (prepared/revised [DATE]) revealed job duties and responsibilities included ensuring all nursing staff followed established departmental policies and procedures, assisting in implementing and coordinating department policies and procedures, interpreting department policies and procedures to personnel/residents/visitors/family members and others as necessary, involving the resident/family in planning objectives and goals for the resident, assisting in setting standards for department personnel, and executing resident care policies in the absence of the medical director and/or the attending physician. The job description indicated the DON must be knowledgeable of nursing and medical practices, standards of practice and state practice acts and procedures, as well as laws, regulations and guidelines that pertain to long-term care. Through interviews with the DON throughout the survey, it was determined she did not guide staff and/or did not understand or ensure implementation of policies in regard to resident discharges, leave of absence policies, or the role of guardians in providing input into the care of residents deemed incompetent to make their own decisions. On [DATE] at 11:18 A.M., Regional RN #897 provided a signed attestation that the DON received DON bootcamp training on [DATE], [DATE] and [DATE]. Among the topics were medical records and the discharge process. 4. The facility failed to have an updated accurate facility assessment addressing the services which were available and could be provided at the facility. On [DATE] at 1:59 P.M., the Administrator verified the facility assessment was drafted from a generic company assessment and had not been individualized to the facility and its services.

Based on review of the facility assessment and interview, the facility failed to ensure the assessment was accurate and pertinent to the facility and its available services. This had the potential to affect all 72 residents residing in the facility. Findings include:Review of the facility assessment revealed the assessment was updated 07/10/25. The assessment was not specific to the facility and portions were incomplete. Examples of this included a section regarding offering diverse spiritual, religious programs with the area for specifics about the programs being offered being blank, as well as the frequency they would be held. The assessment indicated the facility had a specialized dementia care unit where staff received additional training related to Alzheimer's and dementia care. The assessment further addressed activities for the dementia care unit with blank areas. The assessment indicated the facility offered in-house dialysis services with an onsite dialysis provider and addressed staff training for dialysis care. The assessment had an area for ancillary services which had a place for the facility to specify who they had contracts with. The information was blank. The assessment indicated the facility employed a risk nurse but did not specify how many hours a week were required. During an interview with the Administrator on 09/09/25 at 1:59 P.M., she verified the facility assessment was not specific to the facility as there was no dementia unit or dialysis done in the facility. The Administrator stated when the assessment was completed the non-applicable areas should have been deleted or the areas marked not applicable. The Administrator provided no rationale for the other areas which were left blank.

Based on medical record review and interview the facility failed to ensure progress notes were comprehensive, accurate and in chronological order for Resident #13, #25, #63, #76, and #83. This affected five (Residents #13, #25, #63, #76, and #83) of six residents records reviewed for clinical documentation. The facility census was 72. Findings include:1. Record review revealed Resident #76 was admitted [DATE] with diagnoses of local infection of the skin and subcutaneous tissue, secondary malignant neoplasm of bone, malignant neoplasm of cervix uteri, staphylococcus, Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) of the right buttock, Stage III pressure ulcer of the sacral region, and opioid dependence. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was cognitively intact, dependent on staff for showers, dressing, transfers, and bed mobility, and required maximal assistance for toileting hygiene. Review of the progress notes revealed the last note was dated 07/28/25 with 07/23/25 listed as the date of service. Resident #76 was seen that day by the wound care nurse practitioner (NP) who recommended surgical debridement of the sacral wound at the hospital at which time Resident #76 refused. Interview on 09/08/25 at 11:34 A.M. with the Director of Nursing (DON) revealed Resident #76 was sent to the hospital on [DATE] for further assessment of a wound and did not return. The DON confirmed there were no status updates or discharge documented in the resident's record after the hospital transfer. Interview on 09/08/25 at 2:00 P.M. with Admissions Director (AD) #804 revealed Resident #76 was transferred to Mercy Health Hospital and then to University of Pittsburgh Medical Center (UPMC) and was subsequently discharged . AD #804 reported multiple attempts were made to reach Resident #76's spouse; however, none were documented. Follow up interview on 09/08/25 at 2:26 P.M. with AD #804 revealed the nurse was to document the admitting diagnoses whenever a resident was admitted to the hospital, and AD #804 was to track the individual while hospitalized . AD #804 reported she tracked residents that were admitted to hospitals that were in network including local hospitals. If transferred to an out of network hospital, AD #804 followed up with the family or representative for updated information. Resident #76 was initially admitted to a local hospital but then transferred to UPMC which was out of network. AD #804 confirmed she did not document any of the information in the resident record. 2. Review of Resident #13's medical record revealed diagnoses including delusional disorders, anti-social personality disorder, anxiety disorder, difficulty walking, fall and insomnia. During review of Resident #13's progress notes, it was noted some notes failed to be comprehensive and accurate. a. A nursing note by Licensed Practical Nurse (LPN) #861 dated 05/24/25 at 7:11 P.M. indicated Resident #13 signed out leave of absence (LOA) around 3:45 P.M. stating he was going to the store. Resident #13 had not returned back yet at this time. All parties were aware. During an interview on 08/28/25 at 8:18 A.M., LPN #861 stated the parties referred to in her progress note on 05/24/25 at 7:11 P.M. was only the on-call unit manager. b. A nursing note by LPN #858 dated 05/25/25 at 10:50 P.M. indicated the nurse called the guardian to make her aware Resident #13 had signed out, left and had returned. The nurse left a voice mail requesting the guardian to call back. On 09/02/25 at 11:22, LPN #858 stated Resident #13 had not left the faciity on [DATE]. The note dated 05/25/25 at 10:50 P.M. was referring to the LOA on 05/24/25. 3. Review of Resident #25's medical record revealed an admission date of 06/09/22 with diagnoses included schizoaffective disorder, major depressive disorder (MDD), anxiety, hypertension, and the need for assistance with personal care. Review of Resident #25's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had impaired cognition. She required set-up assistance with eating, substantial assistance with oral hygiene, toileting hygiene, dressing, personal hygiene and bed mobility. Resident #25 was dependent on staff for showers. Review of Resident #25's care plan dated 07/31/25 revealed she had impaired cognition related to intellectual disability and cognitive communication deficit. Staff were to administer all medications, keep routine as consistent as possible in order to decrease confusion, and staff to provide visible clocks, a calendar, low-glare, consistent care routines, familiar objects, and reduced sensory noise as much as possible. Review of Resident #25's progress notes dated 08/28/25 revealed there were no progress notes related to the incident of witnessed staff-to-resident verbal abuse on 08/25/25. Interview on 09/08/25 at 2:25 P.M. with the Administrator and with Social Service Designee (SSD) #850 revealed they confirmed no charting was completed on 08/28/25 regarding the abuse investigation, notification to physician, family or the police. 4. Review of the closed medical record for Resident #63 revealed an admission date of 07/14/25 and a discharge date of 08/28/25. Resident #63 had diagnoses including encephalopathy, anorexia, severe protein-calorie malnutrition, cognitive communication deficit, post-traumatic stress disorder (PTSD), cocaine use, adult failure to thrive, anxiety disorder, depression, hypertension, cancers of the urinary tract, nasal cavities, middle ear, and accessory sinuses, and nicotine dependence. Review of Resident #63's 5-day MDS 3.0 assessment dated [DATE] revealed the resident had impaired cognition that improved over time while at the facility to be intact. Resident #63 required setup assistance with eating, oral hygiene, and toileting hygiene, additionally she required supervision with showers and dressing and was independent with bed mobility. Review of Resident #63's progress notes revealed multiple late entry notes for example note entered by LPN #585 on 07/16/25 at 1:48 A.M. effective for 07/14/25 at 8:41 P.M., entered by SSD #850 on 07/26/25 at 11:45 A.M. effective for 07/24/25 at 11:44 A.M., entered by SSD #850 on 07/26/25 at 11:52 A.M. effective for 07/25//25 at 11:51 A.M., entered by LPN #858 on 07/29/25 at 1:16 A.M. effective for 07/27/25 at 9:09 P.M., entered by LPN #902 on 08/01/25 at 1:54 A.M. effective for 07/31/25 at 1:52 A.M., entered by LPN #858 on 08/17/25 at 12:37 A.M. effective for 08/15/25 at 10:50 A.M., Additionally, there was a resident to resident incident that occurred on 08/26/25 that was not documented on in Resident #63's chart and finally a note was entered by Assisted Director of Nursing (ADON) #805 on 08/29/25 at 8:37 A.M. effective for 08/28/25 at 6:34 P.M. Interview on 08/29/25 at 12:52 P.M. with ADON #805 confirmed all examples of late documentation. Interview on 09/02/25 at 1:11 P.M. with LPN #858 and SSD #850 confirmed all examples of late documentation and stated at times, there was not enough time in the day to chart everything that happened. 5. Review of Resident #83's medical record revealed an admission date of 01/07/18 and a discharge date of 006/26/25. Diagnoses included ataxic cerebral palsy, epilepsy, anemia, thoracic aortic aneurysm, schizophrenia, obsessive compulsive disorder, MDD, and need for assistance with Activities of Daily Living (ADL) and personal care. Review of Resident #83's discharge MDS 3.0 assessment dated [DATE] revealed the resident had slight impairment of cognition, and required supervision with eating, and oral hygiene they required substantial assistance for toileting hygiene, showers, dressing, and personal hygiene. Review of Resident #83's progress notes from 04/28/25 to 06/26/25 revealed on 04/28/25 there was a urinalysis with culture and sensitivity (UA C&S) ordered with no supporting documentation as to why or who ordered it and if Resident #83's family was notified. Further review of Resident #83's progress notes revealed there were late entry progress notes entered on 06/04/25 at 2:29 P.M. effective for 05/05/25 at 2:09 P.M. and another late entry note dated 06/09/25 at 2:09 P.M. effective for 05/06/25 at 2:09 P.M. Interview on 08/27/25 at 12:45 P.M. with the DON confirmed the late entry documentation for Resident #83 for antibiotic use was completed one month later. The DON had no explanation why documentation was not completed timely. Interview on 09/08/25 at 4:22 P.M. with RN #844 revealed Resident #83 was experiencing altered mental status. She was more depressed due to a roommate change. She thought it was a behavior and ordered the UA C&S. RN #844 confirmed she did not document the behaviors the resident was having, and she did not document if she notified the NP or the Physician. RN #844 confirmed she did not notify the family of the new order for the UA C&S, nor did she document any of this information. Review of the undated facility policy titled Clinical Documentation Standards revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety is primary concern for our residents, staff, and visitors. Maintaining the integrity, quality, and safety of medical records can help provide effective communication between practitioners that may serve to enhance resident outcomes. This facility uses both electronic medical records and paper medical records. A complete record contains an accurate and functional representation of actual experience of the resident and must contain enough information to show that the status of the individual resident is known, and a plan of care has been identified to meet the care needs identified in the medical record. Nurses will follow the basic standard of practice for documentation including but not limited to providing a timely and accurate account of resident information in the medical record, documenting legibly in English using only acceptable medical abbreviations. The nurse is expected to document accurately, truthfully, to the best of his/her knowledge, what is heard or seen during assessments or encounters that concern the resident. They are to not document opinions or impressions, and they are to document entries during the work shift and complete all entries before leaving the facility for that shift. This deficiency represents noncompliance investigated under Complaint Number 1366500 (OH00167393).

Based on observation, interview, record review, facility policy review, review of the memorandum from the Department of Health & Human Services, review of guidelines from the Centers for Disease Control and Prevention, review of the facility's Tuberculosis (TB) Risk Assessment and Control Plan and Tuberculosis Symptom Screen Policy-Employee, the facility failed to ensure staff used appropriate infection control practices during incontinence care for Resident #6. This affected one (Resident #6) of six residents reviewed for infection control. In addition, the facility failed to ensure appropriate Tuberculosis screening for two employees. This had the potential to affect all 72 residents residing in the facility. Findings include:1. Review of the medical record for Resident # 6 revealed an admission date of 06/05/25 with diagnoses including immobility syndrome (paraplegic), severe protein-calorie malnutrition, extended spectrum beta lactamase (ESBL) resistance, dysphagia, gastrojejunal ulcer unspecified as acute or chronic without hemorrhage or perforation, and current gastrostomy status for enteral feeds. Resident #6 was dependent on staff for toileting hygiene, incontinence care, dressing, and transfers. Resident #6 required supervision for personal hygiene, eating, and oral hygiene. Physician orders effective June 2025 included enteral nutrition orders of Jevity 1.5 at 70 milliliters/hour (ml/hour) times 22 hours. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and was dependent on staff for toileting hygiene. Resident #6 was frequently incontinent for bowel and bladder. Observation of incontinence care on 08/27/25 at 10:42 A.M. revealed Certified Nurse Assistant (CNA) #837 gathered all supplies and placed them on the bedside table with clean towel underneath. She washed her hands, donned gloves, and personal protective equipment (PPE), removed Resident # 6's blankets, soiled brief and chux pad and disposed in garbage can. She cleaned Resident #6 from front to back with no concerns. She failed to remove her soiled gloves and perform proper hand hygiene before applying a new brief to Resident #6. Interview on 08/27/25 at 10:50 A.M. with CNA #837 verified gloves were not changed and hand hygiene was not performed after incontinence care before applying a clean brief for Resident #6. Review of Hand Hygiene in Healthcare Settings, Healthcare Providers, Glove Use, last reviewed 01/08/21, from the Centers for Disease Control and Prevention, located at https://www.cdc.gov/handhygiene/providers/index.html revealed gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene during patient care if gloves become visibly soiled with blood or body fluids following a task and moving from work on a soiled body site to a clean body site on the same patient. 2. Review of CNA #831's personnel file revealed a date of hire of 04/06/23. Results from a two-step Mantoux test with tests administered 01/10/20 and 01/17/20 were available. There was no evidence of annual screening being completed between 2020 and the hire date of 04/06/23. There was no evidence of TB testing or screening until screening dated 06/11/25. On 09/04/25 at 2:00 P.M., the Administrator verified there was no evidence of tuberculosis skin testing being completed upon hire in 2023. Although CNA #831 had provided two-step testing results from January 2020 there was no evidence of ongoing screening since that time. The only screening information able to be located was from 2025. 3. Review of CNA #812's personnel file revealed a hire date of 08/14/24. There was evidence of two-step tuberculosis skin tests being performed 08/31/23 and 09/09/23. There was no evidence of testing or screening for tuberculosis upon hire. The screening form was completed 06/10/25. On 09/04/25 at 2:00 P.M., the Administrator verified there was no evidence of tuberculosis skin testing or screening being completed upon hire. Review of the facility's Tuberculosis (TB) Risk Assessment and Control Plan, reviewed 02/24/22, revealed for a low-risk facility, all healthcare workers should complete the Tuberculosis Symptom Screen and Individual Tuberculosis Risk Assessment upon hire. Initiate two step tuberculosis skin testing TST_ or a single blood assay for tuberculosis upon hire to test for infection after the Symptom screen and risk assessment was completed unless the healthcare worker had a baseline positive or newly positive test for tuberculosis or who had a positive reaction to a previous two-step TST in which one chest x-ray to exclude the presence of active TB disease. All employees were to complete the Tuberculosis Symptom Screening and Individual Tuberculosis Risk Assessment annually and as indicated. Review of the facility's Tuberculosis Symptom Screen Policy-Employee (undated) revealed employees were to be screened at a minimum upon hire and annually for signs and symptoms of tuberculosis using the screening tool. In addition to the screening tool, employees were required to complete the Individual Tuberculosis Risk Assessment upon hire and annually to establish a baseline and identify employees who may be at an increased risk for tuberculosis.

Based on record review, interview and policy review, the facility failed to ensure care conferences were completed quarterly for Residents #4, #25, #43, and #83. This affected four (Residents #4, #25, #43, and #83) of the eight residents reviewed for care conferences. The facility census was 72. Findings include:1. Record review revealed Resident #4 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, dysphagia, chronic obstructive pulmonary disease, and adjustment disorder with mixed anxiety and depression. Review of Resident #4's progress notes revealed Resident #4's last care conference was 10/05/23. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired as evidenced by a score of eight out of 15 on the Brief Interview for Mental Status (BIMS). Resident #4 was dependent on staff for all activities of daily living (ADL). Review of Resident #4's care plan revealed it was routinely revised or updated with the most recent revision occurring on 08/07/25. Interview on 08/03/25 at 4:53 P.M. with Social Service Designee (SSD) #850 revealed the last care conference for Resident #4 was 02/07/25, but she was unable to provide documented evidence to support a care conference was held. 2. Record review revealed Resident #83 was admitted on [DATE] with diagnoses of ataxic cerebral palsy, epilepsy, nutritional anemia, schizophrenia, and obsessive-compulsive disorder. Review of Resident #83's progress notes revealed a care conference was conducted 02/10/25. The last care conference prior to that was 10/17/23. Review of Resident #83's care plan revealed it was routinely revised or updated with the most recent revision occurring 02/26/25. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #83 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Resident #83 required moderate assistance for toileting hygiene, set up/clean up assistance for eating, and supervision for all other ADL. Interview on 08/03/25 at 4:53 P.M. with SSD #850 confirmed the last care conference for Resident #83 was 10/17/23. 3. Record review revealed Resident #25 was admitted on [DATE] with diagnoses of schizoaffective disorder, major depressive disorder, obesity, chronic kidney disease, and type II diabetes. Review of Resident #25's progress notes revealed a care conference was conducted 02/10/25. The last care conference prior to that was 11/14/23. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #25 was moderately cognitively impaired as evidenced by a BIMS score of eight out of 15. Resident #25 required maximal assistance with oral hygiene, toileting hygiene, personal hygiene, and transfers. Review of Resident #25's care plan revealed it was routinely revised or updated with the most recent revision occurring 06/30/25. Interview on 08/03/25 at 4:53 P.M. with Social Service Designee #850 confirmed no other care conferences were completed after 11/14/23 for Resident #25. 4. Record review revealed Resident #43 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, encephalopathy, occlusion and stenosis of the right carotid artery, and aphasia. Review of Resident #43's progress notes revealed the last care conference occurred 11/03/23. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #43 was severely cognitively impaired as evidenced by a BIMS score of four out of 15. Resident #43 was dependent on staff for toileting, dressing, and shower transfers and moderate assistance for personal hygiene, and toilet and chair transfers. Review of Resident #43's care plan revealed it was routinely revised or updated with the most recent revision occurring 08/19/25. Interview on 08/03/25 at 4:53 P.M. with SSD #850 revealed the last care conference for Resident #43 was 02/07/25, but she was unable to provide documented evidence to support a care conference was held. Review of the undated Plan of Care Overview Policy revealed the facility would review care plans quarterly and/or with significant changes in care. Attendees would sign and date the care plan meeting agendas/documents. This deficiency represents noncompliance investigated under Complaint Number 1366500 (OH00167393).

Based on record review and interview, the facility did not ensure Resident #83's guardian was permitted to consent or decline influenza and COVID immunizations. This affected one (Resident #83) of three residents reviewed for guardian's consent to treatment. The facility census was 72. Findings include:Review of the closed medical record revealed Resident #83 was admitted [DATE] with diagnoses of ataxic cerebral palsy, epilepsy, nutritional anemia, schizophrenia, and obsessive-compulsive disorder. Review of the emergency contacts revealed co-guardians were listed as the primary contacts. Review of the Amended Letters of Co-Guardianship filed with Mahoning County Probate Court on 12/09/15 revealed Resident #83's father and Resident #83's son were appointed co-guardians of person only and not estate for an indefinite time period or until revoked. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #83 required moderate assistance for toileting hygiene, set up/clean up assistance for eating, and supervision for all other activities of daily living (ADL). Review of Resident #83's current care plan revealed the term guardian was absent from the care plan; however, the term resident representative was used throughout. Review of the undated COVID-19 Vaccination Declination Resident Form revealed it was signed by Resident #83 and not signed by a co-guardian. Review of the Influenza Vaccine Consent form dated 2/24 revealed it was signed by Resident #83 and not signed by a co-guardian. Interview on 09/08/25 at 3:25 P.M. with the Director of Nursing (DON) confirmed she was unsure of the consent process, so she had Resident #83 sign the consent and/or declinations. The DON reported she contacted the guardian by phone first although it was not documented in the record.

Based on medical record review and interview, the facility failed to ensure residents were informed of risks and benefits of medication prior to initiation of the medications. This affected two (Residents #2 and #10) of five residents reviewed for medication use. The facility census was 72. Findings include:1. Review of Resident #2's medical record revealed diagnoses including chronic obstructive pulmonary disease, weakness and paralysis of one side of the body following a stroke, type two diabetes mellitus, atherosclerosis (accumulation of plaque in the arteries), hyperlipidemia, peripheral vascular disease, hypertension, insomnia, bipolar disorder, generalized anxiety disorder, overactive bladder and gastroesophageal reflux disease. Medication orders included apixaban (anticoagulant) 5 milligrams (mg) every morning and at bedtime (02/22/23), atorvastatin calcium (used to treat high cholesterol) 80 mg at bedtime (12/07/23), Plavix (anti-platelet) 75 mg every morning (12/07/23), divalproex sodium (anti-convulsant) 250 mg every morning and at bedtime (01/23/24), duloxetine HCl 30 mg twice a day for depression (04/30/25), ezetimibe (cholesterol lowering medication) 10 mg at bedtime, gabapentin (anticonvulsant) 800 mg three times a day (12/07/23), furosemide (diuretic) 20 mg in the morning (12/07/23), Lantus (insulin) 25 units every morning and every bedtime), meloxicam (non-steroidal anti-inflammatory) 7.5 mg every day, metformin HCL (anti-diabetic) 1000 mg twice a day, naloxone HCL 0.4 mg as needed for opioid overdose, and trazodone (antidepressant) 25 mg at bedtime. On 09/08/25 at 11:46 A.M., Regional Registered Nurse (RN) #896 provided a consent to treat from Psychotherapies services dated 09/22/22 which had a statement which indicated Resident #2 understood that medication management might involve the risk of physical side effects, which might increase over time and/or persist after the conclusion of treatment. The form indicated the resident understood she was encouraged to talk to the treating clinician about any side effects or other adverse effects she was experiencing. Regional RN #896 verified she was unable to locate any documentation informing Resident #2 of the potential risks and benefits of the individual medications she was prescribed. 2. Review of Resident #10's medical record revealed diagnoses including type two diabetes mellitus, generalized anxiety disorder, mild intellectual disabilities, anemia in chronic kidney disease, schizoaffective disorder, major depressive disorder, hypothyroidism, hyperlipidemia, chronic kidney disease stage two, diabetic polyneuropathy, slow transit constipation, ataxia, vitamin B12 deficiency anemia, vitamin D deficiency, and hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was cognitively intact. Medication orders included clozapine (anti-psychotic) 150 mg at bedtime (04/14/23), divalproex sodium (anticonvulsant) 750 mg every morning and every bedtime (02/25/23), and trazodone (antidepressant) 50 mg every bedtime. On 09/08/25 at 11:46 A.M., Regional RN #896 verified the facility had been unable to locate evidence of Resident #10 being informed of risks and benefits of the medication she was receiving.

Based on medical record review and interview, the facility failed to honor a resident's bathing preferences. This affected one (Resident #79) of 13 residents interviewed during a resident council meeting regarding receipt of care in a timely manner. The facility census was 72. Findings include:During a resident council meeting on 08/27/25 between 1:15 P.M. and 1:55 P.M., Resident #79 stated she had been at the facility for one week with no showers provided. Resident #79 stated she had spoken with several nursing assistants about getting a shower. Nursing assistants responded Resident #79 was not on the shower schedule. Review of Resident #79's medical record revealed an admission date of 08/20/25. Diagnoses included type two diabetes mellitus with diabetic polyneuropathy, generalized muscle weakness, anxiety disorder, depression, anemia, hyperlipidemia, bipolar disorder, hypertension, arthropathic psoriasis, osteoarthritis, and lumbago with sciatica. An admission nursing assessment dated [DATE] indicated Resident #79 was alert and oriented to person, place and time. The assessment indicated Resident #79 preferred a shower on day shift twice a week. Review of Resident #79's bathing records revealed Resident #79 received a shower on 08/20/25. Bed baths were documented on 08/22/25, 08/23/23, and 08/25/25. Review of the shower schedule revealed Resident #79 was not on the list. Interview on 08/27/25 at 3:38 P.M., Licensed Practical Nurse (LPN) #843 verified the shower schedule did not contain Resident #79's name. On 08/28/25 at 8:23 A.M., the Administrator was informed of Resident #79 reporting she had not received showers per her preference as well as documentation indicating one shower was provided and times bed baths and showers were recorded were not consistent with Resident #79's preference. No additional information was provided.

Based on medical record review, interview and facility policy review, the facility failed to notify Resident #83's guardian of a change in condition requiring hospitalization. The facility also failed to notify Resident #13's guardian of his intent to sign out on leave of absence (LOA) to get her input and failed to inform her of Resident #13's return to the facility involving police escort in a timely manner. This affected two (Residents #13 and #83) of 22 residents reviewed for notification. The facility census was 72. Findings include:1. Review of Resident #13's medical record revealed an admission date of 05/23/25. Resident #13 had a letter of guardianship for person only for an indefinite time dated 04/30/25. Resident #13 had diagnoses including delusional disorders, anti-social personality disorder, anxiety disorder, apraxia (a neurological condition characterized by loss of the ability to perform activities that a person is physically able and willing to do), difficulty walking, and insomnia. Resident #13 had no physician orders regarding LOA. A nursing note by Registered Nurse (RN) #847 dated 05/24/25 at 12:19 A.M. indicated Resident #13 arrived at the facility at 8:16 P.M., transported from the hospital. Resident #13 ambulated into the facility independently while carrying his personal belongings. Upon arrival, Resident #13 immediately expressed his intention to sign out and return home. Resident #13 was provided with education regarding his care plan and the importance of staying at the facility, but he remained insistent on leaving. Unit Manager #844 was made aware of the situation and advised that Resident #13 be re-educated, especially since he reportedly had no alternative place to go. Unit Manager #844 also sent the contact information of Resident #13's legal guardian to notify her of the situation. Resident #13's guardian was contacted, informed of Resident #13's desire to leave and advised that Resident #13 should remain at the facility as he has no safe discharge destination. Resident #13's guardian instructed staff to calm him and, if necessary, use the pink slip (involuntary psychiatric hold) process should he become aggressive. Resident #13 was encouraged to stay and agreed to watch television (TV) for a few minutes before making a final decision. Resident #13 was escorted to the TV lounge and made comfortable. After spending some time there, Resident #13 approached staff and requested to be taken to his room, stating he would remain at the facility for the night and reconsider leaving the following day. A nursing admission assessment dated [DATE] indicated Resident #13 was admitted with a cognitive disorder. Resident #13 was alert and oriented to person, place and time. It was unknown if Resident #13 had a history of exit seeking or wandering. The elopement part of the assessment indicated Resident #13 did not have a history of wandering and/or a pattern tied to Resident #13's past. Resident #13 was not accepting the new admission situation, and Resident #13 had expressed anxiety/apprehension to leave the facility. Resident #13 was determined to be at risk for elopement or unsafe wandering. A baseline care plan dated 05/24/25 indicated Resident #13 was at risk for elopement. Interventions included assessing for hunger, thirst, ambulation, and toileting needs. Wandering evaluations were to be completed upon admission/re-admission, quarterly and as necessary. Resident #13 was to be evaluated for need of a secure unit and the medical provider notified as needed. Interventions included providing diversionary activities as needed and redirecting Resident #13 when appropriate. A nursing note by Licensed Practical Nurse (LPN) #861 dated 05/24/25 at 7:11 P.M. indicated Resident #13 signed out LOA around 3:45 P.M. stating he was going to the store. Resident #13 had not returned at that time. The note included all parties were aware. Review of a LOA sign out sheet dated 05/24/25 revealed Resident #13 signed out at 4:09 (did not indicate if A.M. or P.M. or include an anticipated return time) to go downtown. Sign in was at 8:24 or 8:29 (last number not completely legible) the same day. A nursing note by RN #846 dated 05/24/25 at 10:46 P.M. indicated Resident #13 was returned to the facility with police escorts at 8:10 P.M. No complaints were made. A nursing note dated 05/25/25 at 10:50 P.M. indicated the nurse called the guardian to make her aware Resident #13 had signed out, left and had returned. The nurse left a voice mail requesting the guardian to call back. There was no further documentation of discussions with Resident #13's guardian. A Nurse Practitioner (NP) note by NP #889 dated 07/31/25 indicated Resident #13 was hospitalized on [DATE] due to psychotic and cognitive disorders. Resident #13 was involuntarily probated by his sister for delusions involving Satan stealing his cigarettes and believing his sister was possessed by demons. Resident #13 exhibited poor hygiene, flight of ideas, paranoia and delusions. On 08/27/25 at 8:15 A.M., the Director of Nursing (DON) was interviewed regarding Resident #13 being permitted to leave the facility LOA on 05/24/25 when the guardian had indicated she did not wish for him to leave the facility on 05/23/25. The DON verified because Resident #13 was assessed as cognitively intact and the guardian had stated she did not want him to leave to go home but gave no other parameters for LOA the facility did not believe it was necessary to contact the guardian for feedback. During an interview on 08/27/25 at 11:27 A.M., Resident #13's guardian stated Resident #13 had a long psychiatric stay prior to his admission to the facility. She stated when she was contacted by the facility the night Resident #13 was admitted , she did tell the facility Resident #13 was homeless and had nowhere to go, and if he was unstable the facility should send him back to the psychiatric hospital. Resident #13's guardian stated she presumed staff would know with his history and wanting to leave the facility, he should not be allowed to sign out LOA unless he was accompanied by family or someone from the facility. The guardian stated had staff consulted with her, Resident #13's guardian would have told them there were to be restrictions on Resident #13 signing himself out LOA. Resident #13's guardian stated she believed it was poor judgement on the facility's part if they let him sign himself out LOA. Resident #13's guardian stated she was not notified of Resident #13 leaving LOA and subsequently returning with police intervention. During an interview on 08/28/25 at 8:18 A.M., LPN #861 stated the parties referred to in her progress note on 05/24/25 at 7:11 P.M. was the on-call unit manager (later identified as Unit Manager #844). LPN #861 verified the guardian was not notified when she identified Resident #13 had not returned. Review of the facility undated Resident Leave of Absence policy revealed a resident who was cognitively intact with independent decision making with a physician's order may sign themselves out for LOA. The procedure indicated a physician's order was to be obtained for the resident to leave the facility with or without supervision. The physician was to be alerted if the resident was at risk for elopement. Provide the resident or family/responsible party with the facility phone number as needed and instructions to contact the facility if return was delayed more than one hour from the anticipated return time. Contact the resident or family/responsible party if they had not returned within one hour of the anticipated return time. Notify the Executive Director if unable to contact the resident or responsible party, or if they refuse to return. 2. Record review revealed Resident #83 was admitted on [DATE] with diagnoses of ataxic cerebral palsy, epilepsy, nutritional anemia, schizophrenia, and obsessive-compulsive disorder. Review of the Amended Letters of Co-Guardianship filed with Mahoning County Probate Court 12/09/15 revealed Resident #83's father and son were appointed co-guardians of person only for an indefinite time period or until revoked. Review of the obituary for Resident #83 father revealed he passed away 11/27/22 thus making the son the sole guardian of person. The record was not updated to reflect Resident #83's son was the guardian and the primary contact. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #83 required moderate assistance for toileting hygiene, set up/clean up assistance for eating, and supervision for all other activities of daily living (ADL). Review of progress note dated 06/19/25 at 9:08 A.M. revealed LPN #856 reported Resident #83 “looked out of it” when she went to her room. LPN #856 called Resident #83's name with no response then proceeded to do a sternal rub, still with no verbal stimuli; however, her eyes were open and blinking. Vital signs were taken. Resident #83 was assessed by the NP, and both the physician and NP ordered she be sent to the hospital for evaluation. Resident #83's family was contacted by the NP with no response. There was no other progress note entries made after 06/19/25 at 9:08 A.M. Interview on 09/04/25 at 1:20 P.M. with LPN #856 confirmed she was the nurse that sent Resident #83 to the hospital and the author of the 06/19/25 progress note. LPN #856 reported she attempted to contact Resident #83's son but was unsuccessful, so she then called the phone number listed for Resident #83's father which was not a valid number. No voice message was left for Resident #83's son who was the legal living guardian. LPN #856 then reported the NP “took over and called the son herself and left a voice message”. LPN #856 further reported that the father's number was called first for changes in condition, but the son was contacted when the father's number was disconnected. Interview on 09/11/25 at 3:53 P.M. with NP #902 revealed that on 06/19/25 she attempted to contact Resident #83's father, but no one answered. She was unable to recall if she left a voice message but stated she did not like to leave messages that may cause panic which was a habit of hers. NP #902 did advise the staff to continue to attempt to contact the family. Review of the undated Notification of Change Policy revealed the center must inform the resident, consult with the resident's medical practitioner and/or notify the residents' representative, authorized family member or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification included a transfer or discharge of the resident from the center. This deficiency represents noncompliance investigated under Master Complaint Number 1366502 (OH00167399) and Complaint Numbers 1366501 (OH00167396) and 1366500 (OH00167393).

Based on record review, interview, observation and facility policy review, the facility failed to ensure Resident #25 were free from staff-to-resident verbal abuse. This affected one (Resident #25) or two residents reviewed for abuse. The facility census was 72. Findings include:Review of the medical record revealed Resident #25 was admitted on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder (MDD), anxiety, hypertension, and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition. She required set up assistance with eating, substantial assistance with oral hygiene, toileting hygiene, dressing, personal hygiene and bed mobility. Resident #25 was dependent on staff for showers. Review of the care plan dated 07/31/25 revealed Resident #25 had impaired cognition related to intellectual disability and cognitive communication deficit. Interventions included staff were to administer all medications, keep routine as consistent as possible in order to decrease confusion, and staff to provide visible clocks, a calendar, low-glare, consistent care routines, familiar objects, and reduced sensory noise as much as possible. Observation on 08/28/25 at 9:45 A.M. revealed Certified Nursing Assistant (CNA) #816 was verbally abusive to Resident #25 when she yelled loudly and aggressively at Resident #25 and stated, Stop crying, or I will shut your door. There were no other residents in the room or hallway. Resident #25 was crying but could barely be heard. Review of the progress notes dated 08/28/25 revealed there were no progress notes related to the incident of witnessed verbal abuse that occurred on 08/25/25. Interview on 08/28/25 at 9:46 A.M. with CNA #816 revealed when the Surveyor asked why she was speaking to the resident in that tone and manner, CNA #816 stated because she needs to shut up and stop crying, she was upsetting other residents, and it needs to stop. On 08/28/25 at 9:47 A.M. incident of verbal abuse was reported to the Administrator and the Regional Director of Clinical Operations (RDCO) #869. While walking up the hall to the Administrators office, CNA #816 came down the hall and very closely approached the surveyor and asked where the [expletive] are you going then went back down to the nurses' station and waited there. On 08/28/25 at 9:49 A.M. the Administrator and RDCO #869 interviewed CNA #816, ensured Resident #25 was safe and escorted CNA #816 out of the building and began their investigation. Interview on 09/08/25 at 2:00 P.M. with Resident #25 revealed she was scared when CNA #816 yelled at her and told her she was going to shut the door. Observation on 09/04/25 at 9:58 A.M. of Resident #25 revealed she was sitting on the side of their bed crying with staff present trying to console the resident. Observation made on 09/08/25 at 1:54 P.M. of Resident #25 revealed they were resident quietly in their room with no distress noted. Review of the undated facility policy titled Ohio Abuse, Neglect, and Misappropriation revealed it was the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of tier property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property. Furthermore, it is the intent of this facility to employ only properly screened persons as a part of the resident care team by the applicable requirements. This deficiency represents noncompliance investigated under Complaint Number 1366499 (OH00167390).

Based on record review, staff interview, review of the shower audit tool and facility policy review, the facility failed to ensure Resident #6 received showers as scheduled. This affected one (Resident #6) of one resident reviewed for activities of daily living (ADL). The facility census was 72. Findings include:Record review revealed Resident #6 was admitted on [DATE] with diagnoses of immobility syndrome, severe protein-calorie malnutrition, and extended spectrum beta lactamase (ESBL) resistance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was dependent on staff for toileting hygiene, showers, dressing, and transfers. Resident #6 was cognitively intact. Review of Resident #6's current care plan revealed Resident #6 had an ADL self-care performance deficit and required the staff to do all of the effort or have two or more staff to assist. Interview on 08/25/25 at 11:08 A.M. with Resident #6 revealed she was not bathed regularly and at times went one to two weeks without a shower or bed bath. Review of Resident #6's progress notes from June to September 2025 revealed on Thursday 08/28/25 it was noted Resident #6 refused a shower but requested a bed bath be given the following day. There was no documented evidence Resident #6 ever received a shower/bed bath on 08/29/25 as requested. The progress note dated 09/03/25 at 6:28 A.M. revealed Resident #6 received a bed bath. Interview on 09/08/25 at 10:49 A.M. with Certified Nursing Assistant (CNA) #829 revealed specific room numbers were assigned for showers each day; however, there were issues getting showers completed either because there was not enough staff or some staff unwilling to shower residents. Interview on 09/08/25 at 8:42 A.M. with Resident #6 revealed a shower was received the evening of 09/07/25 by CNA #845 which was not the assigned shower day. The shower was received on Sunday when her scheduled shower days were Wednesdays and Fridays. Interview on 09/08/25 at 10:21 A.M. with the Director of Nursing (DON) who was unable to dispute Resident #6 did not receive showers as scheduled and denied there were any staffing issues that affected residents getting showered. Interview on 09/08/25 at 10:49 A.M. with CNA #845 confirmed Resident #6 requested a shower. CNA #845 provided Resident #6 a shower because time allowed. CNA #845 denied any staffing concerns and was unable to provide an explanation as to why Resident #6 was not showered on Wednesdays and Fridays, which were the scheduled days. Review of the Shower Audit Form updated 08/25/25 confirmed Resident #6's scheduled shower days were Wednesdays and Fridays on the night shift which was from 7:00 P.M. to 7:00 A.M. Review of the Shower Sheet and Body/Skin Infection Form for Nurse Aides revealed a bed bath/shower was completed for Resident #6 on 06/09/25, 06/15/25, 06/27/25, 07/02/25, 07/25/25 (refused), 08/27/25 (refused) and 09/02/25. No other documentation was provided to show additional showers or bed baths were given. Review of the undated Routine Resident Care Policy stated routine daily care was provided by a CNA under the supervision of a nurse. Routine care included but was not limited to bathing, dressing, eating/hydration, and toileting. Review of the undated Perineal Care Policy stated perineal care would be planned for each individual resident to meet his/her specific needs, choice, and frequency.

Based on record review, observation, interview, and facility policy review, the facility failed to ensure residents were provided with one-on-one activities to meet their interests and needs. This affected three (Residents #25, #29, and #83) of three residents reviewed for activities. The facility census was 72. Findings include:1. Review of Resident #25's medical record revealed an admission date of 06/09/25 with diagnoses included schizoaffective disorder, major depressive disorder (MDD), anxiety, hypertension, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had impaired cognition and required setup assistance with eating, substantial assistance for oral hygiene, toileting, dressing, personal hygiene, and bed mobility, and finally Resident #25 was dependent on staff for showers. Review of the care plan dated 07/31/25 revealed Resident #25 was alert and oriented and could make her needs known. She continued to sleep a lot throughout the day, enjoyed Bingo when she was able to attend; however, for right now, she just wanted room visits. Staff would encourage her to participate in activities. Activity staff would continue room visits, and ensure her needs were met. Goals and interventions included Resident #25 was encouraged to participate when she was up and out of bed, staff would also do one-on-one visits. Staff were to encourage the resident to attend activities to support participation. Staff were to invite the resident to scheduled activities and provide one-on-one visits if unable to attend out-of-room events. Review of Resident #25's one-on-one master list for August 2025 revealed she was to receive a one-on-one activity twice a week on Wednesday and Saturday. Review of Resident #25's Record of One-on-One Activities for August 2025 revealed there was only one entry for the month stating the resident denied the activity. There were initials present by staff, but no one could read them. Interview on 09/08/25 at 10:32 A.M. with Resident #25 revealed she was not offered the opportunity to go out of her room to go to activities, and she would like to. She stated staff were mean to her and kept her in her room. Resident #25 stated staff from activities only came into her room when they wanted to, and they did not do anything with her when they came in. Interview on 09/09/25 at 12:12 P.M. with Activity Director (AD) #800 revealed documentation and one-on-one room visits were a problem. Surveyor asked for one month of documentation and a list of all one-on-one residents, and AD #800 stated she would not be able to find one month of documentation for one-on-one visits because she knew it did not exist. Observations made on 09/10/25 of Resident #25 at multiple times throughout the day revealed there were no one-on-one activities observed being completed during these observations. Interview on 09/12/25 at 12:00 P.M. with Activity Assistant (AA) #803 revealed some one-on-one activities were completed for Resident #25, but none of them were documented. AA #803 stated there was only one, one-on-one activity documented for August 2025. No other documentation was provided. 2. Review of Resident #29's medical record revealed an admission date of 08/01/24 with diagnoses including chronic respiratory failure with hypercapnia, obstructive sleep apnea, morbid obesity, chronic kidney disease (CKD) stage II, spinal stenosis, osteoarthritis, and MDD. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #29 had intact cognition, was dependent on staff for toileting hygiene, showers, dressing, transfer including sit to lying, lying to sitting and required moderate assistance by staff for rolling left to right. Resident #29 used a wheelchair for mobility. Review of the care plan dated 02/19/25 revealed Resident #29 had little or no activity involvement related to little interest or pleasure in doing things outside of his room. Resident #29 would carry on a conversation with the activity's assistants about his gaming on his iPad and his streaming services and didn't mind the one-on-one visits. Goals and interventions included Resident #29 would participate in activities of choice through the review date, Resident #29 would show engagement in activities of interest, Resident #29 would accept and participate in one-on-one visits. Staff would assist with transport to activities as needed, encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities. Staff would interview and determine resident activity preferences, they would introduce the resident to others with similar interests, invite the resident to scheduled activities, and provide one-on-one in-room visits if unable to attend out-of-room events. Review of facility one-on-one master list dated August 2025 revealed Resident #29 was to have one-on-one visits with activities twice a week on Sundays and Thursdays. Review of Resident #29's Record of One-on-One Activities form dated for 08/21/25 stated the resident just wanted to vent and chat, and on 08/24/25 staff sat and spoke with the resident about movies and gave the resident a daily chronicle to read. On 08/31/25 staff just sat and chatted with the resident. On 09/06/25 and 09/07/25 staff chatted about movies, family issues, video games, and showed pictures of movie actors he liked. There was no other documentation provided to show Resident #29 received one-on-one activities that were completed twice a week as scheduled. Review of Resident #29's Activity Participation Task from 08/11/25 to 09/07/25 revealed the resident refused all daily activities offered. Interview on 09/09/25 at 10:34 A.M. with AD #800 revealed the activity staff does not document when one-on-one activities are completed. AD #800 stated she had just started with the company, and it was her understanding there was no documentation showing when one-on-one activities were completed. Interview on 09/09/25 at 10:58 A.M. with Resident #29 revealed he does not like to participate in out-of-room activities. He stated he would rather just stay in his room and do what he wants to. The activity department does not do things he likes to do like playing video games or watching the movies he liked to watch. Resident #29 stated that even when the activity department comes in his room, they do not always do what he wants to, there was always an agenda with them. 3. Review of Resident #83's closed medical record revealed an admission date of 01/07/18 and a discharge date of 006/26/25. Diagnoses included ataxic cerebral palsy, epilepsy, anemia, thoracic aortic aneurysm, schizophrenia, obsessive compulsive disorder, MDD, and need for assistance with Activities of Daily Living (ADL) and personal care. Review of the discharge MDS 3.0 assessment dated [DATE] revealed Resident #83 had a slight impairment of cognition. She required supervision with eating, and oral hygiene and substantial assistance for toileting hygiene, showers, dressing, and personal hygiene. Review of the care plan dated 12/17/21 initiated for personalized activities revealed Resident #83 slept most of the day. However, when she was awake, she enjoyed coming to activities and participating in coffee social and talking with peers. Resident #83 also enjoyed Bingo and Bonkers, she loved to color and do art. She would attend parties and events; she chose when she wanted to participate in activities. Goals and interventions included the resident would participate in activities of choice; she would show engagement in activities of interest and would participate in one-on-one room visits. Review of Resident #83's activity participation documentation from 04/01/25 to 06/26/25 revealed on 04/02/25, 04/04/25, 04/07/25, 04/25/25, 05/26/25, and on 06/16/25 Resident #83 was not offered to participate in any activity throughout the day. Additionally, there was no documentation to support one-on-one activities that were offered and completed for this resident. Interview on 09/09/25 at 10:34 A.M. with the AD #800 revealed Resident #83 attended activities frequently including nails, talk sessions, movies, birthday parties, and Bingo. AD #800 stated after the residents decline in health, the activity department provided one-on-one visits with her. AD #800 was currently looking for documentation of participation in activities and one-on-one visits. AD #800 returned and revealed they did not have any one-on-one documentation to show one-on-one visits were provided to Resident #83. Interview on 09/09/25 at 11:56 A.M. with AD #800 revealed at the end of November 2024, the resident #83 would attend activities including nails, coffee social, birthday party, Bingo, even if she did not participate. After Christmas and spring, she started to get moodier with residents and declined to come down to activities, looked sicklier, and had declining health. Interview on 09/09/25 at 12:00 P.M. with AA #803 revealed Resident #83 was placed on one-on-one room activities due to the residents' decline in health; however, most of her one-on-one activities were sitting and chatting with the resident. AA #803 stated no documented evidence of the one-on-one activities existed. Review of the undated facility policy titled Activities Program revealed the facility was to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The activity program consists of individual and small and large group activities which are designed to meet the needs and interests of each resident and includes, at a minimum: social activities, indoor and outdoor activities, activities away from the facility, Religious programs, Creative activities, intellectual and educational activities, exercise activities, individualized activities, in-room activities, and community activities.

Based on medical record review and interviews, the facility failed to ensure Resident #83's emergency contact was notified of a change in condition. This affected one (Resident #83) out of three residents reviewed for notification of change in condition. The facility census was 72. Findings include:Review of Resident #83's closed medical record revealed an admission date of 01/07/18 and a discharge date of 06/26/25. Diagnoses included ataxic cerebral palsy, epilepsy, anemia, thoracic aortic aneurysm, schizophrenia, obsessive compulsive disorder, major depressive disorder (MDD), and need for assistance with Activities of Daily Living (ADL) and personal care. Review of Resident #83's emergency contacts revealed the resident's father was listed as emergency contact #1; however, throughout the investigation it was identified the resident's father passed away in November of 2022. Resident #83's brother was listed as emergency contact #2. Review of the discharge MDS 3.0 assessment dated [DATE] revealed Resident #83 had slight impairment of cognition, she required supervision with eating, and oral hygiene and substantial assistance for toileting hygiene, showers, dressing, and personal hygiene. Review of Resident #83's progress notes from 04/28/25 to 06/26/25 revealed on 04/28/25 there was a urinalysis with culture and sensitivity (UA C&S) ordered with no supporting documentation as to why or who ordered it and if Resident #83's family was notified. Further review of Resident #83's progress notes revealed there were late entry progress notes entered on 06/04/25 at 2:29 P.M. effective for 05/05/25 at 2:09 P.M. and another late entry note dated 06/09/25 at 2:09 P.M. effective for 05/06/25 at 2:09 P.M. There was no evidence in the progress notes the resident's emergency contact was notified. Additionally, on 06/19/25 at 9:08 A.M. it was documented by Registered Nurse (RN) #844 that she went into Resident #83's room to find the resident looked out of it, she called the resident's name with no response, did a sternal rub on the resident with no response; the resident's eyes were open and blinking, but she was not responsive. Vital signs were assessed: blood pressure 98/71, heart rate 97, temperature 97.5 degrees Fahrenheit (F) and oxygen saturation was 97 percent on room air. RN #844 spoke with the physician who gave an order to send the resident to the hospital. Resident #83 was also evaluated by the Nurse Practitioner (NP) who also ordered the resident to go to the hospital. The progress note stated the resident's family was contracted by the NP with no response. Interview on 08/27/25 at 12:45 P.M. with the Director of Nursing (DON) confirmed the late entry documentation for Resident #83 for antibiotic use was completed one month later. The DON had no explanation why documentation was not completed timely. The DON confirmed Resident #83's father who was listed as emergency contact #1 had passed away in 2022, and the chart was not updated; therefore, no one in the resident's family was notified of her change in condition. Interview on 09/08/25 at 4:22 P.M. with RN #844 revealed Resident #83 was experiencing altered mental status. She was more depressed due to a roommate change. She thought it was a behavior and ordered the UA C&S. RN #844 confirmed she did not document the behaviors the resident was having, and she did not document if she notified the NP or the Physician. RN #844 confirmed she did not notify the family of the new order for the UA C&S, nor did she document any of this information. Review of the undated facility policy titled Notification of Change in Condition revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs, concerns of the residents, The safety of residents, staff, and visitors is of primary importance. The purpose of this policy is to provide guidance for notifications made to residents, resident representatives, and authorized family members for resident changes in condition. Changes may include but are not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes, therapy services changes, transfer, hospitalizations, or death.This deficiency represents noncompliance investigated under Complaint Number 1366500 (OH00167393).

Based on medical record review and interview, the facility failed to ensure physician visits were provided in accordance with regulations for two (Residents #72 and #74) of three residents reviewed for physician visits. The facility census was 72. Findings include:1. Review of Resident #72's medical record revealed an admission date of 06/25/25. Diagnoses included rhabdomyolysis, chronic obstructive pulmonary disease, depression, hypertension, gout, adult failure to thrive, chest pain, and insomnia. The physician and nurse practitioner documented entries for visits on 06/26/25. There was no further evidence of physician visits as of 09/09/25. On 09/09/25 at 1:57 P.M., Regional Registered Nurse (RN) #896 verified she was only able to locate evidence of Resident #72 being visited by the physician on 06/25/25. All other visits were made by the nurse practitioner. 2. Review of Resident #74's medical record revealed an admission date of 06/10/25. Diagnoses included type two diabetes mellitus, hypertension, peripheral vascular disease, major depressive disorder, hyperlipidemia, anemia, spinal stenosis and displaced fracture of the upper end of the right humerus. The nurse practitioner made the initial medical evaluation instead of the physician. The nurse practitioner visited 06/17/25. The physician's initial visit notes were dated 06/19/25. On 09/09/25 at 1:57 P.M., Regional RN #896 verified Resident #74's initial medical evaluation in the facility was made by the nurse practitioner instead of the physician.

Based on medical record review, review of medication information, and interview, the facility failed to ensure adequate monitoring of laboratory values to determine if medications were within recommended therapeutic range. This affected one (Resident #2) of five residents reviewed for medication use. The facility census was 72. Findings include:Review of Resident #2's medical record revealed diagnoses including bipolar disorder, generalized anxiety disorder, chronic respiratory failure and chronic obstructive pulmonary disease. Divalproex sodium delayed release (Depakote) (anti-convulsant) 250 milligrams (mg) every morning and bedtime for bipolar disorder was ordered on 01/23/24. There was no evidence of a Depakote level being obtained since initiation of the Depakote. During an interview on 09/03/25 at 9:33 A.M., Certified Nurse Practitioner (CNP) #889 stated she started in July 2025 and was unaware Resident #2 had not received a Depakote level and she would order one. Review of Medscape information regarding Depakote revealed valproic acid level range was 50-100 micrograms per milliliter (mcg/ml) with a toxic level greater than 100 mcg/ml. Monitoring of serial valproic acid levels was required to maintain the drug within the narrow recommended therapeutic range.

Based on medical record review and interview, the facility failed to arrange for outside services with an orthopedic doctor in a timely manner. This affected one (Resident #5) of 12 residents reviewed for accidents and follow up actions taken related to accidents. The facility census was 72. Findings include:Review of Resident #5's medical record revealed diagnoses including left sided weakness and paralysis following a stroke, chronic obstructive pulmonary disease, generalized muscle weakness, cognitive communication deficit, major depressive disorder, atrial fibrillation, heart disease, stage three chronic kidney disease and viral hepatitis C. A nursing note dated 06/10/25 at 1:40 A.M. indicated Resident #5 was found on the bathroom floor in which he sustained a skin tear to the left hand knuckles. Resident #5 stated he was trying to go to the bathroom. A note dated 06/10/25 at 3:12 P.M. indicated Resident #5 had fallen and had new left hand swelling. X-ray results were pending. A Nurse Practitioner note dated 06/12/25 revealed x-ray results were reviewed, and Resident #5 would be referred to orthopedics for further management. An order was written for referral to orthopedics to the first available provider for a closed fracture of the distal end of the left radius and closed dislocation of the distal radioulnar joint of the left wrist. A nursing note dated 06/30/25 at 10:35 A.M. revealed the nurse confirmed the orthopedic provider received the referral request and would contact the facility that week to schedule an appointment. There was no further documentation of an appointment being made or attempts to contact the orthopedic office to follow up until 09/02/25 at 11:31 A.M. when a note was made indicating multiple attempts were made to contact ortho for follow up with no return calls. A referral would be made to an alternate location. A note dated 09/02/25 at 3:02 P.M. indicated an ortho appointment was made for 09/18/25. On 09/02/25, Resident #5 was admitted to the hospital with chest pain. During an interview on 09/04/25 at 11:32 A.M., Unit Manager #844 provided a sticky note attached to Resident #5's face sheet with the dates of 06/27, 07/16 and 08/04, stating those were dates she attempted to contact the orthopedic office regarding the referral and setting up an appointment. Unit Manager #844 stated she printed the paperwork to send to the orthopedic office on 06/16/25. The call she placed on 06/27/25 would have been to confirm the information was received and which orthopedic doctor would see Resident #5. Even though a note on 06/30/25 revealed it was confirmed the orthopedic doctor had gotten a referral and would call back with an appointment time, she had not called back when she had not received an appointment until 07/16/25 then again 08/04/25. Unit Manager #844 stated she would not call the orthopedic office every day. Unit Manager #844 stated during that time frame there had been a lot of staff turnover and changes in the Director of Nursing (DON) and unit manager jobs, and she was trying to cover unit manager for the entire facility. Unit Manager #844 stated she recalled at some point staff telling her the orthopedic office had called for her but could not provide a time frame. An appointment had now been made.

Based on observation, record review, review of controlled drug administration records, review of facility policy and interviews, the facility failed to develop and implement a comprehensive and individualized pain management program, including assessment/monitoring of pain and administration of narcotic pain medication (Percocet) to meet Resident #45's needs and prevent severe pain. Actual harm occurred on 09/18/23 when as needed (PRN) Percocet 5-325 milligrams (mg) was not available to administer to Resident #45 as requested and as ordered by the physician. On 09/18/23 at 10:21 A.M. Resident #45 rated her pain level an eight on a scale of zero (no pain) to 10 (severe pain). Resident #45 was administered a dose of Percocet on 09/19/23 at 12:23 P.M. for severe pain rated at a level nine out of 10 after having gone over 48 hours without receiving the Percocet as requested. The resident verbalized she was in excruciating pain during this time-period with facial grimacing with movement of her legs and difficulty with ambulation related to the severe pain This affected one resident (#45) of two residents reviewed for pain management. The facility census was 66. Findings include: Review of medical record for Resident #45 revealed an admitted [DATE]. Diagnoses included unilateral primary osteoarthritis of the right knee, pain in unspecified knee, unspecified abnormalities of gait and mobility, uncomplicated psychoactive substance abuse, and major depressive disorder. Review of a care plan initiated 03/31/23 revealed Resident #45 had complaints of acute/chronic pain disease process related to substance use disorder and osteoarthritis. The goal was for Resident #45 to verbalize relief of pain. Interventions included provide medications per orders, monitor for signs and symptoms of side effects, and evaluate effectiveness of medication. The care plan revealed to observe for pain every shift, administer non-pharmacological interventions, and notify medical provider, resident representative if interventions were unsuccessful, or if current complaint was a significant change from resident's experience of pain. There were no new interventions added after the initial care plan date of 03/31/23. Review of Resident #45's physician's orders revealed an order dated 04/04/23 for one 600 milligram (mg) Ibuprofen Oral Tablet (non-steroidal anti-inflammatory drug) by mouth every six hours as needed for pain and an order dated 05/07/23 for one 500 mg Acetaminophen Extra Strength (non-narcotic pain reliever) tablet by mouth every six hours as needed for mild pain. Review of the facility Pain Observation Tool V5-V2, dated 06/29/23 revealed Resident #45 did not verbalize and/or exhibit non-verbal symptoms of pain, did not receive scheduled or as needed pain medication, and the resident stated deep relaxation and frequent position changes would help relieve pain. Pain management intervention was not necessary and there was no need for a change in interventions in the care plan. There was no additional Pain Observation Tool V5-V2 completed after 06/29/23. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and required supervision with set up for bed mobility, transfers, and locomotion. Resident #45 during the reference period of the assessment was not on any routine or as needed pain medications and was not receiving any non-pharmacological pain-relieving interventions. Review of an 08/11/23 physician progress note, authored by Physician #850, revealed Resident #45 was complaining of continued pain in the knees, was having difficulty walking, and was not getting any pain medications. The physical exam revealed pain in the right knee with movement and positive crepitus (a cracking or popping sound) of the knee. The plan was to consult orthopedics to evaluate for knee replacement and to start Percocet for pain. Record review revealed a physician order, dated 08/11/23 for Percocet (Oxycodone with Acetaminophen) 5-325 mg one tablet by mouth every eight hours as needed for pain. Review of a 09/12/23 physician progress note, authored by Physician #850, revealed Resident #45 was complaining of continued pain in the knees but was improving with pain meds. The resident was having difficulty walking and there was pain in the right knee with movement. Review of the nursing progress notes between 09/13/23 and 09/27/23 revealed the notes did not contain any assessment of Resident #45's pain, request for pain medication and use of non-pharmacological interventions for pain management during this time period. Review of the controlled drug administration record for Resident #45 revealed a script for 26 tablets of Percocet was filled on 08/31/23, the last tablet was signed out on 09/17/23 at 9:00 A.M, and a new script for 30 tablets Percocet written and filled on 09/19/23. Review of the pain level vital section documentation of the medical record for 09/17/23 revealed no pain assessments were completed on 09/17/23. There was no documentation by nursing to reflect why the Percocet ran out on 09/17/23, whether or not the as-needed Acetaminophen was offered while waiting for the Percocet to be re-filled until 09/19/23 nor any documentation to reflect if the nurses attempted to get a Percocet from the facility starter box (which was a secured medication containment system at the facility where various medications including narcotics supplied from the pharmacy could be pulled until the medications arrived from the pharmacy). Review of the September 2023 MAR revealed pain levels were to be assessed every shift. On 09/17/23 Resident #45's pain level was not documented on the MAR nor was any Percocet, Ibuprofen or Acetaminophen documented as being administered to Resident #45. The next pain level was assessed on 09/18/23 at 10:21 A.M. and was assessed to be rated a level eight. On 09/18/23 at 5:02 P.M. the resident continued to rate pain at a level eight. On 09/19/23 at 10:43 A.M. the resident's pain was assessed to be a nine (out of 10 as the most severe pain). Further review of September 2023 Medication Administration Record (MAR) for Resident #45 confirmed she also did not receive any Percocet on 09/18/23 but did receive on 09/18/23 Ibuprofen at 10:21 A.M. for pain at a level rated an eight out of 10 and again received Ibuprofen at 5:02 P.M. with pain rated a level eight. On 09/19/23 she received Ibuprofen at 10:43 A.M with a pain level rated nine and finally received the Percocet on 09/19/23 at 12:23 P.M. for pain level of seven. There was no documentation she received any Acetaminophen on 09/17/23, 09/18/23, 09/19/23, or 09/20/23. Interview on 09/19/23 at 8:28 A.M. with Licensed Practical Nurse (LPN) #722 verified the supply of Percocet for Resident #45 had run out on 09/17/23 and the facility was waiting for the script to be signed to re-order it. LPN #722 said some Percocet could be pulled from the starter box, but she did not do that because she had to wait for a prescription to pull a Percocet from the starter box. LPN #722 verified Resident #45 had a pain level rated a nine during this time period. Interview on 09/19/23 at 8:52 A.M. with Resident #45 revealed she was in excruciating pain and rated her pain at a level a seven out of 10. She stated the facility had run out of her Percocet, which was why she hadn't received any of her Percocet medication. Observation at the time of interview revealed Resident #45 was laying down in her bed and when she moved her legs to the side of the bed to sit up, she grimaced in pain as she moved her legs. Interview on 09/19/23 at 11:59 A.M. with Resident #45 revealed she was currently rating her pain level a seven and it was difficult to walk because the pain was excruciating. Observation at the time of the interview revealed Resident #45 was walking slowly while holding onto the handrails on the wall as she walked. Resident #45 had facial grimacing with the movement of her legs. Interview on 09/20/23 at 7:54 A.M. with Resident #45 revealed she had received Percocet last night and stated the plan was to get knee replacements in December2023 because her knee problems were causing the pain. Observation at the time of the interview revealed she was not physically exhibiting any signs or symptoms of being in pain and said her pain had been relieved with the administration of Percocet. Interview on 09/21/23 at 1:55 P.M. with LPN #732 revealed it took some time to get pain medications re-ordered at the facility and the normal process was to ask for a re-order before the medication ran out. Interview on 09/21/23 at 2:03 P.M. with Resident #45 revealed on 09/17/23 and 09/18/23, she had difficulty walking and sleeping due to increased pain when her Percocet medication was not given to her. The resident stated when she turned in bed on those days, she would get a jolt of pain and would see stars from the severity of the pain. The resident reported when she received the Percocet on 09/19/23, she was able to get a better night's sleep and the pain level became more tolerable. She stated she did take the Ibuprofen when there was no Percocet, but the pain remained rated between a seven and nine. Resident #45 was visibly upset about having to wait for the Percocet order to be refilled and stated with tears I feel like I don't matter. I am a person and I do matter. Interview on 09/21/23 at 2:26 P.M. with Nurse Practitioner #810 revealed the normal process to ensure residents had their Percocet would be when the prescribed medication was getting low, the facility would reach out to the provider to see if the prescription could be refilled. The time it took for the provider to re-order varied and depended on various factors. She stated she was not sure what happened and why there was a delay in the prescription getting re-filled for Resident #45. Interview on 09/21/23 at 2:31 P.M. with Pharmacy Representative #851 revealed the new script for Percocet was written, filled, and delivered on 09/19/23. Interview on 09/21/23 at 3:30 P.M. with State tested Nursing Assistant (STNA) #775 revealed on 09/18/23 Resident #45 seemed to be in more pain and was moving slower. Interview on 09/21/23 at 3:38 P.M. with STNA #740 revealed Resident #45 was walking slower earlier in the week (no date provided) due to pain in her knees. Interview on 09/25/23 at 2:29 P.M. with the Director of Nursing (DON) revealed the normal procedure to ensure Resident #45 had her Percocet would be to ask for a re-order when there were seven pills left. The floor nurse was responsible for re-ordering the medication. The DON said she had not been made aware the Percocet medication for Resident #45 had run out before it could be refilled, and she was not aware Resident #45 had been in pain as a result. The DON had no explanation of why the medication had not been ordered earlier to prevent the facility from running out of medication. Interview on 09/27/23 at 2:26 P.M. with Physician #850 revealed he was the physician for Resident #45 and was familiar with her condition of pain and a history of substance abuse. Physician #850 stated Resident #45's pain was valid, she was not attention seeking pain medication due to her history of substance abuse, and if she did not receive the Percocet, she would absolutely be in pain. Review of the undated facility policy Pain Management and Assessment revealed the facility provided resident centered care that would meet the psychological, emotional, and physical needs and concerns of the residents and, regarding pain management considerations, pharmacological interventions would be provided. Review of facility policy Non-Controlled Medication Orders, dated September 2018, revealed medications would be administered only upon the receipt of a clear, complete, and signed order of a person lawfully authorized to prescribe.

Based on observation, record review, facility policy and procedure review, and interview the facility failed to implement adequate interventions to prevent the development of bilateral deep tissue injury pressure ulcers to Resident #46's bilateral heels. The facility also failed to implement a treatment timely following the identification of the ulcers. Actual harm occurred on 09/22/22 when Resident #46, who had severe cognitive impairment and required extensive two person staff assistance for bed mobility, was found to have bilateral deep tissue injuries (defined as persistent non-blanchable deep red, maroon or purple discoloration, intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to both heels due to immobility with lack of evidence of preventative measures being in place prior to the development. This affected one resident (#46) of three residents reviewed for wound care. Findings include: Review of the medical record for Resident #46 revealed an admitted [DATE]. Diagnoses included ataxia, Alzheimer's disease, and type two diabetes mellitus. Review of skin pressure ulcer risk assessment dated [DATE] revealed Resident #46 was at moderate risk for skin breakdown. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had severe cognitive impairment. Resident #46 required extensive two-person physical assistance for bed mobility and transfers; extensive one-person physical assistance for dressing and eating; total dependence of two-persons for toilet use; and total dependence of one-person for personal hygiene. Resident #46 was frequently incontinent of urine and always incontinent of bowel. Resident #46 had no listed stageable or unstageable pressure ulcers. Resident #46 was listed as at risk for developing pressure ulcers. Review of care plan dated 09/16/22 for Resident #46 revealed she was at risk for developing pressure ulcers related to impaired mobility. Interventions included to encourage her to turn and reposition and perform weekly skin checks. There was no documented evidence Resident #46 was being assisted with turning and repositioning as identified on the care plan. Review of nursing progress note dated 09/22/22 authored by Licensed Practical Nurse (LPN) #535 for Resident #46 revealed the nurse was called into the resident's room to assist with care. During the transfer of Resident #46, LPN #535 observed marks on the resident's feet. LPN #535 documented the areas seem to be pressure ulcers. LPN #535 documented the nursing assistants were instructed to put Resident #46's feet up on a pillow while in bed and all parties were notified. Review of wound assessment dated [DATE] for Resident #46 authored by LPN #535 revealed the resident had acquired deep tissue injuries to her bilateral heels from immobility. There was no evidence to support any additional assessment of the deep tissue injuries to include measurement or description of the areas. There was no evidence of any physician ordered treatment to the bilateral deep tissue injuries to Resident #46's bilateral heels. There was no additional documentation of any assessment of Resident #46's bilateral deep tissue injuries to the heels. Review of physician's orders for Resident #46 dated 09/27/22 revealed to apply skin prep to both heels twice a day and wear heel protectors while in bed. This order was discontinued on 12/02/22. Review of nurse practitioner wound care notes dated 09/27/22 for Resident #46 revealed the resident's left heel had an unstageable deep tissue injury that was acquired in house on 09/22/22. The area was observed at 100% slough. Measurements were 3.01 centimeters (cm) length by 4.21 cm width with no depth. Resident #46's right heel was also listed as an unstageable deep tissue injury that was acquired in house on 09/22/22. It was described as 100% slough and measured 1.69 cm length by 1.76 cm width with no depth. Review of physician's order for Resident #46 dated 12/02/22 revealed to clean left and right heels with normal saline solution, apply betadine soaked gauze, and dry sterile dressing daily and as needed. The right heel order was discontinued on 12/09/22 and the left heel order was discontinued on 01/13/23. Review of physician's order dated 12/10/22 revealed to clean right heel with normal saline solution and apply betadine and dry sterile dressing daily and as needed. This order was discontinued on 01/05/23. Review of wound nurse practitioner note dated 01/05/23 revealed Resident #46's right heel unstageable deep tissue injury was healed. Review of wound nurse practitioner note dated 01/12/23 revealed Resident #46's unstageable deep tissue injury measured 1/18 cm length by 1.39 cm width with no depth. The wound was described at 100% slough and eschar, and improving. The left heel wound was acquired in house on 09/22/22. Review of physician's order dated 01/14/23 for Resident #46 revealed to clean left heel with normal saline solution and apply calcium silver alginate dressing and cover with a dry sterile dressing daily and as needed. Telephone interview on 01/04/23 at 10:40 A.M. with Resident #46's daughter revealed she is not happy with the care her mother is receiving at the facility. She reported her mother has wounds on both of her heels from them never getting her out of bed. Interview on 01/05/23 at 2:30 P.M. with the Director of Nursing (DON) confirmed there was no documentation of wound care interventions or treatments for Resident #46 in place from when her bilateral heel deep tissue injuries were observed on 09/22/22 until the wound nurse assessed them on 09/27/22. Observation of wound care on 01/10/23 at 11:00 A.M. with LPN #577 for Resident #46 revealed the left heel was observed as 100% slough, surrounding skin was pink and dry. Right heel wound was observed as newly healed. LPN #577 confirmed the wound nurse practitioner wanted the heel dressed for another week to ensure the left heel was completed healed. Interview on 01/18/23 at 3:30 P.M. with LPN #535 revealed on 09/22/22 a nursing assistant caring for Resident #46 reported to her the resident's heels were not right. LPN #535 went into the room to assess Resident #46's heels and discovered they were boggy and discolored black. LPN #535 then informed the clinical manager (who is no longer employed at the facility) and LPN #535 did receive orders for Resident #46 to apply skin prep and wear boots while in bed on 09/22/22 but LPN #535 did not the orders into the electronic medical record. LPN #535 confirmed Resident #46 can ambulate herself while up in her wheelchair but when she gets into bed she does not move or change positions. LPN #535 confirmed the care plan dated 09/16/22 revealed to encourage Resident #46 to turn and reposition. LPN #535 reported Resident #46 is agreeable to interventions but sometimes it is hard to know if she understands the directions because English is her second language. Subsequent interview on 01/18/23 at 3:44 P.M. with the DON confirmed the clinical manager who allegedly took the order on 09/22/22 for Resident #46 is no longer employed with the facility and they have no way to reach her. The DON confirmed Resident #46 will follow directions if asked. The DON reported sometimes Resident #46 is non-compliant with care and needs to be redirected. The DON also reported Resident #46's daughter prefers the resident's bed to be completely flat at all times and will enter the facility in the morning and remove anything that prevents the bed from staying flat. The DON confirmed Resident #46's heel wounds were acquired in house from immobility. She reported during that time Resident #46 was being treated for a urinary tract infection and more lethargic then usual. The DON also confirmed the care plan dated 09/16/22 did state to encourage Resident #46 to turn and reposition but had no documentation that Resident #46 was being turned and repositioned during that time. Review of facility policy pressure ulcer prevention: high risk revised 05/31/22 revealed staff must monitor for consistent implementation of interventions, evaluate the effectiveness of interventions, revise intervention and or goals as indicated, and communicate change in interventions to the caregiving staff. This deficiency represents non-compliance investigated under Complaint Number OH00138562.

Based on closed record review, review of a coroner report and photographs obtained by the coroner, review of a facility self-reported incident (SRI), review of a police report, review of facility policies and procedures related to Resident Rights and Ohio Abuse/Neglect, review of Centers for Disease Control (CDC) guidance on lice and [MEDICATION(S)] and interviews with facility staff, Resident #83's legal guardian, Funeral Director #305, local Police Detective #301 and Coroner Investigator #302 the facility failed to prevent an incident of neglect involving Resident #83. The facility failed to provide adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83 expired in the facility on [DATE]. Actual harm occurred on [DATE] at 11:45 P.M. when review of a coroner report revealed Resident #83 was found in bed in her room on her back with extremely soiled pillows/bedsheet. The resident was identified to have a severe lice infestation and a right ear open wound/sore with pus, which was yellowish, whitish, greenish/ pink-tinged, thick fluid produced with infection present. Prior to the identified coroner's finding, the facility failed to monitor effectiveness of [MEDICATION(S)] for the resident and failed to adequately treat itching/scratching which resulted in the severe lice infestation which was not identified until the time of the resident's death. This affected one resident (#83 of two residents reviewed for lice infestation. The facility census was 81. Findings include: Review of the closed medical record for Resident #83 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #83 was moderately cognitively impaired for decision making. This assessment indicated Resident #83 required staff supervision and staff set-up assistance for bed mobility, transferring, walking in room, walking in the corridor and eating and required extensive assistance from one staff for dressing, toilet use and personal hygiene. Review of the care plan, dated [DATE], revealed no care plan was implemented to address Resident #83's head lice infestation and/or to treat any conditions or symptoms associated with lice infestation, including itching. Review of progress notes by Certified Nurse Practitioner (CNP) #306 on [DATE], [DATE] and [DATE] indicated Resident #83's skin was free of rashes or [CONDITION(S)]. The note on [DATE] also indicated Resident #83 had no behaviors. A progress note, dated [DATE] at 5:54 P.M. and written by Physician #303 indicated Resident #83 was pleasantly confused, calm, was getting up to the bathroom and had no complaints. Review of Resident #83's physician orders for September and [DATE] revealed weekly skin evaluations were to be completed by licensed nursing staff (initiated on [DATE]). No orders for over-the-counter head or prescription head [MEDICATION(S)] were found. Review of weekly skin assessments dated [DATE], [DATE], [DATE], [DATE], and [DATE] revealed Resident #83 had no open areas on any part of her body. There were no weekly skin assessments completed from [DATE] through [DATE]. Review of a progress note, dated [DATE] at 9:16 P.M. and written by Physician #303, revealed Resident #83 had lice, had been treated several times and it made her head itch. Physician #303 indicated Resident #83 seemed to have completed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . ([CONDITION(S)] is a superficial reddening of the skin, usually in patches, as a result of injury or irritation). The note indicated they would monitor for reoccurrence. Review of nursing progress notes from [DATE] through [DATE] revealed no documentation of head lice, no documentation of any assessments or treatment provided for Resident #83 related to lice or itching. There was no documentation of any open areas or wounds. Review of facility infectious disease logs for ,d+[DATE] and ,d+[DATE] revealed no documentation of Resident #83's lice infestation. On [DATE] at 8:00 P.M., a late entry nursing note revealed Resident #83 was resting in bed with oxygen in place. No other information or assessment was recorded at that time. On [DATE] at 11:20 P.M. a nursing progress note revealed Resident #83 was found without vital signs by a State tested Nursing Assistant (STNA). Another nurse was notified, the crash cart was obtained, 911 was called and cardiopulmonary resuscitation (CPR) was initiated. The note indicated emergency medical technicians arrived and took over CPR. The nurse then notified Resident #83's guardian and the Hospice agency. Review of Mahoning County Coroner's report titled, Naturally Appearing Death Report, dated [DATE] at 11:45 P.M., revealed Resident #83's was found in bed in her room on her back. The report indicated the resident was found with extremely soiled pillows/bedsheet. She was noted to have a severe lice infestation and she had a right ear open wound/sore with pus, which was yellowish, whitish, greenish or pink-tinged, thick fluid produced with infection present. Record review revealed the facility submitted an SRI to the State agency involving Resident #83 and an allegation of neglect due to the circumstances and condition she was found in by emergency medical personnel called to the nursing home at the time of her death on [DATE]. The SRI was initiated on [DATE]. The SRI indicated emergency medical personnel called the police due to bloody drainage found and possible trauma. The information section indicated Resident #83 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were assessed for lice. The SRI indicated all residents with guardians were interviewed in person to ensure the residents were receiving adequate care. Head to toe assessments were completed for non-interviewable residents. There were multiple witness statements written by LPN #118, indicating lice treatments and care had been provided to Resident #83. However, none of these witness statements were dated and timed to indicate when they were written and this information was not recorded in Resident #83's record. The SRI included an interview with Physician #303 on [DATE] (no time listed) which said he talked to the coroner's office and was told trauma was ruled out but neglect would be in their findings due to the lice. Physician #303 said he told them Resident #83 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was an interview with BOM #119 dated [DATE] indicating she had spoken to Resident #83's guardian related to treatments given for lice. There were statements obtained from the staff present in the building at the time Resident #83 stopped breathing and required CPR and what they did in response to her change in condition. There were no other statements related to an investigation of the lice treatments being ineffective and no investigation of the lack of treatment/interventions for Resident #83's itching and scratching resulting in an infected ear wound and bloody, crusted areas on her head, scalp and shoulder/chest areas as evidenced by the coroner's investigation and photographs taken in her room at the time of Resident #83's death. There was no other information recorded to indicate the allegation of neglect, specific to Resident #83, was thoroughly investigated. The facility incorrectly unsubstantiated the allegation of neglect. Interview on [DATE] at 7:04 A.M. with STNA #147 revealed she had cared for Resident #83 in late [DATE]. She said the resident's her pillowcases were always full of something draining from her head and she remembered she had to change the pillowcases often. She said she reported this to nursing staff, but could not recall a specific nurse. Interview on [DATE] at 3:39 P.M. with Licensed Practical Nurse (LPN) #118 revealed the LPN was the facility Infection Control Specialist. LPN #118 revealed Resident #83's lice was reported to her on [DATE] and an over-the-counter lice shampoo treatment was completed that day. LPN #118 revealed Resident #83 was examined on [DATE] and received another lice shampoo treatment and her hair was cut short. LPN #118 revealed Resident #83 was checked for lice on [DATE] and received another treatment and more of Resident #83's hair was cut. LPN #118 indicated a wound was never observed on Resident #83's ear but said the resident scratched her right ear and called it her sore ear. However, review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Telephone interview on [DATE] at 8:06 A.M. with Youngstown Police Department staff, Detective #301, revealed he was the homicide detective assigned to the case involving Resident #83. Detective #301 revealed he was called about the resident because local police officers were concerned. The police had been called to the nursing home by emergency medical personnel due to the condition of Resident #83. Detective #301 said he interviewed facility staff on duty that evening at the nursing home and no one would confirm the last time Resident #83 had been seen alive. Detective #301 said when he first saw Resident #83, there were so many lice on her head that her hair was actually moving. Detective #301 reported there was blood coming from Resident #83's head and lice were seen crawling in and out of her ears and nose. He said he had been a homicide detective for over [AGE] years in many large cities and had seen many bodies but he had never seen the number of lice he saw on Resident #83. Detective #301 said the Mahoning County Coroner's office was called to the scene and photographs were taken. Interview with LPN #189 on [DATE] at 8:30 A.M. revealed she was assigned to care for Resident #83 on [DATE], the day the resident passed away. LPN #189 revealed she started her shift at 7:00 P.M. LPN #189 revealed she was aware Resident #83 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The LPN denied administering any medications to the resident between 7:00 P.M. and 11:20 P.M. even though the resident had medications scheduled to be administered during this time period. LPN #189 revealed she had not seen an ear wound and did not see lice/bugs on Resident #83 until she started performing cardiopulmonary resuscitation (CPR) on her. Interview on [DATE] at 8:39 A.M. with Mahoning County Coroner Investigator #302 via telephone confirmed she was the investigator assigned to Resident #83's case and confirmed she did take photos on [DATE] and recorded the findings in the resident's death report. She said she questioned the facility staff about the last time Resident #83 was checked and her bed linens were changed but they were not forthcoming and did not answer the questions. The photographs taken in the room at the nursing home by Mahoning County Coroner Investigator #302 were reviewed. These photos revealed Resident #83 had an approximately two-inch diameter brownish/black crusted area at her left temple in her hair. Sections of her hair were matted to her head. Additional pictures of her head showed multiple dark reddish to brown/black areas of dried drainage on her scalp. The bed sheet near her head/neck area had an area of dried reddish, serosanguinous drainage (serosanguinous refers to fluids leaving the body and is a mixture of blood and the liquid part of blood called serum and may be light red to pink-tinged depending on the amount of red blood cells in the drainage). There were numerous lice and nits noted throughout the resident's hair, near her scalp. There were multiple small scabbed areas scattered on her left upper chest and shoulder areas. There were two photographs of her pillowcases which were soiled with dried pinpoint drops of reddish/brown drainage around where the resident's head would have been on the pillows. One pillowcase had a line of dried red, bloody drainage which had settled in the seam, extending about half-way across the pillowcase. Two photos showed an obvious wound in Resident #83's outer ear/[NAME] area. The wound border had a yellowish, pus appearance around approximately three-fourths of the opening. There was also thick yellow pus noted on the inside of the wound. The area around the wound was slightly purplish in color and there was a small amount of dried brownish drainage above the open area, in the upper ear. There was one photograph of Resident 83's nightstand. The top drawer was open and there were small cans of unopened pop, a couple bottles of pop, a comb and a hairbrush. There was a large number of lice scattered in the drawer on and around these items. Interview on [DATE] at 8:52 A.M. with LPN #205 revealed she worked during the day of [DATE] until 7:00 P.M. LPN #205 said Resident #83's guardian would never give permission to shave the resident's head to control the lice infestation. LPN #205 revealed Resident #83's sheets were changed daily due to the drainage coming out of her head. She said Resident #83 itched a lot had and was always constantly picking at her head and ears, but the LPN said she did not really think much of it. Interview on [DATE] at 9:01 A.M. with STNA #109 revealed he worked the evening of [DATE] until 11:00 P.M. STNA #109 revealed he had last seen Resident #83 on [DATE] at 10:30 P.M. when he went to say goodnight to her. STNA #109 revealed he was the only STNA that Resident #83 trusted to assist her with showers. STNA #109 said every time he found lice nits in Resident #83's hair he would report it to the nurse on duty. STNA #109 reported he had to change the resident's pillowcases frequently on [DATE] because of the pink-tinged soiling from her hair, which he stated was also reported to the nurse. Interview with the Director of Nursing (DON) on [DATE] at 9:11 A.M. revealed she was called to the facility when Resident #83 passed away on [DATE]. The DON revealed she had checked Resident #83 the morning of [DATE] and she did not see a wound on her ear. The DON verified Resident #83 did not have a care plan in place related to lice and associated itching, did not have any physician's orders for [MEDICATION(S)] and they had no evidence weekly skin assessments from [DATE] and [DATE] were completed. During a subsequent interview on [DATE] at 9:30 A.M. LPN #118 revealed she did re-check Resident #83 on either [DATE] or [DATE] for lice and did see some dead lice on the resident's pillow and assumed the outbreak was over. However, LPN #118 never followed up again with Resident #83. LPN #118 confirmed no interventions for Resident #83's ear were implemented. Interview with the Administrator on [DATE] at 9:41 A.M. confirmed Resident #83 had been found with active lice and an open wound on her ear at the time of her death in the facility. Interview on [DATE] at 10:52 A.M. with Physician #303 revealed he had last seen Resident #83 on [DATE]. Physician #303 revealed he was aware the resident had lice but stated the lice were gone but the resident was still picking and picking. Physician #303 revealed the wound in her ear was from her picking. During a subsequent interview on [DATE] at 12:13 P.M. LPN #205 confirmed she did care for Resident #83 on [DATE] and passed all the resident's daytime medications as evidenced by her initials entered on the medication administration record. LPN #205 reported she was unable to recall that specific day but reported Resident #83 was always scratching her head and ears. LPN #205 said she noticed Resident #83's fingernails were caked with black material from scratching. She verified there were no interventions attempted or implemented for Resident #83's scratching/itching at that time. Interview with Resident #83's guardian, Legal Guardian #304, on [DATE] at 1:23 P.M. the legal guardian revealed she was notified of the presence of lice on [DATE] and agreed Resident #83 should have her hair cut. She said she saw Resident #83 on [DATE] and she still had lice. Legal Guardian #304 revealed she reported the lice to staff and told them the resident needed treated again. She said she was never asked if they could shave Resident #83's head. She said Business Office Manager (BOM) #119 notified her on [DATE] Resident #83 still had lice and they could not get it under control and they would have to send her out of the facility for treatment. Telephone interview on [DATE] at 1:30 P.M. with Funeral Director #305 revealed Resident #83's body was brought to his facility on [DATE] from the Mahoning County Coroner's office. He reported Resident #83 was so infested with lice that a bug bomb was administered to Resident #83 and the embalming room to try to eradicate the lice. Funeral Director #305 reported the Cuyahoga County Coroner's office picked Resident #83 up on [DATE] for an autopsy. Funeral Director #305 revealed Resident #83's body was returned on [DATE] to his facility in two body bags. He said they attempted to remove the body bags but as soon as they were unzipped bugs began coming out. Funeral Director #305 reported Resident #83's body was in two body bags and would be sealed in the casket before the funeral to prevent further infestation. Interview with BOM #119 on [DATE] at 8:22 A.M. verified she spoke with Resident #83's guardian about her lice and treatments and the guardian gave permission twice for them to cut the resident's hair. This information was not recorded in Resident #83's medical record. Review of facility policy, OHIO Abuse, Neglect and Misappropriation, revised [DATE], revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents and the intent of the facility was to prevent abuse, mistreatment or neglect of residents. In the event of a situation identified as abuse or neglect, an investigation by executive leadership would immediately follow. This policy indicated statements would be obtained from staff related to the incident and statements should be in writing, signed and dated at the time written. The statements should include first hand knowledge and what was seen or heard by the staff member. Review of facility policy titled, Resident Rights, dated [DATE], revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. This policy indicated the safety of residents, visitors, and employees was a top priority of care. Review of guidance related to lice from the Centers for Disease Control (CDC) at www.cdc.gov revealed after each treatment, checking the hair and combing with a nit comb to remove nits and lice every ,d+[DATE] days may decrease the chance of self-reinfestation. Continue to check for ,d+[DATE] weeks to be sure all lice and nits are gone. If live lice are still found eight to 12 hours after treatment, but are moving more slowly than before, do not retreat. The medicine may take longer to kill all the lice. Comb dead and any remaining live lice out of the hair using a fine-toothed nit comb. If after eight to 12 hours of treatment, no dead lice are found and lice seem as active as before, the medicine may not be working. It indicated they you are not to retreat until speaking with the health care provider as a different pediculicide may be necessary. If your health care provider recommends a different pediculicide, carefully follow the treatment instructions contained in the box or printed on the label. Nits should be combed from the hair shaft. After each treatment, checking the hair and combing with a nit comb to remove nits and lice every ,d+[DATE] days may decrease the chance of self-reinfestation. Continue to check for ,d+[DATE] weeks to be sure all lice and nits are gone. Retreatment is meant to kill any surviving hatched lice before they produce new eggs. For some drugs, retreatment is recommended routinely about a week after the first treatment (seven to nine days, depending on the drug) and for others only if crawling lice are seen during this period. Retreatment with [MEDICATION(S)] shampoo is not recommended. Review of the facility policy, titled Lice hair/pubic/body, revised [DATE], revealed the facility would promote a safe environment free from pests. Lice was defined as tiny, light brown parasitic insects that live in the scalp and hair of humans for up to 30 days, feeding on human blood from the head and scalp. Nits are eggs from lice which attach to the hair shaft and hatch in seven to 10 days. It takes 10 days for lice to reach adulthood and female lice can lay six to eight eggs per day. This policy stated head, body and pubic lice are not part of the normal care environment and efforts must be made to identify, treat, monitor and prevent lice and prevent it from spreading to other residents, staff or visitors. This policy indicated symptoms of lice infestation included persistent itching of the scalp and back of the neck, crusting of areas in the scalp due to scratching, sleeplessness and increased irritability. The policy directed the staff to visually inspect and assess the resident. They were to search the top of the head, neck and around the ears for red bite marks. It said scratch marks may be visible in the head, neck, and face area. The policy indicated secondary bacterial infections could occur with wound discharge and/or crusting. Small brown or light brown bugs may be visible in the hair and white, pearl-like oval shaped tiny eggs (nits) may be seen on the hair shafts. If lice or nits were visible, facility staff were to contact the physician/provider for treatment options. The findings of the assessment were to be documented in the resident's medical record. The treatment section indicated a shampoo-like treatment would be completed, combing would be done to remove lice/dead lice and nits, and they would remove lice and nits from other areas where they may have fallen. Secondary treatment, similar to initial treatment, would be provided seven to 10 days after initial treatment and nits had hatched. This deficiency substantiates Master Complaint Number OH 697 and Complaint Number OH 544. This deficiency is an example of continued non-compliance from the annual and complaint survey dated [DATE].

Based on closed medical record review, review of a facility's self-reported incident (SRI) investigation, staff, resident, physician and family interviews, the facility failed to protect one resident (Resident #75) from sexual abuse by State tested Nurse Aide (STNA) #96. This resulted in Immediate Jeopardy for Resident #75 who was made to engage in a sexually inappropriate act by STNA #96. This affected one of one resident reviewed for sexual abuse of three residents reviewed for abuse. The facility census was 74. The administrator and director of nursing (DON) were notified on 09/29/15 at 12:05 P.M. that Immediate Jeopardy began on 09/23/15 at approximately 8:03 P.M. when a facility video recording revealed STNA #96 entered Resident #75's room and closed the door. At 8:12 P.M., the resident's family arrived for a visit and entered the resident's room. Family Member #101 observed STNA #96 sitting next to Resident #75 with his penis exposed and Resident #75's hand on STNA #96's penis. Family member #101 left the room and reported the observation to STNA #77. STNA #77 went to Resident #75's room and observed the resident in her wheelchair and STNA #96 standing in the room. STNA #96 walked out of the room. STNA #77 checked Resident #75 to ensure the resident was safe, left the room and reported the incident to Registered Nurse (RN) #46. RN #46 attempted to locate STNA #96 to remove him from the building, but STNA #96 had clocked out at 8:13 P.M. and left the facility. RN #46 notified the DON and the resident's physician (Physician #97) of the allegation of sexual abuse. The DON notified the local police department of the allegation of sexual abuse. STNA #96 did not return to the facility and resigned his position per a phone conversation with the DON on 09/24/15. The Immediate Jeopardy was removed on 09/23/15 at 8:13 P.M. when STNA #96 clocked out and left the facility and the facility initiated the following corrective actions: · On 09/23/15, RN #46 assessed Resident #75 and found no visible injury. · On 09/23/15 (no time documented) the DON notified the physician and local police department of the incident of sexual abuse. · On 09/23/15 at 10:00 P.M. Resident #75 was sent to the hospital for evaluation for sexual abuse. · On 09/23/15 (no time documented) The DON interviewed all second shift employees who worked 09/23/15 related to the sexual abuse allegation. The employees interviewed included RN #46, STNA #77, STNA #35, STNA #2, STNA #47, Laundry Assistant #1 and Licensed Practical Nurse (LPN) #20. · On 09/24/15, the DON began staff education related to allegations of abuse, including sexual abuse contained in the facility's Policy titled Components of Abuse and Neglect dated 01/2014. · On 09/24/15 (no time indicated) all 60 interviewable residents were interviewed by the licensed social worker or the DON to ensure they did not experience any sexual abuse. · On 09/24/15 (no time documented) The DON audited all employee files to ensure appropriate pre-employment screening and receipt of resident rights, professional standards of conduct and abuse policies. · On 09/24/15 (no time documented) The DON developed a weekly abuse audit procedure, the audits were to continue for four weeks and as needed. The audits included staff interviews related to abuse policies and procedures. The weekly abuse audit procedure was developed but had not yet been initiated. The audits were to start on 09/29/15. · On 09/25/15, the assistant director of nursing (ADON) completed education for all 92 facility staff related to allegations of abuse, including sexual abuse, contained in the facility's Policy titled Components of Abuse and Neglect dated 01/2014. · 09/29/15, the ADON began completing physical assessments to identify any signs of abuse on the eleven residents identified as not interviewable. Although the Immediate Jeopardy was removed, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility continued to complete the assessments for all residents who were not interviewable and the facility was in the process of completing audits and verifying the corrective action taken was effective. Findings include: Review of the closed medical record for Resident #75 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. Review of Resident #75's Minimum Data Set 3.0 (MDS) assessment dated [DATE] indicated the resident was unable to be interviewed, had long and short term memory impairment, had severely impaired cognitive skills for decision-making, was inattentive and had disorganized thinking. Review of an SRI revealed on 09/23/15 at 8:03 P.M. the family of Resident #75 reported to STNA #77 when they entered the room of Resident #75, they observed the hand of Resident #75 on the private part of a male STNA. The family member (unspecified) indicated STNA #96 was forcing Resident #75 to touch his penis. STNA #77 entered the room of Resident #75 and observed Resident #75 sitting in her wheelchair and STNA #96 standing up. Resident #75's gown was on appropriately and STNA #96's clothes were not disheveled. STNA #96 left the room and STNA #77 immediately notified RN #46. RN #46 entered the room of Resident #75 and spoke with the family. The family (unspecified) said she observed a big, tall guy sitting next to Resident #75 and indicated the resident was touching STNA #96's penis. The family said Resident #75 was sitting in a wheelchair and STNA #96 was in a chair next to her. During the conversation, STNA #96 walked past the room of Resident #75 and the family identified him as the abuser. A staff member (unidentified) told RN #46 they witnessed STNA #96 clock out and exit out the back door. Another staff member (unidentified) told RN #46 that STNA #96's car was not in the parking lot. RN #46 spoke with Resident #75. Resident #75 was alert and pleasantly confused. Resident #75 was unable to tell what happened. Resident #75 said she wanted to use the bathroom and lay down. RN #46 left the room to call the police. Two STNAs (unidentified) changed Resident #75. The resident's disposable brief and tabs were intact, but she was incontinent of urine. The local police department was notified, a report was filed and the crime unit arrived and processed the room on 09/23/15 (no time indicated). The resident was transferred to the hospital for a rape evaluation and treatment on 09/23/15 at 10:00 P.M. Review of the social worker Care Coordination Note written by the hospital Licensed Social Worker (LSW) #100, during the resident's admission at the hospital and dated 09/25/15 at 11:03 A.M. indicated when an RN was cleaning the patient, the patient stated get him off me , don't let him touch me. Resident #75 asked LSW #100 for a warm blanket. She was provided the warm blanket and responded thank you for being so kind . Review of the facility's video camera indicated at 8:03 P.M. STNA #96 entered the room of Resident #75. At 8:12 P.M. two women were standing outside the room of Resident #75 for several seconds, then entered the room. They left and returned with STNA #77. At 8:13 P.M. STNA #96 left the room, clocked out and left through the back door. On 09/24/15 STNA #96 called the DON and resigned his position. He was asked twice to provide a statement, but he declined. STNA #96 was no longer an employee of the facility. Review of the personnel record for STNA #96 revealed he was hired on 05/28/15. The facility completed reference checks from two previous employers on 05/26/15 with no negative references. The nurse aide registry search was completed 05/21/15 and indicated STNA #96 was in good standing and had an expiration date of 10/10/16. STNA #96 had a criminal background check by the Bureau of Criminal Investigation and Identification submitted 05/27/15 and completed 06/01/15, with no disqualifying events identified. STNA #96 signed receipt of the facility's zero tolerance abuse policy, the Resident's Bill of Rights, the Abuse, Neglect and Misappropriation of Funds policy, the Professional Standards of Conduct Policy and the employee handbook on 05/28/15. STNA #96 had a performance evaluation dated 09/08/15 indicating he met expectations in all areas, including customer services and patient relations. The record did not indicate any disciplines related to abuse. Review of the Inservice Training Attendance records dated 09/24/15 and 09/25/15 revealed all 92 facility employees were educated on the facility's abuse policy and procedure either in person or by telephone. The education was completed by the ADON. Interview with the DON on 09/29/15 at 9:20 A.M. revealed she interviewed all second shift staff working on 09/23/15 right after the incident. The DON revealed the facility did not assess residents who were not interviewable for possible sexual abuse and did not interview all other staff to determine if inappropriate sexual conduct was known or suspected immediately after the incident. Interview on 09/29/15 at 9:40 A.M. with Physician #97, the medical director and attending physician for Resident #75, revealed Resident #75 was new to the facility and was pleasantly confused. Physician #97 said he was notified of the sexual abuse allegation on 09/23/15 and sent Resident #75 to the hospital for a full evaluation and examination. Physician #97 said the hospital did not contact him regarding the resident after she left the facility and he was not aware of her condition or her current residence. During interview on 09/29/15 at 12:25 P.M. Family Member #101 verified she was in the facility on 09/23/15 with another family member to visit Resident #75. Family Member #101 said the resident's door was closed and she thought care was being provided, so she waited a few minutes. When she opened the door, the privacy curtain by the door was pulled. There was no other resident residing in the room. She could see Resident #75's feet by the wheelchair and the legs of another person. She pulled open the curtain and saw Resident #75 sitting in her wheelchair and a man sitting in a chair next to her. The man's pants were open in the front and her family member was holding his penis. She asked the man what he was doing and he just looked at her. Family Member #101 went to get the nurse, but found STNA #77 and told STNA #77 what she observed. STNA #77 said the nurse was on a break. STNA #77 came to the room and the man walked out. Family Member #101 said the nurse came in, checked Resident #75 and called the administrator. Family Member #101 called the police and the police came. She said she wiped the resident's hands with sanitizer and the resident went to the hospital. Family Member #101 revealed the rape nurse at the hospital did a physical examination of the resident, but did not do a full rape test because it would be too traumatic for Resident #75. Resident #75 was admitted to the hospital and now resides in another nursing home. On 09/29/15 at 12:55 P.M. interview with LPN #16 revealed she was recently inserviced on abuse and neglect, including sexual abuse. She had knowledge of the facility's abuse policy and procedures. She was aware of the sexual abuse allegation but did not work with STNA #96. She said she had no complaints from residents related to inappropriate touching by any male STNA. On 09/29/15 at 1:05 P.M. interview with STNA #5 revealed she was recently inserviced on abuse and neglect, including sexual abuse. She had knowledge of the facility's abuse policy and procedures. On 09/29/15 at 1:15 P.M. interview with STNA #27 revealed she was recently inserviced on abuse and neglect, including sexual abuse. She had knowledge of the facility's abuse policy and procedures. On 09/29/15 at 1:39 P.M. a telephone interview with STNA #77 verified the family reported that Resident #75 had her hand on the penis of STNA #96 in her room with the door closed. STNA #77 ran to the room and observed STNA #96 standing in the room. STNA #96 left the room quickly. Resident #75 was changed because her brief was wet with urine, but she was not cleaned in case evidence was needed. On 09/29/15 at 1:43 P.M. the local police department was contacted for interview. The investigating officer, Officer #98, was unavailable for interview. On 09/29/15 at 1:45 P.M. a telephone interview with RN #46 revealed STNA #77 reported the allegation of sexual abuse to her. RN #46 made sure Resident #75 was safe and not injured, and then she attempted to look for STNA #96. When she learned he had already left the facility, she called the DON. RN #46 spoke with the family who said they thought at first STNA #96 was just holding Resident #75's hand but then the family realized STNA #96's penis was exposed and Resident #75's hand was on his penis and stroking it. The DON arrived and took over the investigation. The DON called the police, but the police had already arrived. On 09/30/15 at 9:40 A.M. interviews with Residents #14 and #15 revealed all staff treated them well and they have never abused or touched them inappropriately. They said they would report it. On 09/30/15 at 9:45 A.M. interviews with Residents #70 and #71 revealed the staff was kind. They have never been abused by staff. They have male staff care for them and have never been touched inappropriately by a male or female staff member. They would report it to a nurse. Review of the facility's abuse policy and procedure dated January of 2014 revealed it contained all components for screening, training, prevention, identification, investigation, protection and reporting.

Based on observation, interview and record review, the facility failed to provide prompt pain management for Resident #61. On 05/10/11 at 8:40 A.M., Resident #61 was observed crying, complaining of pain and asking for help with no staff intervention. This affected one of two residents reviewed for pain management, of 34 residents identified on pain management programs. Findings include: Resident #61 was re-admitted to the facility on [DATE] after a surgical repair of a left [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED]. Review of a re-admission pain assessment dated [DATE] revealed Resident #61 experienced severe pain in the left hip. Resident #61 expressed the pain verbally and also by grimacing, agitation, anxiety and restlessness. A scale to predict pressure sore risk dated 04/29/11 revealed Resident #61 had no sensory perception impairment. She had no sensory deficit which would limit her ability to feel or voice pain or discomfort. Review of a nurses note dated 05/03/11 revealed Resident #61 was readmitted to the hospital for complaints of pain and discoloration of the left lower leg. Review of the hospital history and physical dated 05/03/11 revealed Resident #61 had "impending gangrene with [MEDICAL CONDITION] in junction with left lower extremity extreme pain. The patient had very minimal help from the initial surgical intervention, (repair of the left hip) probably the patient is going to end up losing the leg on both sides. At present there is no apparent evidence of any gangrene and he (doctor) wants to wait for demarcation". Resident #61 remained hospitalized for [REDACTED]. Resident #61 was readmitted to the facility 05/05/11. Review of the nursing admission assessment revealed Resident #61 had daily, severe pain in the left hip and left heel. The admission skin assessment revealed the left heel was necrotic (dead tissue). The re-admission orders [REDACTED]. During the initial tour of the facility on 05/10/11 at 8:40 A.M., Resident #61 was observed in a wheelchair in front of the nurses station. Resident #61 had a soft boot on the left foot. The resident was moaning, grimacing, crying, rubbing her left leg and calling out "Help me. Somebody help me. Somebody. It hurts. Oh my God. It hurts me". Licensed Practical Nurse (LPN) #11 approached the resident and adjusted the left heel soft boot. She asked the resident if the pain was relieved. Resident #61 continued to rub her leg and said "It feels better, but, oh, it hurts. God help me. It hurts so bad." LPN #11 told the resident she would check with the resident's nurse regarding pain medication. The unit nurse was observed at the end of the hallway administering medications. LPN #11 exited the unit in the opposite direction. At 8:45 A.M., Resident #61 continued to complain of pain. She was crying out, "Oh help me God. It hurts so bad." Licensed Practical Nurse (LPN) #9, was seated at the nurses station writing in a resident record. She was approximately 12 feet away from the resident. LPN #9 did not respond to the resident's behavior. State tested Nurse Assistant #10 was passing breakfast trays. She passed in front of Resident #61 twice, while delivering the breakfast trays but did not respond to Resident #61. At 8:50 A.M., LPN #12 stopped and asked the resident about her pain. Resident #61 continued to cry, moan, grimace and rub her leg. She stated, "It hurts so bad". LPN #12 told Resident #61 she would help her by getting the unit nurse. At 9:00 A.M., no one had arrived to assist the resident and LPN #9 remained at the nurses station without acknowledging Resident #61. At 9:01 A.M., Resident #61 continued to moan, call out for help and rub her left leg. LPN #9 rose from the nurses station and began to exit the unit. During an interview at the time of the observation LPN #9 stated "I'm on my way to catch the bus. Her nurse knows." LPN #9 left the unit. During an interview at 9:04 A.M. with LPN #12, she revealed she had told the unit nurse about the resident's pain earlier and the unit nurse was getting Resident #61 something for pain. During an interview at 9:07 A.M. with the unit nurse, LPN #13, she revealed she had just been informed of Resident #61's pain. LPN #13 verified she was not informed by LPN #11 at 8:40 A.M. or LPN #12 at 8:50 A.M. LPN #13 reviewed the Medication Administration Record. She verified that Resident #61 had not received pain medication since the previous day, 05/09/11 at 1:45 P.M. At 9:10 A.M. LPN #13 administered [MEDICATION NAME] to Resident #61. Following the administration of the medication, Resident #61 was sent via a transport ambulette for [MEDICAL TREATMENT] therapy. During an interview with STNA #10 on 05/10/11 at 9:30 A.M. she revealed Resident #61 "always does that." She also revealed she did not inform the unit nurse because the nurse "probably gave her her meds (medications) already". Review of the resident's potential for pain Plan of Care dated 04/15/11 revealed, "assess for need of pain medication when resident calls "help me". She does this often and it means different things "i.e. pain, movement, hunger, 'go to work' etc." Additional interventions included, administering pain medication as ordered, re-orienting the resident to her [MEDICAL CONDITION] as she often will say "I don't know what happened to me", and reposition for comfort. Review of the 'Pain Management' policy and procedure dated 06/08 revealed it was the facility's policy to respect and support the resident's rights to optimal pain management. The purpose of the policy was to effectively manage pain to remove the adverse psychological and physiological effects of unrelieved pain. The policy also revealed "It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and relief from pain". This citation substantiates Complaint Number OH 536.