Every finding on record at Capital City Gardens Rehabilitation and Nursing Ce

Based on observation and interviews, the facility failed to ensure a safe, comfortable, and homelike environment. This had the potential to affect all 91 residents in the facility.Findings include:Observation on 04/19/26 at 7:30 A.M. revealed the walls, paneling, and floorboards around the C hall nursing station appeared severely damaged and were in significant disrepair with exposed drywall and missing floorboards.Observations on 04/19/26 at 7:36 A.M. in the shower room of hall B revealed exposed hot water shutoff pipes visible through missing drywall/door covering, ripped/missing drywall covering on the wall immediately outside of the shower, no privacy curtain around the toilet, plumbing fixtures at the shower head were held together by disposable gloves, and soiled grout throughout the shower with approximately one foot of missing tile exposing bare wall at the bottom of the shower.Interview on 04/19/26 at 10:02 A.M. with Maintenance Director #417 revealed pipes for the hot water shutoff should be covered in the B hall shower room. Further interview at this time revealed Maintenance Director #417 was unaware of the gloves holding together the shower head. Maintenance Director #417 stated they believed the gloves were holding together the shower head due to a water leak from the fixture. Maintenance Director #417 verified the other listed findings stating they would not want their home to appear how the shower room does.Observation on 04/19/26 at 10:10 A.M. revealed there was no privacy curtain around the toilet in the shower room of C hall, disposable gloves were holding together the shower head in C hall shower room, and there was a lightbulb not securely installed or covered hanging from exposed electrical wiring directly above the shower. Concurrent Interview with Maintenance Director #417 revealed the Maintenance Director #417 stated nobody tells me about this type of thing. Maintenance Director #417 verified the other listed findings of disrepair in the shower room of C hall including the exposed lightbulb and wiring above the shower and the shower head that was being held together by disposable gloves.Interview on 04/19/26 at 10:16 A.M. with Maintenance Director #417 verified the walls around the nurse's station of C hall were in significant disrepair.Observation on 04/20/26 at 1:00 P.M. revealed loose railing at the bottom of the handicapped ramp entrance/exit at the front of the facility. The railing was easily movable with application of regular force. There was also observed crumbling/broken concrete below the railing on the upper-level railing closer to the front entrance doors of the facility, next to the steps up to the front door. Interview on 04/20/26 at 4:08 P.M. with the Regional [NAME] President of Maintenance #204 verified the railing along the handicapped ramp entrance/exit outside the front of the facility was loose and they were aware that residents hold on to this rail for assistance while using the ramp, however they were unaware that the rail was movable with regular force. Regional [NAME] President of Maintenance #204 revealed they were aware of the crumbling/broken concrete below the railing on the upper walkway closer to the main entrance doors. This deficiency represents non-compliance investigated under Complaint Numbers 2979015 and 2784905.

Based on observations and interviews, the facility failed to ensure the food was prepared and stored in a safe and sanitary manner. This had the potential to affect all but two residents who the facility identified did not receive food from the kitchen. The facility census was 91. Findings include:Observation on 04/19/26 at 7:07 A.M. of the kitchen revealed Dietary Aide #217 in the kitchen preparing breakfast trays with waist length braids and no hairnet on. Dietary [NAME] #215 verified the observation at the time of the observation.Observation on 04/19/26 at 7:09 A.M. of the ready refrigerator in the kitchen revealed one cup container of applesauce, one eight-ounce glass of orange juice, one clear container of pudding, and ten salads in brown bowls wihich were undated. Dietary Aide #217 verified the undated food items at the time of the observation.Observation on 04/19/26 at approximately 7:10 A.M. walk in refrigerator near the dry food storage revealed one bowl of chicken noodle soup, one bag of mozzarella cheese, one bag of salad, and one bag of cheddar cheese which were opened and undated. Dietary [NAME] #216 verified the findings at the time of the observation.Review of the facility policy Food Receiving and Storage dated July 2014 revealed all foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).

Based on observation, staff interviews, and review of facility policy, the facility failed to follow enhanced barrier precautions, and failed to ensure intravenous (IV) bags were properly secured and not on lying on a soiled surface. This affected one (Resident #3) of 14 residents reviewed for enhanced barrier precautions and had the potential to affect 34 residents identified by the facility on enhanced barrier precautions. The facility census was 91.Findings include:Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with the primary diagnosis of abscess of liver, additional diagnoses include resistance to Vancomycin (antibiotic) and bacterial infections involving multiple species of bacteria such as enterococcus, proteus mirabilis, and pseudomonas.Further review of Resident #3's medical record revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment.Review of Resident #3's physician orders revealed the resident had active orders for an intravenous (IV) antibiotic Ceftazime with a start date of 04/18/26, along with an order for enhanced barrier precautions with a start date of 03/24/26 related to indwelling medical devices, wounds, and/or infection with a multidrug resistant organism (MDRO).Observation on 04/19/26 at 10:56 A.M. revealed an IV bag labeled Ceftazime was on the floor beneath Resident #3's bed while the IV bag was still connected to Resident #3's peripheral IV located in their Right arm. Further observation at this time revealed signage labeled Enhanced Barrier Precautions along with infection control instructions for visitors and staff was posted outside of Resident #3's room. Personal Protective Equipment (PPE) including disposable gloves and gowns were observed to be available outside of Resident #3's room for use when entering the room.Interview on 04/19/26 at 10:56 A.M. with Certified Nursing Assistant (CNA) #621 verified that the IV bag of Ceftazime was lying directly on the floor beneath Resident #3's bed while the bag was still connected to the resident's IV line. Further interview with CNA #621 at this time also verified the IV bag should not be on the floor when connected to a resident.Observation on 04/19/26 at 1:30 P.M. revealed CNA #621 was providing incontinence care to Resident #3. CNA # 621 was observed to no be wearing a gown. Observation at this time revealed the enhanced barriers precaution posted on Resident #3's door included instructions for staff to wear disposable gloves and a gown while providing high-contact resident care such as transferring the resident or toileting/incontinence care assistance.Interview on 04/19/26 at approximately 1:35 P.M. with CNA #621 verified they were not wearing a gown while providing incontinence care to Resident #3. The CNA revealed they went into Resident #3's room to transfer the resident from their wheelchair to their bed, and during this time realized the resident had been incontinent of bladder and needed incontinence care including changing the resident's briefs. CNA #621 verified they were aware that Resident #3 was on enhanced barrier precautions.Review of the facility policy titled Enhanced Barrier Precautions (EBP) Policy and Procedure (effective 04/01/24) revealed enhanced barrier precautions are an infection control intervention designed to reduce transmission of resistant organisms that employes targeted gown and glove use during high contact resident care activities. Further review of the policy revealed examples of resident care activities that would require gown and glove use included transferring and changing briefs or assisting with toileting.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure antipsychotic medications were used for an indicated diagnosis. This affected one, Resident (#73) out of five residents reviewed for unnecessary medications. The facility census was 91.Findings include:Review of the medical record for Resident #73 revealed the resident was admitted to the facility on [DATE] with diagnoses that included intervertebral disc disorder with radiculopathy in the lumbar region, chronic obstructive pulmonary disease, Type Two Diabetes Mellitus, alcoholic cirrhosis of the liver with ascites, generalized muscle weakness, and need for assistance with personal care. Additional review of Resident #73's medical record revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment.Review of medication orders in Resident #73's medical record revealed an order for Lurasidone (antipsychotic) 20 milligram (mg) tablets, one tablet taken once a day for antipsychotic, with a start date of 11/12/25. Review of Resident #73's psychiatric note dated 03/24/26 revealed the following statement: Gradual dose reduction (GDR) of Lurasidone was discussed; however, the patient declines. Will continue to reassess due to lack of a CMS- supported indication. Plan to increase Trazodone (antidepressant) and monitor response, tolerability, and potential side effects. Further review of the same psychiatric note revealed the following statement: The patient is currently on Lurasidone 20mg without an appropriate diagnosis according to CMS guidelines. His symptoms will be closely monitored, and a gradual dose reduction (GDR) will be attempted when he is clinically stable.Interview on 04/22/26 at approximately 3:45 P.M. with Regional Registered Nurse (RN) #212 verified Resident #73 had an active order for Lurasidone 20mg daily, was still receiving this medication, and the use of this medication for Resident #73 was not indicated or recognized as appropriate per Centers for Medicare and Medicaid Services (CMS) guidelines, but the medication was clinically indicated. RN#212 stated another provider involved in Resident #73's care that was not a psychiatric specialist had documented Resident #73 as having a mood disorder, and Regional RN #212 stated they believed this was an acceptable indication for use of the antipsychotic Lurasidone.Review of the Food and Drug Association (FDA) document Highlights of Prescribing Information (revised 03/2018) for lLrasidone revealed indications for usage of Lurasidone include the following: treatment of adult and adolescent patients with schizophrenia, monotherapy treatment of adult and pediatric patients with major depressive disorder associated with bipolar I disorder, and adjunctive treatment with Lithium (antimanic) or Valproate (antiseizure) in adult patients with major depressive episode associated with bipolar I disorder.Review of the facility policy titled Antipsychotic Medication Use (revised December 2016) revealed residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.

Based on record review, resident and staff interviews, and review of the facility policy, the facility failed to investigate an allegation of verbal abuse. This affected one, Resident (#2) out of five residents reviewed for freedom from abuse, neglect, and misappropriation. The facility census was 91.Findings include:Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included frostbite with tissue necrosis of unspecified sites, vascular [NAME]-Danlos syndrome, chronic viral hepatitis, and major depressive disorder. Further review of Resident #2's medical record revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment.Review of the document, Care Conference dated 04/07/26 contained in Resident #2's medical record revealed no mention of staff making disrespectful comments regarding Resident #2's feet, and no mention of smell as an issue related to the resident's feet.Interview on 04/19/26 at 11:36 A.M. with Resident #2 revealed they felt facility staff had not been speaking to them in a respectful manner, and specifically that staff comments regarding the condition of her necrotic feet were hurtful. Further interview at this time with Resident #2 revealed there was an incident approximately two weeks prior to the day of the interview where Certified Nursing Assistant #519 told the resident that she stinks while assisting her with a shower, and that her (necrotic) feet smell.Interview on 04/19/26 at 1:55 P.M. with Resident #2's mother revealed after speaking with Resident #2, she raised her concerns about the facility staff's alleged disrespectful comments towards Resident #2 regarding the smell of her feet with the facility Administrator during a recent care conference that was held on 04/07/26. Interview on 04/19/26 at approximately 2:20 P.M. with Resident #2 revealed they would consider the comments made by nursing aides regarding her feet were hurtful and that she would consider these types of statements to be verbal abuse.Interview on 04/19/26 at 3:28 P.M. with the facility Administrator revealed they did recall having a care conference with Resident #2's mother on 04/07/26 and that amongst other concerns, the staff noticing the smell of Resident #2's feet was brought to his attention during the care conference. The Administrator stated he did not investigate the issue, as he did not recognize the situation to be an allegation of verbal abuse. The Admionistrator revealed he did offer a room change for the resident as he could understand how one might feel humiliated if they were told their feet stink or smell in the context of active necrosis due to a medical condition. The Administrator confiimed he did not investigate this concern as an allegation of verbal abuse. Interview on 04/20/26 at 9:00 A.M. with Resident #73 revealed their room was directly across the hall from Resident #2's room, and that they had heard staff speaking disrespectfully to Resident #2 on several occasions regarding the resident's personal hygiene and condition of their feet. Resident #73 revealed they had heard staff telling Resident #2 that she stinks. Resident #73 stated Her feet are rotting; she can't control that. She is a young lady and deserves respect. It's not right. Review of the facility policy titled Abuse Investigation and Reporting (revised July 2017) revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Further review of this policy revealed findings of abuse investigations will also be reported.

Based on record review, observation, and interviews, the facility failed to ensure a follow up appointment was scheduled in a timely manner for Resident #49. This affected one resident out of seven reviewed for wound care. The facility census was 91. Findings include:Review of the medical record revealed Resident #49 had an admission date of 10/23/25 with diagnoses of, but not limited to, arthritis due to other bacteria, right hip, muscle wasting and atrophy, muscle weakness, need for assistance with personal care, lumbar spina bifida with hydrocephalus, neuromuscular dysfunction of bladder, paraplegia, neurogenic bowel, heart failure, attention-deficit hyperactivity disorder, acute kidney failure, major depressive disorder, gastritis, anemia, gastro-esophageal reflux disease, narcolepsy, and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #49 dated 01/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The quarterly MDS dated [DATE] revealed no psychosis, no verbal or physical behavior, and no rejection of care. The quarterly MDS dated [DATE] revealed Resident #49 was independent in all care, had an ostomy and an indwelling catheter. The MDS had Resident #49 coded to have one stage four pressure ulcer which was present on admission. Review of a progress note dated 02/04/26 revealed Resident #49 had three new wounds to his left lateral foot, left posterior lower calf, and a fluid filled blister to the bottom of his left foot. Review of a wound note dated 02/24/26 revealed Resident #49 had ankle-brachial index (ABI) which was normal. Referral made to outside dermatology office for further evaluation, waiting for them to call for an appointment. Instructed staff to call again if they do not receive a call back from dermatology department. Review of a progress note dated 02/17/26 revealed an order was received for the facility to schedule a dermatology appointment for Resident #49. Review of a progress note dated 02/25/26 revealed the facility called an outside dermatology office and was told the dermatology office was a week behind on referrals and is currently unable to schedule an appointment until they get to Resident #49's referral and will call the facility back. Interview on 04/22/26 at 10:21 A.M. with Licensed Practical Nurse (LPN) unit manager #425 revealed the wound Nurse Practitioner (NP) had requested a referral for dermatology for Resident #49. LPN unit manager #425 stated she had faxed the referral to an outside dermatology office and called the outside dermatology office. LPN unit manager #425 stated someone at the dermatology office told her the office was about a week behind in scheduling and could not schedule an appointment now. LPN unit manager #425 stated the outside dermatology office stated they would call back to the facility. LPN unit manager #425 stated she called the dermatology office back in about a month to follow up and they still could not schedule. There was no progress note regarding a follow up call to the outside dermatology office, and the LPN unit manager #425 verified Resident #49 still did not have an appointment at the dermatology office.

Based on review of the facility's water management plan, staff interview, and review of the Centers for Disease Control and Prevention (CDC) Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit), the facility failed to have an adequate water management plan. This had the potential to affect all 93 residents residing in the facility. The census was 93. Findings include: Review of the facility's Waterborne Pathogens Plan dated revised 01/07/24 revealed the hot water temperatures ranges to be checked, 105 degrees Fahrenheit (F) to 120 degrees F, was not a preventative range for Legionella growth. Further review revealed there was not a specified timeframe for temperature checks or control points of where temperatures would be taken. There was no specified temperature range to for hot water storage. There was no recommended flushing schedule of low-water flow or infrequently used areas and fixtures. Review of the CDC Legionella Control Toolkit revealed facilities should store hot water at temperatures above 140 degrees F and ensure hot water in circulation does not fall below 120 F. Recirculate hot water continuously, if possible. The facility should flush low-flow piping runs and dead legs at least weekly, and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. Interview with the Administrator and Maintenance Director #120 on 02/04/26 at 1:39 P.M. confirmed the above concerns with the facility's Waterborne Pathogens Plan. The deficiency represents non-compliance investigated under Complaint Number 2734119.

Based on resident record review, observations, staff interviews, and review of policy, the facility did not have proper personal protective equipment in the laundry room to manage infectious material. Also, the facility did not follow proper isolation procedures for Resident #89. This had the potential to affect 87 residents of 89 residents in the facility. The facility identified two residents (#13 and #43) who did not have the facility launder their items. The facility census was 89. Findings include: 1. Observation of the facility laundry room, on 03/04/25 at 8:32 A.M., revealed there was no personal protective equipment in the laundry room. Interview on 03/04/25 at 8:36 A.M., with Housekeeping Supervisor #340 confirmed there was no personal protective equipment in the laundry room for handling infectious materials. Interview with Laundry Aide #330 on 03/04/25 at 9:44 A.M., confirmed there was no personal protective equipment in the laundry room for handling infectious materials. Interview with Corporate Nurse #304 on 03/06/24 at 10:00 A.M., revealed on 03/04/25, there were two residents (#12 and #32) who were on transmission-based precautions due to infections. Review of the policy titled Infection Control, dated August 2014 revealed that gloves will be worn for contact with any potentially hazardous materials. 2. Review of Resident #89's medical record revealed an admitted [DATE], with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of Resident #89's physician orders revealed that he had a hemodialysis catheter in his right upper chest wall. Resident #89 was on Enhanced Barrier Precautions related to this indwelling medical device, effective on 02/26/25. Observations on 03/05/25 at 4:46 P.M. and on 03/06/25 at 9:00 A.M., revealed Resident #89 did not have a sign on his door or outside of his room indicating that he was on Enhanced Barrier Precautions. Interview on 03/06/25 at 9:14 A.M., with the Director of Nursing confirmed Resident #89 was on Enhanced Barrier Precautions and did not have a sign on his door or outside of his room notifying staff of the precautions. Review of the policy titled Enhanced Barrier Precautions dated 04/01/24, revealed when implementing Enhanced Barrier Precautions, it is critical to ensure that staff has an awareness of the facility's expectations about hand hygiene and gown/glove use. To accomplish this, the facility posts signage on the door or outside of the resident room indicating that Enhanced Barrier Precautions are to be used.

Based on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure air temperatures remained in the appropriate range. This affected three (#81, #79, and #247) of seven resident rooms observed for air temperatures. Also, the facility failed to repair a sink to prevent continuous dripping noises. This affected one (#59) of seven residents rooms observed. The census was 89. Findings include: 1. Review of Resident #81's medical record revealed an admission dare on 12/15/24. Her diagnoses included cachexia, unspecified protein calorie malnutrition, hypotension, fatty liver, post traumatic stress disorder, borderline personality disorder, bipolar disorder, polyneuropathy, vitamin A deficiency, asthma, type II diabetes, malingerer, anxiety disorder, muscle weakness, cellulitis, pulmonary embolism, anemia, thrombocytopenia, and intellectual disability. Review of her minimum data set (MDS) assessment, dated 12/20/24, revealed she was cognitively intact. Observation on 03/03/25 at 4:03 P.M., revealed Resident #81 underneath three different blankets, lying in her bed. She expressed that it was very cold in her room. Observation of with Regional Maintenance Director #300 during this time, found that his air temperature tool deemed the room to be 77 degrees, but the air vent to her room was blowing cold air and there was cold air blowing in from her window, which is where her bed was located. Regional Maintenance Director #300 confirmed they would have the Heating Ventilation Air Conditoning (HVAC) vendor to the facility as soon as possible to assess the heating units for each room that had issues. Observation on 03/04/25 at 7:38 A.M., revealed Resident #81 was again under three blankets in bed, but she was covering her head with the blankets as well. The room was frigid to feel, and Resident #81 confirmed she was cold. Regional Maintenance Director (RMD) #300 entered Resident #81 room and confirmed with his air temperature tool that it was 66 degrees in her room. He confirmed the HVAC vendor would be in the facility that day to work on the units. Administrator offered for Resident #81 to move to a semi-private room for the time being, but she declined due to wanting to remain in her private room. Interview with Resident #81 on 03/03/35 at 4:03 P.M. and 03/04/25 at 7:40 A.M., confirmed her room is constantly that cold. She confirmed the maintenance staff told her that a valve needed to be replaced in her room unit, but she is unsure if that has been completed. She confirmed she was covering her head on 03/04/25 because she did not want icicles to form from her nose because it was so cold. Interview with RMD #300 on 03/04/25 at 7:45 A.M. and 03/05/25 at 9:00 A.M., confirmed that Resident #81 room temperature on 03/04/25 was 66 degrees. He confirmed that was too cold and they would be addressing the issue. On 03/05/25, he confirmed the HVAC vendor came to the facility and found that the HVAC lines needed to be bled so they got air pockets out. The system is working appropriately now. 2. Review of Resident #79's medical record revealed an admitted [DATE]. Her diagnoses included end stage renal disease, type I diabetes, hypertension, chronic pain syndrome, asthma, hypothyroidism, insomnia, polyneuropathy, other psychoactive substance abuse, anxiety disorder, major depressive disorder, scoliosis, history of falling, and anemia. Review of her MDS assessment, dated 01/24/25, revealed she was cognitively intact. Observations on 03/04/25 at 7:53 A.M., found that Resident #79 room was 68 degrees, after she had complained her room was cold. The temperature was confirmed by Regional Maintenance Director #300. Interview with Resident #79 on 03/04/25 at 7:53 A.M., confirmed her room was cold and had been that way for about a week. She stated she doesn't want to move, but would prefer to have her heat fixed soon. Interview with RMD #300 on 03/04/25 at 7:55 A.M. and 03/0/25 at 9:00 A.M., confirmed Resident #79 room temperature was 68, which was outside the acceptable range. He gave same reason as Resident #81 room for being cold; they had to bleed the HVAC lines to get the air pockets out. They would be monitoring the affected rooms three times daily until they have deemed the temperature issue has been resolved. 47059 3. Review of Resident #247's medical record revealed admitted [DATE], with diagnoses that included iron deficiency anemia, peripheral vascular disease, end stage renal disease with dependence on renal dialysis, type 2 diabetes mellitus with neuropathy and retinopathy, psychoactive substance abuse, atrial fibrillation, seizures, and an acquired absence of left leg below the knee. Review of the admission MDS assessment dated [DATE] revealed Resident #247 was cognitively intact with brief interview for mental status (BIMS) score of 13/15. Interview on 03/03/25 at 09:48 A.M., with Resident #247 in his room, revealed Resident #247 feels the room is always cold. Resident #247 has been in the facility for a week and there has been no heat in the room the whole time. Resident #247 states he has asked several times for the heat to be fixed and the temperature in the room never gets warmer. Observation on 03/03/25 at 10:30 A.M., of Resident #247's room with RDM #300 revealed the air thermometer registered a temperature fluctuating between 69- and 70-degrees Fahrenheit. Interview on 03/03/25 10:33 A.M., with RDM #300 confirmed room temperature reading topped out at 70.7 degrees Fahrenheit. Regional director of maintenance #300 confirmed room temperature readings should be warmer at 71 - 81 degrees Fahrenheit. 49039 4. Review of the medical record for Resident #59 revealed an admitted [DATE], with diagnoses of major depressive disorder, post-traumatic stress disorder, panic disorder, schizophrenia, psychoactive substance abuse, anxiety, insomnia and unspecified mood disorder. Review of the care plan dated 10/27/23 revealed Resident #59 has diagnoses of anxiety with an intervention of maintaining a calm environment. Review of MDS assessment completed 01/17/25 revealed Resident #59 has a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact. Review of functional abilities section revealed the resident requires supervision or touching assistance with oral hygiene, toileting, and personal hygiene. Observation on 03/05/25 at 3:46 P.M., of Resident #59 revealed a significant buildup of scaling between the porcelain and the left handle of the sink faucet. This buildup prevented the sink from shutting off completely, causing a continuous flow of water to spill into the sink basin Interview on 03/05/24 at 3:44 P.M., with Resident #59 voiced concern regarding the constant leaking of the sink since admission to the facility, the resident voiced that staff members were notified of the issue and the noise was annoying. Observation on 03/06/25 at 10:31 A.M., of Resident #59's room revealed the sink was still leaking with the large amount of scaling and build up. Interview on 03/06/25 at 10:35 A.M., with Maintenance Director #178 confirmed presence of building up on the sink, he confirmed he was unaware of the issue and currently did not have a request out to fix the sink. Review of policy titled, Quality of Life - Homelike Environment dated May 2017, revealed residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe temperatures (71-81 degrees). This deficiency represents non-compliance investigated under Complaint Numbers OH00162277, OH00162188, and OH00161970.

Based on medical record review, staff interview and policy review, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected three (#3, #15, and #59) of four residents reviewed for Pre-Admission Screening and Resident Review (PASARR) documents. The census was 89. Findings include: 1. Review of Resident #3's medical record revealed an admitted [DATE]. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she was cognitively intact. Review of Resident #3 PASARR document, dated 11/03/22, revealed under Section E, the diagnoses listed were panic or other severe anxiety disorder. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASARR document: bipolar disorder, major depressive disorder, and post traumatic stress disorder. Review of her progress notes revealed no evidence to support the state mental health agency was notified of the significant mental health changes as required. 2. Review of Resident #15's medical record revealed an admitted [DATE]. Her diagnoses were acute pulmonary edema, type II diabetes, ulcerative colitis, respiratory failure, major depressive disorder, chronic obstructive pulmonary disease, lymphedema, atrial fibrillation, chronic kidney disease (stage III), anxiety disorder, repeated falls, muscle weakness, dorsalgia, bipolar disorder, anemia, insomnia, heart failure, hypertension, adult failure to thrive, mood disorder, and nicotine dependence. Review of her MDS assessment, dated 02/13/25, revealed she was cognitively intact. Review of Resident #15 PASARR document, dated 02/15/24, revealed under Section E, the diagnoses listed were mood disorder and depression. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASARR document: bipolar disorder, anxiety disorder, and adult failure to thrive. Review of her progress notes revealed no evidence to support the state mental health agency was notified of the significant mental health changes as required. Interview with Social Services #207 on 03/06/25 at 8:35 A.M., confirmed she had not notified the state mental health agency of the significant changes for either resident. 49039 3. Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses of major depressive disorder, post-traumatic stress disorder, panic disorder, schizophrenia and psychoactive substance abuse. Updated diagnoses included anxiety, insomnia and unspecified mood disorder. Review of preadmission screening and resident review (PASRR) identification screen dated 04/10/23 revealed diagnoses present were schizophrenia, mood disorder, panic or other severe anxiety disorder and post-traumatic stress disorder. Review of physician orders dated 08/19/24 revealed Melatonin capsule three milligrams (mg) at bedtime for insomnia. Review of MDS assessment completed 01/17/25 revealed Resident #59 has a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact. Review of additional active diagnoses included insomnia. Review of physician note dated 02/16/25 revealed diagnoses of depressive disorder with anxiety and insomnia, treated with escitalopram, buspirone and Melatonin with a follow up with psychiatry. Review of psychiatric note dated 02/18/25 revealed Resident #59 reports stable anxiety, however has a history of excessive worrying which occurs more days than not, for greater than 6 months with the following symptoms: restlessness, daytime fatigue, irritability and sleep disturbance. Interview on 03/06/25 at 8:35 A.M. with Admissions/Social Services #207 confirmed Resident #59 PASARR screening completed on 04/10/23 was inaccurate because it did not include the diagnosis of insomnia. Additionally, this incorrect review had been sent to the Department of Aging and would need to be corrected. Review of the undated policy tiled, Resident Assessment - Coordination with PASARR Program, revealed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Additionally any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

Based on record review, staff interview, and policy review, the facility failed to ensure weekly weights were obtained per physician orders. This affected two (#77 and #92) of five reviewed for nutritional monitoring. The facility census was 96. Findings include: 1. Review of the medical record for Resident #92 revealed an admitted [DATE], with diagnoses of acute and subacute infective endocarditis, bacteremia, viral hepatitis, presence of heart valve replacement, rheumatic tricuspid insufficiency, shortness of breath, psychoactive substance use, hypertension, pulmonary embolism without acute cor pulmonale and edema. Review of nutritional assessment review dated 11/15/24 revealed Resident #92's most recent weight measurement for Resident #92, taken on 11/12/24, showed a weight of 178 pounds. To help maintain a stable weight, interventions included fluid restriction, protein supplements three times daily, double protein with meals, a no-added-salt diet, and weekly weight monitoring. Review of the medical record for Resident #92 revealed the only weight taken by facility staff was on 11/12/24 with a result of 178 lbs. Review of the care plan dated 11/15/24 revealed Resident #92 has nutritional problem related to recent surgery, infective endocarditis, bacteremia, hepatitis, shortness of breath, psychoactive substance abuse, hypertension, and anxiety. As of 11/27/24, it is noted to continue monitoring weekly weights to establish a baseline. Interventions include following the prescribed fluid restriction, serving the ordered diet, recording meal intake at each meal, and having the dietitian assess and make any necessary diet adjustments. Additionally, the resident will be monitored for any significant weight loss. Review of physician orders dated 11/15/24 revealed an order for fluid restriction was placed, limiting intake to 1500 milliliters every 24 hours. Additionally, on 11/16/24, an order for a house shake was made for three times a day. On 11/17/24, an order for weekly weight checks for four weeks, followed by monthly weigh-ins. Review of care conference dated 11/18/24 revealed Resident #92 current diet includes no added salt, regular texture, and a fluid restriction of 1500 milliliters per day. They are also receiving a house shake three times a day. The resident has reported weight loss during their hospital stay, with a goal of maintaining their weight. Review of admission minimum data set (MDS) assessment completed 11/19/24 revealed Resident #92 had a brief interview for mental status of 15, indicating the resident was cognitively intact. Additionally the record revealed the resident has not experienced a 5% weight gain or loss in the past month, nor a 10% or greater weight change over the last six months. Review of section K Swallowing/Nutritional status revealed a weight of 178 pounds (lbs). Interview on 03/05/25 at 5:17 P.M., with Corporate Nurse #304 confirmed the facility has recognized an issue with staff not consistently obtaining weekly weights upon admission and as ordered. The facility has been actively working on finding a solution to this issue and tracking progress Interview on 03/06/25 at 11:46 A.M., with Dietician #302 confirmed Resident #92 has physician orders to have weekly weights since admission. The dietitian confirmed the resident has several risk factors for weight loss or gain, including diagnosis of hepatitis with a history of ascites, cardiac disorder with prescribed antibiotics, a prolonged hospital stay, and a fluid restriction. She also confirmed that facility staff did not complete the weekly weights as ordered. 37100 2. Review of Resident #77's medical record revealed an admitted [DATE]. His diagnoses included fracture of tibia or fibula, end stage renal disease, type II diabetes, edema, hyperlipidemia, congestive heart failure, dependence on renal dialysis, hypertension, insomnia, muscle weakness, and acquired absence of spleen. Review of his minimum data set (MDS) assessment, dated 02/04/25, revealed he was cognitively intact. Review of Resident #77's weights, dated 01/29/25 to 02/10/25, revealed the following weights and dates they were taken: 01/29/25 (200 pounds), 02/05/25 (186.7 pounds), 02/07/25 (180.2 pounds), 02/10/25 (180.2 pounds), and 02/10/25 (182.3 pounds). From 01/29/25 to 02/05/25, there was a decrease of 6.7 percent, and from 01/29/25 to 02/07/25, there was a decrease of 9.9 percent. Review of Resident #77's nutritional progress note, dated 02/06/25 and 02/14/25, revealed a trigger for 5 percent and 7.5 percent weight decrease respectively. It was documented that there may be some expected weight fluctuation, but the dietitian recommended that the weekly weights continue so they could establish a weight baseline. Also, there was a note that the initial weight could be erroneous, so they wanted to continue the weekly weights. Review of Resident #77's physician orders, dated 02/03/25, revealed the facility was to take Resident #77 weights on a weekly basis for a month. Review of Resident #77's nutritional care plan revealed an intervention added on 02/14/25 for the facility to continue weekly weights. Review of Resident #77's weights, dated 02/10/25 to 03/06/25, revealed no further weights were taken, which did not comply with the dietary recommendation and the physician/nutritional order as written to establish his baseline weight. Interview with Dietitian #302 on 03/06/25 at 11:43 A.M. confirmed weights weekly for first four weeks is standard and what she would have liked to have happened for Resident #77. She reviewed the weights for the first two weeks, and then put an order/recommendation that she wanted the weekly weights to continue to get two more weights. She confirmed she didn't count the 02/07/25 and 02/10/25 weights as weekly weights; only verifications. She confirmed there was no additional weight in the record. She confirmed she is not certain the initial weight of 200 was accurate or they got it from hospital records/from him personally, which is why she wanted to weekly weights to continue to establish an accurate baseline weight. Review of the policy titled, Weight Assessment and Intervention, dated September 2012, revealed the team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Weight assessment includes nursing staff will measure residents weights on admission, the next day, and weekly for two weeks thereafter. If no weights concerns are noted at this point, weights will be measured monthly thereafter.

Based on medical record review, resident interview, staff interview, and facility document review, the facility failed to allow residents to refuse treatment without the threat of being discharged from the facility. This affected one (Resident #201) of two residents reviewed for dignity/rights. The census was 89. Findings include: Review of Resident #201's medical record revealed an admitted [DATE]. Resident #201's diagnoses included osteomyelitis, fusion of spine, asthma, discitis, intraspinal abscess and granuloma, arthritis due to other bacteria, methicillin susceptible staphylococcus aureus, bacteremia, viral hepatitis C, other psychoactive substance abuse, subluxation of L4/L5 (lumbar) vertebra, anemia, depression, anxiety disorder, muscle weakness, difficulty walking, and need for assistance with personal care. Review of the minimum data set (MDS) assessment, dated 02/25/25, revealed she was cognitively intact. Review of Resident #201's Substance Use Disorder Program agreement revealed she signed the form to agree to substance use treatment in the facility on 02/13/25. She signed this document while she was in the hospital, prior to being admitted to the facility. Interview with Resident #201 on 03/03/25 at 2:39 P.M. and 03/06/25 at 12:11 P.M., confirmed she felt forced to go through the stepping stones program (substance abuse program) while in the facility; she confirmed she does not want to be a part of it. She stated she does not remember talking or hearing about the stepping stones program at this facility. She remembers talking to someone in the hospital about multiple facilities she could go to, but she chose to go to the one she was in right now. She stated the facility Administrator and Stepping Stones Counselor #303 both went to her room after she was admitted and told her she needed to sign a variety of consent form or she would be discharged from the facility. She stated she could not remember what the consent forms were, but she was confident she was told that she needed to sign the documents and participate in the stepping stones program, or she would be discharged from the facility. She stated she would not have admitted to this facility had she known she would have had to go through with the stepping stones program. She confirmed she did not want to go to counseling, did not want to drug test, and did not want to have visitors in a public place. Interview with Corporate Director #301 and [NAME] President of Business Development (VPBD) #305 on 03/06/25 at 10:05 A.M., revealed each resident who has a history of substance abuse, the facility will be notified about a possible referral due to this facility having the stepping stone program. The residents will sign a contract prior to entering the facility for medical care. They are told about the stepping stones program prior to admitted to this facility, while they are at the hospital. The facility hospital liaison goes to the hospital, discusses the program and what is expected of them if they are admitted , and get them to sign the contract that they will participate in the stepping stone program. They continued to say the resident signed the contract to participate in the stepping stones program, so they have to participate when they are in the facility. When asked if a resident would be discharged if they did not participate, their answer was, each resident is different, but it would be discussed. Interview with Administrator on 03/06/25 at 12:00 P.M., revealed the resident will sign a contract at the hospital prior to being admitted to the facility, to participate in the stepping stones program. The hospital liaison will review the contract with the resident prior admitted to the facility, and then the resident will sign it. He confirmed if the resident comes into the facility, and they determine they don't want to do the stepping stones program, they will try to find another facility for the resident and perform a safe discharge. Interview with Stepping Stones Counselor #303 on 03/06/25 at 12:27 P.M., revealed the hospital will give referrals to the facility about those who have a positive drug test or a history of substance abuse. She confirmed if they don't sign the consent forms (transportation, medical care, etc) in the facility for treatment, they can not go forward with stepping stones, and they will be removed from that program. She stated she has no decision power as to whether the resident stays in the facility if they don't continue with the stepping stones program. Review of the undated facility agreement titled, Substance Use Disorder Program, revealed a Stepping Stone's counselor will conduct in-house counseling sessions on a frequency to be determined where attendance for those in the substance use disorder program is mandatory. Refusal to attend such sessions will result in immediate discharge planning due to refusals to participate as previously agreed prior to admission. The candidate for admission to the facility and Substance Use Disorder program will also agree, prior to admit, to the following protocol based on the team collaboration with the physicians and certified nurse practitioners (CNP) involved in the Substance Abuse program: leave of absences (LOA) based on physician order, supervised visits with outside visitors in a common area, visitors alone in the resident's rooms based on discretion of the physician and interdisciplinary team (IDT), ancillary physician appointments outside the facility may require a responsible escort, random labs and urine drug screens on an as needed basis. The resident will be immediately discharged based on the IDT investigation for any violation of the Substance Use program in collaboration with the involved physicians and CNPs. Review of Facility Services Agreement between this facility and Stepping Stones Outpatient Services, LLC, dated 03/10/21, revealed the agreement identified Stepping Stones as provider throughout the language of the agreement. Under the section of Resident Choice, the agreement stated, the parties agree that nothing contained in this agreement shall prevent any resident from electing services from any health care provider of resident's or their legal representative's choosing and at no time shall any resident of the facility be obligated to use the services offered by provider.

Based on medical record review, staff interview and policy review, the facility failed to ensure all resident Pre-Admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected three (#3, #15, and #59) of four residents reviewed for PASARR documents. The census was 89. Findings include: 1. Review of Resident #3's medical record revealed an admitted [DATE]. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she was cognitively intact. Review of Resident #3 PASARR document, dated 11/03/22, revealed under Section E, the diagnoses listed were panic or other severe anxiety disorder. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASARR document: bipolar disorder, major depressive disorder, and post traumatic stress disorder. 2. Review of Resident #15's medical record revealed an admitted [DATE]. Her diagnoses were acute pulmonary edema, type II diabetes, ulcerative colitis, respiratory failure, major depressive disorder, chronic obstructive pulmonary disease, lymphedema, atrial fibrillation, chronic kidney disease (stage III), anxiety disorder, repeated falls, muscle weakness, dorsalgia, bipolar disorder, anemia, insomnia, heart failure, hypertension, adult failure to thrive, mood disorder, and nicotine dependence. Review of her MDS assessment, dated 02/13/25, revealed she was cognitively intact. Review of Resident #15 PASARR document, dated 02/15/24, revealed under Section E, the diagnoses listed were mood disorder and depression. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASARR document: bipolar disorder, anxiety disorder, and adult failure to thrive. Interview with Social Services #207 on 03/06/25 at 8:35 A.M. confirmed the PASARR documents for Residents #3 and #15 need to be updated to accurately reflect her diagnoses. 49039 3. Review of the medical record for Resident #59 revealed an admitted [DATE], with diagnoses of major depressive disorder, post-traumatic stress disorder, panic disorder, schizophrenia and psychoactive substance abuse. Updated diagnoses included anxiety, insomnia and unspecified mood disorder. Review of preadmission screening and resident review (PASARR) identification screen dated 04/10/23 revealed diagnoses present were schizophrenia, mood disorder, panic or other severe anxiety disorder and post-traumatic stress disorder. Review of physician orders dated 08/19/24 revealed Melatonin capsule three milligrams (mg) at bedtime for insomnia. Review of minimum data set (MDS) assessment completed 01/17/25 revealed Resident #59 has a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact. Review of additional active diagnoses included insomnia. Review of physician note dated 02/16/25 revealed diagnoses of depressive disorder with anxiety and insomnia, treated with escitalopram, buspirone and Melatonin with a follow up with psychiatry. Review of psychiatric note dated 02/18/25 revealed Resident #59 reports stable anxiety, however has a history of excessive worrying which occurs more days than not, for greater than 6 months with the following symptoms: restlessness, daytime fatigue, irritability and sleep disturbance. Interview on 03/06/25 at 8:35 A.M., with Admissions/Social Services #207 confirmed Resident #59 PASARR screening completed on 04/10/23 was inaccurate because it did not include the diagnosis of insomnia. Review of the undated policy titled, Resident Assessment - Coordination with PASARR Program, revealed the facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The social services director shall be responsible for keeping track of each resident;s PASARR screening stats, and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).

Based on medical record review, observations, staff interviews and review of policy, the facility failed to ensure communication between the facility and dialysis vendor regarding dialysis treatments was on going for continuity of care. This affected one (#24) of one resident reviewed for dialysis. Seven residents currently receive dialysis treatments. The facility census was 89 residents. Findings include: Review of Resident #24's medical record revealed an admission on 02/16/23, with diagnoses that included chronic kidney disease, end stage renal disease, chronic viral hepatitis C, hypertension and dependence on renal dialysis. Review of Resident #24's physician orders revealed a standing appointment for dialysis at an outside dialysis clinic three times weekly. Orders for nursing to complete a pre- and post-dialysis communication form on Mondays, Wednesdays and Fridays. Observation of Resident #24's hard chart on 03/04/25 at 3:24 P.M., revealed some post dialysis forms in the hard chart, but not in completion. Interview on 03/04/25 at 3:24 P.M., with Licensed Practical Nurse (LPN) #154, revealed when Resident #24 returns from dialysis, she does not always bring a communication sheet from the dialysis center with her. LPN #154 revealed when Resident #24 does not return with a communication form, she does not follow up with the dialysis center or inquire about the services performed at the dialysis center. Observation on 03/04/25 at 3:38 P.M., of a binder in the Director of Nursing's office revealed the remainder of the dialysis communication forms for Resident #24 were located in this binder. Interview on 03/04/25 at 3:38 P.M., with the Director of Nursing (DON) confirmed the communication with the dialysis center needed to be more defined. Interview on 03/06/25 at 12:40 P.M., with the DON revealed she expects the nurses to read the communications from the dialysis center. Review of an undated policy titled Hemodialysis revealed there should be ongoing communication between the dialysis center staff and the facility, including but not limited to weight changes, medication administration, and treatment complications.

Based on observation, medical record review, staff interviews, and policy review, the facility failed to secure and store medications appropriately. This affected one (#72) of 24 residents observed during the annual survey. The facility census was 89. Findings include: Review of Resident #72's medical record revealed an admitted [DATE], with diagnoses that included cerebral infarction, dysphagia, major depressive disorder, psychoactive substance abuse, disorientation, anxiety disorder and pain. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact, mild depression, with no signs of psychosis noted. Review of records for Resident #72 revealed no assessment or screening for self - medication documented and there was no physician's order to administer self-medications. Observations on 03/04/25 at 9:12 A.M. noted a medicine cup with several tablets and capsules on the over bed table for Resident #72. Interview on 03/04/25 at 9:12 A.M. with Resident #72 revealed Resident #72 had been sleeping. Resident #72 then stated those pills might be his morning medications he would need to ask his nurse. Interview on 03/04/25 at 9:15 A.M. with Licensed Practical Nurse (LPN) #154 confirmed the medication cup with morning medications for Resident #72 were left on the overbed table. Resident #72 was still eating breakfast when the medications were brought in and Resident #72 prefers to take medications after breakfast. LPN #154 stated she didn't realize he hadn't taken the medication yet. Interview on 03/06/25 at 8:40 A.M., with the Director of Nursing (DON) confirmed the expectations are the nurse will follow the professional standards of medication administration including watching the patient take the medication at the time the medication is brought into the room. Review of the policy titled, Administering Medications, dated December 2012 confirmed the expectations and process to prepare, administer, and document the administration of medications according to standard professional practice guidelines. This deficiency represents non-compliance investigated under Complaint Numbers OH00162277.

Based on medical record review and staff interview, the facility failed to provide parameters for as needed pain medication. This affected one (#3) of five residents reviewed for unnecessary medications. The census was 89. Findings Include: Review of Resident #3's medical record revealed an admission on 03/05/19. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she was cognitively intact. Review of Resident #3 physician orders, dated December 2024 to March 2025, revealed an order for acetaminophen 325 milligrams (mg), three tablets every six hours as needed for pain. Also, there was an order for Naproxen 500 mg every 12 hours as needed for pain. Finally, an order for oxycodone 5 mg every six hours for pain. None of the medications had parameters as to which pain medication should be given and what pain level each medication should be given at. Review of Resident #3 medication administration record (MAR), dated December 2024 to February 2025, revealed the following as needed pain medications were administered: in December 2024, acetaminophen was administered five times for pain levels between 3 and 8, Naproxen was administered five times all for pain level of 6, and oxycodone was administered a total of 55 times for pain levels between 0 to 8. For January 2025, acetaminophen was administered 18 times for pain levels between 5 and 8, Naproxen was administered twice for pain level 6 and oxycodone was administered a total of 57 times for pain levels between 0 and 9. Lastly, in February 2025, acetaminophen was administered eight times for pain levels between 3 and 10, Naproxen was administered once for pain level 5, and oxycodone was administered 48 times for pain levels between 4 and 10. Interview on 03/06/25 at 10:00 A.M., with Licensed Practical Nurse (LPN) #154, confirmed she has not typically seen parameters for resident as needed pain medications. She will ask the residents pain level and provide pain medications related to the pain level. She will administer the higher strength medication (examples include oxycodone, tramadol, etc) for pain levels 6 to 10, and the lower strength medication (acetaminophen, ibuprofen, etc) for pain levels 1 to 5. She will document the pain level and which medication she administered. Interview on 03/06/25 at 10:17 A.M., with Director of Nursing (DON) confirmed the doctor does not order parameters for as needed pain medications. The doctor allows the residents to make the decision on which pain medication they want to take. Nurses will ask if resident is in pain, and if the resident has multiple pain medications, they will ask the resident which medication they want. DON confirmed Resident #3 does not have any parameters for her as needed pain medications.

Based on medical record review, review of hospital records and staff interviews, the facility failed to ensure a resident's respiratory needs were being met. This affected the one resident (#196) of one resident reviewed for oxygen use. The facility census was 89 residents. Findings include: Review of Resident #196's medical record revealed an admission on 01/16/25, with diagnoses that included chronic obstructive pulmonary disease, unspecified asthma, pulmonary embolism and heart failure. Review of Resident #196's census revealed she was hospitalized from 02/09/25 until 02/28/25. Review of Resident #196's physician orders revealed she was ordered to have a Bilevel Positive Airway Pressure (BiPap) face mask, humidified, oxygen at 3 liters per minute at bedtime starting on 01/30/25 and ending on 02/27/25. On 03/04/25, Certified Nurse Practitioner #350 entered orders for Resident #196 to have BiPap to be worn at bedtime. Resident #196's record was silent for BiPap orders from 02/28/25 until 03/04/25. Review of Resident #196's hospital records dated 02/26/25 revealed she had physcian orders for a BiPap and she needed to wear it for a minimum of six hours at night on a daily basis, or she would risk death. Interview on 03/05/25 at 2:30 P.M., with the Director of Nursing, confirmed Resident #196's BiPap orders were omitted from her facility readmission orders on 02/28/25 and were not entered into her orders until 03/04/25. Interview on 03/06/25 at 8:54 A.M., with Certified Nurse Practitioner #350 confirmed when Resident #196 was readmitted to the facility on [DATE], she should have had BiPap orders entered into her physician orders, as she should never be without her BiPap daily.

Based on record review, review of facility investigations, staff interviews, and facility policy and procedure, the facility failed to ensure allegations of abuse and misappropriation had thorough investigations and documentation of the investigation. This affected three residents (#86, #94, and #95) out of four residents reviewed for allegations of abuse and misappropriation. The facility census was 89. Findings include 1. Review of the medical record for Resident #94 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included surgical aftercare, endocarditis, bacteremia, shortness of breath, anxiety, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact with a BIMS of 15 and was independent with mobility. Review of the online Self-Reported Incident (SRI) #254189 dated 11/18/24 revealed Resident #94 reported, during a care conference with social services staff, that he had to wake up Certified Nursing Aide (CNA) #55 for assistance. The resident also reported when he woke the CNA up, the CNA pushed Resident #94 away. The social service staff reported the allegation to the Administrator and an investigation was initiated. The summary stated the facility conducted a further interview with Resident #94, interviews with like residents, and interviews with staff. The facility also revealed they completed a head-to-toe assessment on the resident, reviewed Resident 94's care plan, removed the CNA from the schedule and reviewed CNA #55's employee file. Review of the SRI investigation file revealed only a face sheet and care plan for Resident #94 were included. Upon request of further documentation the facility provided staff education, standardized questionnaire interviews with like residents and identical typed statements from staff. Review of the six identical staff statements revealed the statements were dated 11/19/24 and stated, I am unaware of any incident or allegation of abuse by a staff member toward Resident #94 or of any Resident at Capital City Gardens. None of the statements recalled events of the shift in question or interactions with Resident #94 or CNA #55 during the shift in question. Review of CNA #55's statement revealed he/she denied the allegation. The SRI investigation further revealed the facility had no interviews or statements from Resident #94, who reported the abuse allegation. The investigation revealed social service staff spoke with the resident during the care conference, and then the facility completed an initial interview/statement with the resident, and they also completed a follow-up interview/statement with the resident that was the same as the initial statement. Further review of the facility investigation revealed the facility had no actual statement written or signed as true by Resident #94. Interview on 12/11/24 at 1:07 P.M. with the Administrator revealed Resident #94's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed facility had no written statements or signed statements of Resident #94's direct account of the allegation. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself. 2. Review of the medical record for Resident #86 revealed an admitted [DATE]. Diagnoses included hemiparesis, cerebral infarction, diabetes, dysphagia, anemia, heart failure and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact with a BIMS of 14 and was dependent with transfers and activities of daily living. Review of Resident #86's progress notes dated 11/26/24 revealed the resident reported another resident entered her room and groped her breast. The police were notified and a report was made. Review of the Self-Reported Incident (SRI) #254518 dated 11/26/24 revealed Resident #86 reported a male resident (Resident #46) entered her room and touched her inappropriately and the resident was also asked to reveal her breasts. An unnamed staff reported the allegation to the Administrator and an investigation was initiated. The summary revealed police were notified and interviews with like residents and staff were also completed. Resident #86 was interviewed by social service staff and revealed she had no recollection of the allegation and she denied interactions with Resident #46. Review of the SRI investigation file revealed along with the summary of the investigation, only a face sheet and care plan for Resident #86 was included. Upon request of further documentation, the facility provided facility education, standardized questionnaire interviews with like residents and identical typed statements from staff. Review of the six staff statements revealed the facility had identical statements dated 11/27/24 that stated, I am unaware of any incident or allegation involving inappropriate behavior or touching between Resident #46 and #86 or of any allegation involving appropriate behavior or touching between any resident. None of the staff statements recalled events of the shift in questions or interactions with Resident #46 or Resident #86 during the shift in question. Review of the signed statement from Resident #46 revealed he denied any knowledge of the issue or wrongdoing. Review of the additional information provided for the SRI investigation revealed the facility had no interviews or statements from Resident #86 with specific details of her allegation. The facility had only provided a three-question questionnaire with yes or no answers from Resident #86. The questions were Do you feel safe? and the resident answered yes; Has another resident ever entered your room without being invited, if yes did you report it and what happened? the resident answered no; and If someone enters your room or touches you without consent, do you know how to report it? and the resident answered that they would call the police. Interview on 12/11/24 at 1:07 P.M. with the Administrator revealed Resident #86's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed the facility had no written statements or signed statements of Resident #86's direct account of the allegation. He also stated they facility came to the conclusion that Resident #46 was involved due to the initial report from Resident #86, but when the resident was re-interviewed, she denied anything happened. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself. 3. Review of the medical record for Resident #95 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included cervical displacement, cutaneous abscess, endocarditis, opioid use, bacteremia, chronic hepatitis, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was cognitively intact with a BIMS of 15 and was independent with transfers and mobility. Review of the Self-Reported Incident (SRI) #253938 dated 11/11/24 revealed Resident #95 reported she was missing a half-carat diamond earring, but there was no specific allegation that it was stolen or as misappropriated. The resident had endorsed she wrapped the earring in a napkin and may have thrown it away, but an investigation was initiated. The summary revealed interviews were conducted with like residents and staff. Review of the SRI investigation file revealed standardized questionnaire interviews with like residents. The facility provided no evidence of interviews or statements from Resident #95, who reported the allegation, and also failed to provide any evidence of staff statements. Interview on 12/11/24 at 1:07 P.M. with Administrator revealed Resident #95's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed the facility had no written or signed statements of Resident #95's direct account of the allegation, nor any staff statements related to the investigation of missing items. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself. Interview on 12/12/24 at 8:18 A.M. with Regional Clinical Nurse #100 revealed the facility corporate office used universal statements. She acknowledged facility investigations should be complete and thorough and verified the investigation files were not complete and documents had to be located from various sources at the facility, and several items remained unaccounted for including staff statements and resident statements. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/27/17, revealed it was the facility's policy to investigate all alleged violations involving Abuse, Neglect, and Misappropriation. It stated the facility staff shall immediately report all such allegations to administration/designee. The policy revealed the allegation shall be investigated and the investigation shall include interviews with the accused and all witnesses. A statement shall be obtained from the resident(s) involved, the accused, and each witness. The policy further stated the evidence of the investigation should be documented.

Based on interview, observation, record review and policy review, the facility failed to implement infection control procedures during a dressing change and while storing soiled laundry. This affected one (Resident #92) of three residents reviewed for wounds and had the potential to affect all residents residing in the facility. The facility census was 93. Findings include: 1. Review of the medical record for Resident #92, revealed an admitted [DATE]. Diagnoses included but were not limited to type 2 diabetes mellitus with diabetic neuropathy, human immunodeficiency virus disease, pneumonia due to other gram-negative bacteria and methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of resident is rarely/never understood. The resident was assessed to require total dependence on all aspects of assisted with daily living care. Review of the active plan of care dated 09/25/24 for Resident #92 revealed enhanced barrier precautions related to indwelling medical device with interventions to wear gown and gloves for high contact resident care. Review of the active physician order dated 09/21/24 for Resident #92 revealed enhanced barrier precautions related to indwelling medical device and/or wound and /or infection during high contact resident care activities. Further review revealed a physician order dated 11/11/24 for this resident revealed a wound order for the chest area: cleanse with normal saline, pat dry, apply collagen, cover with border dressing. Observation on 11/14/24 at 1:02 P.M. of Licensed Practical Nurse (LPN) #399 revealed a wound dressing change was completed to the left chest area of Resident #92. LPN #399 did not don a gown prior to providing wound care to Resident #92 despite requiring the use of enhanced barrier precautions. Observation also revealed LPN #399 did not wash her hands after a glove change when removing the soiled dressing and donned a new pair of gloves to complete wound care. Interview on 11/14/24 at 1:11 P.M. with LPN #399 verified no hand washing was completed between the removal of soiled gloves (worn when removing the soiled dressing) and the donning of new gloves. The LPN also verified a gown was not worn during the dressing change despite the resident having orders for enhanced barrier precautions. Review the facility policy titled Wound Care revised October 2010 revealed put on exam gloves, loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle and to wash and dry hands thoroughly. Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 revealed examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include wound care. 2. Observation on 11/14/24 at 10:15 A.M. revealed a stairwell leading to the basement with a small landing. Further observation revealed the facility's laundry room was located in the basement. Interview on 11/14/24 at 10:30 A.M. with Laundry Staff (LS) #357 revealed since the facility's elevator has been out of order, the laundry staff have had to take the laundry up and down the stairs. LS #357 stated the staff will throw the soiled laundry down the stairs to the landing and then the laundry staff will remove the laundry from the landing and place it in the cart at the bottom of the stairs which is then taken to the laundry room for processing. Observation on 11/18/24 at 1:11 P.M. revealed a large pile of bagged and unbagged soiled laundry on the landing of the stairwell leading to the basement of the facility. There were several unbagged clothing articles, towels and a visibly soiled washcloth lying on the steps. There was an empty wheeled cart located at the bottom of the stairwell. Interview on 11/18/24 at 1:16 P.M. with LS #252 confirmed the unbagged soiled laundry laying on the landing and the visibly soiled washcloth laying on the step. LS #252 donned gloves and removed the laundry from the landing and the stairs and placed it in the cart at the bottom of the stairwell. Observation on 11/19/24 at 2:20 P.M. revealed a moderate sized pile of bagged, soiled laundry located on the landing of the stairwell, leading to the facility basement. Interview on 11/19/24 at 2:25 P.M. with Regional Registered Nurse (RRN) #550 confirmed the bagged soiled laundry located on the stairwell landing. RRN #550 stated the expectations of the staff were to ensure soiled laundry was bagged and handled using infection control procedures which included not having the soiled laundry be thrown down the stairwell and stored on the landing of the stairwell until the laundry staff could remove and take it to the laundry room. This deficiency represents non-compliance investigated under Complaint Number OH00159824.

Based on observation, staff and resident interviews, review of plumbing invoices, and review of facility policy, the facility failed to maintain a safe, functional, and sanity environment in the shower room for the B hallway. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 93. Findings Include: Review of the plumbing company invoice #143340436 dated 11/12/24 revealed plumbing company arrived at the customers property for a shower drain back up. After attempting to cable the shower drain, the blockage was removed and restored flow to the drain. Review of the plumbing company invoice #143544314 dated 11/13/24 revealed the facility was experiencing emergency flooding in the B hallway over the course of three days. The plumbing company attempted to clear the main line using high pressure jetter and a camera to evaluate the line. Observation on 11/14/24 at 10:10 A.M. revealed the shower room located on the B hallway there were multiple ceramic tiles laying on the floor revealing the wet wall material. There was a hole approximately three inches in diameter into the wall behind the toilet at the base of the wall. In the shower stall/area, there was a brown substance with dried particles of building material and dirt in a circle pattern radiating from the drain in the center of the shower stall/area. The shower room for B hallway had been removed from service for resident use. Interview on 11/14/24 at 10:55 A.M. with Resident #35 revealed there had been water in the hallway and in the room coming from the B hallway shower room on Monday 11/11/24 into Tuesday 11/12/24, the water was brown in color and had a horrible smell. Resident #35 stated the administration had offered to relocate Resident #35 and spouse Resident #34, neither Resident #34 or Resident #35 wanted to be separated so they remained in their room. Resident #35 stated the shower room has not been usable since the flooding occurred. Observation on 11/18/24 at 7:50 A.M. revealed the shower room located on the B hallway had been placed back into service for resident use. The shower stall/area had been cleaned with the previous brown substance and dried building material and dirt having been removed and the shower area appeared to have been recently used for showering. There continued to be a three-inch diameter hole at the base of the wall behind the toilet and the wall tiles continued to be laying on the floor with the wall material exposed. Review of the facility timeline email of the emergency flooding received on 11/18/24 at 9:11 A.M. authored by the Regional Director of Plant Operations (RDPO) #512 revealed on 11/12/24 at 9:20 A.M. there was reported severe flooding of the bathroom at the facility which included most of the hallway and leaking into several resident rooms (rooms and hallway was not identified). The plumbing company was contacted, arrived at the facility and had stated the blockage was removed and flow was restored at 10:30 A.M. RDPO #512 stated at approximately 6:30 P.M. on 11/12/24 the facility notified of the emergency flooding in the B hall shower room extending into the hallway and nurse's station area. The local water valve located in the B hallway shower was turned off which ceased the drain backup in the shower. At approximately 8:30 P.M. the drain in the B hallway shower began backing up again into the shower room and the hallway. At this time the decision was made to shut the main water valves off which completely ceased all drainage backups. The plumbing company was contacted and advised the facility they would be returning to the facility on [DATE] to address the drainage backup. The facility then made available emergency water sources and personal hygiene wipes for use to the staff and the residents. All the main water lines for the sprinkler system were still active for any potential emergencies that could occur. On 11/13/24 the plumbing company returned to the facility with the results of troubleshooting and use of cameras revealed the main blockage was located in the line around the B hallway shower room. This blockage was determined to be the same blockage which was identified and supposedly removed on 11/12/24. Once the blockage was fully pushed through the line to the main drain line, water was slowly restored resulting in several shut off valves were blown off due to the water pressure. The plumbing company repaired all shut off valves and water was restored to the facility. The blockage was fully pushed through the main line to the street line and was determined to be several wash cloths and other pieces of fabric debris which caused the blockage in the facility. Interview on 11/18/24 at 10:30 A.M. with Certified Nursing Assistant (CNA) #335 revealed CNA #335 was not working during the water problems on 11/11/24 and 11/12/24. When CNA #335 returned to work on 11/14/24 B hallway shower room was not usable and the residents had to use the C hallway shower room for showers but the shower room was now back in use. Interview on 11/18/24 at 10:45 A.M. with CNA #236 revealed the facility has had problems with the plumbing for a long time. CNA #236 stated there are residents which will get mad at the facility and have been known to flush non-flushable items down the toilets causing plumbing issues and water leaks. CNA #236 stated, while the facility had the plumbing company fixing the most recent plumbing problem, the water had to be turned off and the facility had passed out wipes, large bottles of water and smaller bottles of water to the staff and the residents to use during the period the water was turned off. Interview on 11/14/24 at 3:15 P.M. with the Administrator confirmed the facility had experienced a plumbing failure on 11/11/24 and 11/12/24 causing water damage to the B hallway shower room. The Administrator stated the plumbing company had been contacted and subsequently came to the facility on [DATE] to investigate and fix the plumbing failure. The plumbing company had to return on 11/13/24 for continued drainage and flooding issues which were located and repaired. The Administrator stated the plumbing company had located a clog in the pipe which had been identified as wash cloths. Review of the facility's policy titled, Maintenance Service dated 12/09 revealed, Maintenance is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at al times. This deficiency represents non-compliance investigated under Complaint Number OH00159812.

Based on medical record review, observations, facility staff interviews, resident interviews, family interviews, review of a fire drill report, review of emergency response reports, review of report of fire email communication, review of facility video camera footage, review of hospital records, review of the fire investigation report, and review of the facility policies for smoking and Oxygen Administration, the facility failed to ensure the residents environment remained as free from accident hazards as is possible when one resident (#19), who utilized oxygen therapy and who smoked cigarettes, possessed smoking materials, including cigarettes and a cigarette lighter, in her room. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, negative health outcomes and/or death when on 09/26/24 at 11:46 P.M. a fire occurred in Resident #19's room which ignited the resident's mattress/bedding on fire resulting in the resident sustaining severe burns to her legs, torso, and arm. Consequently, Resident #19 was transferred to the hospital and admitted to the Surgical Intensive Care Unit (SICU) for treatment of extensive burns received on her legs, torso, and arm. Resident #19 was treated for acute respiratory failure with hypoxia and intubated with a moderate inhalation injury. This affected one (#19) resident who resided in Room B05 and placed an additional nine residents (Residents #11, #15, #16, #17, #18, #20, #21, #22, and #23), residing in the same smoke compartment as Resident #19, at potential risk for the likelihood of serious injury, impairment, negative health outcomes, and/or death, due to the potential for the fire and smoke to spread throughout the hall. The facility identified a total of 50 residents currently residing in the facility who smoke (Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #15, #16, #17, #20, #21, #22, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #44, #45, #48, #49, #50, #52, #55, #57, #59, #61, #64, #67, #72, #74, #75, #77, #78, #79, #82, #86, #87, #88, #89, and #91). The total facility census was 88. On 10/03/24 at 3:18 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse (CN) #309, and Regional Director of Operations (RDO) #334 were notified Immediate Jeopardy began on 09/26/24 at 11:46 P.M. when Resident #19, who utilized oxygen therapy and had a lighter and smoking materials in her possession, started a fire in her room igniting her mattress/bedding. Resident #19 was assessed on 09/16/24 to require supervision with smoking and the resident's lighter and cigarettes were to be stored by the facility. The facility's smoking policy and smoking plan indicated residents were not allowed to store their smoking materials in their room. On 09/26/24 at 11:46 P.M., the fire alarm was activated and the fire doors shut at 11:56:10 P.M. Resident #19 was eventually brought out of her room and at 11:57 P.M., Emergency Medical Services (EMS) took over care of Resident #19. EMS transported Resident #19 to the hospital where she was admitted to the SICU for 35% Total Burn Surface Area (TBSA) burn, and status post escharotomy (a surgical procedure that involves cutting through burnt skin to release the eschar and relieve pressure) of the right lower extremity. Resident #19 was treated for acute respiratory failure with hypoxia and intubated with a moderate inhalation injury. The Fire Department's Investigation Report dated 09/26/24 revealed smoked and unsmoked cigarettes, cigarette pack, and a lighter were found near the original location of the bed. The conclusion was an accidental fire caused by smoking materials in close proximity to high concentration oxygen. Observation on 10/15/24 at 1:45 P.M. revealed there was a pile of debris next to the facility sidewalk in the courtyard area and it was the debris from Resident #19's room on 09/26/24. The debris included a lighter with scorch marks on it. The Immediate Jeopardy was removed on 10/18/24 when the facility implemented the following corrective actions: On 09/26/24 at 11:46 P.M., the fire alarm sounded which transmits an alarm to the fire department of the fire. On 09/26/24 at approximately 11:46 P.M., the facility's incident investigation indicated Licensed Practical Nurse (LPN) #251 called 911 to report the incident of fire. On 09/26/24 from 11:50 P.M. through 11:52 P.M., residents are seen via facility video camera footage to be directed out of their rooms and attempting to make their way off the hallway. On 09/26/24 at 11:53 P.M., LPN #251 was observed via video footage to take a fire extinguisher into the resident's room, identified as Room B05. A subsequent interview with the nurse revealed she could see fire in the room, and she was able to extinguish the fire by utilizing the extinguisher, but was not able to rescue the resident due to the smoke and everything was wet (as a result of the activation of the sprinkler system). She stated she could not see in the room, and she kept tripping on items. Video camera footage noted other staff were observed standing outside the door to Room B05. Two male residents are observed to be closing resident room doors concurrently to contain the fire. On 09/26/24 at 11:55 P.M. per the video, Columbus Police Officers are visible on the hallway and enter Room B05. LPN #251 and State tested Nurse Aide (STNA) #248 were also in the room with Resident #19. On 09/26/24 at 11:56:10 P.M., Resident #19 was observed on the video footage being brought out of Room B05 in the bed and was pushed down the hallway by LPNs #251 and #444, and STNA #248 with Police Officers following. On 09/26/24 at 11:56:14 P.M., the Columbus Fire Department is seen on video footage arriving at the facility in response to the 911 call and enter the facility and walk toward Room B05. On 09/26/24 at 11:57 P.M., the care of Resident #19 was turned over to the emergency medical responders at this time. On 09/27/24 at 12:02 A.M., the facility had completed a head count of residents, and all 90 residents were accounted for. On 09/27/24 at 1:10 A.M., the Columbus Fire Department exited the facility, and a Fire Watch was initiated and completed by the Administrator and DON. On 09/27/24 at 1:15 A.M., Respiratory Assessments were initiated by Unit Manager/LPN #225, and LPN #203 on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who resided in the same smoke compartment where the fire was located, with no adverse reactions noted. The assessments were completed on 09/27/24 at 3:10 A.M. On 09/27/24 at 1:00 A.M. through 3:00 A.M., cleaning of the fire debris in Room B05 and the adjacent hall area began by Maintenance Director #390 and Regional Environmental Services #805. On 09/27/24 at 3:00 A.M., all residents who lived in the smoke compartment where the fire occurred were temporarily moved to open rooms in the B and C halls. On 09/27/24 at 8:00 A.M., four sprinkler heads were replaced in Room B05 by Fire Safety Company #800 to maintain safety in the building and restore water to the facility. On 09/27/24 at 11:00 A.M., all 88 residents were interviewed for post incident safety, conducted by Admissions, Licensed Social Worker (LSW) #270 and Human Resource Director #259 (Resident #19 was in the hospital and a male resident discharged Against Medical Advice on the morning of 09/27/24). On 09/27/24 at 11:41 A.M., the facility smoking policy was reviewed and revised by [NAME] President of Clinical services #340 to make all smoking supervised and all smokers have to submit smoking articles to staff. The smoking process was updated to divide all smokers into two groups (A & B), residents are given two cigarettes for smoke break, and the staff smoking supervisor has the only lighter and lights all cigarettes during smoke breaks. On 09/27/24 at 12:00 P.M., the Fire Department inspected the facility and cleared the facility from Fire Watch. The facility was notified the residents could return to their original rooms as the facility was deemed safe by the fire department. On 09/27/24 at 12:00 P.M., the two fire extinguishers that were used and deployed during the fire were replaced by Maintenance Director #390 to ensure adequate tools for fire safety are available to the staff. On 09/27/24 at 1:00 P.M., all department managers were educated by the Regional Director of Clinical Services (RDCS) #810 on the Smoking Policy, Change in Condition Policy, and Fire Safety (RACE & PASS) Policy. Those receiving education were the Administrator, Admissions/Licensed Social Worker (LSW) #270, Maintenance Director #390, Unit Manager LPN #225, Human Resources #259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, and Housekeeping Manager #850. On 09/27/24 at 1:21 P.M., an all-staff education was initiated by Department Managers and the DON for the facility's employees. The education was in person and by telephone/text covering facility policies related to Change in Condition, Smoking, and Fire Safety (RACE & PASS). Staff were able to return/continue to work once training was completed. The education was completed on 09/27/24 at 7:52 P.M. On 09/27/24 at 1:30 P.M., the Administrator held a meeting with the 50 residents (Residents # 1,# 2, #3, #5, #7, #8, #9, #10, #11, #12, #15, #16, #17, #20, #21, #22, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #44, #45, #48, #49, #50, #52, #55, #57, #59, #61, #64, #67, #72, #74, #75, #77, #78, #79, #82, #86, #87, #88, #89, and #91) who smoke to review and sign the revised Smoking Policy and smoking process, including smoke break times and groups A & B. All 50 Residents were educated, agreed, and signed the new smoking policy. On 09/27/24 beginning at 11:59 A.M. and completed by 1:44 P.M., smoking assessments began on all residents that currently smoke by Unit Manager LPN #579 and Unit Manager LPN #225 to ensure up to date assessments are in place for all smokers. On 09/27/24 beginning at 11:00 A.M. and completed by 3:06 P.M., all 88 resident rooms were searched by the Department Managers for smoking contraband. Non-permitted smoking articles were found in the rooms of Residents #33, #79, #82, #49, and #64, who were previously unsupervised smokers. This contraband was collected and further education provided to these residents by the Administrator and LSW #270. On 09/27/24 beginning at 10:45 A.M. and completed by 3:30 P.M., all 88 residents were assessed by Unit Manager LPN #225, Unit Manager LPN #579, and Registered Nurse (RN) #820 for a change in condition to assess for any changes in physical and mental condition, including distress from the incident. No residents were found to have a change in condition. On 09/27/24 at 4:00 P.M., a Fire Drill was conducted by Maintenance Director #390 without incident. On 09/27/24 at 4:13 P.M., the Fire Marshall was notified by the Administrator of the incident of fire via the Fire Marshall's electronic portal. On 09/27/24 beginning at 3:23 P.M. and completed by 4:45 P.M., a second Respiratory Assessment was initiated on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who lived in the same smoke compartment where the fire occurred, by RN #229, LPN # 251, LPN #444, and LPN #203 with no adverse reaction noted. On 09/27/24 at 6:06 P.M., the care plans of residents who were previously unsupervised smokers were revised to now being supervised smokers by Minimum Data Set (MDS) LPN #855. On 09/27/24 at 6:15 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, RDCS #810, LSW #270, Maintenance Director #390, Unit Manager LPN #225, Human Resources #259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, Housekeeping Manager #850, and Medical Director #900. The following audits to be conducted: Resident Smoke Breaks - five times a week for four weeks, then one time a week for four weeks, completed by the DON. Room Sweeps for Smoking Materials - three times per week for four weeks and one time a week for four weeks, completed by the Departmental Managers. Fire Drills on Each Shift - weekly for eight weeks (7a-7p and 7p-7a), completed by Maintenance Director #390. Assess/Re-educate as needed - staff knowledge of Fire Safety RACE/PASS - weekly/per shift times eight weeks, completed by Maintenance Director #390. Although the Immediate Jeopardy was removed on 10/18/24, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, depression, anxiety, and suicidal ideation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview of Mental Status score of 15 (out of 15) which indicated she was cognitively intact. Resident #19 required setup assistance with meals and oral intake. Resident #19 was dependent on staff with personal hygiene, dressing, and transfers. Resident #19 was dependent on staff with using her manual wheelchair. Review of the physician order dated 09/16/24 revealed Resident #19 had an order for five liters of oxygen per minute by nasal cannula, routine. Resident #19's oxygen was to be monitored every shift. Review of the plan of care dated 09/13/24 revealed Resident #19 had mood problems related to agitation with hallucinations, suicidal ideations, and delirium. Interventions included to administer medication, assist the resident in positive coping skills, behavioral health consult, educate the resident and family regarding expectations of treatment, monitor and document risk for harm to self, suicidal plan, past attempts at suicide, possession of suicidal note, trying to harm self, refusing to eat or drink, sense of hopeless or helplessness, and impaired judgement or safety awareness. Resident #19 was to be monitored for mood patterns, anxiety, sad mood, behavior monitoring protocol, monitor increased anger, and observe for signs and symptoms of mania and hypomania, and increased irritability. Review of Resident #19's medication administration record (MAR) for September 2024 revealed behaviors were assessed every shift and the resident was coded as not having any behaviors at the facility. Resident #19 had an order for Hydroxyzine (used to control anxiety and tension) 25 milligrams (mg), give 12.5 mg every eight hours as needed for 14 days dated 09/14/24. The MAR revealed the resident received the medication on 09/13/24 at 6:15 P.M., 09/18/24 at 4:04 P.M., 09/19/24 at 9:04 A.M., 09/21/24 at 8:39 A.M., 09/22/24 at 1:52 P.M., 09/23/24 at 10:09 A.M., 09/25/24 at 3:52 P.M., and on 09/26/24 at 10:23 P.M. All doses provided were documented as being effective. Review of the Smoking-Safety Screen dated 09/16/24 revealed Resident #19 had been evaluated for smoking and safety. Resident #19 stated she smoked in the morning one to two cigarettes per day. Resident #19 could light her own cigarette, needed a smoking apron, had dexterity problem, no visual deficit, and had cognitive loss. Resident #19 needed the facility to store the lighter and cigarettes for safety. The care plan was updated for smoking safety. The decision by the interdisciplinary team was Resident #19 was safe to smoke with supervision. Review of the plan of care dated 09/25/24 revealed Resident #19 was a smoker. The care plan was updated on 09/27/24 and indicated Resident #19 chooses not to follow smoking policy at times. Interventions included to instruct the resident about smoking risks and hazards, and about smoking cessation. Resident #19 was instructed about the facility policy on smoking, locations, times, and safety concerns. Monitor Resident #19's oral hygiene, observe clothing and skin for signs of cigarette burns, notify charge nurse immediately if it was suspected resident had violated facility smoking policy, resident required a smoking apron while smoking, and Resident #19 required supervision while smoking. Review of the facility document titled Incident Investigation-Room [Resident #19's room] Fire dated 09/26/24 through 09/27/24 revealed the following: staff interviews and statements revealed their actions during the active incident and during the evacuation appeared consistent with the video surveillance. Two residents interviewed (Resident #08 and Resident #17) stated Resident #19 was yelling, which was normal in the evening for Resident #19. One resident reported shortly before the fire alarm activated, the resident was heard shouting, I'll show them. The statement seems to stand alone without sufficient context to determine its meaning. Interviews and video surveillance reveal the fire alarm sounded at approximately 11:45 P.M. on 09/26/24. Video shows staff responding appropriately using both the RACE and PASS method of dealing with an active fire. Staff used fire extinguishers to extinguish the flames. At approximately 11:46 P.M., emergency 9-1-1 was called. The local police arrived at the facility at 11:54 P.M. and the Fire Department and EMS arrived at 11:58 P.M. The local police and staff had already evacuated Resident #19 from her room. Resident #19 was examined by medics and transported to the hospital. The report stated Emergency Department notes provided helpful information in determining the origin of the fire. The notes state that the resident intentionally started the fire to get staff's attention. Where the resident obtained an instrument, i.e., matches, a lighter, etc. to ignite the fire cannot be determined. As a supervised smoker, the resident would have had her smoking material and paraphernalia collected at the time of her previous smoking session. An examination of the room [Resident #19] and the bed the resident was in was not determinative as to the source of ignition. The Administrator and Maintenance Director #390 closely examined the room and debris looking for a burned cigarette and/or a source of ignition. No cigarettes or lighters or matches were discovered in the debris. However, it can be noted that the bed was the origin of the fire. In fact, there appeared to be two separate ignition points. One point of origin appears to be on the resident's right-hand side of the bed at about the midpoint of the bed; the other point of origin (which looked to be the original point of origin) appeared at the right-side foot of the bed. The report listed the facilities conclusion as: facility staff responded appropriately at the time of the incident, ensuring the fire was extinguished, the residents and others were safely evacuated. Facility staff provided care to the resident prior to the incident. The resident started the fire intentionally and with knowledge that her actions could result in significant harm. The facility will continue to monitor other residents' for both physical and psycho social well-being. The facility will cooperate with the fire department in their investigation of the incident. The report was completed by the Administrator. Review of the witness statement from Resident #17 dated 09/27/24 revealed she was in her room on the evening of 09/26/24. Resident #17 stated it was a little before midnight. Resident #17 was waiting for the midnight movie to come on her television when she started to hear Resident #19 in her room next door, yelling Help, Help. Resident #17 thought nothing of this as Resident #19 generally does yell out in the evenings. Resident #19 started to rattle the side rail of her bed, as well. Resident #17 heard Resident #19 say I'll show them. Resident #17 stated when she moved around in her room, she saw smoke coming out from under her bathroom door. Resident #17 then stated she heard the fire alarm go off. Resident #17 went to the hall to yell for help. Review of the witness statement from Resident #08 dated 09/27/24 revealed he was lying in his bed and heard yelling. Resident #08 stated someone was banging on the wall. Resident #08 stated the fire alarm then went off and he saw smoke. Resident #08 ran to get the fire extinguisher and handed it to the nurse. Resident #08 stated the sprinkler system was going off in the room. Resident #08 could not see anything due to the smoke. Resident #08 saw staff coming, and the local police showed up. Review of the witness statement from STNA #248 dated 09/27/24 revealed there was an alarm on 09/26/24 at 11:45 P.M. RN #229 came to C station to ask him to hurry, and they needed help to get Resident #19 out of her room. STNA #248 stated he immediately went down to Resident #19's room and saw smoke and heard Resident #19 screaming. STNA #248 entered the room and was unable to see anything. STNA #248 managed to get hold of the bed, pushed everything out of his way, and pulled Resident #19 out of the room. The bed was then pushed out of the building. Resident #19 was taken to the hospital. Review of the witness statement by LPN #251 dated 09/27/24 revealed the fire alarm sounded, then looked at the fire panel to see the location of fire. LPN #251 ran to the room of Resident #19 where the fire was located. Resident #08 handed her the fire extinguisher. Resident #19's room was full of smoke, and the water sprinklers were on. LPN #251 stated she could not see anything, but the fire was on the foot of Resident #19's bed. LPN #251 stated she used the fire extinguisher and yelled for help to get the woman out of the room. LPN #251 stated she called 9-1-1 to report the fire in Resident #19's room. Review of the Fire Department's Investigation Report dated 09/26/24 revealed smoked and unsmoked cigarettes, cigarette pack, and a lighter were found near the original location of the bed. The conclusion was an accidental fire caused by smoking materials in close proximity to high concentration oxygen. Review of the EMS report dated 09/27/24 revealed upon arrival to the facility, Resident #19 was alert and oriented and suffering from third degree burns to 15% of her lower left leg and lower right leg. Resident #19 had just been evacuated minutes before arrival. Resident #19 was quickly assessed and given 25 milligrams (mg) of Ketamine for pain and then transferred to the medic. Resident #19's condition was stable and transferred to Hospital #500's burn unit. Review of the hospital document titled Rehabilitation Psychology Follow-Up Note dated 09/30/24 at 5:49 P.M. by Hospital Psychologist (HP) #499 revealed the examination was done related to mental status exam and humanistic interventions. HP #499 stated Resident #19 was alert and oriented, to person, place, time, and generally to situation. Resident #19 was being hospitalized due to burns. Resident #19 had difficultly providing accurate personal history, speech was normal rate, volume, and prosody (a word to describe the rate, rhythm, and melody of speech), but with word finding issues and frequent verbal preservation. Resident #19's mood was anxious; affect appropriate, and congruent. Eye contact at time intense and at other times she was observed staring off into space. Resident #19 asked to walk and later then swim and did not appreciate that there would be any barriers to these activities. Though content relevant to conversation and questioning but with off-topic responses and evident confusion. Delayed in responding to questions rather than most recent prompt. Resident #19 denied perceptual abnormalities, staring into space occasionally but denied any hallucinations when asked. Denied suicidally but endorsed setting a fire to get the attention. Resident #19 discussed that she was calling for help and thought she would set a fire to get help. Resident #19 discussed thinking she was somewhere else. Resident #19 stated the nursing home and funeral home interchangeably and also noted that she thought her son was in the next room at the time. She denied that this was an attempt to die or inflict intentional injury. She reported using lighter to set the fire. Resident #19 was aware of her burns and the association with her actions and the fire that was set. Review of the hospital document titled Critical Care Attestation dated 10/01/24, by Critical Care Physician (CCP) #450 revealed Resident #19 had been admitted to hospital for 35% TBSA burn, and status post escharotomy of the right lower extremity. Review of the hospital document titled [NAME] Flow Sheet (a tool useful in the management of burns for estimating TBSA) dated 10/01/24 revealed Resident #19 had the following burns: anterior trunk had 13% injury with 5% second degree burns, right lower arm had 3% injury with 2% second degree burns, right thigh had 9.5% injury with 2% second degree burns and 2% third degree burns with 4% total area, right leg was 7% third degree burn, left leg was 7% injury with 5% third degree burn, and right foot was 3.5% injury with 3.5% third degree burns. Resident #19 had injuries to head, neck, posterior trunk, right and left buttocks, right upper arm, left upper arm, left lower arm, right and left hand and left thigh that had suffered injury. Interview on 10/02/24 at 10:01 A.M. with STNA #240 revealed Resident #19 was not sure what happened to her. STNA #240 stated Resident #19 had set her bed on fire. STNA #240 stated Resident #19 must have had her lighter in her room but was not sure. Sometimes residents at the facility keep their smoking paraphernalia. Interview on 10/02/24 at 10:05 A.M. with STNA #246 stated she did not know what happened to Resident #19 only that she had a fire in her room and was taken to the hospital with burns. STNA #246 stated she arrived at the facility to assist with evacuation of residents at the facility due to the fire that night. STNA #246 stated she had recently received education on fire training on 09/27/24, including the use of a fire extinguisher, but stated she forgot what the fire acronyms RACE and PASS stood for. Interview on 10/02/24 at 10:15 A.M. with STNA #223 stated sometimes the smoking products do not get returned by the residents. STNA #223 stated she does not know what she learned in the fire training. Interview on 10/02/24 at 10:20 A.M. with STNA #235 stated she was not sure about the fire, but that the next day she was educated on 09/27/24. The education included fire drills, using closest exit for evacuation, and to close all resident room doors in the area of the fire. Interviews on 10/02/24 at 10:28 A.M. with the Administrator stated Resident #19 was alert and oriented, supervised smoker, and lit the mattress on fire. At 10:50 A.M., the Administrator showed a picture of Resident #19's burned hospital bed. The hospital bed had a burned area at the foot of the bed on the right lower side of the bed on the top surface of the mattress that was black, charred, and debris was peeled away and attached to bed. The right-side middle area of the bed at the handrail was burned in large circle that was about 12 inches in diameter. The Administrator stated he reviewed the facility's video footage for dates 09/26/24 and 09/27/24 that showed staff was in providing routine care to Resident #19. Interviews on 10/02/24 at 11:55 A.M. with Resident #03, at 12:00 P.M. with Resident #12, at 3:00 P.M. with Resident #89, at 3:38 P.M. with Resident #22 and at 5:00 P.M. with Resident #08 confirmed before the facility had the fire incident on 09/26/24, the facility staff was not monitoring the residents closely in taking cigarettes and lighters away from residents. The five residents all confirmed they were allowed to keep smoking materials with them and not hand them in to the facility. Resident #22 stated Resident #19 was known to keep her materials including a lighter in her room. Resident #08 stated Resident #19 had family in to visit her on 09/26/24 and he heard them fighting about something. Resident #08 stated Resident #19 was yelling and upset. Interview on 10/02/24 at 12:39 P.M. with STNA #214 stated the fire alarm went off, and then looked at the fire panel to identify Resident #19's room was on fire. STNA #214 headed to Resident #19's room, and before arriving, Resident #17 came out of her room, and stated there was smoke coming out of her door from the connecting bathroom to Resident #19's room. STNA #214 touched the door, and it was not hot then opened the door and looked into the room. STNA #214 stated Resident #19's room had pure black smoke in the room and no fire was seen. STNA #214 stated he could not see or go into the room due to all the smoke in the room as it irritated his throat, and he could not breathe. STNA #214 verified he did not go into Resident #19's room. STNA #214 stated the staff was supposed to collect all the smoking products, but sometimes residents keep their smoking products on them. Observation on 10/02/24 at 3:00 P.M. of the facility's video footage provided by the Administrator, DON, and CN #309 who reviewed the facility video dated 09/26/24 through 09/27/24 revealed a fire alarm started on 09/26/24 at 11:45 P.M. The video showed flashing fire alarms, and in the nurse's station at the beginning of the hall, the call light for Resident #19's room was not lit up. Resident #08 was seen assisting residents at the facility with closing doors, checking rooms, evacuating residents, and grabbing a fire extinguisher to hand to staff. At the end of the video Resident #19 was seen coming down the hall in her hospital bed with staff. The bed was burnt but not on fire. The Administrator stated there was no additional video footage of inside the fire doors to be able to see Resident #19's room after the fire doors closed at 11:45 P.M. Review of the facility interview dated 10/03/24 with the Administrator, Regional Director of Operations (RDO) #334, and the daughter of Resident #19 stated they had interviewed the daughter who provided additional information for the incident on 09/26/24. The daughter denied she had spoken to her mother (Resident #19). The daughter stated she visited her mother (Resident #19) the day of the fire. The daughter stated she left a lighter with Resident #19. The daughter stated she had no idea if her mother had started the fire, but it was possible. Interview on 10/03/24 at 9:21 A.M. with Resident #17 stated before the fire alarm went off at the facility, she had heard Resident #19 in her room constantly yelling for the staff and putting her call light on to get staff. Resident #17 stated she turned around in her room to see smoke pouring out from her bathroom door which was connected to Resident #19's room that shared the same bathroom. Resident #17 stated she came out into the hallway to see staff looking in the glass window of the double fire doors that closed. Resident #17 stated it was like slow motion, and staff were not fast enough. Resident #17 stated the staff never took our cigarette products away and the residents were pissed they could no longer keep their smoking products on them. Interview on 10/03/24 at 10:09 A.M. with the Administrator stated the facility had performed respiratory assessments, head to toe assessments, and residents who smoked signed another smoking agreement. Residents who were smokers at the facility had room sweeps with their permission, one resident denied permission Resident #08, and later then let facility staff sweep the room. The Administrator stated our system worked flawlessly, and our fire system had no problems. Interview on 10/03/24 at 10:10 A.M. with the DON stated they had no issues identified after the fire. The DON stated they changed their smoking set up on 09/27/24 and started two smoking gro [TRUNCATED]

Based on medical record review, facility staff interviews, review of the fire investigation report, observation of facility video camera footage, review of the facility submitted Self-Reported Incident (SRI), and review of facility policy, the facility failed to ensure a resident was free from neglect when staff did not timely implement fire procedures when a mattress/bedding fire occurred in Resident #19's room. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, negative health outcomes and/or death when on 09/26/24 at 11:46 P.M. a fire occurred in Resident #19's room which ignited the resident's mattress/bedding on fire, activating the fire alarm and sprinkler system and facility staff did not attempt to immediately implement fire protocols to rescue, contain and/or extinguish the fire in Resident #19's room until 11:53 P.M. on 09/26/24. Resident #19 sustained burns to her legs, torso, and arm, was transferred to the hospital and admitted to the Surgical Care Intensive Care Unit (SICU) for treatment of extensive burns received on her legs, torso, and arm. Resident #19 was treated for acute respiratory failure with hypoxia and intubated with a moderate inhalation injury. This affected one (#19) resident who resided in Room B05 and placed an additional nine residents (Residents #11, #15, #16, #17, #18, #20, #21, #22, and #23), residing in the same smoke compartment as Resident #19 at potential risk for the likelihood of serious injury, impairment, negative health outcomes, and/or death, due to potential for the fire and smoke to spread throughout the hall. The facility census was 88. On 10/10/24 at 2:47 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse (CN) #309, and Regional Director of Operations (RDO) #334 were notified Immediate Jeopardy began on 09/26/24 when facility staff did not timely and appropriately implement fire safety protocols and procedures, in accordance with facility policy, to rescue residents, contain the fire, extinguish the fire, and evacuate residents who resided in the compartment where the fire was located. On 09/26/24 at 11:46 P.M., the fire alarm was activated and the fire doors shut. On 09/26/24 at 11:53 P.M., facility staff were observed, via video camera footage, to enter Resident #19's room with a fire extinguisher and Resident #19 was brought out of her room at 11:56:10 P.M. and at 11:57 P.M., Emergency Medical Services (EMS) took over care of Resident #19. Emergency Medical Services (EMS) transported Resident #19 to the hospital where she was admitted to the SICU for 35% Total Burn Surface Area (TBSA) burn, and status post escharotomy (a surgical procedure that involves cutting through burnt skin to release the eschar and relieve pressure) of the right lower extremity. Resident #19 was treated for acute respiratory failure with hypoxia and intubated with a moderate inhalation injury. The affected ten residents' (#11, #15, #16, #17, #18, #19, #20, #21, #22, and #23) who resided in the smoke compartment were the fire was located. The Immediate Jeopardy was removed on 10/18/24 when the facility implemented the following corrective actions: On 09/26/24 at 11:46 P.M., the fire alarm sounded which transmits an alarm to the fire department of the fire. On 09/26/24 at approximately 11:46 P.M., the facility's incident investigation indicated Licensed Practical Nurse (LPN) #251 called 911 to report the incident of fire. On 09/26/24 from 11:50 P.M. through 11:52 P.M., residents are seen via facility video camera footage to be directed out of their rooms and attempting to make their way off the hallway. On 09/26/24 at 11:53 P.M., LPN #251 was observed via video footage to take a fire extinguisher into the resident's room B05, identified as Room B05. A subsequent interview with the nurse revealed she could see fire in the room, and she was able to extinguish the fire by utilizing the extinguisher, but was not able to rescue the resident due to the smoke and everything was wet (as a result of the activation of the sprinkler system). She stated that she could not see in the room, and she kept tripping on items. Video camera footage noted other staff were observed standing outside the door to Room B05. Two male residents are observed to be closing resident room doors concurrently to contain the fire. On 09/26/24 at 11:55 P.M., Columbus Police Officers are visible on the hallway and enter Room B05. LPN #251 and State tested Nurse Aide (STNA) #248 were also in the room with Resident #19. On 09/26/24 at 11:56:10 P.M., Resident #19 was observed on the video footage being brought out of Room B05 in the bed and was pushed down the hallway by LPNs #251 and #444, and STNA #248 with Police Officers following. On 09/26/24 at 11:57 P.M., the care of Resident #19 was turned over to the emergency medical responders at this time. On 09/27/24 at 12:02 A.M., the facility had completed a head count of residents, and all 90 residents were accounted for. On 09/27/24 at 1:10 A.M., the Columbus Fire Department exited the facility, and a Fire Watch was initiated and completed by the Administrator and DON. On 09/27/24 at 1:15 A.M., Respiratory Assessments were initiated by Unit Manager/ LPN #225, and LPN #203 on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who resided in the same smoke compartment where the fire was located, with no adverse reactions noted. The assessments were completed on 09/27/24 at 3:10 A.M. On 09/27/24 at 1:00 A.M. through 3:00 A.M., cleaning of the fire debris in Room B05 and the adjacent hall area began by Maintenance Director #390 and Regional Environmental Services #805. On 09/27/24 at 3:00 A.M., all residents who lived in the smoke compartment where the fire occurred were temporarily moved to open rooms in the B and C halls. On 09/27/24 at 8:00 A.M., four sprinkler heads were replaced in Room B05 by Fire Safety Company #800 to maintain safety in the building and restore water to the facility. On 09/27/24 at 11:00 A.M., all 88 residents were interviewed for post incident safety, conducted by Admissions, Licensed Social Worker (LSW) #270 and Human Resource Director # 259 (Resident #19 was in the hospital and a male resident discharged Against Medical Advice on the morning of 09/27/24). On 09/27/24 at 12:00 P.M., the Fire Department inspected the facility and cleared the facility from Fire Watch. The facility was notified the residents could return to their original rooms as the facility was deemed safe by the fire department. On 09/27/24 at 12:00 P.M., the two fire extinguishers that were used and deployed during the fire were replaced by Maintenance Director #390 to ensure adequate tools for fire safety are available to the staff. On 09/27/24 at 1:00 P.M., all department managers were educated by the Regional Director of Clinical Services (RDCS) #810 on the Smoking Policy, Change in Condition Policy, Fire safety (RACE & PASS), and Abuse and Neglect Policy. Those receiving education were the Administrator, Admissions/Licensed Social Worker (LSW) # 270, Maintenance Director #390, Unit Manager LPN #225, Human Resources #259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, and Housekeeping Manager #850. On 09/27/24 at 1:21 P.M., an all-staff education was initiated by Department Managers and the DON for the facility's employees. The education was in person and by telephone/text covering Change in Condition Policy, Smoking Policy, Fire Safety (RACE & PASS) and Abuse and Neglect Policies. Staff were able to return/continue to work once training was completed. The education was completed on 09/27/24 at 7:52 P.M. On 09/27/24 beginning at 11:00 A.M. and completed by 3:06 P.M., all 88 resident rooms were searched by the Department Managers for smoking contraband. Non-permitted smoking articles were found in the rooms of Residents #33, #79, #82, #49, and #64, who were previously unsupervised smokers. This contraband was collected and further education provided to these residents by the Administrator and LSW #270. On 09/27/24 beginning at 10:45 A.M. and completed by 3:30 P.M., all 88 residents were assessed by Unit Manager LPN#225, Unit Manager LPN #579, and Registered Nurse (RN) #820 for a change in condition to assess for any changes in physical and mental condition, including distress from the incident. No residents were found to have a change in condition. On 09/27/24 at 4:00 P.M., a Fire Drill was conducted by Maintenance Director #390 without incident. On 09/27/24 at 4:13 P.M., the Fire Marshall was notified by the Administrator of the incident of fire via the Fire Marshall's electronic portal. On 09/27/24 beginning at 3:23 P.M. and completed by 4:45 P.M., a second Respiratory Assessment was initiated on Residents #17, #20, #18, # 15, #21, #23, #22, #16, and #11, who lived in the same smoke compartment where the fire occurred, by RN # 229, LPN # 251, LPN #444, and LPN #203 with no adverse reaction noted. On 09/27/24 at 6:15 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, RDCS #810, LSW # 270, Maintenance Director #390, Unit Manager LPN #225, Human Resources # 259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, Housekeeping Manager #850, and Medical Director #900. The following audits to be conducted: Resident Smoke Breaks- five times a week for four weeks, then one time a week for four weeks, completed by the DON. Room Sweeps for Smoking Materials- three times per week for four weeks and one time a week for four weeks, completed by the Departmental Managers. Fire Drills on Each Shift - weekly for eight weeks (7a-7p and 7p-7a), completed by Maintenance Director #390. Assess/Re-educate as needed - staff knowledge of Fire Safety RACE/PASS - weekly/per shift times eight weeks, completed by Maintenance Director #390. Although the Immediate Jeopardy was removed on 10/18/24, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Included: Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, depression, anxiety, and suicidal ideation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview of Mental Status score of 15 (out of 15) which indicated she was cognitively intact. Resident #19 required setup assistance with meals and oral intake. Resident #19 was dependent on staff with personal hygiene, dressing, and transfers. Resident #19 was dependent on staff with using her manual wheelchair. Review of the physician order dated 09/16/24 revealed Resident #19 had an order for five liters of oxygen per minute by nasal cannula, routine. Resident #19's oxygen was to be monitored every shift. Review of the plan of care dated 09/13/24 revealed Resident #19 had mood problems related to agitation with hallucinations, suicidal ideations, and delirium. Interventions included to administer medication, assist the resident in positive coping skills, behavioral health consult, educate the resident and family regarding expectations of treatment, monitor and document risk for harm to self, suicidal plan, past attempts at suicide, possession of suicidal note, trying to harm self, refusing to eat or drink, sense of hopeless or helplessness, and impaired judgement or safety awareness. Resident #19 was to be monitored for mood patterns, anxiety, sad mood, behavior monitoring protocol, monitor increased anger, and observe for signs and symptoms of mania and hypomania, and increased irritability. Review of Resident #19's medication administration record (MAR) for September 2024 revealed behaviors were assessed every shift and the resident was coded as not having any behaviors at the facility. Resident #19 had an order for Hydroxyzine (used to control anxiety and tension) 25 milligrams (mg), give 12.5 mg every eight hours as needed for 14 days dated 09/14/24. The MAR revealed the resident received the medication on 09/13/24 at 6:15 P.M., 09/18/24 at 4:04 P.M., 09/19/24 at 9:04 A.M, 09/21/24 at 8:39 A.M., 09/22/24 at 1:52 P.M., 09/23/24 at 10:09 A.M., 09/25/24 at 3:52 P.M., and on 09/26/24 at 10:23 P.M. All doses provided were documented as being effective. Review of the Smoking-Safety Screen dated 09/16/24 revealed Resident #19 had been evaluated for smoking and safety. Resident #19 stated she smoked in the morning one to two cigarettes per day. Resident #19 could light her own cigarette, needed a smoking apron, had dexterity problem, no visual deficit, and had cognitive loss. Resident #19 needed the facility to store the lighter and cigarettes for safety. The care plan was updated for smoking safety. The decision by the interdisciplinary team was Resident #19 was safe to smoke with supervision. Review of the plan of care dated 09/25/24 revealed Resident #19 was a smoker. The care plan was updated on 09/27/24 and indicated Resident #19 chooses not to follow smoking policy at times. Interventions included to instruct the resident about smoking risks and hazards, and about smoking cessation. Resident #19 was instructed about the facility policy on smoking, locations, times, and safety concerns. Monitor Resident #19's oral hygiene, observe clothing and skin for signs of cigarette burns, notify charge nurse immediately if it was suspected resident had violated facility smoking policy, resident required a smoking apron while smoking, and Resident #19 required supervision while smoking. Review of the facility document titled Incident Investigation-Room [Resident #19's room] Fire dated 09/26/24 through 09/27/24 revealed the following: staff interviews and statements revealed their actions during the active incident and during the evacuation appeared consistent with the video surveillance. Two residents interviewed (Resident #08 and Resident #17) stated Resident #19 was yelling, which was normal in the evening for Resident #19. One resident reported shortly before the fire alarm activated, the resident was heard shouting, I'll show them. The statement seems to stand alone without sufficient context to determine its meaning. Interviews and video surveillance reveal the fire alarm sounded at approximately 11:45 P.M. on 09/26/24. Video shows staff responding appropriately using both the RACE and PASS method of dealing with an active fire. Staff used fire extinguishers to extinguish the flames. At approximately 11:46 P.M., emergency 9-1-1 was called. The local police arrived at the facility at 11:54 P.M. and the Fire Department and EMS arrived at 11:58 P.M. The local police and staff had already evacuated Resident #19 from her room. Resident #19 was examined by medics and transported to the hospital. The report stated Emergency Department notes provided helpful information in determining the origin of the fire. The notes state that the resident intentionally started the fire to get staff's attention. Where the resident obtained an instrument, i.e., matches, a lighter, etc. to ignite the fire cannot be determined. As a supervised smoker, the resident would have had her smoking material and paraphernalia collected at the time of her previous smoking session. An examination of the room [Resident #19] and the bed the resident was in was not determinative as to the source of ignition. The Administrator and Maintenance Director #390 closely examined the room and debris looking for a burned cigarette and/or a source of ignition. No cigarettes or lighters or matches were discovered in the debris. However, it can be noted that the bed was the origin of the fire. In fact, there appeared to be two separate ignition points. One point of origin appears to be on the resident's right-hand side of the bed at about the midpoint of the bed; the other point of origin (which looked to be the original point of origin) appeared at the right-side foot of the bed. The report listed the facilities conclusion as: facility staff responded appropriately at the time of the incident, ensuring the fire was extinguished, the residents and others were safely evacuated. Facility staff provided care to the resident prior to the incident. The resident started the fire intentionally and with knowledge that her actions could result in significant harm. The facility will continue to monitor other residents' for both physical and psycho social well-being. The facility will cooperate with the fire department in their investigation of the incident. The report was completed by the Administrator. Review of the EMS report dated 09/27/24 revealed upon arrival to the facility, Resident #19 was alert and oriented and suffering from third degree burns to 15% of her lower left leg and lower right leg. Resident #19 had just been evacuated minutes before arrival. Resident #19 was quickly assessed and given 25 milligrams (mg) of Ketamine for pain and then transferred to the medic. Resident #19's condition was stable and transferred to Hospital #500's burn unit. Review of the hospital document titled Rehabilitation Psychology Follow-Up Note dated 09/30/24 at 5:49 P.M. by Hospital Psychologist (HP) #499 revealed the examination was done related to mental status exam and humanistic interventions. HP #499 stated Resident #19 was alert and oriented, to person, place, time, and generally to situation. Resident #19 was being hospitalized due to burns. Resident #19 had difficultly providing accurate personal history, speech was normal rate, volume, and prosody (a word to describe the rate, rhythm, and melody of speech), but with word finding issues and frequent verbal preservation. Resident #19's mood was anxious; affect appropriate, and congruent. Eye contact at time intense and at other times she was observed staring off into space. Resident #19 asked to walk and later then swim and did not appreciate that there would be any barriers to these activities. Though content relevant to conversation and questioning but with off-topic responses and evident confusion. Delayed in responding to questions rather than most recent prompt. Resident #19 denied perceptual abnormalities, staring into space occasionally but denied any hallucinations when asked. Denied suicidally but endorsed setting a fire to get the attention. Resident #19 discussed that she was calling for help and thought she would set a fire to get help. Resident #19 discussed thinking she was somewhere else. Resident #19 stated the nursing home and funeral home interchangeably and also noted that she thought her son was in the next room at the time. She denied that this was an attempt to die or inflict intentional injury. She reported using lighter to set the fire. Resident #19 was aware of her burns and the association with her actions and the fire that was set. Review of the hospital document titled Critical Care Attestation dated 10/01/24, by Critical Care Physician (CCP) #450 revealed Resident #19 had been admitted to hospital for 35% total Burn Surface Area (TBSA) burn, and status post escharotomy (a surgical procedure that involves cutting through burnt skin to release the eschar and relieve pressure) of the right lower extremity. Review of the hospital document titled [NAME] Flow Sheet (a tool useful in the management of burns for estimating TBSA) dated 10/01/24 revealed Resident #19 had the following burns: anterior trunk had 13% injury with 5% second degree burns, right lower arm had 3% injury with 2% second degree burns, right thigh had 9.5% injury with 2% second degree burns and 2% third degree burns with 4% total area, right leg was 7% third degree burn, left leg was 7% injury with 5% third degree burn, and right foot was 3.5% injury with 3.5% third degree burns. Resident #19 had injuries to head, neck, posterior trunk, right and left buttocks, right upper arm, left upper arm, left lower arm, right and left hand and left thigh that had suffered injury. Interview on 10/02/24 at 10:05 A.M. with STNA #246 stated she did not know what happened to Resident #19 only that she had a fire in her room and was taken to the hospital with burns. STNA #246 stated she arrived at the facility to assist with evacuation at the facility due to the fire that night. STNA #246 stated she had recently received education on fire training on 09/27/24, including the use of a fire extinguisher, but stated she forgot what the fire acronyms RACE and PASS stood for. Interview on 10/02/24 at 10:15 A.M. with STNA #223 verified they had been educated about fire evacuation, and using the fire extinguisher but did not know the date of the education. STNA #223 stated she does not know what she learned. Interview on 10/02/24 at 10:20 A.M. with STNA #235 stated she was not sure about the fire, but that the next day she was educated on 09/27/24. The education included fire drills, using closest exit for evacuation, and to close all resident room doors in the area of the fire. STNA #235 stated she could recite what the acronym of RACE meant which was rescue, alarm, contain, and evacuate. STNA #235 stated she was not sure about PASS and its meaning. Interview on 10/02/24 at 12:39 P.M. with STNA #214 revealed the fire alarm went off, and he looked at the fire panel to see Resident #19's room was on fire. STNA #214 stated he headed to Resident #19's room, and before arriving, Resident #17 came out of her room, and stated there was smoke coming out of the connecting bathroom door shared between her room and Resident #19's room. STNA #214 stated he touched the door to Resident #19's room and it was not hot then opened the door and looked into the room. STNA #214 stated Resident #19's room had pure black smoke in the room and no fire was seen. STNA #214 stated he could not see or go into the room due to all the smoke in the room had irritated his throat and he could not breath. STNA #214 stated he did not go into Resident #19's room. STNA #214 stated he knew the resident was in the room, and thought he heard her. STNA #214 stated he then turned around and went into two other residents' rooms to assist them in evacuation. STNA #214 stated he had in-service training for fire that included RACE and PASS. Observation on 10/02/24 at 3:00 P.M. of the facility's video footage provided by the Administrator, DON, and CN #309 who reviewed the facility video dated 09/26/24 through 09/27/24 revealed a fire alarm started on 09/26/24 at 11:45 P.M. The video showed flashing fire alarms, and in the nurse's station at the beginning of the hall, the call light for Resident #19's room was not lit up. Resident #08 was seen assisting residents at the facility with closing doors, checking rooms, evacuating residents, and grabbing a fire extinguisher to hand to staff. At the end of the video Resident #19 was seen coming down the hall in her hospital bed with staff. The bed was burnt but not on fire. The Administrator stated there was no additional video footage of inside the fire doors to be able to see Resident #19's room after the fire doors closed at 11:45 P.M. Interview on 10/03/24 at 10:09 A.M. with the Administrator stated the facility had performed respiratory assessments, head to toe assessments, and residents who smoked signed another smoking agreement. Residents who were smokers at the facility had room sweeps with their permission, one resident denied permission, Resident #08, and later then let facility staff sweep the room. The Administrator stated our system worked flawlessly, and our fire system had no problems. Interview on 10/03/24 at 10:10 A.M. with the DON stated they had no issues identified after the fire. The DON stated we educated the residents again, and had them sign the smoking policy, and signed that they agreed not to keep their smoking products. Interview on 10/03/24 at 11:24 A.M. with the Administrator revealed prior to 09/26/24, the facility would only educate residents at time of admission on the smoking policy, but staff were expected to know the policy and educate residents even after being admitted to the facility. Review of additional camera footage provided to the survey agency on 10/08/24 from the facility revealed the camera footage contained multiple (four) camera's video feed and included the smoke compartment where Resident #19's room was located. The timeline of the following events was obtained from the provided camera's footage. The time was captured on Camera 7 footage and Camera 9 captured the hallway where Resident #19's room was located. The date of the footage is 09/26/24. At 11:50:29 P.M., STNA # 214, STNA #230 and LPN #444 were observed walking onto the hallway. At 11:50:34 P.M., the three staff are observed to walk past a fire extinguisher which was on the wall to their left. None of the staff picked up the extinguisher. At 11:50:43 P.M., STNA #214 was observed to open the door to Room B05, and black smoke was observed to come out of the room. The three staff were observed to flee from the room, STNA #230 and LPN #444 were observed to walk back up the hallway, and STNA #214 was observed to walk further down the hallway. At 11:50:44 P.M., STNA #230 and LPN #444 walked past the fire extinguisher hanging on the wall again which was now on their right side as they were coming back up the hallway. They did not attempt to pick up the extinguisher. At 11:50:46 P.M., STNA #230 and LPN #444 are observed to walk past Resident #17 who was observed in a wheelchair coming out of a resident room and into the hallway, neither staff member assisted Resident #17 in getting off the hallway where there was a room with black smoke coming out of the door, but the staff were seen to walk up the hallway off camera and leave Resident #17 attempting to move herself off the hallway on her own. At 11:50:55 P.M., Resident #17 was joined in the hallway by Resident #16 who was observed to walk out of a resident room which was just past the fire extinguisher hanging on the wall. Smoke was observed to continue to come into the hallway from Room B05 and no staff were observed on the hallway to assist residents, extinguish the fire, or contain the fire. The two residents are seen just congregating in the hallway. At 11:51:04 P.M., STNA # 214 was observed back at the end of the hallway and entered a room on the opposite side of the hallway from Room B05. Black smoke continues to come into the hallway form Room B05. No resident room doors have been shut and no other staff are observed on the hallway. At 11:51:20 P.M., STNA #230 and LPN #444 are observed to enter the hallway and direct Resident #16 and #17 off the hallway using hand gestures. At 11:51:24 P.M., STNA #230 and LPN #444 are observed on the hallway close to Room B05 but across the hall, the smoke in the hallway is thick and it is hard to see past the two staff. Neither of the staff grabbed the fire extinguisher off the wall as they walked down the hallway toward Room B05. No room doors were closed as the staff walked down the hallway. At 11:51:30 P.M., Resident #11 is visible sitting in a wheelchair in a room doorway two doors up the hallway on the same side of the hall as Room B05 across from STNA #230 and LPN #444 who are observed to be standing in the hallway, STNA #214 is visible at the end of the hallway, and smoke continues to fill the hallway. STNA #230 and LPN #444 are seen to turn and make their way back up the hallway past the fire extinguisher, without evacuating Resident #11 who was in the doorway. The staff did not attempt to shut any room doors or assist any residents to leave the hallway. At 11:51:34 P.M., STNA #214 was observed to stop at the doorway where Resident #11 is observed sitting in the wheelchair and raise his arm straight out toward the resident. Then the STNA is observed to continue to walk up the hallway, past the resident and past the fire extinguisher and exit the hallway. STNA #214 did not shut any resident room doors as he walked from one end of the hallway to the other end. At 11:51:45 P.M., Resident #21 is seen ambulating at the end of the hallway and Resident #15 was observed to be standing in a room doorway. The resident at the end of the hallway walks past Room B05 staying close to the other side of the hallway and LPN #444 was observed to wave the resident toward the fire door and off the hallway. The resident is no longer seen on camera and is off the hallway where the fire was. At 11:52:38 P.M., Resident #15 who was standing in the doorway was observed to exit his room walking with a walker and a hat on his head, and he exits the hallway with the fire. At 11:52:40 P.M., Resident #11 who was sitting in a wheelchair in his doorway is observed to wheel out of his room and into the hallway. At 11:52:43 P.M., LPN #251 was observed coming on the hallway where the fire is located, and grabbed the wheelchair of Resident #11 and moved him off the hallway at 11:52:53 P.M. At 11:52:54 P.M., LPN #251 was observed on the hall walking toward Room B05 carrying a fire extinguisher. LPN #251 was observed to enter Room B05 at 11:53 :09 P.M., exit the room at 11:53:14 P.M., reenter the room at 11:53:15 P.M. and re-exit the room by herself at 11:53: 30 P.M. At 11:53:44 P.M., Resident #08 and Resident #21 are observed on the hallway shutting room doors, staff are observed standing outside Room B05, and smoke is observed filling the hallway. At 11:55:29 P.M., the Columbus Police Officers are visible on the hallway and enter Room B05. LPN #251 and STNA # 248 were also in the room with Resident #19. At 11:56:10 P.M., Resident #19 was brought out of Room B05 and down the hall by LPNs #251 and #444, and STNA #248 with Police Officers following. Interview and observation of the facility video camera footage with Regional Director of Operations (RDO) #334 on 10/09/24 at 2:00 P.M. confirmed the facility did not follow their policy and procedures regarding fire safety and they did not rescue the resident in the room where the fire occurred timely and the facility staff did not implement the fire procedures and take a fire extinguisher to the room and attempt to extinguish the fire. He confirmed multiple staff walked past a fire extinguisher hanging on the wall and did not attempt to pick up the extinguisher and the staff did not evacuate other residents on the hallway where the fire was located and/or shut the room doors to contain the fire. Review of the facility submitted SRI dated 10/10/24 revealed after a review of the facility's video surveillance on 10/09/24, related to a fire incident on 09/26/24 at approximately 11:46 P.M., the Administrator launched an investigation for Neglect due to staff response to the fire. The Summary of Incident and Investigation noted the following: On 9/26/2024 at approximately 11:45 P.M., the facility fire alarm was activated. Staff on the A/B hall observed the fire panel and noted the fire to be in Room B-5. A review of the facility's video surveillance showed facility staff viewing the fire panel and immediately proceeding to Room B-5. The video footage shows that the door to B-5 was closed, and smoke was coming from under the door. A facility STNA opened the door and noted the Resident's bed to be the source of the smoke/fire. The facility sprinkler system had activated. The door to Room B-5 was left open while staff retrieved a fire extinguisher and returned to the room and sprayed the contents of the fire extinguisher on the source of the fire. Simultane [TRUNCATED]

Based on observation, medical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure appropriate care and treatment to a resident with a new wound. Actual harm occurred to Resident #3 when Resident #3's wound was treated without a physician order, the physician was not notified of the new wound, the wound worsened into a stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed.) and currently an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar), and the open wound was exposed to possible infections when it was placed on an unsanitary pillow. This affected one (Resident #3) of three residents reviewed for wounds. The facility identified 20 residents with wounds. The facility census was 88. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included congestive heart failure, depression, muscle wasting atrophy, pulmonary embolism, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #3 had intact cognition and he required extensive assistance of two staff for bed mobility and transfers and he required extensive assistance of one staff for toilet use, personal hygiene, and dressing. Resident #3 was at risk for pressure ulcers, but he had no current pressure issues. Review of Resident #3's pressure ulcer risk assessment dated [DATE] revealed the resident was at high risk for the development of pressure ulcers. Review of the care plan dated 01/09/23 revealed Resident #3 had a pressure ulcer and/or potential for pressure ulcer development related to decreased mobility and a left heel wound had resolved with interventions to administer medications and treatments as ordered, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size, and stage, and weekly wound documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate. Review of Resident #3's physician orders revealed on 02/28/23, an order to apply zinc to Resident #3's left heel and leave open to air every day. There was also a physician order dated 01/06/23 to encourage and attempt to float heels while in bed every shift. Review of Resident #3's skin assessment dated [DATE] (and signed/locked on 04/20/23 at 11:24 A.M.) revealed the resident had a reddened area on the left heel measuring 5.0 centimeters (cm) long by 3.0 cm wide with no drainage or odor. There was no change in treatment orders or plan of care and no evidence the physician was notified of the new reddened area from 04/17/23 to 04/19/23. Review of Resident #3's skin assessment dated [DATE] revealed the resident had a stage three pressure ulcer to the left heel, acquired on 04/17/23. It measured 4.0 cm in length by 3.8 cm wide by 0.1 cm in depth with no odor, 10% slough, a moderate amount of serosanguinous drainage, and the peri wound tissue was macerated. The resident's family and physician were notified, and there was a new order to cleanse with normal saline, pat dry, apply nickel thick medihoney to wound bed then cover with cut to fit calcium alginate, cover with ABD and wrap with kerlix daily. Review of the nursing note dated 4/20/23 at 11:23 A.M. revealed Resident #3 was noted with a treatment in place to the left lower extremity heel. Upon investigation of the wound, it was found that the nurse assessed the area on 04/17/23 and implemented a treatment (although no new physician order from 04/17/23 to 04/19/23). The nurse also worked yesterday (04/19/23) and placed/changed the treatment. The wound was measured and staged this shift (04/20/23), the physician was notified of the wound and a message was left for the family, but the resident was his own responsible party and was made aware of his updated status. The resident will be seen on wound rounds Monday (04/24/23). The resident's heels were floated upon assessment. The resident was to have feet washed as he refused a shower at this time. Laboratory orders, air mattress, prostat (a high protein supplement), and prevalon boots (protects the heels) were implemented after speaking with the physician. Review of Resident #3's skin assessment dated [DATE] revealed the resident had an unstageable pressure ulcer to his left heel. The wound had 60% slough, 15% granulation tissue, and 25% intervening skin, it had no odor or signs of infection and the wound measured 5.1 cm by 5.9 cm with an undetermined depth. It stated the Wound CNP was notified on 04/24/23 and she stated the wound was unavoidable. The assessment indicated the slough from the wound was mechanically debrided and she changed the order to pack the wound with medihoney and cover with an ABD pad and wrap with kerlix daily. Observation and interview on 04/20/23 at 9:29 A.M. with Registered Nurse (RN) #114 revealed Resident #3 had a yellow/green/brown soiled undated kerlix wrapped around his left heel and his heels were slightly elevated with a blue pillow that did not have a pillowcase. RN #114 removed the soiled kerlix and an odor was present on the kerlix. RN #114 rested the resident's open wound on the blue pillow that the resident's soiled dressing had been sitting on. RN #114 stated she knew the dressing was changed by night shift last night though there was no date on the dressing, she stated there was no odor on the wound yesterday, and the order was for it to have zinc and a kerlix dressing. Observation on 04/20/23 at 9:47 A.M. with Licensed Practical Nurse/Unit Manager (LPN/UM) #115 and RN #117 revealed they were going to complete Resident #3's dressing change. They confirmed the open wound had been lying on the soiled pillow prior to their dressing change. LPN #115 held the resident's left leg up while RN #117 cleansed the area with normal saline and gauze, applied medihoney with calcium alginate, covered it with an ABD pad, and wrapped the area with kerlix. After the dressing change was completed, LPN #115 sat the residents' newly covered/dressed heel on the soiled pillow, she then obtained a cleaning solution and wiped the pillow clean, applied a pillowcase to the pillow, and elevated the resident's heels from the bed. Interview on 04/20/23 at 12:30 P.M. with RN #114 confirmed she sat the open wound on the soiled pillow. She also stated on 04/17/23 when she noticed the new wound, it was just red, unopened, non-odorous, and it measured 5.0 cm by 3.0 cm per her assessment. She stated the resident had a wound there previously that had healed, and she thought he was still being seen by the wound care team, and verified she failed to notify the physician about the new red area, and she also failed to notify her colleagues (nurses and aides) that she had found that the resident had a new wound forming. Interview on 04/20/23 at 10:14 A.M. with the Director of Nursing (DON) revealed on 04/17/23, RN #114 identified that there was a new wound on Resident #3. The DON confirmed she was not notified of the wound, and she found out about it when the surveyor found out about it. She stated she believed Resident #3 had a heel wound that healed on 02/27/23 and on 03/01/23, there was a new order for zinc and open to air as a preventative measure. She confirmed the kerlix was not part of the zinc order. Additionally, at 11:05 A.M., the DON stated she spoke to RN #114 again, she said on 04/17/23 RN #114 found the wound, but she thought the resident was still being seen on wound rounds so she did not tell the physician. She said she put the kerlix on yesterday (04/19/23) because it was now open and starting to have drainage. The DON stated she measured it today as a stage three pressure ulcer. Interview on 04/24/23 at 9:08 A.M. with Wound Certified Nurse Practitioner (CNP) #130 revealed when she observed Resident #3's wound today (04/24/23), it was an unstageable pressure wound with slough, she debrided it today, and started him on just medihoney. She stated she was here weekly, she comes early on Mondays, but she was not notified of Resident #3's wound from Monday (04/17/23) through today (04/24/23). She revealed the staff notified her about it today (04/24/23). She stated the wound was larger because there was one big open area and one small open area, so she included them both in one measurement. She revealed if slough was present, it was unstageable since you cannot determine the depth, though staging was difficult. She stated nurses can stage if they feel comfortable, and she can educate them on how to stage and they do pretty well, but if it was staged wrong, she will say error in staging and she will document what it really was. Wound CNP #130 stated Resident #3's wound measured 5.1 cm by 5.9 cm with no depth since unstageable, but 30% of that was skin, 15% was granulation tissue, and 55% was slough, there was moderate serous drainage, with no signs or symptoms of infection. She stated her new order was going to be for Medihoney, ABD and kerlix daily. The subsequent interview on 04/24/23 at 11:46 A.M. with Wound CNP #130 and the DON revealed the CNP stated Resident #3's heel wounds were unavoidable, he digs his heels into the bed, and he will scooch himself down. They stated the resident got an air mattress and has heel boots now. The CNP stated the DON's assessment of the wound on 04/20/23 was accurate, even with the slough present, it was only 10% and you could still see some of the wound bed, so it was a technical stage three pressure ulcer. The CNP stated it was her company's policy to stage anything with slough as unstageable, though now the slough was at 55% today (04/24/23) so it would be unstageable for sure as there was a lot more slough than there was on 04/20/23. The DON stated the resident also may have possible peripheral vascular disease which could contribute to wound deterioration or growth . Review of the facility policy titled Wound Care, dated October 2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. It stated staff should place a disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. It also stated after the wound is dressed, mark the tape with initials, time, and date, and apply it to the dressing. Review of the facility policy titled, Prevention of Pressure Ulcers/Injuries, dated July 2017, revealed the residents will have a comprehensive skin assessment upon admission and the skin would be inspected daily when performing care or assisting with personal care or activities of daily living, including identifying signs of developing pressure injuries and inspecting pressure points (including heels). The policy stated staff were to evaluate, report and document potential changes in skin. This deficiency represents non-compliance investigated under Master Complaint Number OH00142188 and Complaint Number OH00142173.

Based on medical record review, staff and family interviews, and review of the facility [CONDITION(S)] contract, the facility failed to ensure residents received hemodialysis as ordered/scheduled. Actual harm occurred on 06/04/22 when Resident #90 was not dialyzed as scheduled and was subsequently hospitalized in the intensive care unit (ICU) for fluid volume overload on 06/06/22. This affected one (Resident #90) out of three residents reviewed for [CONDITION(S)]. The facility identified three residents in the facility who received [CONDITION(S)]. The census was 86. Findings include: Review of Resident #90's medical record revealed an admitted [DATE]. Resident #90 was discharged to an acute care hospital on 06/06/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge Summary dated 06/02/22 revealed Resident #90 was discharged to the facility with orders to continue renal diet with [CONDITION(S)]. Review of Resident #90's medical record revealed no physician orders for [CONDITION(S)], monitoring/type of [CONDITION(S)] site, and where and when Resident #90 was to receive [CONDITION(S)]. Review of the Interim Plan of Care dated 06/02/22 revealed Resident #90 had the following medical conditions: [CONDITION(S)], shortness of breath, CHF, and [CONDITION(S)]. Further review of the interim plan of care revealed no goals or interventions to direct the staff regarding Resident #90's care needs. Review of the Nurses Note dated 06/04/22 at 4:13 P.M., revealed Resident #90 stated she was to receive [CONDITION(S)] every Monday, Wednesday and Friday. The [CONDITION(S)] company did not see Resident #90 today (06/04/22) because she was not on the list. The note indicated management was notified. Review of the Certified Nurse Practitioner (CNP) #400 progress note dated 06/06/22 at 12:00 A.M. revealed the resident was at a specialty hospital from 05/07/22 through 06/02/22 at which time she was found to have acute decompensated heart failure with recovered ejection fracture managed with hemodialysis which was continued upon discharge. The note indicated Resident #90 missed [CONDITION(S)] on Saturday (06/04/22) due to unknown circumstances. Resident #90 would need transferred to the hospital for hemodialysis in the setting of mild fluid volume overload and encephalopathic symptoms. Review of the progress note dated 06/06/22 at 7:47 P.M. revealed Resident #90 was sent to the local hospital emergency room (ER) per request of the CNP at approximately 11:45 A.M. Review of Resident #90's medical record revealed no written evidence Resident #90's [CONDITION(S)] site was assessed and/or monitored, and Resident #90 was assessed for fluid volume overload prior to the CNP assessing Resident #90 on 06/06/22. Review of the email dated 05/31/22 from Admissions Director #246 revealed Resident #90 was to receive in-house [CONDITION(S)]. Review of the email provided by the Administrator dated 06/01/22 revealed Resident #90 was clinically and financially approved for in-house [CONDITION(S)] at the facility and the [CONDITION(S)] was to be completed on Tuesday, Thursday, and Saturday. Further review of the emails revealed the Director of Nursing (DON) questioned why Resident #90 was not dialyzed on 06/04/22 as CNP #400 was sending Resident #90 to the ER. Interview with Resident #90's niece on 06/16/22 at 2:10 P.M., revealed on 06/04/22 when she arrived at the facility she was informed of the missed [CONDITION(S)] scheduled for 06/04/22 and was not provided a reason as to why Resident #90 missed [CONDITION(S)] on 06/04/22. She requested management be notified so Resident #90 could receive [CONDITION(S)]. On 06/06/22, she was notified Resident #90 was transferred to the local emergency room (ER) at which time Resident #90 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #90 was immediately dialyzed, placed on a [CONDITION(S)] machine and placed in the ICU where she remained until 06/12/22. She stated Resident #90 remained at the hospital. Interview with the Director of Nursing (DON) on 06/14/22 at 2:16 P.M., verified Resident #90 had no physician orders for [CONDITION(S)], monitoring or assessment of Resident #90's [CONDITION(S)] site, as well as the type of [CONDITION(S)] access site. The DON verified Resident #90 did not receive her scheduled [CONDITION(S)] on 06/04/22 as scheduled. Interview with CNP #400 on 06/22/22 at 9:00 A.M., revealed he sent Resident #90 out to the emergency room (ER) for an evaluation due to altered mental status, mild respiratory distress, and lack of having [CONDITION(S)]. He said he saw Resident #90 first thing in the morning on 06/06/22 and felt she could not wait for her scheduled [CONDITION(S)] on 06/07/22. Review of the facility [CONDITION(S)] contract, dated 04/01/22, revealed the provision of hemodialysis and [CONDITION(S)] related services, such as training and support to those persons with end-stage [CONDITION(S)] ([CONDITION(S)]) who are residents in the facility. The [CONDITION(S)] company shall provide [CONDITION(S)] services to residents as ordered by the physician or requested by the facility. This deficiency substantiates Complaint Number OH 356.

Based on observation, record review, and staff interview, the facility failed to ensure preventative measures were in place to prevent the development of a pressure ulcer. This resulted in actual harm when Resident #82 developed an avoidable deep tissue injury to the heel. This affected one (Resident #82) of four residents reviewed for pressure ulcers. The facility census was 84. Findings include: Record review revealed Resident #82 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Charting dated 01/11/22 revealed Resident #82 was admitted without wounds. Resident #82 had a physician order dated 04/07/22 for a weekly skin assessment every night shift on Monday. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/19/22, revealed the resident was alert and oriented. Behaviors included inattention, physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, rejection of care, and other behavioral symptoms not directed towards others. The resident required extensive assistance of one to two or more staff for bed mobility, transfers, locomotion on and off the unit, dressing, personal hygiene, and was totally dependent on two staff members for toilet use. The resident had no pressure ulcers. Review of the plan of care dated 04/19/22 revealed the resident was at risk for skin breakdown due to decreased mobility. Interventions included encourage and assist the resident to turn and reposition as tolerated and as needed (PRN), pressure reducing mattress, and pressure reducing wheelchair cushion. The care plan had no interventions related to pressure relief to the feet. Review of the nursing notes dated 05/02/22 at 2:25 P.M. by Licensed Practical Nurse (LPN) #1000 documented Resident #82 had a suspected deep tissue injury to the left heel. The wound doctor was to examine the area on 05/03/22. The Certified Nurse Practitioner (CNP), and Director of Nursing were made aware. A new order for skin preparation was initiated. On 05/02/22, Resident #82 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pressure ulcer risk assessment dated [DATE] revealed the resident was at risk for the development of pressure ulcers. Review of Resident #82's medical record revealed no evidence weekly skin assessments were completed from 04/07/22 through 05/24/22. During an interview on 05/14/22 at 12:58 P.M., Unit Manager #769 stated Resident #82 was followed by the wound doctor, who came in every Tuesday. She stated a facility staff nurse rounded with the doctor and would report any concerns or changes. During observations on 05/13/22 at 1:23 P.M., 1:43 P.M. and 2:08 P.M. and on 05/31/22 at 7:18 A.M. and 9:04 A.M., Resident #82 had a sock on her left foot and her heel was resting directly on the bed. There were no pressure reliving devices in place. During observation on 05/18/22 at 7:33 A.M., Resident #82's heel was covered with an ABD pad and wrapped in Kerlix. Her heel was resting directly on the bed. There was a dark purple, golf ball sized, area on the inner side of her heel. Resident #82 stated at the time of the observation the area had been present for about three weeks and was painful. She said she had seen the wound doctor on 05/17/22. Review of the Wound Evaluation and Management summary, dated 05/10/22, documented a deep tissue injury of the left heel which measured two centimeters (cm) long, four cm wide, with no depth noted. The summary dated 5/17/22 documented an unstageable pressure ulcer that measured three cm long, two and a half cm wide, with no depth. The treatment plan was for skin prep daily. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised March 2014, revealed the nurse was to describe and document full assessments of pressure ulcers including the location, stage, length, width, depth, and presence of exudates. Further review of the policy revealed during resident visits, the physician would evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. Review of facility policy titled Pressure Ulcers/Injuries Overview, revised July 2017 revealed a pressure ulcer/injury referred to localized damage to the skin and/or underlying soft tissue usually over a bony prominence. Further review of the policy revealed a Deep Tissue Pressure Injury (DTPI) was another stage of pressure ulcers. This deficiency substantiated Complaint Number OH 416.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of hospital continuity information, review of a staff statement, staff interviews, and review of facility policies for Cardio-Pulmonary Resuscitation (CPR) and Advance Directives, the facility failed to initiate CPR or contact Emergency Medical Services (EMS) for Resident #01 who was found unresponsive, without a pulse or respirations. Resident #01's medical record had no documented evidence of a current code status. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm when Resident #01 did not receive CPR and EMS was not contacted for assistance. This affected one (Resident #01) of three residents reviewed for death in the facility. The facility identified 76 residents designated as having a Full Code status. The facility census was 85. On [DATE] at 1:06 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] at 7:41 A.M. when Registered Nurse (RN) #23 assessed Resident #01 and found Resident #01 had shallow respirations and an oxygen saturation of 54 percent with a [CONDITION(S)] mask. RN #23 attempted to recheck Resident #01's pulse oximetry reading when Resident #01's respirations and pulse ceased. RN #23 did not initiate CPR for Resident #01 at any time. Certified Nurse Practitioner (CNP) #40 confirmed Resident #01 had no pulse and had expired. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE], the Director of Nursing (DON) initiated education with all licensed nursing staff in person or via phone and reviewed the Advanced Directives and CPR policies as well as situations when CPR was performed with emphasis on what their role was during a code. The nurses were educated how to confirm code status and the location of resident code status in the clinical record. Education was completed on [DATE] by 11:59 P.M. with all licensed nursing staff. All newly hired staff were educated on the process during orientation. · On [DATE] by 1:00 P.M., Social Service Designee (SSD) #30 completed a whole house audit on the code status and physician orders for residents to ensure the code status was current and correct for each resident. The audits were to be conducted weekly for one month, then monthly and reported to the Quality Assurance Performance Improvement (QAPI) quarterly committee. · On [DATE] by 1:00 P.M., Corporate Registered Nurse #50 conducted an audit to ensure all emergency equipment used to perform CPR was present and functional. · On [DATE] by 3:00 P.M., Corporate Registered Nurse #50 conducted an audit of all licensed nursing staff to ensure CPR certification was current. At least one nurse that was CPR certified was on each shift to ensure CPR was initiated when appropriate. Human Resource Director #51 completed continued audits of the CPR certification for all licensed nursing staff each month. · On [DATE] by 5:00 P.M., Human Resource Designee #51 conducted audits of new hires and current nurses weekly for one month, then monthly, in order to ensure CPR certified nurses were always on duty. · An ad hoc QAPI committee meeting was conducted on [DATE] by the interdisciplinary teams consisting of the Administrator, DON, and Medical Director #100. The facility deficient practice and self-imposed plan of correction for failing to have a code status physician order and a signed code status form in Resident #01's chart was discussed. All audits were reported at the QAPI committee quarterly meetings conducted on [DATE] and [DATE] for review and recommendations. · Review of the staff education sign-in-sheets and documentation of phone calls dated [DATE] and [DATE] revealed all nurses were educated by the DON regarding emergency response procedures by [DATE] at 11:59 P.M. The sign-in-sheet included all licensed nurses working in the facility. · Review of the chart audits for code status completed on [DATE] revealed 76 residents were reviewed for code status and physician order verification by SSD #30. SSD #30 completed additional audits of seven to 10 resident records on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] with no identified concerns. · Interview with Resident #03 on [DATE] at 4:10 P.M., Resident #06 on [DATE] at 4:15 P.M., and Resident #08 on [DATE] at 4:20 P.M. revealed all three residents had no concerns regarding their care or code status. · Interview with 10 staff including the Administrator and DON on [DATE] at 1:50 P.M., SSD #30 at 2:30 P.M., LPN #46 at 3:07 P.M., RN #42 at 4:05 P.M., RN #33 at 4:25 P.M. and on [DATE] at 1:50 P.M. by phone with Certified Nurse Practitioner (CNP) #40, LPN #20 at 4:02 P.M., LPN #31 at 4:07 P.M., and by phone with LPN #25 at 6:24 P.M. revealed there were no similar occurrences with a lack of CPR or physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing staff confirmed they would immediately administer CPR and call emergency services for any resident who was a full code or had no code status. · Review of four additional resident medical records including two closed records (Resident #10 and Resident #11) who appropriately received CPR and two current residents (#03 and #08) revealed no concerns with code status verification or CPR. · On [DATE], the DON provided documentation of completed monthly audits for all licensed nurses providing resident care which verified current CPR certification for all but one current nurse, Licensed Practical Nurse (LPN) #20. There will always be at least one CPR certified nurse working while LPN #20 is on duty. An American Red Cross CPR course was scheduled to take place by [DATE] for all licensed nurses. Findings include: Review of the closed medical record for Resident #01 revealed an admitted [DATE] from a local hospital. Resident #01's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 was listed as representing herself and Resident #01's husband was listed as the first emergency contact or next of kin. There was no evidence that Resident #01 had a guardian or power of attorney. Review of Resident #01's medical record revealed there was no evidence of a code status form in the facility medical record. Review of Resident #01's most recent Minimum Data Set assessment dated [DATE] revealed Resident #01 was aphasic, had short-term and long-term memory loss, and had severely impaired cognition. Review of a skilled nursing progress note dated [DATE] revealed Resident #01 was in a persistent vegetative state. Review of Resident #01's physician orders revealed there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a progress note dated [DATE] at 7:41 A.M. revealed Registered Nurse (RN) #23 assessed Resident #01 and found Resident #01 with shallow respirations and an oxygen saturation of 54 percent with a [CONDITION(S)] mask. RN #23 attempted to recheck Resident #01's pulse oximetry reading when Resident #01's respirations and pulse ceased. RN #23 did not complete CPR for Resident #01 at any time. Certified Nurse Practitioner (CNP) #40 confirmed Resident #01 had no pulse or respirations. The nurse documented Resident #01's code status was Do-Not-Resuscitate Comfort Care-Arrest (DNRCCA). Review of the hospital continuity information revealed Resident #01 was found with COVID-19 in [DATE]. There was a physician's order dated [DATE] at hospital admission of a DNRCCA code status which was discontinued when Resident #01 was discharged to the facility on [DATE]. Review of RN #23's statement regarding Resident #01's death obtained on [DATE] confirmed there was no CPR initiated and/or call to emergency services because she determined Resident #01 was a DNRCCA based on the hospital continuity information. Interview on [DATE] at 12:20 P.M. with the DON verified there was no code status form or physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview by phone on [DATE] at 12:50 P.M. with CNP #40 revealed the facility staff were responsible for ensuring all resident code status forms were updated upon admission. CNP #40 was aware RN #23 did not initiate CPR or call emergency services for Resident #01 based on a DNRCCA code status from the hospital continuity paperwork. Interview with SSD #30 on [DATE] at 1:32 P.M. revealed the previous social worker failed to obtain Resident #01's code status upon admission. SSD #30 stated she was responsible for updating all resident code status forms upon admission and completed all the medical record audits for resident code status's since [DATE]. Phone interview with Resident #01's husband on [DATE] at 11:30 A.M. revealed Resident #01's code status form signed in [DATE] was a full code. Resident #01's husband stated he never changed Resident #01's code status, and no code status form was completed at the facility. Review of the facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation (CPR), revised [DATE], revealed the facility was to adhere to resident's rights to formulate advance directives. In accordance with these rights, the facility implemented guidelines regarding CPR. The facility followed current American Heart Association guidelines regarding CPR. If a resident experienced a [CONDITION(S)] or was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR initiated CPR unless the resident had a known Do Not Resuscitate (DNR) order that specifically prohibited CPR or there were obvious signs of irreversible death including rigor mortis. If a resident's DNR status was not clear, CPR was initiated, and emergency services contacted. Review of the facility policy titled Advance Directives, revised [DATE], revealed newly admitted residents/representative and the healthcare team reviewed Advanced Directives regarding the resident's wishes about the end of life care they wished to receive and the existence of any written advance directives. Information regarding the advanced directive was displayed prominently in the medical record. This deficiency substantiates Complaint Number OH 657.

Based on medical record review, staff interview, resident family interview, review of the facility's investigation report, and review of the local hospital records, the facility failed to ensure a resident was provided safe bed mobility during care. This resulted in Actual Harm when the State tested Nursing Assistant (STNA) #205 provided bed mobility alone and rolled the resident away from her and the resident slipped and rolled out of the bed onto the floor. The Resident #25 was sent to the hospital and sustained an injury and reopened a surgical incision to the parietal lobe requiring six stitches to the skull. This affected one resident (#25) of three residents reviewed for falls. The facility identified 24 residents who required assistance of two staff for bed mobility. The facility census was 84. Findings include: Review of the medical record revealed Resident #25 was admitted on [DATE]. Diagnoses included nontraumatic intracerebral hemorrhage, hypertension, dysphagia, cerebral aftercare, and surgical aftercare from craniotomy with piece of parietal skull removal, [CONDITION(S)], [CONDITION(S)] following cerebral infarct. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. The cognitive assessment revealed the resident was rarely/never understood and required extensive assistance of two staff members and was totally dependent on staff for bed mobility and transfers. The resident was always incontinent of bladder and bowel. The Resident had a surgical wound from a craniotomy. Review of the plan of care revealed the Resident #25 was at risk for falls from cerebral vascular accident ([CONDITION(S)]) with [CONDITION(S)] and [CONDITION(S)] with a recent fall on 08/22/21 with a [CONDITION(S)]. Interventions included ensure non-skid footwear, helmet on when out of bed, keep the bed in the lowest position, and have a perimeter mattress over to provide boundary to prevent extremities from sliding off the bed. The care plan revealed the resident has an activities of daily living (ADL) deficit. Interventions included two-person assistance for bed mobility. Review of the progress note dated 08/22/21 revealed around 3:40 P.M. Registered Nurse (RN) # 85 was informed by the State tested Nursing Assistant (STNA) the resident was rolled to her right side and all the resident's weight was on the right side of the bed. The resident began to slide and the STNA was unable to stop her before she fell to the floor. Upon entrance to the room, the RN #85 found the resident laying on the floor between the floor and the wall. A pool of blood was noted on the floor under the Resident #25's head. The staff called nine-one-one for emergency transport to the hospital. The resident was alert with her eyes open with blood noted to the nares and the top of the scalp. The RN #85 informed the resident's emergency contact of the fall incident and the hospitalization and the emergency contact hung up on the nurse. The progress note dated 08/23/21 at 2:02 A.M. written by Licensed Practical Nurse (LPN) #90 revealed the Resident #25 returned from the hospital with sutures to the right side of the head and reported to the nursing staff the computerized tomography (CT) scans were negative at the emergency department. Interview on 09/01/21 at 3:30 P.M., the resident's family #26 revealed the resident had a fall that was investigated by the facility. The resident's family stated they spoke to the hospital staff and were informed the resident was rolled off the bed during care and landed on her head which reopened her surgical incision. Interview on 09/02/21 at 3:45 P.M., the RN #85 revealed she was the Resident #25's assigned nurse on 08/22/21 when the resident had a fall incident. She stated she was working in another resident's room and when she exited the room, she noticed the STNA was waving at her and yelled she needed help urgently. Upon entrance to the room, the resident was laying on the floor and had fallen between the bed and the wall. The RN #85 stated the STNA pointed out the pool of blood under resident's head and she knew the resident needed to go to the hospital. She called nine-one-one immediately and called for more staff to assist. The RN #85 revealed she was never asked to assist in providing care for the resident prior to the injury and there was not a concern with staffing levels. The RN #85 stated the resident was dependent for transfers and could not have rolled out of bed herself. The RN #85 denied being part of the investigation and revealed the previous Administrator never asked her what had happened. The RN #85 revealed she was no longer employed at the facility and the event occurred on her second to last shift. Interview on 09/07/21 at 12:55 P.M., the STNA #205 revealed she provided care to the Resident #25 when she fell off the bed. The STNA #205 stated she noticed the residents tube feed had leaked onto the bed linens and when she rolled the resident away from her toward the wall, the resident slipped and continued rolling off the bed and landed on the floor. The STNA #205 stated the resident's bed was not in a lowered position. The STNA #205 stated she had not checked the assistance needs of the resident before she completed bed mobility. Review of the fall incident investigation revealed the previous Administrator spoke with the STNA #205 who provided care when this incident occurred and completed an interview and took a written statement. Due to the STNA not checking the resident record to verify assistance needs prior to providing care and completing care alone when the resident required two-person assistance, the STNA was given a verbal disciplinary action on 08/24/21 and left her employment by personal choice on 08/28/21. The facility completed ADL training on 08/24/21 and in-serviced one third of the nursing and aide staff on the staffing roster. Review of the hospital records revealed the resident presented to the hospital after a fall from the bed at the facility, where the resident hit her head on the floor. The resident had a recent craniotomy and upon evaluation had a large scalp laceration of eight centimeters that required six stitches. This deficiency substantiates complaint number OH 189 and complaint number OH 181.

Based on medical record review, review of a facility investigation, review of a police incident report, review of a facility Self-Reported Incident (SRI), observation of a facility video, review of a weather report, observations, interviews with staff and a family member and review of the facilities elopement policy and procedure, the facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as being cognitively impaired and at risk for elopement. This resulted in Immediate Jeopardy and serious injury when one resident (#01) eloped from the facility, without staff knowledge, and was missing for approximately six hours. When the resident was finally located, he was admitted to the hospital for evaluation related to a [MEDICAL CONDITION] spine second vertebra (L2) and of the right olecranon (elbow). This affected one (#01) of three residents reviewed for risk of elopement. The facility identified two residents at high risk for elopement. The facility census was 93. On 08/19/20 at 3:39 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 08/14/20 at 9:42 P.M. when Resident #01 exited the unit through a side door used for smokers. State tested Nursing Assistant (STNA) #70 let Resident #01 outside while residents were smoking but failed to tell STNA #71 the resident was outside. Resident #01 then exited through a gate to the sidewalk on a corner street behind the facility. Approximately six hours later, Resident #01 was located outside, down a cement pathway, that leads to a side door of the building next door. Resident #01 was found lying on his side after falling in front of the door. The cement pathway was approximately four feet wide and 65 feet long with a declining slope of approximately 25 percent (%) and its use was for a ramp for wheelchairs. Resident #01 was assessed and found to have an abrasion to his right forearm (elbow area). Resident #01 was transferred and admitted to the hospital for evaluation related to a fracture of L2 and of the right elbow. The Immediate Jeopardy was removed on 08/15/20 when the facility implemented the following correction actions: · On 08/15/20 at 3:15 P.M., Resident #01 was located and was transferred to the hospital for evaluation and treatment. · On 8/15/20 at 2:30 A.M., the DON or the designee began all staff in-service training regarding resident elopement risks/smoking area. The staff training included providing a list of residents who were identified as smokers and the elopement book was reviewed. The in-service training was completed on 08/15/20. · On 08/15/20, STNAs #70 and #71 were disciplined for failing to provide Resident #01 adequate supervision resulting in an elopement. · On 08/15/20, the DON or designee completed a whole house audit to identify residents at risk for elopement and identify residents who smoke for staff reference. · On 08/15/20 at 7:30 A.M., the DON initiated smoking audits to ensure only those residents who smoked are in the courtyard and that all who are in the courtyard return inside following smoke breaks. The audits will be completed by the DON or designee and will be completed twice weekly for four weeks then monthly thereafter. · On 08/15/2020, the Maintenance Supervisor installed chime alarms to both gates in the outside courtyard to alert staff of anyone trying to come in or go out of the courtyard. · On 08/17/20 at 7:00 A.M. and 1:30 P.M., the DON or designee completed all staff in-service training to provide reinforced education regarding elopement and smoking supervision. · On 08/18/20 at 4:00 P.M., the Maintenance Supervisor removed/replaced the gate with a permanent fence in the outside courtyard located outside Unit A's exit door. The fence will limit only one exit/entrance from outside of the facility. · On 08/19/20, review of the medical records for two (#02 and #03) additional residents, reviewed for elopement, revealed no concerns. Observation of Resident #02 and #03 on 08/19/20, revealed elopement interventions were in place. · Observation on 08/19/20 at 11:00 A.M. of the facility exit doors revealed they were automatically locked, and a key fob was used by staff to unlock the doors. Observation of the facility gate leading into the Unit A exit into the courtyard revealed a chime alarm had been placed. Additional observations on 08/19/20 at 4:00 P.M. of the facility fence where the gate used to be revealed the facility had put in a permanent piece of fence and had removed the gate. · On 08/19/20 and 08/20/20, an interview with Registered Nurse (RN) #50 and STNA #71 confirmed they received in-service training regarding supervision and the facility policy to prevent elopements. RN #50 and STNA #71 were knowledgeable regarding the facilities policy to prevent elopements. Although the Immediate Jeopardy was removed on 08/15/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of Resident #01's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #01 was transferred and admitted to the hospital on [DATE]. Review of Resident #01's quarterly Minimum Data Set (MDS) assessment, dated 05/21/20, revealed the resident had impaired cognition with a brief interview for mental status (BIMS) of five out of 15. The assessment identified the resident to have behaviors of wandering (saying he wanted to go to work or home). Resident #01 required supervision while in his wheelchair, and extensive one to two person assist for toileting. The MDS documented Resident #01 rarely did use his walker. Review of the plan of care dated 05/26/20 revealed Resident #01 was at risk for elopement/wandering behavior related to a history of attempts to leave the facility unattended, impaired safety and disoriented to place. Interventions included provide structured activities: toileting, walking inside and outside, reorientation strategies. Identify pattern of wandering, divert as needed and intervene as appropriate. Review of the elopement risk assessments dated 06/26/20 revealed Resident #01 scored a six (scores of 10 or higher indicate at risk) and wanderguard was in place. On 08/10/20, the elopement risk assessment revealed Resident #01 scored a 13 and wanderguard was discontinued due to the facility being on lock down during the pandemic and stating thus not warranted at this time. Review of Resident #01's physician orders [REDACTED]. Further record review revealed Resident #01 was not identified as a resident who smoked. Review of the nurse notes dated 08/15/20 at 4:23 A.M. revealed the DON was notified at midnight, Resident #01 was not in his room or the facility. RN #50 stated she looked for Resident #01 as she last saw him on 08/14/20 at 9:30 P.M. walking up the unit hall with a walker. So around 11:30 P.M., she went to check on him in his room and noted Resident #01 was not in bed or his room. Code Amber was called and staff searched the facility and outside perimeter. The DON responded by coming into facility. The facility and perimeter was searched again with no success. Emergency services was contacted as was Resident #01's son. The Columbus Police Department (CPD) arrived and took description along with what Resident #01 was wearing which was grey sweatpants, black t-shirt, and white shoes. Resident #01 was ambulating with a walker. CPD searched the facility twice and searched the perimeter. Cameras were reviewed with CPD and detectives. CPD officer arrived back at the facility after the search and stated Resident #01 was found by the canine dog at a church behind the facility and he had fallen. The DON went with the officer and assessed the resident. Resident #01 was responsive, laughing, and joking. Resident #01 stated that he had gotten off work and was heading home. Resident #01 had sustained a laceration to the right forearm, unable to measure due to awaiting Emergency Management Team (EMT), but the DON stated she cleansed the area with normal saline, patted the area dry, and wrapped it in kerlix. Resident #01 was assisted to a wheelchair with staff to get off of the ground. No other injuries were noted and no complaints of pain were voiced by the resident. CPD and the DON sat with resident until the paramedics and the son arrived. Neurological (neuro) checks were performed with no adverse reactions noted. EMT's arrived and took Resident #01 to the local hospital for evaluation and treatment. Review of the facilities elopement investigation dated 08/18/20 revealed on 08/14/20 at 9:42 P.M. Resident #01, while utilizing his walker, was let out Unit A door and allowed into an outside courtyard where resident's smoke by STNA #70. STNA #71 was outside supervising the smokers and did not realize STNA #70 had let Resident #01 outside. STNA #70 allowed Resident #01 to exit the facility assuming he was a smoker. On 08/14/20 at 11:30 P.M., RN #50 noted Resident #01 was not in his room when she went to look for him. An Amber alert was initiated immediately, and staff responded to the page. Resident #01 was not found after a search of the entire facility and outside perimeter. On 08/15/10 at 12:00 A.M. the DON was notified and responded by coming into the facility to perform a further search without success. On 08/15/20 at 12:30 A.M., emergency responders were contacted by the DON and Resident #01's son was notified by RN #50. On 08/15/20 at 12:40 A.M., police arrived, and a thorough search was conducted throughout the facility without the resident being observed. On 08/15/20 at 2:00 A.M. the detective arrived and another search of the outside perimeter/facility inside was completed without success. On 08/15/20 at 3:15 A.M., police notified the DON that Resident #01 was observed on a pathway behind the facility lying on the ground. The DON responded and assessed the resident with noted laceration to right forearm and left hand. Resident #01 was assisted into a wheelchair, that was brought from facility. Resident #01 was laughing and in good spirits. The son was notified and EMT contacted by the police department. On 08/15/20 at 3:30 A.M., the EMT's arrived and Resident #01 was taken to the local hospital per request of the resident's son. Review of the police incident report dated 08/15/20 revealed the police department received a call of a resident identified as Resident #01. The police incident report documented Resident #01 was last seen on 08/14/20 at 9:30 P.M. Resident #01 was last seen wearing white/blue t-shirt and jeans. Caller from the facility stated staff searched the entire building and could not find Resident #01. Search completed on 08/15/20 at 3:39 A.M. and Resident #01 was sent to local hospital. Review of Resident #01's hospital medical record revealed on 08/15/20 the resident presented to the emergency room after a fall. Resident #01 lives at a nursing facility and reportedly escaped and fell down a hill. Resident #01 was awake, alert, has dementia and is an unreliable historian. Resident #01 had abrasions on his forearm and head. During the evaluation Resident #01 complained of pain, unclear specifically where but includes bilateral knee, abdominal, and right arm pain. Resident #01 was found to have a fracture of L2 and of the right elbow and would have an orthopedic (ortho) evaluation. On 08/16/20, Resident #01 was evaluated by ortho who determined the resident could be discharged from the hospital without surgical intervention. On 08/16/20, Resident #01 was discharged to a family members home. Review of a facility SRI dated 08/18/20 titled Neglect/Mistreatment Abuse revealed an incident of possible neglect occurred 08/14/20 at 9:42 P.M. Further review of the SRI revealed Resident #01 was let outside to an outside courtyard where other residents were smoking and another STNA was assisting with smoking. Resident #01 then made it out of courtyard gate. Staff were immediately in-serviced on communication as STNA who was out with other residents was unaware of Resident #01 being let out into the courtyard. Both STNA's (#70 and #71) involved received disciplinary action. Staff education was implemented immediately. Smoking list was provided to staff of those residents that can go out and smoke. Resident #01's son and physician were made aware. The SRI was unsubstantiated regarding neglect. Interview with STNA #70 on 08/18/20 at 4:00 P.M. and again on 08/19/20 at 11:00 A.M. was attempted but the staff did not return the phone call. On 08/19/20 at 4:00 P.M. an interview with the DON revealed Resident #01 was found outside following his elopement on 08/15/20 and was down a pathway. Further observations with the DON of the pathway where Resident #01 was found revealed the pathway leads to a side door of the building next door to the facility and is not on the facilities premise. The DON stated Resident #01 was found lying on his side after falling in front of the door to the building next door. The observations revealed there is a cement pathway that is approximately four feet wide and 65 feet long with a declining slope of approximately 25%. This pathway is used by the building next door as a ramp for wheelchairs. The observations revealed there was no lighting down the cement pathway. The DON stated through their investigation, Resident #01 left the facility unsupervised on 08/14/20 at approximately 9:42 P.M. out the Unit A exit door into the courtyard and at the time the resident was ambulating with his walker. The DON confirmed when Resident #01 was found on 08/15/20, he was without his walker and he had left his walker along the pathway. Interview on 08/19/20 at 7:10 P.M. with RN #50 revealed she had last seen Resident #01 on 08/14/20 at 9:30 P.M. when he was walking down the hall. RN #50 stated on 08/14/20 at 11:30 P.M. she went to administer Resident #01's medication and noticed he was not in his bed or room. RN #50 stated she immediately started an Amber Alert and staff started searching for the resident. RN #50 revealed on 08/15/20 at 12:00 A.M. the staff had not located Resident #01, so she notified the DON. Interview on 08/19/20 at 1:00 P.M. with Resident #01's family member revealed he was notified by the nurse on 08/15/20 at 1:30 A.M. that Resident #01 was missing from the nursing home. Resident #01's family member stated he went to the facility and helped search for the resident. Resident #01's family member also stated he did not know what would have happened if the police canine dog had not located the resident. Resident #01's family member stated the resident was located down an unlit pathway, that was lined with overgrown shrubs and no handrails. Resident #01's family member stated the resident was found at the bottom of this pathway (ramp) curled up. Resident #01's family member stated the resident did not smoke and should have never been let out the door. Observation with the Administrator on 08/19/20 at 2:00 P.M. of a facility video from a camera located near the Unit A exit door revealed the video was dated 08/14/20 at 9:42 P.M. In the video, STNA #70 was leaning against the wall in front of Unit A exit door. Resident #01's back was observed to the camera, but it appeared Resident #01 spoke to STNA #70. STNA #70 then opened the Unit A exit door and let Resident #01 out into the courtyard. Resident #01 was wearing a dark t-shirt, grey sweatpants and exited the Unit A exit doors with a walker. Interview on 08/20/20 at 7:00 P.M. with STNA #71 revealed he does a head count when residents go out to smoke and another head count when letting them back inside after smoking. STNA #71 stated both head counts were the same on 08/14/20. STNA #71 stated he was not aware STNA #70 had let Resident #01 out into the courtyard. STNA #71 stated the facility policy is to not allow dementia residents outside with the smokers. Review of the Columbus Weather Underground Report revealed on 08/14/20 the sunset was at 8:24 P.M. Further review of the weather report revealed on 08/15/20 at 12:51 A.M., the outside temperature was 60 degrees Fahrenheit (F), at 1:51 A.M., the outside temperature was 61 degrees F and at 2:51 A.M., the outside temperature was 59 degrees F. Review of facility policy titled Elopement, dated 12/2007 and amended on 08/10/2020, revealed the facility will continue to assess for risk of elopement/wandering upon admission, quarterly, and with any signs and symptoms of risk. This deficiency substantiates Complaint Number OH 073.

Based on observation, medical record review, resident and staff interview, and a review of the disciplinary investigation report log, the facility failed to provide a safe two person transfer resulting in an injury during a shower transfer. Actual harm occurred when the resident was transferred with one person assist and the incorrect lift resulting in a fracture of the resident's left arm. This affected one (#70)of three resident's reviewed for accidents/injuries. The facility census was 92. Findings Include: On 03/03/15 at 1:29 P.M. a review of the resident record for Resident #70 revealed the resident was cognitively impaired. A review of the resident ADL care plan dated 04/10/13 revealed a mechanical lift was required with two assists for all transfers. Review of the medical record indicated that a Hoyer lift was required for transfers. Further record review revealed the resident was listed as a two (plus) person assist with all transfers, total dependence with showers, and two person assist with showers. On 03/03/15 at 9:40 A.M. an interview with the B Hall Manager revealed Resident #70 had a shower on 02/06/15 that appeared to be uneventful at the time of the shower. However, the B Hall Manager reported that on 02/07/15 the B Hall Manager received a call at home after the staff noticed a bruise on Resident #70's left shoulder. The physician was notified at that time, and an order was received to monitor the resident while giving Tylenol for pain. Further interview revealed that later that same day Resident #70 started complaining of more pain, and the physician ordered an X-ray that came back positive for a fracture the next morning on 02/08/15. Further interview and record review revealed the doctor ordered that Resident #70 be sent to the hospital for evaluation, and returned to the facility that same day with new pain medication, and an order to follow-up with Orthopedics (Ortho) Clinic. Further medical record review revealed the resident did follow-up with Ortho Clinic on 02/19/15 and has another appointment with Ortho Clinic scheduled on 03/05/15. On 03/03/15 at 12:20 P.M. an interview with Resident #70 revealed "a man hurt my arm". State tested Nurse Aide (STNA) #44 was observed sitting behind a curtain assisting another resident with the midday meal. An interview with STNA #44 revealed that STNA #44 had assisted Resident #70 with a shower on 02/06/15 but "she was fine". On 03/03/15 at 12:30 P.M. an interview with STNA #42 revealed no knowledge of any resident being abused, but reports that Resident #70 had an injury to the left arm or shoulder. Further interview revealed Resident #70 had reported to STNA #42 that "a man did it", but there was no man working when the resident was injured. On 03/03/15 at 12:33 P.M. an interview with STNA #110 revealed no knowledge of any resident being abused, but reports that Resident #70 has a fractured arm. Further interview revealed Resident #70 reported a man hurt the residents arm, but no man was working when the injury was noted. On 03/03/15 at 12:45 P.M. an interview with STNA #44 revealed no knowledge of anyone abusing residents and STNA #44 reports "I would report it". During the interview STNA #44 it was noted she had a deep voice. On 03/03/15 at 1:10 P.M. an interview with the Administrator and the Director Of Nursing (DON) revealed an investigation had been completed concerning the left arm injury sustained by Resident #70 and STNA #44 was disciplined and retrained concerning lifts and resident rights after it was determined the resident was injured on 02/06/15 while being lifted during a shower. Further interview revealed that during the investigation it was determined that Resident #70 referred to STNA #44 as "a man", and STNA #44 was not following the care plan while showering Resident #70 on 02/06/15. On 03/03/15 at 4:25 P.M. a review of the investigation summary revealed that it was determined that STNA #44 failed to use a proper mechanical lift which resulted in injury/fracture to Resident #70's left arm. Further review of the investigation summary revealed the employee failed to check the plan of care before performing the task with Resident #70. Further review of the investigation paperwork provided by the facility confirmed a stand-up lift was used with one person assist during a shower provided by STNA #44 on 02/06/15. On 03/03/15 at 4:41 P.M. a review of the personnel file for STNA #44 revealed that STNA #44 has a current STNA license. Further review of the disciplinary portion of the personnel file revealed that STNA #44 was disciplined for the actions on 02/06/15. This was an incidental deficiency found during the investigation of Complaint Number OH 833.

Based on record review and staff interview, the facility failed to provide appropriate treatment and services to restore as much normal bladder function as possible. This affected two (Resident #46 and #88) of three residents reviewed for urinary incontinence. Harm occurred to Resident #46 when her bladder incontinence increased from occasionally incontinent to frequently incontinent without intervention. The facility identified 52 residents who were occasionally or frequently incontinent of bladder and 38 residents who were occasionally or frequently incontinent of their bowels. Findings include: 1. Review of Resident #46's medical record revealed Resident #46 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #46 was readmitted [DATE] and 05/19/13. Physician orders [REDACTED]. Admission paperwork from the hospital revealed Resident #46 had frequency, urgency, dysuria, incontinence and nocturia however review of the admission 03/29/13 Urinary Incontinence and Indwelling Catheter assessment revealed Resident #46 had no risk factors, bladder irritants, diagnostic procedures or appliances and was on antihypertensives. The assessment indicated she had no incontinence. Review of the 04/04/13 admission Minimum Data Set (MDS) assessment indicated Resident #46 was occasionally incontinent of bladder and required the extensive assistance of two staff for toileting. Review of the 08/26/13 quarterly MDS assessment revealed Resident #46 was frequently incontinent of urine and required the extensive assistance of one staff for toileting. Review of the Intervention task sheets the State tested Nursing Assistants (STNA) use for documentation of toileting revealed Resident #46's incontinence had increased since admission. Resident #46 was admitted [DATE]. There were no documented episodes of incontinence in March of 2013. In April and May of 2013 there were five episodes of incontinence documented each month. STNA documentation for June of 2013 revealed there were 10 episodes of urinary incontinence. In July of 2013, 28 episodes of incontinence were documented and in August of 2013, 44 episodes of urinary incontinence were documented by the STNA's on their task sheets. From the 03/28/13 admission through the end of August there were 13 episodes of bladder incontinence on day shift, 70 episodes on afternoon shift and eight episodes on night shift. Review of the urinary incontinence plan of care revealed the incontinence was related to functional incontinence, use of diuretic medication with a goal of no complications due to incontinence. The interventions included to assist with toileting, provide incontinence care as needed, report changes in skin integrity found during daily care and report signs and symptoms of urinary tract infections such as flank pain, complaint of burning, pain, fever, hematuria and change in mental status. There was no evidence the facility attempted a toileting program to improve the resident's incontinence. On 10/22/13 at 3:54 P.M. in an interview with Resident #46 she revealed that she knows when she has to go to the bathroom but is blind and needs assistance getting to the toilet. Resident #46 said she takes blood pressure medicine which keeps the staff busy with toileting her. Resident #46 indicated that she wears pull ups as a precaution. On 10/23/13 at 10:32 A.M. STNA's #26 and #68 and Licensed Practical Nurse #107 indicated Resident #46 knows when she has to go to the bathroom and is mostly continent on day shift. On 10/23/13 at 1:57 P.M. the Director of Nursing (DON) verified the facility did not complete a bladder assessment with the readmissions on 05/10/13 or 05/19/13 or with the increase in incontinence per facility policy. The DON further verified the inaccurate admission urinary incontinence assessment on admission that indicated Resident #46 was continent of bowel and bladder. On 10/24/13 at 9:15 A.M. the DON verified the facility had not attempted a toileting program for Resident #46 since admission. The facility did not initiate a toileting program to prevent further decline in urinary incontinence when the incidents of incontinence increased. Review of the 2012 facility policy titled Urinary Incontinence Practice Guide Flow Sheet revealed an assessment should be completed on admission, readmission and with a change in continence. 2. Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission comprehensive assessment dated [DATE] revealed Resident #88 was assessed as occasionally incontinent. Resident #88 was discharged to the hospital on [DATE] with a return date of 06/05/13. On 06/12/13 an assessment was completed as required with the resident's urinary continence being assessed as always continent. On 10/24/13 a review of the care plan for Resident #88 showed no revisions in the area of urinary incontinence since the initiation date of 05/17/13. On this date the care plan states " At risk for complications r/t (related to) occasional urinary incontinence." No restorative interventions or programs are addressed to assist Resident #88 to regain the level of always continent as assessed on 06/12/13. Two more assessments were completed in August of 2013, one for significant change on 08/04/13 and one after a return from the hospital on [DATE]. Both assessments listed Resident #88 as again being occasionally incontinent. Licensed Practical Nurse (LPN) #6 stated during interview on 10/24/13 at 11:20 A.M. confirmed that the resident was incontinent at times. LPN #6 provided no information on interventions or programs to return the resident to the level of continence as documented on the 06/12/13 assessment.