Every finding on record at Carecore at Mary Scott

Based on record review and staff and resident guardian interviews, the facility failed to follow a resident's legal guardian's requests to not allow the resident to go on unsupervised Leave of Absences (LOA's) from the facility. This affected one (#59) out of three reviewed for supervision. The facility census was 59. Findings include: Review of the medical for Resident #59 revealed an admission date of 09/13/17 with diagnoses of bipolar disorder, current episode manic severe with psychotic features, anxiety disorder, and schizoaffective disorder. Review of the Annual Minimum Data Set (MDS), dated [DATE] revealed Resident #59 was cognitively intact with a brief interview mental status (BIMS) of 15 out of 15. Review of the care plan, dated 06/20/18 revealed Resident #59 was at risk for injury related to elopement, not a wanderer, unsatisfied with guardian placement, has intent to leave facility, and Schizophrenia, with interventions of update boundaries, mental status and guardian guidance/consent. Guardian sometimes gives permission for resident to sign self out. Review of the Amended Letters of Guardianship, dated 06/09/22 revealed Resident #59 was deemed incompetent and a legal guardian was in place over person only through the probate court of [NAME] county, Ohio. Review of the Release of Responsibility for Leave of Absence form, revealed between 12/26/25 and 04/20/26 Resident #59 signed herself out and went on unsupervised LOA's from the facility 159 times. Interview on 04/28/26 at 10:34 A.M. with Resident #59's guardian confirmed she has asked the facility Director of Nursing (DON) and the Administrator for months to not let Resident #59 leave the facility unsupervised due to the resident having Schizophrenia and is not taking her medications. Interview with Resident #59's guardian also confirmed despite the request the facility allows Resident #59 to go on unsupervised LOA's and she has seen the resident downtown at a bus stop punching people and at the bread store. Interview on 04/28/26 at 2:26 P.M. with Regional Director of Clinical Operations (RDCO) #209 confirmed the facility has allowed Resident #59 to leave the facility unsupervised on a daily based because the resident has a BIMS of a 15, cognitively intact and because she has rights, Interview with RDCO #209 also confirmed Resident #59 has a guardian who has voiced she does not want the resident to go on LOA's. Interview on 04/28/26 at 3:42 P.M. with Administrator and the DON confirmed they have allowed Resident #59 to leave the facility unsupervised on a daily basis, even though the guardian informed the facility to not let the resident leave. Interview with the Administrator and DON confirmed they allowed Resident #59 to leave on her own because of resident rights and resident has a BIMS of 15, which means she is cognitively intact. Interview with the Administrator and DON also confirmed that the facility has filed with the courts on resident's behalf for a new guardian. This deficiency represents non-compliance investigated under Complaint Number 2983488.

Based on medical record review, staff interview, review of a facility document, review of email correspondence, and policy review, the facility failed to ensure timely assistance with a resident/family initiated request for discharge to another facility. This affected one (Resident #27) out of three residents reviewed for discharge. The facility census was 64.Findings Included:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included type two diabetes, dementia, nutritional deficiency, acute kidney failure, transient ischemic attack, and atherosclerotic heart disease.Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of eight documented cognitive impairment. Resident #27 was set up or clean-up for oral care, and personal hygiene. Resident #27 was independent for personal hygiene, toileting, bathing, dressing upper and lower body, and placing shoes on and off feet. Review of a progress note dated 01/21/26 the Licensed Practical Nurse (LPN) #300 documented Resident #27 stated she was supposed to move to another facility today, Resident #27 was informed she had no transfer or discharge orders to leave the facility. Resident #27 became agitated and was redirected multiple times.Review of a progress note dated 01/23/26 the Social Service Worker (SSW) #240 spoke with Resident #27's daughter and guardian about recent behaviors. Resident #27's daughter stated she was requesting a transfer to another facility with a memory care unit. The referral has been sent.Review of an admission progress note dated 02/05/26 the Admissions Director (AD) #162 spoke with Resident #27's daughter, who was also power of attorney, who wanted referrals sent to other facilities with memory care units. AD #162 reached out to their Senior Social Worker #250 to assist with the request.Review of a facility document titled Durable Power of Attorney for Financial Matter date April 2025 revealed it was signed by Resident #27, her family, and a witness.Review of an email correspondence dated 02/05/26 from the AD #162 to the Senior Social Worker #250 that Resident #27's daughter, also the power of attorney, would like the resident moved to another facility with a memory care unit. The AD #162 documented Resident #27's daughter would like the referrals sent to the following facilities and listed five facilities by name in the email. A return email by the Senior Social Worker #250 documented she would take care of these by the end of the business today (02/05/26). Review of an email correspondence dated 02/12/26 from the AD #162 to the Senior Social Worker #250 requesting an update. The Senior Social Worker #250 replied to the email she would physically be in the building on Tuesday. The email correspondence further documented she had state in three of her facilities and it was a little crazy.Interview on 03/25/26 at 9:45 A.M., SSW #240 said he sent the referral on 01/23/26 and he was let go from his work position on the same day. Resident #27 told the facility she wanted to leave. The SSW #240 said he spoke with the daughter who said she wanted her mother, Resident #27, to go to another facility. Resident #27 was having behaviors and really did not want to stay at this facility. Interview on 03/25/26 at 10:10 A.M., the Senior Social Worker #250 said she told AD #162 to send the referrals for Resident #27. Interview on 03/25/26 at 11:00 A.M., the AD #162 said she was not told to send the referrals out. The AD #162 further said the Senior Social Worker #250 told her she was sending the referrals out for Resident #27 in an email. The AD #162 verified there was only one referral sent out on 01/23/26. Review of the facility policy titled Discharge Planning Policy and Procedures, dated 07/28/25 revealed the facility was committed to ensuring that all residents discharges are conducted in a safe, person-centered, and compliant manner in accordance with Center of Medicaid and Medicare regulations. Discharges will be planned collaboratively with the residents, their representatives, and the interdisciplinary team, with a focus on continuity of care, residents' rights, and regulatory compliance.This deficiency represents non-compliance investigated under Complaint Number 2805346.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure weekly skin assessments and treatments were completed as ordered. This affected one (Resident #23) out of three residents reviewed for wounds. The facility census was 64.Findings Included:Review of the medical record for Resident #23 revealed an admission date of 08/27/22. Diagnoses included morbid obesity, anxiety disorder, nonpsychotic mental disorder, schizoaffective disorder, chronic pain syndrome, osteoarthritis, and major depression. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #23 had Brief Interview of Mental Status (BIMS) score of 10 revealing she had moderate cognitive impairment. Resident #23 was bed bound and required staff assistance for activities of daily living (ADL). Review of the weekly skin assessment dated from 12/18/25 where the heel wound was identified through 03/23/26 revealed Resident #23 had skin assessments on 02/03/26 and 03/17/26. Review of the treatment administration record (TAR) dated from 12/18/25 through 03/24/26 revealed the left heel wound was documented as completed. Specifically, on the dates 03/21/26 Licensed Practical Nurse (LPN) #204 signed the treatment was completed. On 03/22/26, LPN #202 signed the treatment was completed. On 03/23/26, LPN #155 signed the treatment was completed.Review of a physician order dated 03/06/26 revealed Resident #23 had a wound care order to cleanse the left heel with wound cleanser or normal saline, pat dry, apply collagen to the wound bed, and cover with a border foam dressing every night and as needed.Review of the plan of care dated 03/24/26 revealed Resident #23 was at risk for skin breakdown related to incontinence, decreased mobility, impaired cognition secondary to dementia and obesity. Resident #23 was resistive to care and turning and repositioning. A treatment was in place for the left heel. Interventions included complete skin treatments, monitor effectiveness, change treatments as indicated per physician orders, encourage residents to turn and reposition every two hours and as needed.Observation and interview on 03/24/26 at 11:24 A.M., of Resident #23's left heel dressing with LPN #206 verified the dressing on Resident #23's left heel was dated 03/22/26 with the initials of LPN #204. LPN #206 verified the dressing on Resident #23's left heel was two days old. The Director of Nursing (DON) was in the room at the time of the observation.Interview on 03/24/26 at 12:15 P.M., the DON also verified Resident #23's left heel dressing had the date of 03/22/26. The DON verified LPN #204 worked night shift on 03/21/26 and dated the dressing of the left heel 03/22/26 and signed the TAR on 03/21/26. Interview on 03/24/26 at 12:22 P.M., LPN #202 stated he did not know Resident #23 had treatment for her left heel. LPN #202 stated he was not falsifying documentation when signing the treatment off. LPN #202 verified he had not completed the left heel treatment on 03/22/26. During a follow-up interview on 03/24/26 at 2:02 P.M., the DON stated she expected nursing staff to complete skin assessments weekly and document the findings on the facility skin review that it was done; unless a resident refused or was out of the facility. The DON verified Resident #23 had only two skin assessments completed on 02/03/26 and 03/17/26. The DON said the wound had improved and it was smaller in size.Review of the facility policy titled Wound Care dated 2001 revealed the purpose of this procedure was to provide guidelines for the care of wounds to promote healing. Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice.Review of the facility policy titled Pressure Injury Risk Assessment dated '2001' revealed that the purpose of this procedure was to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission was completed. Repeat the risk assessment weekly for the first four weeks, if there was a significant change in condition, or as often as was required based on the resident's condition. Conduct a comprehensive skin assessment with every risk assessment. This deficiency represents non-compliance investigated under Complaint Number 2784368.

Based on interview, observation, record review, and facility policy review, the facility failed to date opened vials of insulin and failed to remove expired insulin from two of four medication carts observed. The facility census was 71.Findings include:An observation on 12/12/25 at 9:45 A.M. of the medication cart for the 100 Hall revealed a vial of Lantus (a type of insulin) with an open date of 11/13/25. During a concurrent interview, Licensed Practical Nurse (LPN) #7 stated Lantus was good for 28 days after the open date, which meant the vial of Lantus was expired and should have been removed from the medication cart. LPN #7 stated that the medication carts were checked weekly during the medication cart audits, and the nurse giving the medication was expected to check the labels of medications for expiration dates prior to giving the medication. LPN #7 stated she would discard the expired insulin. An observation on 12/12/25 at 9:55 A.M. of the medication cart for the 200 Hall revealed one vial of insulin that had an open date of 10/31/25. Three vials of insulin had been opened, insulin used, and the vials were left undated as to when they were opened. During an interview on 12/12/25 at 9:55 P.M., LPN #8 stated the insulins were good for a month after opening. LPN #8 stated she had no information on the medication cart that identified when each type of insulin expired, and she just had to remember. LPN #8 stated if a resident was given an insulin that had expired, the insulin may not be as effective in controlling the resident's blood sugar. LPN #8 stated it was the responsibility of the nurse that opened the vial of insulin or opened the insulin pens to place a date on the containers when opened. During an interview on 12/12/25 at 11:32 A.M., the Infection Preventionist (IP) stated the unit managers were responsible for checking the carts weekly to make sure all medications were labeled, dated, and remove all expired, discontinued, and opened but undated medications. The IP stated that removing those medications from the carts helped prevent medication errors. The IP stated it was also the responsibility of the nurses to check expiration dates and medication labeling as they gave medication. The IP stated expired insulin may not be as effective and put the resident at risk of uncontrolled blood sugar. During a telephone interview on 12/12/25 at 11:46 A.M., the Medical Director (MD) stated that expired medications, such as insulin, were not as effective but otherwise caused no harm to the residents. During an interview on 12/12/25 at 2:28 P.M., the Interim Director of Nursing (IDON) stated that when a vial of insulin or an insulin pen was opened, the nurse was expected to put the open date on the vial or pen. The IDON stated that most insulin was good for 28 days, but there were exceptions. The IDON stated the process for making sure expired insulin or undated insulins were removed from the medication carts included weekly checks by the unit manager. The IDON stated she was the manager for the 100 Hall and 200 Hall and stated she had last checked those carts two weeks prior. The IDON stated she expected the nurses giving the insulin to also check the vials for expiration or lack of dating and stated that undated and expired medications should be discarded. The Administrator was interviewed on 12/13/25 at 10:43 A.M. and stated nurses should not use expired insulin, and if the insulin were undated, the insulin should not be used since the nurse would not know if the insulin had expired. A facility policy titled, Medication Labeling and Storage, dated 2001, indicated, Multi-dose vials that have been opened or accessed (e.g. [exempli gratia, for example], needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and facility document and policy review, the facility failed to ensure food was prepared and served in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff wore beard restraints during food preparation, and the facility failed to ensure chemical test strips used to check the concentrations of sanitizing solutions were not expired. This affected all residents who ate food prepared in the kitchen. Findings include:1. An observation on 12/10/25 at 9:45 A.M. revealed Dietary [NAME] (DC) #5 was not wearing a beard restraint to cover his beard and mustache while preparing pork chops and cornbread. An observation on 12/10/25 at 11:47 A.M. revealed DC #6's hair restraint was not covering his beard while he was preparing mechanically altered pork chops. An observation on 12/10/25 at 11:54 A.M. revealed DC #6's hair restraint was not covering his beard while he was preparing pureed pork chops. An observation on 12/10/25 at 12:04 P.M. revealed DC #6's hair restraint was not covering his beard while he was preparing mechanically altered coleslaw. During an interview on 12/10/25 at 2:47 P.M., DC #5 stated that he should have worn the beard restraint to cover his beard and mustache as soon as he entered the kitchen. DC #5 stated he should have worn the beard restraint so that no hair fell on the food and for infection control reasons. During an interview on 12/10/25 at 2:58 P.M., DC #6 stated he should have covered both his beard and mustache while in the kitchen, so that no loose hair went to the food. During an interview on 12/11/25 at 3:11 PM, the Dietary Manager (DM) stated staff should use hair restraints to cover their beards and mustaches until the beard restraints could be ordered so that no hair follicles fell in the food to contaminate the food. During an interview on 12/11/25 at 3:23 P.M., the Dietetic Technician Registered (DTR) stated hair restraints to cover the beards and mustaches should have been used so that hair did not go in the food. During an interview on 12/13/25 at 10:59 A.M., the Administrator stated hair restraints should be worn before entering the kitchen and should cover the head, beard, and mustache to prevent contamination of food. A facility policy titled, Food Preparation and Service, revised April 2019, indicated, Policy Statement - Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. The section Food Preparation Area revealed 5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. The section Food Service/Distribution revealed 7. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.[et cetera, and other similar things]) so that hair does not contact food. 2. During a concurrent observation and interview on 12/10/25 at 10:12 A.M., the Dietary Manager (DM) indicated ammonium chloride was the sanitizing solution used for pots and pans and when sanitizing kitchen surfaces. An observation of the DM using QT-40 strips to test two buckets of sanitizing solution revealed the DM stated the strips' expiration date was 10/15/16, and she would order a new test strips because they were not effective. During an interview on 12/10/25 at 10:18 A.M., the DM revealed a chlorine based sanitizing solution was used during the final rinse of the facility's low temperature dishwashing machine. The DM stated the chlorine test strips' expiration date was June 2024, and she would order new ones because the strips were not effective. During an interview, on 12/11/25 at 3:23 P.M., the DTR stated the dietary staff should have checked the expiration dates of the testing strips used in checking the concentration of sanitizing solutions. The DTR stated the testing strips should not be expired to make sure the chemicals sanitized well. During an interview on 12/13/25 at 10:50 A.M., the Administrator stated the testing strips should not be expired and should be within date to show a true outcome of what was tested and to avoid false negative testing. A facility policy titled, Sanitization, revised November 2022, indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. The policy also indicated, 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. The section Low-Temperature Dishwasher (Chemical Sanitization) indicated, (3) The chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. The policy also indicated 6. Manual washing and sanitizing is a three-step process for washing, rinsing and sanitizing, and Chemical sanitizing solutions (e.g. [exempli gratia, for example], chlorine, iodine, quaternary ammonium compound) are used according to manufacturer's instructions. A facility document titled [Brand Name] QT-40 [Quaternary 40, chemical test strips used to measure the concentration of quaternary ammonium in sanitizing solutions] revealed a copy of the bottle label of the facility's test strips. The label revealed the expiration date of the facility's QT-40 test strips was 10/15/16, and the label did not indicate the reference range for the correct concentration of quaternary ammonium. A facility document titled [Brand Name] Chlorine Test Paper [chemical test strips used to measure the concentration of chlorine in sanitizing solutions] label revealed a copy of the bottle label of the facility's test strips. The label revealed the expiration dates of the facility's chlorine test strips was June 2024, and the label did not indicate the reference range for the correct concentration of chlorine. This violation represents noncompliance investigated under Complaint Number 2612053.

Based on interview, record review, and facility policy review, the facility failed to allow a resident to determine their own treatment options. This affected one (#43) of two residents reviewed for exercising treatment options. The facility census was 71. Findings include: An admission Record revealed the facility admitted Resident #43 on 07/12/25. According to the admission Record, Resident #43 had a medical history that included diagnoses of type II diabetes mellitus, essential hypertension, old myocardial infarction (heart attack), unspecified diastolic heart failure, atherosclerotic heart disease, schizophrenia, psychosis, depression, adjustment disorder with mixed anxiety and depressed mood, and attention-deficit hyperactivity disorder-combined type. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/20/25, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #43 did not exhibit hallucinations, delusions, or rejection of care during the assessment timeframe. Resident #43's Care Plan Report revealed no documentation related to repeatedly requesting to be transferred to the hospital. Resident #43's Progress Notes revealed a note, dated 08/23/25 at 12:14 A.M., that indicated that Resident #43's roommate got the nurse and told her that Resident #43 was not doing well. The note indicated that on assessment, the nurse found Resident #43 to be pale, with their skin clammy and cool to the touch. The note indicated that the resident was twitching uncontrollably, had urinated on themself and was unstable. The note revealed that Resident #43 requested to go to the hospital. Per the note, the nurse called the primary care provider (PCP), who ordered laboratory tests, including a drug screen, and to monitor the resident. The note indicated that Resident #43 informed the nurse that they had nothing to eat. The note indicated that the nurse provided the resident with a sandwich. The note indicated that the nurse monitored the resident for the rest of the shift and had no further concerns. Resident #43's Progress Notes revealed a note, dated 09/09/25 at 12:18 P.M., that revealed that earlier in the shift, Resident #43 reported difficulty breathing. The note indicated that the resident's vital signs were checked. The note revealed that the resident appeared to be sweating and shaking off and on. The progress note revealed that Resident #43 requested to go to the emergency room (ER). The note indicated that when the nurse asked the resident to explain the problem, the resident requested that the nurse not tell the PCP their oxygen saturation. The note indicated that after the nurse informed Resident #43 that the PCP would be told all their vital signs, the resident seemed to calm down. Resident #43's Progress Notes revealed a note, dated 10/19/25 at 2:13 A.M., that revealed that during the night medication pass, the resident complained of diarrhea and was not feeling well. The note indicated that earlier, Resident #43 had complained to the day shift nurse. The note indicated that the nurse gave the resident medication for diarrhea. The note indicated that at 2:00 A.M., Resident #43 approached the nurse and Resident #43 was reminded the nurse had given medication to the resident earlier. Per the note, Resident #43 told the nurse they wanted to go to the hospital due to nausea and continued not to feel well from earlier. The note indicated that the PCP was notified, and a voice message was left. The note indicated that medication was given for nausea and indicated that monitoring would continue. Resident #43's Progress Notes revealed a note, dated 10/19/25 at 5:39 P.M., that indicated that Resident #43 had complaints of chest pain and wanted to be sent to the hospital. The note indicated that the PCP was contacted and instructed the nurse to give the resident an antacid and a muscle relaxer.During an interview on 09/29/25 at 11:14 A.M., Resident #43 stated that Licensed Practical Nurse (LPN) #2 knew there had been a time they wanted to go to the hospital, but the PCP would not let them be sent. The resident stated that they did not sleep for two nights and sweated during the day. Resident #43 stated that the facility staff finally drew blood for laboratory testing, but they felt better by that time. During a follow up interview with Resident #43 on 12/08/25 at 9:38 A.M., Resident #43 stated that LPN #2 knew they wanted to go to the hospital, but her hands were tied because the PCP would not agree to send the resident. The resident stated that around 10/19/25, they had felt bad the entire weekend. Resident #43 stated that when the nurse called the PCP, the PCP stated that the resident had no history of cardiac issues. Resident #43 stated that the chest pain radiated down their left arm. Per the resident, the problem turned out to be anxiety, but they still did not understand why the PCP would not allow the resident to be sent to the hospital for chest pain. LPN #2 was interviewed on 12/09/25 at 10:43 A.M. LPN #2 stated she remembered when Resident #43 requested to go to the hospital and requested she not tell the PCP what their oxygen level was and had told her that their oxygen level dropped when they laid down. The Social Services Director (SSD) was interviewed on 12/11/25 at 11:41 A.M. The SSD stated that while Resident #43 had not reported issues of wanting to go to the hospital and being denied, she had overheard a discussion about the resident wanting to transfer to the hospital during a morning meeting. The SSD stated that she had overheard the conversation but was not involved in the discussion. The SSD stated that she had not followed up with Resident #43 about the issue. The SSD stated that if the resident wanted to go to the hospital, it was their right and if the resident felt they needed to seek healthcare elsewhere, the resident had the right to seek that care. A telephone interview was held with LPN #3 on 12/11/25 at 1:23 P.M. The LPN stated that she remembered Resident #43 requested to go to the hospital twice. She stated that in August 2025, the resident's blood sugar had measured 44. She stated she gave the resident something to eat, the symptoms resolved, and the resident did not request to go to the hospital again. She stated that in September 2025, Resident #43 complained of diarrhea, and she gave the resident medication. She stated she called the PCP, but the PCP did not return the call. LPN #3 stated that while she had not called the PCP many times, his usual reply for any problem was laboratory tests and a drug screen. LPN #3 stated that the times she had been with Resident #43, the resident received adequate treatment in the facility and had not required transfer to the hospital.Attempts were made on 12/11/25 at 1:44 P.M. to call LPN #4, who provided care to the resident when they had the episode with chest pain, and the phone had been disconnected.A telephone interview was held with the PCP on 12/12/25 at 11:41 A.M. The PCP stated that he always gave options to residents of being transferred to the hospital or being treated in the facility. The PCP stated that Resident #43 was able to be treated in the facility as easily as in the hospital, and there was nothing that would have been done in the hospital that could not have been done in the facility. He stated that Resident #43 frequently became frustrated and wanted to go to the hospital, and he referred to Resident #43 as a frequent flier that liked to go to the ER for pain medication. The PCP stated that if Resident #43 had transferred to the hospital in August 2025, September 2025, or October 2025, the hospital would have just sent the resident back to the facility, citing that he knew that because he was an ER physician. The PCP stated that he was aware Resident #43 had a cardiac history but stated that the resident's cardiac problems had not been recent. The PCP stated that Resident #43 saw several counselors, and nothing was going to make the resident happy. Resident #43 was interviewed on 12/12/25 at 2:01 P.M. The resident stated that their blood sugar had been low, and while the blood sugar rose after getting the sandwich, there had been difficulty keeping the blood sugar at a normal level. The resident stated the chest pain in October had radiated to the left arm and added they did not appreciate the PCP telling the nurse there was no cardiac history. Resident #43 stated that even with the symptoms temporarily resolving in August 2025, September 2025, and October 2025, they still would have wanted to be transferred to the hospital. The Interim Director of Nursing (IDON) was interviewed on 12/12/25 at 2:28 P.M. The IDON stated that Resident #43 had the right to be sent to the hospital if requested, even if the PCP refused. The IDON stated that even though Resident #43's symptoms had been resolved, if the resident wanted to go to the hospital, the staff should have complied with the resident's request.The Administrator was interviewed on 12/12/25 at 4:43 P.M. The Administrator stated that when a resident requested to be sent to the hospital, she expected the staff to assess the resident, reach out to the PCP, and if the resident still wanted to go to the hospital, they had the right to be transferred to the hospital. She stated that when Resident #43 wanted to go to the hospital, the resident should have been allowed to go.A facility policy titled, Resident Rights, revised February 2021, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to, which included, e. self-determination; f. communication with and access to people and service, both inside and outside the facility; and s. choose an attending physician and participate in decision-making regarding his or her care. This deficiency represents noncompliance investigated under Complaint Number 2656134.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was provided with reasonable access to a telephone in a private setting. This affected one (#23) of two residents reviewed for privacy. The facility census was 71.Findings include:An admission Record indicated the facility admitted Resident #23 on 11/21/17. According to the admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia, unspecified psychosis, anxiety disorder, and personality disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/25, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was independent with activities of daily living (ADLs). The MDS also indicated the resident had delusions, verbal behavioral symptoms directed toward others, and behavioral symptoms not directed towards others. Resident #23's Care Plan Report, initiated 02/14/25, indicated the resident had a potential for altered behavioral patterns, inappropriate verbal behaviors, intolerance of peers, and yelling at staff and residents. Interventions directed staff to be careful not to invade Resident #23's personal space and to be respectful of the resident's privacy. An observation on 12/10/25 at 3:26 P.M. revealed Resident #23 exited the second floor elevator and proceeded to the telephone station located directly across from the elevators. The observation revealed the telephone station was situated in an open area without doors or walls which allowed residents, staff, and visitors to unintentionally overhear telephone conversations. Resident #23 was observed sitting on their rollator walker (a mobility device with a seat) making a telephone call. An observation on 12/10/25 at 3:30 P.M. revealed another resident and staff exited the elevator and walked passed Resident #23, who was actively engaged in a telephone conversation. During an interview on 12/08/25 at 2:52 P.M., Certified Nursing Assistant (CNA) #14 stated the facility had phones that were not portable for residents to use and privacy was a concern as the designated phone station was an open area with no walls. During an interview on 12/10/25 at 3:43 P.M., Resident #23 stated, There is no privacy. Resident #23 stated they would rather use the telephone on the second floor than the phone on the first floor, where their room was located, due to less people walking by. During a concurrent observation and interview on 12/11/25 at 9:06 A.M., CNA #13 stated the facility had a phone in each station. The observation revealed a phone by the back nursing station close to the rehabilitation room, and there were no walls surrounding the nursing station. An observation of the middle nursing station, close to the elevator, revealed there was no phone that was easily accessible to the residents. The observation revealed the phone was located inside the oxygen storage room/nurse charting (documentation) room with a sign indicating the room was for staff only. CNA #13 stated the phone used to be located by the middle nursing station. During an interview on 12/11/25 at 10:49 P.M., Licensed Practical Nurse (LPN) #16 stated phones were down the 300 hallway and by the nursing station on the 400 hallway. LPN #16 stated the phones were located in the open. LPN #16 stated they used to have a phone by the snack machine but did not think the phone was there anymore. During an interview on 12/12/25 at 2:51 P.M., the Infection Preventionist (IP) stated residents had access to phones by the stations. The IP stated he offered residents use of his office for private phone calls as the nursing stations were open and the facility did not have a designated room for resident calls. During an interview on 12/13/25 at 9:48 A.M., the Interim Director of Nursing (IDON) stated residents should have access to a private area to use the telephone. The IDON stated the facility did not want residents to feel that staff or others might overhear their telephone conversations, particularly when discussing personal information. During an interview on 12/13/25 at 10:50 A.M., the Administrator stated the residents should have privacy when using the facility telephones. A facility policy titled, Resident Rights, revised February 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to access to a telephone, mail, and email; and communicate in person and by mail, email and telephone with privacy. A facility policy titled, Telephones, Resident Use of, revised May 2017, indicated, Designated telephones are available to residents to make and receive private telephone calls. Telephones will be in areas that offer privacy and accommodate the hearing impaired and wheelchair-bound residents. This deficiency represents noncompliance investigated under Complaint Number 2612053.

Based on facility policy review, record review, and interview, the facility failed to report allegations of abuse to the State Survey Agency (SSA). This affected three (#69, #43, and #78) of three residents reviewed for abuse. The facility census was 71.Findings include:1. An admission Record revealed the facility admitted Resident #69 on 07/12/25. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/25, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not exhibit physical behavioral symptoms directed toward others or verbal behavioral symptoms directed toward others during the assessment timeframe. Resident #69's Care Plan Report included a focus area initiated 07/30/25, that indicated the resident had impaired cognitive function/impaired thought process related to dementia. Undated interventions directed staff to communicate with the resident/family/caregivers regarding the resident's capabilities and needs. During a telephone interview on 12/10/25 at 10:34 A.M., Certified Nursing Assistant (CNA) #9 stated that on 12/06/25, Resident #69 told her that Registered Nurse (RN) #10 shoved a bedside table into the resident's knee and that the nurse was rough and disrespectful. She stated that she called the Interim Director of Nursing (IDON) to report the allegation. She stated that the IDON told her she did not believe the CNA. She stated that the resident continued to talk about the incident for the rest of her shift. During an interview on 12/10/25 at 11:14 A.M., Resident #69 stated that a staff member took the resident's table and slammed it against the resident's legs. The resident stated that there was water in a cup and it spilled. Resident #69 stated that the staff did not care or excuse themselves. The resident stated that they (Resident #69) told other staff that the staff member slammed the table into the resident's legs and spilled water, but the resident could not remember who they told. During an interview on 12/10/25 at 1:02 P.M., CNA #11 stated that on 12/06/25, Resident #69 was walking the hall stating that a table was hit against their leg and hurt their leg. She stated that she did not ask the resident who bumped the table into the resident's leg. During a telephone interview on 12/10/25 at 2:31 P.M., RN #10 stated that when she was in Resident #69's room, the resident accused her of spilling water on the resident. She stated that when the resident came out of the resident's room, the resident accused her of shoving a table into the resident's leg. She stated she called the IDON immediately after the resident accused her of shoving the table into the resident's leg to report the allegation. During an interview on 12/10/25 at 3:42 P.M., the IDON stated that RN #10 reported to her that Resident #69 had alleged RN #10 spilled water on the resident. She stated that CNA #9 had reported to her that the CNA heard Resident #69 state that RN #10 was rude. The IDON stated that she denied the Administrator's phone number to CNA #9 because she did not feel it was appropriate to hand it out. She stated that the Administrator was the Abuse Coordinator. During a follow-up interview on 12/10/25 at 4:33 P.M., the IDON stated that being rude was not an allegation of abuse because it did not sound like RN #10 was being abusive. She stated that the allegation that water was spilled was an allegation of abuse if it was purposeful. She stated that abuse needed to have occurred for it to be reportable to the SSA. She stated that when she investigated the allegations, she did not find abuse. During a follow-up interview on 12/11/25 at 8:42 A.M., CNA #9 stated that she requested the Administrator's phone number via a text message on 12/06/25 at 9:14 P.M. to the IDON, and the IDON refused. The resident's record revealed no evidence that the allegations were reported to the SSA. During an interview on 12/11/25 at 3:30 P.M., the Administrator stated that the IDON called her late on 12/06/25 or early 12/07/25 to report that CNA #9 did not want to obtain vital signs, and she and RN #10 had a history of not getting along elsewhere. The Administrator stated that she was not aware of water being spilled or a table being shoved against Resident #69's legs. She stated that it depended on the intent whether the water being spilled on the resident was an allegation of abuse. The Administrator stated that CNA #9, CNA #11, and RN #10, who heard Resident #69 allege that a table was shoved into the resident's legs, should have reported to the IDON or to herself. She stated that the IDON should not have denied CNA #9 her phone number. She stated that she was not aware that CNA #9 had called the IDON about the incident. She stated that she expected staff to report allegations of abuse immediately to the DON who would then report it to her, or they could report the allegation to her themselves. She stated that the facility had two hours to report an allegation of physical abuse to the SSA. She stated that the allegations should have been reported to the SSA when they were reported to the IDON. 2. An admission Record revealed the facility admitted Resident #43 on 07/12/25. According to the admission Record, Resident #43 had a medical history that included diagnoses of type II diabetes mellitus, essential hypertension, old myocardial infarction (heart attack), unspecified diastolic heart failure, atherosclerotic heart disease, schizophrenia, psychosis, depression, adjustment disorder with mixed anxiety and depressed mood, and attention-deficit hyperactivity disorder-combined type. A quarterly MDS, with an ARD of 10/20/25, revealed Resident #43 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #48 did not exhibit hallucinations, delusions, or rejection of care during the assessment timeframe. Resident #43's Care Plan Report revealed no documentation that indicated Resident #43 fabricated stories about staff. During an interview on 09/29/25 at 11:14 AM, Resident #43 stated that CNA #18 told them (Resident #43) to shut up. The resident stated that the CNA told them to shut up when they removed sugar from a coffee cart. The resident stated that the CNA refused to respond when spoken to and was very rude. The resident's allegation was reported to the Administrator on 09/29/25 at 11:45 A.M. Upon returning to the facility on [DATE], a surveyor request was made for all the allegations of abuse that were reported to the SSA. There was no report for the allegation that Resident #43 made against CNA #18. The Social Services Director (SSD) was interviewed on 12/11/25 at 11:40 A.M. The SSD stated that the allegation of verbal abuse involving Resident #43 was not discussed with her in September 2025, after making the Administrator aware that the resident reported that CNA #18 told the resident to shut up. The SSD stated that any staff member telling a resident to shut up would be a form of abuse. The IDON and Regional Director of Clinical Services (RDCS) #21 were interviewed on 12/12/25 at 2:28 P.M. The IDON stated that if she became aware of an allegation of abuse, she immediately reported it to the Administrator, and the alleged perpetrator was suspended pending outcome of the investigation. The IDON stated that CNA #18 was still employed but had not been in the building for months due to a health issue. The IDON stated that if a staff member told a resident to shut up, it was verbal abuse, and the abuse should be reported immediately, then the facility had two hours to report the allegation of abuse to the SSA. The IDON stated that the incident between Resident #43 and CNA #18 had not been discussed at a morning meeting. RDCS #21 stated that she was unaware of the allegation of verbal abuse. An interview was held with the Administrator on 12/12/25 at 4:43 P.M. The Administrator stated that she had not reported Resident #43's allegation of abuse to the SSA, which had been reported to her on 09/09/25. She stated that she may have gotten distracted and forgot to write the allegation down and had forgotten the incident. 3. An admission Record revealed the facility had admitted Resident #78 on 07/20/23. According to the admission Record, the resident had a medical history that included diagnoses of severe recurrent major depression without psychotic features, anxiety disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, and cerebral palsy. An annual MDS, with an ARD of 06/30/25, revealed Resident #78 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #78 scored seven on the Resident Mood interview, which indicated the resident had mild depressive symptoms. The MDS revealed Resident #78 exhibited no behavioral symptoms during the assessment lookback period. Resident #78's Care Plan Report included a focus area initiated on 07/25/23, that revealed the resident wanted to return to the community after a short-term stay for rehabilitation. The Goal was to achieve discharge as planned, with a target date of 09/28/25. Undated interventions directed staff to encourage the resident to follow up with their primary care physician after discharge, encourage the resident and the family to be realistic with expectations, encourage the resident to be as independent as possible, review goals and confirm discharge plans with the resident and family, make referrals as recommended by the interdisciplinary team, and to provide one-to-one visits as needed to assess progress towards discharge plans. The Care Plan Report included a focus area initiated 07/26/23, that indicated Resident #78 had a history of polysubstance abuse. Undated interventions directed staff to gently redirect the resident when/if behaviors occurred and to notify the physician of any suspected substance abuse. An Emergency Notice of Discharge, dated 09/09/25, indicated that Resident #78 was being discharged because the health of other individuals in the facility was endangered. The specific allegations were listed as, Death threat made to a resident in the facility, and Firearms, knife, vial of various pills, fake and real looking police badge were found in the resident's room. The discharge notice indicated that the resident was being discharged to either their home or a homeless shelter. Resident #78's record revealed no evidence of the resident threatening another resident being reported to the SSA. The IDON was interviewed on 12/10/25 at 3:11 P.M. The IDON stated that staff should report an allegation of abuse immediately to their supervisor, herself, or the Administrator. The IDON stated that the Abuse Coordinator for the facility was the Administrator. The IDON stated that when there was an allegation of abuse, the facility had two hours to report the allegation to the SSA. The SSD was interviewed on 12/11/25 at 11:45 A.M. The SSD stated that Resident #78 was discharged because they had brought air soft rifles and handguns that were lifelike into the facility. The SSD stated that the items were found the day before the resident was discharged . The SSD stated that Resident #78 showed the articles to another resident and threatened to harm that resident, and that resident felt fearful. The Administrator was interviewed on 12/12/25 at 4:52 P.M. The Administrator stated that since Resident #78's discharge notice indicated that the resident was being discharged for threatening another resident, it should have been reported to the SSA. A facility policy titled, Abuse, Neglect and Exploitation, last reviewed 01/22/25, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed, VII. Reporting Response included, A. The facility will have written procedures that include, 1. Reporting of all alleged violations to the Administrator, state agency and to all other required agencies (e.g. [exempli gratia; for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. This deficiency represents noncompliance investigated under Master Complaint Number 2688424.

Based on facility policy review, record review, facility document review, and interview, the facility failed to thoroughly investigate allegations of abuse. This affected three (#69, #43, and #78) of three residents reviewed for abuse. The facility census was 71.Findings include:1. An admission Record revealed the facility admitted Resident #69 on 07/12/25. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/25, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not exhibit physical behavioral symptoms directed toward others or verbal behavioral symptoms directed toward others during the assessment timeframe. Resident #69's Care Plan Report included a focus area initiated 07/30/25, that indicated the resident had impaired cognitive function/impaired thought process related to dementia. Undated interventions directed staff to communicate with the resident/family/caregivers regarding the resident's capabilities and needs. A handwritten statement from Certified Nursing Assistant (CNA) #11, dated 12/07/25, indicated that on 12/06/25, a coworker from a contracted staffing agency complained about a nurse being rude. The statement indicated that the staff member kept talking about it just about all day and started talking about the nurse abusing someone. The facility's investigation documents revealed no evidence of Resident #69 or any other residents being immediately interviewed regarding RN #10's treatment of them, no evidence of RN #10 being suspended immediately pending investigation following the allegation, and no evidence of the resident being immediately assessed following the allegation. During a telephone interview on 12/10/25 at 10:34 A.M., CNA #9 stated that on 12/06/25, Resident #69 told her that Registered Nurse (RN) #10 shoved a bedside table into the resident's knee and that the nurse was rough and disrespectful. She stated that she called the Interim Director of Nursing (IDON) to report the allegation. She stated that the IDON told her she did not believe the CNA. She stated that the resident continued to talk about the incident for the rest of her shift. During an interview on 12/10/25 at 11:14 A.M., Resident #69 stated that a staff member took the resident's table and slammed it against the resident's legs. The resident stated that there was water in a cup and it spilled. Resident #69 stated that the staff did not care or excuse themselves. The resident stated that they (Resident #69) told other staff that the staff member slammed the table into the resident's legs and spilled water, but the resident could not remember who they told. During an interview on 12/10/25 at 1:02 P.M., CNA #11 stated that on 12/06/25, Resident #69 was walking the hall stating that a table was hit against their leg and hurt their leg. She stated that she did not ask the resident who bumped the table into the resident's leg. During a telephone interview on 12/10/25 at 2:31 P.M., RN #10 stated that when she was in Resident #69's room, the resident accused her of spilling water on the resident. She stated that when the resident came out of the resident's room, the resident accused her of shoving a table into the resident's leg. She stated she called the IDON immediately after the resident accused her of shoving the table into the resident's leg to report the allegation. She stated that the IDON told her to assess the resident and make sure the resident was okay. She stated that she asked the resident if they were in any pain and she was able to see the resident's legs but did not document the assessment. She stated that CNA #11 went into Resident #69's room with her for the rest of the day. During an interview on 12/10/25 at 3:42 P.M., the IDON stated that RN #10 reported to her that Resident #69 had alleged RN #10 spilled water on the resident. She stated that CNA #9 reported to her that the CNA heard Resident #69 state that RN #10 was rude. She stated that she interviewed the resident on 12/08/2025. She stated that she conducted the interview because RN #10 stated that Resident #69 was saying that the RN spilled water on the resident. She stated she did not document the interview or ask specifically about the incident. She stated that her interview consisted of asking the resident how the resident's day was. She stated that she also obtained statements from RN #10, CNA #11, and a housekeeper. During a follow-up interview on 12/10/25 at 4:33 P.M., the IDON stated that being rude was not an allegation of abuse because it did not sound like RN #10 was being abusive. She stated that the allegation that water was spilled was an allegation of abuse if it was purposeful. She stated that when she investigated the allegations, she did not find abuse. She stated that she conducted an investigation because CNA #11 wrote in her statement that CNA #9 was stating that a nurse abused a resident. She stated that she did not have documentation of interviews with other residents. The IDON stated that the Unit Manager conducted the interviews with other residents. She stated that Resident #69 was protected because she told CNA #11 to be with RN #10 anytime she needed to give medications to Resident #69 and because she (the IDON) was on the phone with the staff throughout the day. During a follow-up interview on 12/11/25 at 8:42 A.M., CNA #9 stated that the IDON told her that she was taking her (CNA #9) off the schedule to complete an investigation. During an interview on 12/11/25 at 8:54 A.M., the Unit Manager/Infection Preventionist (UM/IP) stated that he found out on 12/08/25 that there was agency staff that felt threatened by a nurse, and that the nurse spilled water on a resident. He stated that he talked to three residents, but they were not interviews; he just asked them how their weekend was, and he did not document the conversations. During an interview on 12/11/25 at 3:30 P.M., the Administrator stated that the IDON called her late on 12/06/25 or early on 12/07/25 to report that CNA #9 did not want to obtain vital signs, and she and RN #10 had a history of not getting along elsewhere. The Administrator stated that she was not aware of water being spilled or a table being shoved against Resident #69's legs. She stated that it depended on the intent whether the water being spilled on the resident was an allegation of abuse. She stated that the IDON should have asked in three different ways how it happened. She stated that protecting a resident from abuse would not have included being on the phone. She stated that if an employee was the perpetrator, they should be suspended. She stated that she was not aware of statements obtained from the three employees. She reviewed CNA #11's statement and stated that there should have been an immediate investigation. During an interview on 12/13/25 at 10:38 A.M., the IDON stated that her expectation for conducting an investigation included immediately suspending parties involved; interviewing whoever reported the allegation; start providing education; interview all staff and all residents; and notify family, the Administrator, and the doctor. During an interview on 12/13/2025 at 10:38 AM, the Administrator stated that her expectation for conducting an investigation into abuse allegations included assigning tasks to team members and the investigation being completed immediately. She stated that she expected residents to be kept in a safe manner, staff suspended, authorities called if needed, and the incident to be reported up the corporate chain. Per the Administrator, interviews should be conducted with parties involved, residents involved, staff working in that unit, and possibly dietary, housekeeping, therapy, or respiratory staff. The Administrator stated that assessments should be completed, care plans updated, and hospital records reviewed, if helpful. During an interview on 12/13/25 at 12:59 P.M., the IDON stated that when she assigned CNA #11 to be with RN #10, it was only for Resident #69. She stated that working in pairs was not required when the RN worked with the other residents on the unit. 2. An admission Record revealed the facility admitted Resident #43 on 07/12/25. According to the admission Record, Resident #43 had a medical history that included diagnoses of type II diabetes mellitus, essential hypertension, old myocardial infarction (heart attack), unspecified diastolic heart failure, atherosclerotic heart disease, schizophrenia, psychosis, depression, adjustment disorder with mixed anxiety and depressed mood, and attention-deficit hyperactivity disorder-combined type. A quarterly MDS, with an ARD of 10/20/25, revealed Resident #43 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #48 did not exhibit hallucinations, delusions, or rejection of care during the assessment timeframe. Resident #43's Care Plan Report revealed no documentation that indicated Resident #43 fabricated stories about staff. During an interview on 09/29/25 at 11:14 AM, Resident #43 stated that CNA #18 told them (Resident #43) to shut up. The resident stated that the CNA told them to shut up when they removed sugar from a coffee cart. The resident stated that the CNA refused to respond when spoken to and was very rude. The resident's allegation was reported to the Administrator on 09/29/25 at 11:45 A.M. Upon returning to the facility on [DATE], the surveyors requested all the allegations of abuse that were reported to the State Survey Agency (SSA). There was no report or facility investigation for the allegation that Resident #43 made against CNA #18. The Social Services Director (SSD) was interviewed on 12/11/25 at 11:40 A.M. The SSD stated that the allegation of verbal abuse involving Resident #43 was not discussed with her in September 2025, after making the Administrator aware that the resident reported that CNA #18 told the resident to shut up. The SSD stated that any staff member telling a resident to shut up would be a form of abuse. The IDON and Regional Director of Clinical Services (RDCS) #21 were interviewed on 12/12/25 at 2:28 P.M. The IDON stated that if she became aware of an allegation of abuse, she immediately reported it to the Administrator, and the alleged perpetrator was suspended pending outcome of the investigation. The IDON stated that CNA #18 was still employed but had not been in the building for months due to a health issue. The IDON stated that if a staff member told a resident to shut up, it was verbal abuse, and the abuse should be reported immediately, then the facility had two hours to report the allegation of abuse to the SSA. The IDON stated that the incident between Resident #43 and CNA #18 had not been discussed at a morning meeting. RDCS #21 stated that she was unaware of the allegation of verbal abuse. An interview was held with the Administrator on 12/12/25 at 4:43 P.M. The Administrator stated that she had not reported Resident #43's allegation of abuse to the SSA, which had been reported to her on 09/09/25. She stated that she may have gotten distracted and forgot to write the allegation down and had forgotten the incident. 3. An admission Record revealed the facility had admitted Resident #78 on 07/20/23. According to the admission Record, the resident had a medical history that included diagnoses of severe recurrent major depression without psychotic features, anxiety disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, and cerebral palsy. An annual MDS, with an ARD of 06/30/25, revealed Resident #78 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #78 scored seven on the Resident Mood interview, which indicated the resident had mild depressive symptoms. The MDS revealed Resident #78 exhibited no behavioral symptoms during the assessment lookback period. Resident #78's Care Plan Report included a focus area initiated on 07/25/23, that revealed the resident wanted to return to the community after a short-term stay for rehabilitation. The Goal was to achieve discharge as planned, with a target date of 09/28/25. Undated interventions directed staff to encourage the resident to follow up with their primary care physician after discharge, encourage the resident and the family to be realistic with expectations, encourage the resident to be as independent as possible, review goals and confirm discharge plans with the resident and family, make referrals as recommended by the interdisciplinary team, and to provide one-to-one visits as needed to assess progress towards discharge plans. The Care Plan Report included a focus area initiated 07/26/23, that indicated Resident #78 had a history of polysubstance abuse. Undated interventions directed staff to gently redirect the resident when/if behaviors occurred and to notify the physician of any suspected substance abuse. An Emergency Notice of Discharge, dated 09/09/25, indicated that Resident #78 was being discharged because the health of other individuals in the facility was endangered. The specific allegations were listed as, Death threat made to a resident in the facility, and Firearms, knife, vial of various pills, fake and real looking police badge were found in the resident's room. The discharge notice indicated that the resident was being discharged to either their home or a homeless shelter. The IDON was interviewed on 12/10/25 at 3:11 P.M. and stated that when an allegation of abuse was received, there should be an investigation. The IDON stated that the Abuse Coordinator for the facility was the Administrator. The SSD was interviewed on 12/11/25 at 11:45 A.M. The SSD stated that Resident #78 was discharged because they had brought air soft rifles and handguns that were lifelike into the facility. The SSD stated that the items were found the day before the resident was discharged . The SSD stated that Resident #78 showed the articles to another resident and threatened to harm that resident, and that resident felt fearful. The Administrator was interviewed on 12/12/25 at 4:52 P.M. The Administrator stated that there had not been an investigation to see if Resident #78 had threatened any other residents, and she did not interview any staff to see if anyone had information about Resident #78 threatening other residents. A facility policy titled, Abuse, Neglect, and Exploitation, reviewed 01/22/25, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed, V. Investigation of Alleged Abuse, Neglect and Exploitation included, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The policy continued, B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. [exempli gratia; for example] not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. The policy further indicated, IV. Protection of Resident included, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect alleged victim and integrity of the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. This deficiency represents noncompliance investigated under Master Complaint Number 2688424.

Based on facility policy review, record review, and interview, the facility failed to document in the medical record any behaviors to support the reason for an emergency discharge as documented on an Emergency Discharge Notice of Discharge and Discharge Summary, and failed to assist with coordinating after discharge care as outlined in the physician's Discharge Summary. This affected one (#78) of two residents reviewed for discharge requirements. The facility census was 71.Findings include: A facility policy titled, Discharge Planning Policy and Procedure, last reviewed 07/28/2025, revealed, This facility is committed to ensuring that all resident discharges are conducted in a safe, person-centered, and compliant manner is accordance with CMS [Centers for Medicare and Medicaid Services] regulations F627 and F628. Discharges will be planned collaboratively with the resident, their representative, and the interdisciplinary team, with a focus on continuity of care, resident rights, and regulatory compliance. The policy revealed, 5. Post-Discharge Coordination, Arrange for, which included, Home Health service, Meals on Wheels or nutritional support, Transportation, and Durable Medical Equipment (DME). The policy continued, Schedule a follow-up appointment with the resident's provider within 14 days of discharge. An admission Record revealed the facility had admitted Resident #78 on 07/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of severe recurrent major depression without psychotic features, anxiety disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, and cerebral palsy. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/2025, revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #78 scored 7 on the Resident Mood interview, which indicated the resident had mild depressive symptoms. The MDS revealed Resident #78 exhibited no behavioral symptoms during the assessment lookback period. The MDS indicated that the resident used a wheelchair for ambulation. Per the MDS, the resident was independent with eating but required set-up or clean-up assistance from staff for completion of oral hygiene, toileting hygiene, upper and lower body dressing, donning shoes, and personal hygiene. Per the MDS, the resident required supervision or touching assistance from staff for showering and bathing. The MDS also indicated Resident #78 was independent with going from sitting to lying, standing from a sitting position, and with transfers. The MDS indicated that the resident participated in the MDS assessment and goal setting, with no active discharge planning occurring. The MDS revealed the resident had no desire to speak to anyone about the possibility of leaving the facility and returning to the community. Resident #78's Care Plan Report included a focus area initiated on 07/25/2023, that revealed the resident wanted to return to the community after a short-term stay for rehabilitation. The Goal was to achieve discharge as planned, with a target date of 09/28/2025. Undated interventions directed staff to encourage the resident to follow up with their primary care physician after discharge, encourage the resident and the family to be realistic with expectations, encourage the resident to be as independent as possible, review goals and confirm discharge plans with the resident and family, make referrals as recommended by the interdisciplinary team, and to provide one-to-one visits as needed to assess progress towards discharge plans. The Care Plan Report included a focus area initiated 07/26/2023, that indicated Resident #78 had a history of polysubstance abuse. Undated interventions directed staff to gently redirect the resident when/if behaviors occurred and to notify the physician of any suspected substance abuse. The Care Plan report included a focus area initiated 07/26/2023 that indicated that the resident was at risk for emotional, mental, and physical distress due to traumatic life experiences. Undated interventions indicated that psychiatric or counseling services were to be provided as needed. Resident #78's physician Progress Note, dated 09/03/2025, indicated that the resident had anxiety and depression and should be monitored by staff and reported to the provider as needed. An Emergency Discharge Notice of Discharge, dated 09/09/2025, indicated that Resident #78 was being discharged because the health of other individuals in the facility was endangered. The specific allegations were listed as, Death threat made to a resident in the facility, and Firearms, knife, vial of various pills, fake and real looking police badge were found in the resident's room. The discharge notice indicated that the resident was being discharged to either their home or a homeless shelter. Resident #78's Discharge Summary, completed on 09/09/2025 by the resident's physician, revealed the resident was discharging home. The Discharge Summary indicated that Resident #78 had been a long-term care resident for assistance with activities of daily living. The Discharge Summary indicated that the reason for discharge was because the resident had been found with firearms. The per the Discharge Summary, the discharge plan indicated that after the resident left the facility, they would receive home therapy, social services staff would follow up for any needs with durable medical equipment, and Resident #78 needed to follow up with a primary care physician. The Discharge Summary indicated that Resident #78 had improved back to their baseline and met goals of therapy at the time of discharge. The Discharge Summary revealed the resident was stable and would follow up with providers in the community and follow the treatment plan. Resident #78's medical record revealed no other documented information about Resident #78 threatening any other residents or having weapons in their room. The Social Services Director (SSD) was interviewed on 12/11/2025 at 11:45 AM. The SSD stated that she was primarily responsible for orchestrating and arranging discharges. The SSD stated that when the facility initiated a discharge, the discharge notice included the reasons for discharge and the name of the place the resident was discharging to, including the address of the location, the phone number of the location, and if applicable, the title of the facility. The SSD stated that any behavioral issues for which the resident was being discharged should be on the resident's care plan and in the nurse's progress notes. The SSD stated Resident #78 was discharged because they had brought air soft rifles and handguns that were lifelike into the facility. The SSD stated that those items were found the day before the resident was discharged . The SSD stated that Resident #78 showed the articles to another resident and threatened to harm that resident, and that resident felt fearful. The SSD stated she did not assist in helping the resident with making any follow-up appointments or providing any other services upon discharge. An interview was held with the Administrator on 12/11/2025 at 12:47 PM. The Administrator stated Resident #78 had no known behaviors prior to 09/09/2025, when it was reported that the resident had taken the debit card of other residents and had guns. The Administrator stated the police were called, and Resident #78's family member came to the facility. The Administrator stated the resident was discharged to a local homeless shelter and had been transported by their family member. A telephone interview was held with Resident #78's primary care provider (PCP) on 12/12/2025 at 11:46 AM. The PCP stated that he found out about Resident #78's discharge when facility staff found knives and air rifles in the resident's room. The PCP stated that the facility contacted him immediately and told him Resident #78 had a list of people they were going after. The PCP stated Resident #78 had been a long-term resident in the facility because they had nowhere else to go. He stated Resident #78 was medically stable, and the discharge was safe. The Administrator was interviewed on 12/12/2025 at 4:52 PM. The Administrator stated that prior to Resident #78's emergency discharge, no other ideas or alternatives were discussed. The Administrator stated that the SSD called the homeless shelter prior to the resident arriving. The Administrator stated she was unaware the Discharge Summary included that the resident would be receiving home health services. The Administrator stated that the resident discharged with a family member, so they were not sure if they went to a homeless shelter or not.

Based on facility policy review, record review, and interview, the facility failed to ensure a resident's discharge was accurately and thoroughly documented in the medical record. This affected one (#78) of two residents reviewed for discharge requirements. The facility census was 71.Findings include: An admission Record revealed the facility had admitted Resident #78 on 07/20/23. According to the admission Record, the resident had a medical history that included diagnoses of severe recurrent major depression without psychotic features, anxiety disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, and cerebral palsy. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/25, revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #78 scored seven on the Resident Mood interview, which indicated the resident had mild depressive symptoms. The MDS revealed Resident #78 exhibited no behavioral symptoms during the assessment lookback period. The MDS indicated that the resident used a wheelchair for ambulation. Per the MDS, the resident was independent with eating but required set-up or clean-up assistance from staff for completion of oral hygiene, toileting hygiene, upper and lower body dressing, donning shoes, and personal hygiene. Per the MDS, the resident required supervision or touching assistance from staff for showering and bathing. The MDS also indicated Resident #78 was independent with going from sitting to lying, standing from a sitting position, and with transfers. The MDS indicated that the resident participated in the MDS assessment and goal setting, with no active discharge planning occurring. The MDS revealed the resident had no desire to speak to anyone about the possibility of leaving the facility and returning to the community. Resident #78's Care Plan Report included a focus area initiated on 07/25/23, that revealed the resident wanted to return to the community after a short-term stay for rehabilitation. The Goal was to achieve discharge as planned, with a target date of 09/28/25. Undated interventions directed staff to encourage the resident to follow up with their primary care physician after discharge, encourage the resident and the family to be realistic with expectations, encourage the resident to be as independent as possible, review goals and confirm discharge plans with the resident and family, make referrals as recommended by the interdisciplinary team, and to provide one-to-one visits as needed to assess progress towards discharge plans. The Care Plan Report included a focus area initiated 07/26/23, that indicated Resident #78 had a history of polysubstance abuse. Undated interventions directed staff to gently redirect the resident when/if behaviors occurred and to notify the physician of any suspected substance abuse. The Care Plan report included a focus area initiated 07/26/23 that indicated that the resident was at risk for emotional, mental, and physical distress due to traumatic life experiences. Undated interventions indicated that psychiatric or counseling services were to be provided as needed. Resident #78's physician Progress Note, dated 09/03/25, indicated that the resident had anxiety and depression and should be monitored by staff and reported to the provider as needed. An Emergency Discharge Notice of Discharge, dated 09/09/25, indicated that Resident #78 was being discharged because the health of other individuals in the facility was endangered. The specific allegations were listed as, Death threat made to a resident in the facility, and Firearms, knife, vial of various pills, fake and real looking police badge were found in the resident's room. The discharge notice indicated that the resident was being discharged to either their home or a homeless shelter. Resident #78's Discharge Summary, completed on 09/09/25 by the resident's physician, revealed the resident was discharging home (in contrast with what the discharge notice indicated). The Discharge Summary indicated that Resident #78 had been a long-term care resident for assistance with activities of daily living (ADLs). The Discharge Summary indicated that the reason for discharge was because the resident had been found with firearms (in contrast with what the discharge notice indicated). Per the Discharge Summary, the discharge plan indicated that after the resident left the facility, they would receive home therapy, social services staff would follow up for any needs with durable medical equipment (DME), and Resident #78 needed to follow up with a primary care physician (PCP). The Discharge Summary indicated that Resident #78 had improved back to their baseline and met goals of therapy at the time of discharge. The Discharge Summary revealed the resident was stable and would follow up with providers in the community and follow the treatment plan. The Discharge Summary did not indicate that a homeless shelter was a possible location the resident was being discharged to and also did not list the full reason the resident was discharged according to the Emergency Discharge Notice of Discharge. Resident #78's Progress Notes revealed a note, dated 09/10/25 at 10:23 A.M., that revealed that Resident #78 had been discharged the prior day. The note indicated that Resident #78 had been provided with information about homeless shelters and food banks. The Social Services Director (SSD) was interviewed on 12/11/25 at 11:45 A.M. The SSD stated that she was primarily responsible for orchestrating and arranging discharges. The SSD stated Resident #78 was discharged because they had brought air soft rifles and handguns that were lifelike into the facility. The SSD stated that those items were found the day before the resident was discharged . The SSD stated that Resident #78 showed the articles to another resident and threatened to harm that resident, and that resident felt fearful. The SSD stated she did not assist in helping the resident with making any follow-up appointments or providing any other services upon discharge. An interview was held with the Administrator on 12/11/25 at 12:47 P.M. The Administrator stated Resident #78 had no known behaviors prior to 09/09/25, when it was reported that the resident had taken the debit card of other residents and had guns. The Administrator stated the police were called, and Resident #78's family member came to the facility. The Administrator stated the resident was discharged to a local homeless shelter and had been transported by their family member. A telephone interview was held with Resident #78's PCP on 12/12/25 at 11:46 A.M. The PCP stated that he found out about Resident #78's discharge when facility staff found knives and air rifles in the resident's room. The PCP stated that the facility contacted him immediately and told him Resident #78 had a list of people they were going after. The PCP stated Resident #78 had been a long-term resident in the facility because they had nowhere else to go. He stated Resident #78 was medically stable, and the discharge was safe. The Administrator was interviewed on 12/12/25 at 4:52 P.M. The Administrator stated the SSD called the homeless shelter prior to the resident arriving, but she was unsure what the SSD had told the homeless shelter. The Administrator stated she was unaware the Discharge Summary included that the resident would be receiving home health services. The Administrator stated the best practice was to have the nurses document what time the resident left, who Resident #78 left with, and where the resident was going. The Administrator stated that the resident discharged with a family member, so they were not sure if they went to a homeless shelter or not. A facility policy titled, Discharge Planning Policy and Procedure, last reviewed 07/28/25, revealed, This facility is committed to ensuring that all resident discharges are conducted in a safe, person-centered, and compliant manner is accordance with CMS [Centers for Medicare and Medicaid Services] regulations F627 and F628. Discharges will be planned collaboratively with the resident, their representative, and the interdisciplinary team, with a focus on continuity of care, resident rights, and regulatory compliance. The policy revealed, 4. Discharge Process and Communication (F628) included, Complete a Discharge Summary including, which included, Recap [Recapitulation] of care and services, Resident's status at discharge, and Post-discharge care instructions.

Based on observation, interview, record review, and facility policy review, the facility failed to develop individualized resident-centered care plans with measurable objectives for two (#3 and #61) of 49 residents whose care plans were reviewed. The facility census was 71. Findings include: 1. An admission Record revealed the facility admitted Resident #3 on 07/12/24. According to the admission Record, Resident #3 had a medical history that included diagnoses of cerebral infarction (stroke) and osteoarthritis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/25, revealed Resident #3 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated Resident #3 had no rejection of care. The MDS indicated Resident #3 had functional limitation in range of motion with impairment on one upper extremity and one lower extremity. The MDS revealed Resident #3 was dependent on staff for completion of all activities of daily living (ADLs), except for eating, and was dependent on staff for all mobility. Resident #3's Care Plan Report included a focus area, initiated 07/25/24, that indicated the resident had osteoarthritis and scoliosis. Interventions directed staff to monitor, document, and report contracture formation and joint changes and to use supportive devices such as splints as recommended by occupational therapy. The Care Plan Report was not individualized for Resident #3 and did not include when the resident was to wear the splint or documentation about the resident's contracture including the contracture location. Resident #3's Order Summary Report, that included active orders as of 12/08/25, revealed, Trialing R [right] hand Splint with therapy for 2 hours, dated 06/16/25. Resident #3's Occupational Therapy [OT] Discharge Summary, with dates of service from 11/19/24 through 06/16/25, indicated the resident would tolerate a splint to the right hand with a schedule to be determined by the patient's tolerance with a time of two hours at discharge, 06/16/25. The OT Discharge Summary indicated the resident/staff would demonstrate 100% compliance/competence with the splint wearing schedule. An observation made on 09/29/25 at 9:37 A.M. revealed Resident #3's right hand was contracted with the resident's fingers resting on palm of the resident's hand. The observation revealed no devices were seen in Resident #3's hand to protect the resident's palm. The Interim Director of Nursing (IDON) was interviewed on 12/12/25 at 2:28 P.M. and stated she expected Resident #3's contractures and interventions for contracture management to be care planned. The MDS Coordinator (MDSC) was interviewed on 12/13/25 at 8:54 A.M. and stated that when developing the care plan, she reviewed physician's orders for devices such as hand rolls or splints. The MDSC reviewed Resident #3's care plan and stated she had omitted the care plan for the contractures and the splints. The Administrator was interviewed on 12/13/25 at 10:45 A.M. and stated she expected the contractures and contracture management to be included in the resident's care plan. 2. An admission Record revealed the facility admitted Resident #61 on 09/04/25. According to the admission Record, the resident had a medical history that included diagnoses of acute chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and asthma. An admission (MDS, with an ARD of 09/11/25, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was not a current tobacco user. Resident #61's Care Plan Report did not include a focus area for smoking. Resident #61's Smoking Assessment, completed 12/04/25, indicated the resident was independent, smoked five to ten times a day, and could light their own cigarette. An observation on 12/10/25 at 1:55 P.M. revealed Resident #61 lighting a cigarette in the smoking courtyard. During an interview on 12/12/25 at 10:59 A.M., the Infection Preventionist (IP), who was also a unit manager, stated Resident #61 should have had a care plan for smoking. During an interview on 12/12/25 at 1:52 P.M., the IDON stated care plans were required for residents who smoked. The IDON stated Resident #61 should have had a smoking care plan and did not have one. During a follow-up interview on 12/12/25 at 2:17 P.M, the IDON stated her expectation for smoking care plans was that they were to be initiated upon admission and quarterly. During an interview on 12/12/25 at 4:37 P.M., the Administrator stated her expectation for development of a smoking care plan was upon admission or upon discovery the resident was a smoker. A facility policy titled, Care Plan Revisions Upon Status Change, reviewed 03/06/25, indicated, Care plans will be modified as needed by the MDS [Minimum Data Set] Coordinator or other designated staff member.

Based on interview, observation, record review, and facility policy review, the facility failed to trim and clean the fingernails for one (#8) of three residents reviewed for activities of daily living (ADLs). The facility census was 71. Findings include:An admission Record revealed the facility admitted Resident #8 on 12/22/09 and most recently readmitted the resident on 05/29/21. According to the admission Record, the resident had a medical history that included multiple sclerosis, type II diabetes mellitus, the need for assistance with personal care, and a contracture of the left hand. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/25, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #8 was dependent upon staff for the completion of personal hygiene. Resident #8's Care Plan Report, included a focus area initiated 10/23/23, that indicated Resident #8 had a deficit in self-care related to multiple sclerosis. An undated intervention directed staff to keep the resident's fingernails short and clean. During an observation on 09/29/25 at 9:54 A.M., Resident #8's fingernails extended approximately one inch beyond the tip of their fingers. Resident #8 stated staff had not offered to trim their nails but stated their fingernails needed to be trimmed.During an observation on 09/30/25 at 2:58 P.M., Resident #8 was lying in bed. The resident's nails continued to extend beyond the tip of the finger with black matter underneath.During an observation on 12/08/25 at 10:00 A.M., Resident #8 was lying in bed, with their hands bent inward with their fingers pointed toward the palms. The resident's nails extended beyond the tip of the finger approximately one-quarter of an inch, with black matter under the nails.During an interview on 12/09/25 at 11:23 A.M., Certified Nursing Assistant (CNA) #12 stated the CNAs were responsible for clipping and cleaning nails and added if a resident had diabetes mellitus (DM) then the nurse was responsible for trimming resident's nails.During an interview on 12/09/25 at 2:50 P.M., CNA #13 stated that the CNAs were responsible for cleaning residents' nails, and if a resident had DM, then the nurse was responsible for trimming nails.During an interview on 12/11/25 at 10:48 A.M., CNA #12 stated he had cared for Resident #8 on 12/09/25 and had taken the resident to church services. CNA #12 stated that he had seen the resident's nails and stated they needed to be cut, but since the resident had diabetes, he was not allowed to trim the nails. He stated he had not reported to the nurse that Resident #8's fingernails needed to be trimmed. He stated he had been rushing that day and just had not told the nurse.During an interview on 12/11/25 at 11:09 A.M., CNA #14, who was assigned to care for Resident #8 on 12/11/25, stated she noticed the resident's nails were long and needed to be trimmed but if the resident had diabetes, she could not cut the nails. CNA #14 stated she had not reported the resident's long nails to anyone and stated she was unaware she was to report long nails to the nurse.During an observation on 12/12/25 at 1:20 P.M., Resident #8 was sitting upright in a wheelchair by their bed. The resident's nails continued to extend approximately one-quarter to one-half inch past the tip of the finger, with black matter underneath.During an interview on 12/12/25 at 1:30 P.M., Licensed Practical Nurse (LPN) #8, who was assigned to care for Resident #8, stated she had received no reports that Resident #8's fingernails needed to be cleaned and trimmed. LPN #8 observed the resident's nails and stated that the nails needed to be cleaned and trimmed.During an interview on 12/12/25 at 2:28 P.M., the Interim Director of Nursing (IDON) stated the nursing staff were responsible for clipping residents' nails and added if a resident had a diagnosis of DM, then it was the responsibility of the nurses. The IDON stated she expected the CNAs to alert the nurses if residents' nails needed trimming. The IDON stated Resident #8 had DM, so the nurse would be responsible for trimming their fingernails.The Administrator was interviewed on 12/13/25 at 10:45 A.M. and stated she expected fingernails to be kept clean and trimmed. The Administrator stated that if the CNA was unable to trim nails due to a diagnosis of DM, she expected the CNA to tell the nurse so the nails could be trimmed. A facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview, observation, record review, and facility policy review, the facility failed to place a splint or handroll into residents contracted hands as ordered by the physician. This affected two (#3 #8) of three residents reviewed for contractures. The facility census was 71.Findings include: 1. An admission Record revealed the facility admitted Resident #3 on 07/12/24. According to the admission Record, Resident #3 had a medical history that included cerebral infarction (stroke) and osteoarthritis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/25, revealed Resident #3 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated Resident #3 had not rejected care during the assessment's lookback period. The MDS indicated the resident had functional limitations in range of motion on one upper extremity and one lower extremity. The MDS revealed Resident #3 was dependent on staff for completion of all activities of daily living (ADLs), except for eating, and was dependent on staff for all mobility. Resident #3's Care Plan Report had no documentation about the resident's contractures and no interventions to prevent the contracture from worsening. Further review revealed no information on splint usage, including when the resident was to wear the splint. The Care Plan Report included a focus area initiated on 07/25/24, that indicated the resident had osteoarthritis. Interventions directed staff to use supportive devices such as braces, canes, crutches, and splints as recommended by occupational therapy (OT). An Occupational Therapy OT Discharge Summary, dated 06/16/25 indicated that on 06/16/25 Resident #3 met the goal of tolerating a splint to their right hand with the schedule to be determined by the resident's tolerance. The discharge summary revealed that on discharge, the resident was tolerating the splint for two hours per day. The discharge summary indicated that the long-term goal was that the patient and staff would demonstrate 100% compliance/competence with the splint-wearing schedule. The discharge summary revealed that on discharge, staff and resident compliance with the schedule was 50%. Resident #3's Order Summary Report with active orders as of 12/08/25, revealed an order dated 06/16/25, for trialing a right-hand splint with therapy for two hours. Resident #3's November 2025 and December 2025 Medication Administration Record [MAR] indicated there were no entries that documented when Resident #3's splint had been donned and doffed. During an observation on 09/29/25 at 9:37 A.M., Resident #3's right hand was contracted, with the resident's fingers resting on their palm. During an observation on 09/30/25 at 2:50 P.M., Resident #3 was lying in bed. The splint for Resident #3 was lying on the bookcase. During an observation on 12/09/25 at 10:31 A.M., Resident #3 was lying in bed with their eyes closed. The resident's splint was lying on the overbed table to the left of the resident's bed. During an observation on 12/11/25 at 10:38 A.M., Resident #3 was lying in bed with their eyes closed, sitting in an upright position. The resident's splint was not on the resident's hand, and no rolled cloths had been placed in the resident's clenched fists. During an interview on 12/09/25 at 11:23 A.M., Certified Nursing Assistant (CNA) #12 stated the therapy department educated the CNAs on how to apply splints used by residents and how long to leave the splints on the residents. CNA #12 stated there were no residents in his hall, the hall where Resident #3 lived, that refused to have their splints or hand rolls applied. During an interview on 12/09/25 at 2:50 P.M., CNA #13 stated that the CNAs were responsible for placing splints and rolled wash cloths and towels in residents' hands. CNA #13 stated either the nurse, or the therapy department let the CNA know how to apply the splint and how long to leave splints on. CNA #13 stated there was no one in the hall where she worked that refused to have their splints applied. During an interview on 12/11/25 at 10:54 A.M., CNA #12 stated the therapy department had not given instruction on how to place Resident #3's splints, and he was unsure when the resident was scheduled to wear the splint. CNA #12 stated that the instruction for Resident #3's splint should be found in the bedside table. CNA #12 stated that on 12/09/25 he had not placed Resident #3's splint on because the resident had been in bed all day. During an interview on 12/11/25 at 11:14 A.M., CNA #14 stated she was unaware Resident #3 had a splint and added she had received no education on placing the resident's splint. CNA #14 confirmed Resident #3 had a contracted hand and stated she had not placed a rolled cloth in the resident's hand because she had not been instructed to place anything in the resident's hand. During a concurrent observation, CNA #14 went to the resident's room to look for an instruction guide for the resident's splint and saw Resident #3's splint on the nightstand. CNA #14 stated she had not seen the resident wear the splint and was unable to find information about the splint in the resident's room. During an interview on 12/11/25 at 3:15 P.M., the Rehabilitation Manager (RM) stated education for contracture management including when to apply a splint was done verbally, then staff signed an attendance document. The RM stated that the use of splints was important to prevent skin breakdown or decline of the contracture. The RM confirmed that Resident #3 had a right-hand splint. He stated he had reviewed the educational documentation for Resident #3 and the CNAs that signed the document no longer worked in the facility. The RM stated that when Resident #3 had been discharged from OT on 06/16/25, donning the splint became the responsibility of the nursing department, and the nursing department was responsible for making sure staff complied with the application of the splint. The RM stated he had received no reports from staff that indicated Resident #3 refused to wear the splint. During a telephone interview on 12/12/25 at 11:46 P.M., the Medical Director (MD) stated he expected staff to follow the physician's order. He stated that the continued non-use of splints in contracted hands could potentially make the contractures worse. During an interview on 12/12/25 at 2:28 P.M., the Interim Director of Nursing (IDON) stated that when a resident had an order for a splint, she expected staff to follow the order and place the splint on the resident. The IDON stated that if the splint was not used per orders, the contracture may worsen. The Administrator was interviewed on 12/13/25 at 10:45 A.M. and stated she expected the physician's orders for Resident #3's splint to be followed to prevent skin breakdown and to keep the contracture from getting worse. 2. An admission Record revealed the facility admitted Resident #8 on 12/22/09 and most recently readmitted the resident on 05/29/21. According to the admission Record, the resident had a medical history that included multiple sclerosis, type II diabetes mellitus, the need for assistance with personal care, and a contracture of the left hand. A quarterly MDS, with an ARD of 10/04/25, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #8 was dependent upon staff for the completion of personal hygiene. Resident #8's Care Plan Report, included a focus area initiated 10/23/23, that indicated Resident #8 had a self-care performance deficit related to multiple sclerosis. Interventions directed staff to apply a left-hand towel roll or hand splint, and staff were to encourage range of motion during activities. Resident #8's Order Summary Report, with active orders as of 12/08/25, revealed an order dated 02/27/24, for a left palm roll to be placed in the morning while out of bed and to be taken off at night when in bed. Resident #8's November 2025 and December 2025 Medication Administration Record [MAR] revealed there was no documentation of the donning or doffing of the left palm roll. A Kardex (a care plan accessed by the CNAs instructing them on how to care for a resident) indicated Resident #8 was to have a left-hand towel roll or a hand splint. During an observation on 09/29/25 at 9:30 A.M., Resident #8's left hand was contracted, with the resident's pointer finger sticking straight out toward the thumb and other fingers curved toward the palm. Nothing was seen in the palm of the resident's hand. During an observation on 09/30/25 at 2:58 P.M., Resident #8 was lying in bed with no washcloth or splint in the resident's hand. The resident was unable to say if they had been up in the wheelchair that day or if the splint had been applied. During an observation on 12/08/25 at 10:00 A.M., Resident #8 was lying in bed with both hands bent inward with their fingers pointed toward the palms. There was nothing in the resident's hands to prevent the fingertips from touching the resident's palms. During an observation on 12/09/25 at 11:08 A.M., Resident #8 was sitting in a geriatric chair in the chapel for church service. The resident had no towel roll in their left hand as directed by physician's orders. During an interview on 12/09/2025 at 11:23 A.M., CNA #12 stated the therapy department educated the CNAs on how to apply handrolls and stated there were no residents on Resident #8's hall that refused to have their hand rolls applied. CNA #12 stated there should be an instructional sheet in the resident's room directing how and when to apply the hand rolls. During an observation on 12/11/25 at 10:36 A.M., Resident #8 was sitting in a wheelchair next to the bed. There was no rolled washcloth, towel, or splint in Resident #8's hands. During a follow-up interview on 12/11/25 at 10:48 A.M., CNA #12 stated Resident #8 was to wear the handroll when they were up, but he was not entirely sure what the order for the handroll included. He stated that on 12/09/25 when Resident #8 had been to the church service, he had not applied the resident's handroll and stated he had forgotten. During an interview on 12/11/25 at 11:09 A.M., CNA #14 stated Resident #8 was out of bed at 8:00 A.M. CNA #14 stated she had worked in the facility for six months and had not seen anything in the resident's hand. CNA #14 stated she had not placed anything in Resident #8's hand because she was unaware she was to place anything in the resident's hands. During an interview on 12/11/25 at 3:15 P.M., the RM stated that the order for Resident #8's handroll was placed in February 2024 and the resident was to wear the left palm roll-up while out of bed. The RM defined a left palm roll-up as a washcloth placed in the resident's hand. The RM reviewed the treatment notes for Resident #8 and stated Resident #8's hand splint no longer fit, and a hand roll was recommended. The RM stated measuring Resident #8's contractures to see if the contractures were worse would not be possible since the OT was only in the building two days a week, and an order for an evaluation would be needed before the OT could measure. During a telephone interview on 12/12/25 at 11:46 A.M., the MD stated he expected staff to follow physician's orders. The MD stated that continued non-use of hand rolls or splints in contracted hands could potentially make the contracture worse. During an observation on 12/12/25 at 1:20 P.M., Resident #8 was sitting upright in a wheelchair by their bed. There was not a handroll in the resident's hand. During a concurrent interview, Licensed Practical Nurse (LPN) #8, who was assigned to care for Resident #8 on 12/12/25, stated she was aware that Resident #8 had orders for handrolls and stated they were to be in the resident's hands when the resident was out of bed. LPN #8 went to the resident's room and validated there were no handrolls in the resident's hands. She instructed CNA #14 to get hand rolls and place them in Resident #8's hands, and the CNA replied that therapy had to place the handrolls. During an interview on 12/12/25 at 2:28 P.M., the IDON stated that when a resident had an order for a handroll, she expected staff to follow the order and place the handroll. The IDON stated that if the handroll was not used per orders, the contracture could get worse. The IDON stated Resident #8's hand roll should be documented on the MAR. The Administrator was interviewed on 12/13/25 at 10:45 A.M. and stated she expected the staff to follow the physician's orders and place the handrolls in Resident #8's hand. She stated that not using the hand roll could lead to skin breakdown and worsening of the contracture. A facility policy titled, Functional Impairment-Clinical Protocol, revised September 2012, revealed the section titled, Cause Identification, included, 5. The physician and staff will evaluate the resident for complications secondary to functional decline and/or immobility, such as: f. muscle atrophy/contractures. The policy revealed the section titled, Treatment/Management, indicated, 2. In conjunction with the physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency, and duration of interventions to help achieve anticipated goals and expected outcomes efficiently using available resources

Based on observation, interview, record review, facility policy review, and product operation manuals, the facility failed to ensure resident weight settings were correct on low air loss mattresses. This affected two (#2 and #57) of two residents reviewed for pressure ulcer management. The facility census was 71.Findings include:1. An admission Record indicated the facility originally admitted Resident #2 on 07/29/15 and readmitted the resident on 03/06/23. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure and unspecified head injury. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/25, revealed Resident #2 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated Resident #2 was dependent with activities of daily living (ADLs) and had functional limitations of both upper and lower extremities. The MDS indicated Resident #2 was at risk for pressure ulcers, had no current unhealed pressure ulcers, and was on a pressure-reducing device for the bed. Resident #2's Order Summary Report, dated 01/02/25, indicated a physician's order for low air loss mattress.Resident #2's Care Plan Report, included a focus area, initiated 10/23/23, that indicated the resident had ADLs self-care performance deficit. Interventions included the use of a pressure reducing perimeter mattress. Resident #2's Treatment Administration Record (TAR), dated September 2025, indicated the resident was on a low air loss mattress every shift.Resident #2's Weight Summary, dated 09/16/25, indicated the resident's weight was 173.4 pounds (lbs.).An observation on 09/29/25 at 10:21 A.M. revealed Resident #2's low air loss mattress setting dial was set at 280 lbs.Resident #2's, TAR, dated December 2025, indicated the resident was on a low air loss mattress every shift.Resident #2's Weight Summary, dated 12/02/25, indicated the resident's weight was 174.2 lbs.An observation on 12/08/25 at 10:09 A.M. revealed Resident #2 asleep and lying on their bed with the low air loss mattress setting dial pointing between 240-280 lbs.An observation on 12/09/25 at 9:39 A.M. revealed Resident #2 awake and lying on their bed with the low air loss mattress setting dial pointing between 240-280 lbs.An observation on 12/10/25 at 3:21 P.M. revealed Resident #2 asleep and lying on their bed with the low air loss mattress setting dial pointing between 240-280 lbs.A concurrent observation and interview, on 12/11/25 at 2:08 P.M., revealed Resident #2 was awake and lying on their bed with the low air loss mattress setting dial pointing between 240-280 lbs. Licensed Practical Nurse (LPN) #15 stated the low air loss mattress setting was set-up by the mattress company while the nurses ensured the low air loss mattress pump was turned on and secured to the bed frame.During a telephone interview on 12/11/25 at 10:49 P.M., LPN #16 stated the low air loss mattress setting was set up by the mattress company, and the nurses ensured the low air loss mattress pump was plugged in and the weight settings were correct.During a concurrent observation and interview on 12/12/25 at 1:36 P.M., LPN #17 stated she did not touch the low air loss mattress setting because whoever delivered the low air loss mattress placed the setting.2. An admission Record indicated the facility admitted Resident #57 on 01/17/22. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure, severe protein-calorie malnutrition, muscle wasting and atrophy, and adult failure to thrive. A quarterly MDS, with an ARD of 11/06/25, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #57 was dependent with ADLs except for eating for which they required setup or clean-up assistance. The MDS indicated Resident #57 was at risk for pressure ulcers, had no current unhealed pressure ulcer, and was on a pressure-reducing device for bed. Resident #57's Order Summary Report, dated 04/07/2025, indicated a physician's order for a low air loss mattress. Resident #57's Care Plan Report included a focus area, initiated 01/25/24, that indicated the resident was at risk for skin breakdown related to decreased mobility, malnutrition, pain, and incontinence. Interventions included the use of a low air loss mattress. Resident #57's TAR, dated September 2025, indicated the resident was on a low air loss mattress every shift. Resident #57's Weight Summary, dated 09/11/25, indicated the resident's weight was 90.2 pounds (lbs.). An observation on 09/29/25 at 11:13 A.M. revealed Resident #57's low air loss mattress setting dial was set at 120 lbs.Resident #57's TAR, dated December 2025, indicated the resident was on a low air loss mattress every shift. Resident #57's Weight Summary, dated 12/02/25, indicated the resident's weight was 74.8 lbs.An observation on 12/08/25 at 10:40 A.M. revealed Resident #57 was lying on their bed, with their low air loss mattress setting dial pointing at 120 lbs. An observation on 12/10/25 at 3:18 P.M. revealed Resident #57 was asleep on their bed with their low air loss mattress setting dial set at 120 lbs. An observation on 12/11/25 at 8:59 A.M. revealed Resident #57 was awake on their bed with their low air loss mattress setting dial pointing at 120 lbs. A concurrent observation and interview on 12/11/25 at 1:45 P.M., LPN #17 stated the low air loss mattress was necessary for prevention of skin breakdown. During an interview on 12/12/25 at 2:51 P.M., the Infection Preventionist (IP), who was also a unit manager, stated the low air loss mattress setting was set by the mattress company technician based on the resident's weight, and the facility only made a change if there were issues with the airflow.During an interview on 12/13/25 at 9:35 A.M., the Interim Director of Nursing (IDON) stated the nurses were to ensure the low air loss mattress pump was set at the correct dial setting for the resident's weight to help reduce the risk of getting a pressure ulcer and to prevent damage to the resident's skin. During an interview on 12/13/25 at 10:50 A.M., the Administrator stated the facility should follow the manufacturer's instructions on the use of low air loss mattresses. The Administrator stated the mattress setting was adjusted based on the resident's weight to prevent skin breakdown.A facility policy titled, Pressure Ulcers/Injuries Overview, revised 04/01/22, indicated, Prevention of Pressure Ulcers/Injuries - all facility mattresses are pressure reducing mattresses if we identify a pressure ulcer/injury we go to a low air loss mattress.An undated document titled, Operation Manual for [Brand Name] 2000, [pump and mattress overlay system] indicated, [Brand Name] 2000 pump and overlay system [item #] is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The section Overlay indicated, The [Brand Name] 2000 System comes with a 5' [inch] air cell overlay that provides low air loss, alternation and static pressure redistribution therapy. The section Product Functions indicated, Pressure-Adjust Knob (2) - Determine the patient's weight and set the control knob to that weight setting on the control unit.An undated document titled, Operation Manual for [Brand Name] 3000/3500/3600 [pump and mattress overlay system], indicated, [Brand Name] 3000 pump and mattress system, is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The section Mattress indicated, The [Brand Name] 3000/3500/36000 System comes with an air cell mattress that provides low air loss, alternation and static pressure redistribution therapy. The section Product Functions indicated, Pressure-Adjust Knob (2) - Determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure residents did not retain their own lighters according to the facility policy. This affected three (#61, #5, and #58) of four residents reviewed for smoking. The facility census was 71.Findings include: 1. An admission Record revealed the facility admitted Resident #61 on 09/04/25. According to the admission Record, the resident had a medical history that included diagnoses of acute chronic diastolic (congestive) heart failure; chronic obstructive pulmonary disease, unspecified; and unspecified asthma, uncomplicated. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/11/25, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #61's Care Plan Report revealed no information about the resident smoking. Resident #61's Smoking Assessment, dated 12/04/25, indicated that Resident #61 did not have cognitive loss, visual deficit, or a dexterity problem. The assessment further indicated that the resident was independent, smoked five to ten times a day, and the resident could light their own cigarette. The assessment revealed the resident was provided with the smoking policy, and the plan of care was used to ensure resident was safe while smoking. An admission Record revealed the facility admitted Resident #5 on 02/05/25. According to the admission Record, the resident had a medical history that included a diagnosis of nicotine dependence, unspecified, uncomplicated. A quarterly MDS, with an ARD of 11/12/25, revealed Resident #5 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident had the ability to understand others with clear comprehension. Resident #5's Care Plan Report included a focus area initiated 02/21/25, that indicated the resident had a potential for injury related to smoking. Undated interventions directed staff to secure cigarettes/lighters at the nurses' station. Resident #5's Smoking Assessment, dated 12/10/25, indicated that Resident #5 did not have cognitive loss, visual deficit, or a dexterity problem. The assessment further indicated that the resident required supervision, smoked two to five times a day, and the resident could light their own cigarette. The assessment revealed the resident was provided the smoking policy, and the plan of care was used to ensure resident was safe while smoking. During an observation on 12/10/25 at 1:54 P.M., Resident #5 pulled a lighter from the resident's bag/pouch, went into the smoke [NAME], and lit a cigarette. At 1:55 P.M., Resident #61 lit a cigarette in the smoking courtyard during a resident smoke break. During an interview on 12/10/25 at 1:58 P.M., the Activity Director (AD) stated she did not light Resident #5's or Resident #61's cigarettes, and she did not know what lighter the residents used. During an observation and interview on 12/10/25 at 2:00 P.M., Resident #5 provided their lighter to the AD. The resident stated they (Resident #5) kept lighters because the resident did not get them back when they gave them to the facility staff. During an interview on 12/10/25 at 2:01 P.M., Resident #61 stated that they (Resident #61) lit the cigarette with the lighter the resident kept in a pouch/bag. 2. An admission Record revealed the facility admitted Resident #58 on 08/26/25. According to the admission Record, the resident had a medical history that included a diagnosis of peripheral vascular disease, unspecified. A significant change MDS, with an ARD of 12/03/25, revealed Resident #58 had a BIMS score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident had the ability to understand others with clear comprehension and was a tobacco user. Resident #58's Care Plan Report included a focus area initiated 08/28/25, that indicated the resident was a smoker. Undated interventions directed staff to notify the charge nurse immediately if it was suspected that the resident had violated the facility smoking policy. Resident #58's Smoking Assessment, dated 11/27/25, indicated Resident #58 did not have cognitive loss, visual deficit, or a dexterity problem. The assessment further indicated that the resident required supervision, smoked two to five times a day, and the resident could light their own cigarette. The assessment revealed the resident was provided with the smoking policy, and the plan of care was used to ensure resident was safe while smoking. During an observation on 12/09/25 at 1:46 P.M., during a resident smoke break, Resident #58 handed a lighter to another resident so the resident could light a cigarette. Once the cigarette was lit, Resident #58 placed the lighter in the resident's bag. During an interview at the time of the observation, Licensed Practical Nurse (LPN) #19 stated that she saw the other resident light a cigarette with Resident #58's lighter. Resident #58 took the lighter from the resident's bag and gave it to the LPN. During an interview on 12/10/25 at 9:15 A.M., the AD stated Resident #58 had a lighter and refused to give it to the facility staff. During an interview on 12/12/25 at 6:18 P.M., the AD stated Residents #61, #5, and #58 had not given her their lighters to be stored since she started in her position in July 2025 or since their admission, if it was after her start date. During an interview on 12/12/25 at 10:59 A.M., the Unit Manager/Infection Preventionist (UM/IP), stated Residents #61, #5, and # 58 should not have had a lighter; activities staff should have had them. The UM/IP stated that at the point the lighter was used outside, it should have been a conversation, confiscation, documentation, and notifications to the Director of Nursing (DON), Medical Director (MD), and Responsible Party (RP). He stated that a resident with a lighter could have lit it near supplemental oxygen, could have burned a room down, or could have lost the lighter, and another resident found it. During an interview on 12/12/25 at 1:52 PM, the Interim Director of Nursing (IDON) stated the facility policy was that smokers were supervised and lighters were stored in a locked cart. She stated that she had not been made aware Resident #5 and Resident #61 had lighters and was not made aware Resident #58 had a lighter until the previous day (12/11/25). She stated that a resident having a lighter was dangerous because it could start a fire. During an interview on 12/12/25 at 2:17 PM, the IDON stated her expectation was for staff to maintain a safe and hazard-free environment. She stated that she expected the facility to store lighters in a locked bin. During an interview on 12/12/2025 at 4:26 P.M., the Administrator stated that the AD and activity aides oversaw the smoking activity. She stated that the process of smoking was to complete an assessment, explain times and facility policy, and the AD met with them. The Administrator stated that she had not been aware Residents #5, #61, or #58 were storing their own lighters. During an interview on 12/12/25 at 4:37 P.M., the Administrator stated her expectation was for the facility to be free of accidents. She stated she expected residents to adhere to the smoking policy and the scheduled times and for residents not to have lighters or matches on them.A facility policy titled, Smoking Policy, revised 01/27/25, indicated, All smoking paraphernalia brought into the facility are to be given to the ACTIVITIES Department or staff NURSE for inventory. Lighters are considered a hazard and should be kept and locked in a safe place at all times.

Based on manufacturer guidelines, observation, and interview, the facility failed to ensure staff sanitized a blood glucose monitor after checking a resident's blood sugar and before placing the blood glucose monitor into the medication cart for further use. This affected one (#8) of two residents observed who had their blood sugar checked during medication administration. The facility census was 71.Findings include:An admission Record revealed the facility admitted Resident #8 on 12/22/09 and most recently readmitted the resident on 05/29/21. According to the admission Record, the resident had a medical history that included a diagnosis of type II diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/25, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident had an active diagnosis of diabetes mellitus. Resident #8's Care Plan Report revealed a focus statement initiated 09/23/14, that indicated the resident had a potential for complications related to diabetes mellitus. Interventions directed staff to monitor and record the resident's blood glucose checks per their physician's orders. Resident #8's Order Summary Report, with active orders as of 12/08/25, revealed an order dated 09/23/24 for blood sugar level checks to be completed every six hours. An observation was made on 12/10/25 beginning at 8:00 A.M. during the morning medication administration. Licensed Practical Nurse (LPN) #1 removed a blood sugar monitor from the medication cart, took the monitor into Resident #8's room, and placed the monitor on the resident's bedside table. After completion of the blood glucose test, LPN #1 took the monitor to the medication cart, placed the monitor initially on top of the cart, and then opened a drawer and placed the blood glucose monitor back into the medication cart and stated that she was ready to test the next resident's blood sugar. During an interview on 12/10/25 at 8:36 A.M., LPN #1 stated that there was no reason she did not sanitize the blood glucose monitor prior to placing the monitor back into the medication cart. During an interview on 12/12/25 at 11:21 A.M., the Unit Manager/Infection Preventionist (UM/IP) stated that the expectation was for the blood glucose monitors to be sanitized between each resident to slow the spread of bacteria or other organisms. The IP stated that cleaning blood glucose monitors was customary practice and not something that just this facility expected. During a telephone interview on 12/12/25 at 11:46 A.M., Resident #8's Primary Care Physician (PCP) stated that it was best practice to clean/sanitize the blood glucose monitor between residents. The Interim Director of Nursing (IDON) was interviewed on 12/12/25 at 2:28 P.M. The IDON stated that she expected the blood glucose monitor to be cleaned between residents and expected the monitor to be cleaned before placing it in the medication cart. The IDON stated that the danger of not cleaning the blood glucose monitor could be the spread of infection. The Administrator was interviewed on 12/13/25 at 10:40 A.M. The Administrator stated that she expected the nurses to follow the facility policy, which directed staff to clean the blood glucose monitor between residents' use. The manufacturer's Cleaning & (and) Disinfecting Guidelines for the blood glucose monitor that was used for Resident #8 indicated that the manufacturer suggested cleaning and disinfecting the monitor between patient use. The instructions revealed, Cleaning and disinfecting can be completed by using a commercially available EPA [Environmental Protection Agency] registered disinfectant detergent or germicidal wipe.

Based on medical record review, staff interviews, review of the Ohio Department of Health (ODH) Gateway Application, review of a facility timeline, review of a Narcotic Administration Sheet and policy review, the facility failed to report an allegation of misappropriation to the State Agency. This affected one (#79) out of three residents reviewed for misappropriation. The facility census was 77. Findings include: Review of the medical record for Resident #79 revealed an admission date of 03/05/25 with diagnoses of osteomyelitis, type 2 diabetes mellitus without complications, neoplasm of unspecified behavior of respiratory system, retropharyngeal and parapharyngeal abscess, personal history of malignant neoplasm of larynx, and tracheostomy status. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact, did not eat anything by mouth, and was independent with all activities of daily living. Review of the physician orders revealed an order dated 06/30/25 for Oxycodone Oral Solution 5 milligrams (mg)/5 milliliters (ml), give 20 ml via G-Tube every three hours as needed for pain. Interview on 08/12/25 at 11:52 A.M. with the Director of Nursing (DON) confirmed the facility accepted the liquid Oxycodone from Resident #79's daughter on 06/12/25, and the staff did not verify with the daughter the amount of oxycodone that was remaining in the bottle. Interview with the DON also confirmed on 06/20/25 the daughter reported someone had stolen Resident #79's oxycodone and called the police. Interview confirmed the facility did not report the allegation to the State Agency and accusation of theft for Resident #79 because they knew the medication was accurate. Review of the ODH Gateway Application revealed there was no self-reported incident (SRI) involving an allegation of misappropriation of medication for Resident #79. Review of a facility timeline for Resident #79 investigation revealed on 06/12/25 Resident #79's daughter had brought in a bottle of Oxycodone. Facility staff reported they couldn't accept the bottle. Resident #79 and the family were escorted to the medication cart by Licensed Practical Nurse (LPN) #294. On 06/13/25 the 7:00 P.M. to 7:00 A.M. nurse called the DON at home and stated that Resident #79's medication appeared suspicious, she described it as being light in color and appeared thin. Nurse also stated it was reported that seal was not intact when Resident #79's daughter delivered the medication. There were also questions regarding where the script was and who changed the dosage. There was no paperwork reportedly turned in by the family or resident. On 06/20/25 the police arrived at the facility on Resident #79 due to daughter making a report on missing oxycodone. LPN #294 informed police oxycodone was not missing, it was in a lock box. Review of the Narcotic Administration Sheet revealed on 06/12/25, 250 ml of Oxycodone was signed in. The Narcotic Administration Sheet does not contain any documentation that the seal was broke when the medication was received. There was not any doses documents as administered. Review of the Controlled Substances policy dated November 2022 revealed controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together, and that both individuals sign the designated controlled substance record. This deficiency represents non-compliance investigated under Complaint Number 1313950 (OH00167084).

Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure tracheostomy (trach) supplies were available in accordance with the care plan and facility policy. This affected one (#77) out of three residents reviewed for trach care and services. The facility census was 77. Finding include: Review of the medical record for Resident #77 revealed an admission date of 03/06/23 with diagnoses of anoxic brain damage, epilepsy, unspecified, intractable, without status epilepticus, chronic obstructive pulmonary disease, and acute on chronic systolic (congestive) heart failure. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired, was dependent on staff for all activities of daily living, and resident had a trach. Review of the care plan dated 03/07/23 revealed a care plan for trach related to impaired breathing mechanics injury with interventions of keep extra trach tube and obturator at bedside. If tube is coughed out attempt to reinsert tube. Review of the physician orders revealed an order dated 01/02/25 for trach care daily. Change inner cannula number four (#4) Shiley every day shift related to anoxic brain damage. On 08/11/25 an order was noted for trach size 4UN85H with inner canula size Shiley #4- 41C85 every shift. Observation and interview on 08/12/25 at 7:20 A.M. with Licensed Practical Nurse (LPN) #234 confirmed there was not an extra trach available if Resident #77's current trach became dislodged. Interview with LPN #234 also confirmed the facility does not always have the trach supplies that are needed for Resident #77. Interview on 08/12/25 at 8:37 A.M. with LPN Unit Manager #294 brought a trach size #4 with a cuff stating it was the trach Resident #77 used and was placing the trach at the residents beside. Interview with LPN Unit Manager #294 confirmed Resident #77 did not have a cuffed trach and did not have a physician's order for a cuffed trach. Review of the Tracheostomy Care policy dated 01/10/25 revealed a replacement trach tube must be available at the bedside at all times. This deficiency represents non-compliance investigated under Complaint Number 1313951 (OH00166239).

Based on observation, staff interview and review of facility policy, the facility failed to ensure food items were properly stored. This had the potential to affect all residents, except two (#29 and #80) residents identified by the facility as receiving no nutrition from the kitchen. The facility census was 82. Findings include: Observation on 01/23/25 at 9:10 A.M. of the walk-in freezer revealed a package of opened and undated hot dogs on the top shelf. The hotdog packaging was not sealed, leaving the hot dogs exposed to the freezer elements. Further observation revealed a package of pepperoni, not in the original packaging, which was unlabeled and undated. Observation on 01/23/25 at 9:20 A.M. of the walk-in refrigerator revealed an opened package of shredded cheese, two opened packages of bologna, and sliced turkey wrapped in pan liner paper. Each of the items were undated. Interview on 01/23/25 at 9:35 A.M. with Dietary Manager (DM) #63 verified the hot dogs in the walk-in freezer were not properly sealed or dated and the pepperoni was unlabeled and undated. DM #63 confirmed the identified items in walk-in refrigerator were not dated and further verified wrapping food items in pan liner paper was not appropriate storage. Review of the facility policy titled Carecore Labeling and Dating Guidelines, dated July 2024, revealed refrigerated food must be dated when opened and freezer food must have the date received and the date opened. This deficiency represents non-compliance investigated under Complaint Number OH00161269.

Based on observations, medical record review, staff and resident interviews, police interview, review of the facility's quality assurance investigation, review of the facility ' s Self-Reported Incident (SRI), and review of facility policies, the facility failed to provide adequate supervision to prevent the elopement of two residents (#35 and #49), without staff knowledge, who were cognitively impaired. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Residents #35 and #49 eloped from the facility. Resident #49 was found by staff, a 45-minute waking distance from the facility near a four-lane city street the following day on [DATE]. Resident #35 was not located until the evening of [DATE] where she was found deceased in a heavy wooded area about a 25-minute walking distance from the facility. This affected two residents (#35 and #49) of four residents reviewed for risk of elopement. The facility identified a total of 11 residents as being at risk for elopement. The facility census was 76. On [DATE] at 12:30 P.M., the Administrator, and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 9:55 P.M., when Resident #35 and Resident #49 had eloped from the facility and were missing. Resident #49 was assessed as being at risk for wandering and elopement and had diagnoses of cerebral infarction and encephalopathy. Resident #35 had a diagnosis of dementia. On [DATE] after the 9:30 P.M. resident smoke break, facility staff were unable to locate Residents #35 and #49. Resident #49 was found at a gas station located approximately a 45-minute walking distance from the facility and was returned to the facility on [DATE] at approximately 9:00 A.M. by a facility staff member. At the time of the Immediate Jeopardy notification, Resident #35 remained missing. Resident #35 was subsequently located the evening of [DATE] deceased in a heavy wooded area about a 25-minute walking distance from the facility. The facility failed to provide adequate supervision to prevent the residents from eloping. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 9:55 P.M., Registered Nurse (RN) #67, who was working on the 300 unit where Resident #35 and #49 resided informed the DON she could not locate Residents #35 and #49. State tested Nurse Aide (STNA) #36 had reported to RN #67, the residents were not seen after the 9:30 P.M. resident smoke break in the courtyard. On [DATE] at 9:55 P.M., the DON initiated an internal facility search to locate Residents #35 and #49. On [DATE] at 10:00 P.M., the DON checked the sign-out book, and began a head count, as no sign-out documentation was noted by Residents #35 and #49. On [DATE] at 10:00 P.M., the DON and the staff started the search of the facility grounds. On [DATE] at 11:00 P.M., the DON contacted and informed the Administrator. On [DATE] at 11:03 P.M., the DON and facility staff searched neighboring areas and local stores. On [DATE] at 12:00 A.M., the DON and Administrator contacted law enforcement, the Medical Director, and Resident #35 and #49 ' s family representatives. The family representatives did not respond to the facility notification. On [DATE] at 1:00 A.M., a [NAME] police officer arrived at the facility and took report from the DON. On [DATE] at 2:00 A.M., the DON began gathering written statements from staff regarding Resident #35 and #49. On [DATE] at 7:00 A.M., all staff resumed searching for Residents #35 and #49. On [DATE] at 8:30 A.M., the police reported no new information on the location of Residents #35 and #49. On [DATE] at 9:00 A.M., Resident #49 was found and returned to the facility by STNA #36. Resident #49 was found at a gas station which was located a 45-minute walking distance from the facility. Resident #49 ' s skin assessment was completed by the DON and no injuries were noted. On [DATE] at 9:20 A.M., the facility management team conducted a Quality Assurance and Performance Improvement (QAPI) meeting. The management team included the Administrator, DON, Business Office Manager (BOM) #09, Regional Nurse #120, Minimum Data Set (MDS) Nurse #52, Social Service Designee (SSD) #107, Housekeeping and Laundry Director #93, Maintenance Director #18, Admissions Marketing Director #06, Assistant DON ' s #54 and #55, Staff Scheduler #51, Dietary Manager #48, Activities Director #101, Medical Records Staff #47, and Director of Rehabilitation #108. On [DATE] at 9:25 A.M., the DON started staff education on abuse and neglect, elopement, and changes in resident smoking schedules. On [DATE] at 9:45 A.M., all residents were audited by the DON, Unit Manager (ID ##)This should be the ADON #54 who also was Unit Manager, and Regional Director of Clinical Operations (RDCO) (ID ##120) for risk of elopement. Any residents not assessed had an elopement assessment completed. All residents were audited to ensure they had a Brief Interview for Mental Status (BIMs) test (a 15-point cognitive screening measure that evaluates memory and orientation) by Social Service Designee #107 on [DATE]. Assessments were completed by [DATE] for any resident without one at that time. All residents were audited to ensure that behavioral monitoring was completed on [DATE] by RDCO #120, ADON #54, and MDS #52. The facility implemented a plan for any resident assessed at risk for elopement to be care planned for their specific risk factors with interventions to prevent elopement on [DATE] by the DON, ADON #54, MDS #52, and RDCO #120. This would also be completed upon admission, annually, quarterly and when a resident exhibited any new exit seeking behaviors by the DON/Designee. On [DATE] at 10:00 A.M., an elopement drill was completed with all staff by Maintenance Director #18 with no concerns identified. On [DATE] at 11:15 A.M., Resident #49 ' s family representative visited the resident and attempted to retrace his events in an effort to locate Resident #35. Resident #35 was not located at this time. On [DATE] at 12:00 P.M., Maintenance Director #18 installed additional lighting in the resident supervised smoking area courtyard. Maintenance Director #18 also changed the key code to the exit doors at this time. On [DATE] at 1:30 P.M., Activities Aides #100, #102, and #103 were educated on the new smoking schedule and processes by the Administrator. On [DATE] at approximately 2:00 P.M., three detectives from [NAME] Police Department arrived to talk to the Administrator, DON, and Resident #49. On [DATE] at approximately 2:30 P.M., Resident #49 was escorted by the three detectives from the [NAME] Police Department to retrace Resident #49 ' s steps of [DATE] to locate Resident #35. Resident #35 was not located. On [DATE] at 6:00 P.M., the staff re-searched the surrounding neighborhood and last seen location of Resident #35 and #49. On [DATE] at approximately 7:00 P.M., the family representative, who cared for Resident #35 prior to admission, stated Resident #35 had a history of leaving and accepting rides from strangers. On [DATE] at 8:30 P.M., staff were advised by the Administrator to abort the search for Resident #35 until 7:00 A.M. on [DATE]. On [DATE], all staff were educated by the Administrator and the DON on Abuse and Neglect. On [DATE], all staff were educated by the DON, ADON #54 and ADON #55 on ensuring that wander guards were tested weekly by licensed nurses and staff were informed not to yell out the code, to cover the keypad with hand when punching in the code and do not share code with family members. All staff were also educated on ensuring that doors are secure. On [DATE], RDCO #120 educated Maintenance Director #18 on ensuring door checks are logged as they are checked to ensure door lock functionality. All newly admitted residents and residents readmitted to the facility must have elopement risk assessments upon admission. Any new resident that exhibits new wandering or exit seeking behaviors must have a new elopement risk assessment completed by the nurse. The facility implemented a plan for any staff who witnessed any resident with wandering or exit seeking behaviors to report to the nurse so a new elopement risk assessment could be completed. All newly admitted residents must have a BIMS test completed upon admission and any resident that exhibits new wandering or exit seeking behavior must have a new BIMS completed by SSD #107. The DON or designee would audit all new admissions to ensure that elopement risk assessment is completed, daily for four weeks and then on going as needed. The DON or designee would audit any resident that has new wandering or exit seeking behaviors to ensure that a new elopement risk assessment is completed, daily for four weeks then ongoing as needed. The Administrator or designee would audit all new admissions to ensure that they have completed BIMS upon admission, daily for four weeks then ongoing as needed. The Administrator or designee would audit for residents that exhibit new wandering or exit seeking behavior to ensure they have a new BIMS completed, daily for four weeks then ongoing as needed. The DON or designee would audit Section E of the MDS which codes for the presence or absence of wandering behavior, five times a week for four weeks then ongoing. The DON or designee would audit supervised smoke breaks to ensure residents have returned from the designated smoking area, daily for four weeks and then ongoing. The DON or designee would audit to ensure doors are secure, code remains private, and resident safety is maintained, three days a week and ongoing. All findings will be reviewed in weekly QAPI meeting for four weeks then ongoing. Staff interviews were conducted on [DATE] at 6:55 A.M. with STNA #43, at 6:57 A.M. with STNA #46, at 7:20 A.M. with STNA #91 and Housekeeping Aide #91, and at 9:10 A.M. with Licensed Practical Nurse (LPN) #72 and on [DATE] at 1:30 P.M. with STNA #36 and they verified that they had been educated on elopements and had an elopement drill on [DATE]. Observation on [DATE] at 2:20 P.M. revealed Residents #38, #33, #32, #40, #34, #44, #50, #43, #36, #49 and #59 had wander guards in place as these residents remain at risk for elopement. Review of door audits revealed all facility doors were audited on [DATE] by the DON. Interviews on [DATE] from 8:45 A.M. through 10:22 A.M. with STNAs #25, #46, #13, Housekeeping Aides #85 and 74 and LPN # 71 revealed staff had been in serviced on keeping door codes secure from residents and checking wander guard devices for functionality. STNA #25, #46 and #13 verified a residents accountability form was initiated on [DATE] to ensure residents are returned to their unit after smoke breaks. Interview on [DATE] at 9:15 A.M. the DON stated the dining room door security system was repaired and was functioning at 4:30 P.M. on [DATE]. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring for on-going compliance. Findings include: Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease, anxiety disorder, dementia, falls, atherosclerosis, malnutrition, nicotine dependence and Alzheimer ' s disease. Review of Resident #35 ' s care plans dated [DATE] revealed Resident #35 was at risk for falls related to decreased mobility, impaired cognition and incontinence, and risk for potential complications related to Diabetes Mellitus which included interventions to administer medications and blood sugar checks per physician ' s orders. Review of Resident #35 ' s care plan dated [DATE] revealed Resident #35 had risk for acute confused state characterized by changes in consciousness, disorientation, environmental awareness, and behaviors related to noncompliance with Diabetes Mellitus which included an intervention to monitor blood sugar levels. Review of Resident #35 ' s care plan dated [DATE] revealed Resident #35 had an activities of daily living deficit related to Diabetes Mellitus, syncope and collapse, difficulty walking, and muscle weakness and included interventions for extensive assist of one to two people for transfers and ambulation, and limited assistance for locomotion. Review of Resident #35 ' s smoking care plan dated [DATE] revealed the resident was at risk for injury due to smoking with intervention to provide supervision at all times for smoking. Review of Resident #35's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to have mild cognitive impairment and Resident #35 required extensive assistance with bed mobility, transfers, dressing, and toileting. The resident required limited assistance with locomotion and personal hygiene. Resident #35 also required supervision with eating. Review of Resident #35's elopement risk assessment dated [DATE] revealed the resident was cognitively impaired with poor decision-making skills and was physically capable of leaving the facility independently with a wheelchair. The resident had shown no signs of elopement and had voiced no desire to leave the facility. Review of Resident #35's smoking assessment dated [DATE] revealed the resident had cognitive deficits, smokes two to five times a day and required supervision for smoking. Review of Resident #35's physician orders dated [DATE] through [DATE] revealed Resident #35 was to have received a Cipro 500 milligrams antibiotic for a urinary tract infection. The resident's orders included NovoLog insulin 3 units prior to each meal, measure, and record blood sugar fingerstick prior to each meal and Lantus insulin 6 units at bedtime. Review of Resident #35's progress note dated [DATE] revealed Resident #35 was observed by nurse laying on floor on her left side in the bathroom of her room. Resident #35 reported she did not know what happened, she had gotten dizzy. New order from physician, to continue to monitor and notify of any changes. Review of Resident #35's fall risk screen assessment dated [DATE] revealed she had a history of multiple falls over the last six months, is confined to a chair and disoriented, and unable to independently come to a standing position. Review of Resident #35's blood sugar values log on [DATE] revealed a blood sugar value of 487 milligrams per deciliter (mg/dl) at 8:00 A.M., 423 mg/dl at 12:00 P.M. and 447 mg/dl at 4:00 P.M. Review of Resident #35's progress note dated [DATE] at 12:30 A.M. revealed the DON documented the resident was unable to be located after the 9:30 P.M. smoke break on [DATE]. The resident was reportedly at the designated smoke break; however, when attempts were made to administer the resident her routine evening medications, the resident could not be located. A resident head count and internal search was initiated immediately. The resident was not located. The Administrator, police and Medical Director were notified. A call was placed to the family with no answer and a message was left. Review of Resident #35's elopement care plan dated [DATE] revealed Resident #35 was at risk for elopement due to Alzheimer's Disease, and dementia. Interventions included monitoring resident location on the unit frequently each shift, offering diversional activities, assess if attempt to elope are related to unmet needs, and redirect distract resident from elevator and stairwells. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including encephalopathy, cerebral infarction, opioid abuse, cocaine abuse, nicotine dependence, anxiety disorder and altered mental status. Review of Resident #49's elopement risk assessment dated [DATE] revealed the resident was cognitively intact with poor decision-making skills and newly admitted and not accepting the facility admission. Review of Resident #49's smoking care plan dated [DATE] revealed the resident was at risk for injury due to smoking with intervention to provide supervision at all times for smoking. Review of Resident #49's care plan dated [DATE] revealed that Resident #49 had alteration in cognition and awareness related to diagnosis of cerebral vascular accident. Review of Resident #49's physician orders dated [DATE] revealed Resident #49 received an order for a wander guard monitoring device to left ankle due to the resident may attempt to leave the facility without being accompanied by staff. The order included checking placement every shift. Review of Resident #49's elopement care plan dated [DATE] revealed Resident #49 was at risk for elopement due to confusion. Interventions included wander guard monitoring device to left ankle, offer diversional activity, exit door alarms on, know whereabouts, observe for wandering, safety checks as needed, and resident to activities. Review of Resident #49's smoking assessment dated [DATE] revealed Resident #49 had cognitive loss, smoked two to five times a day, and required supervision with smoking. Review of Resident #49's admission MDS assessment dated [DATE] revealed the resident to have mild cognitive impairment and Resident #49 required supervision with bed mobility, transfers, dressing, eating and toileting. Review of Resident #49's progress note dated [DATE] at 9:30 P.M. revealed RN #67 documented Resident #49 left the facility without signing out. Other residents overheard Resident #49 needed to go to the store. Resident #49 was seen at the last smoke break. RN #67 notified the DON, police, and the Medical Director. A resident head count, internal search and external search was implemented. An attempt was made to contact the daughter. Review of a facility self-reported incident (SRI) dated [DATE] at 1:52 A.M., completed by the Administrator revealed the facility reported missing residents, Residents #35 and #49 to the State agency. The SRI noted an investigation was in progress. Interview and review of the Quality Assurance investigation, dated [DATE] at 9:00 A.M. with the Administrator, DON and Regional Clinical Nurse #120 on [DATE] at 3:35 P.M. revealed Residents #35 and #49 eloped from the facility on [DATE] and were missing after the 9:30 P.M. smoke break, which was monitored by STNA #36 and #34. RN #67's statement revealed Residents #35 and #49 did not return from the 9:30 P.M. smoke break and were missing from the 300 unit when she went to provide medication at 9:55 P.M. Review of the statement from STNA #34 revealed she last saw the residents at the 8:00 P.M. smoke break, returned to the inside of the facility and could not recall if the residents were at the 9:30 P.M. smoke break. Review of the statement of STNA #36 revealed he, along with STNA #34, provided the 9:00 P.M. smoke break, both residents (#35 and #49) attended and STNA #36 did not see the residents after the smoke break. Observation on [DATE] at 2:00 P.M with the Administrator revealed an internal key coded door to the courtyard. The courtyard paved patio measured approximately 50 feet by 20 feet. There was a brick wall approximately four feet high surrounding the courtyard with no gate closure. There was an enclosed clear walled smoking structure at the further point of the patio. There was a paved walkway exit, behind the enclosed walled structure, leading through the brick wall opening. The walkway led down a gradual grade to the parking lot behind the facility. The paved walkway was lined with thick bushes and a very steep grade to the street below. The paved walkway exit was not visible from the facility door. The patio was surrounded by lighting mounted to the side of the facility. Observation on [DATE] at 1:55 P.M. of Resident #49 revealed he was on the 300-unit hallway ambulating without difficulty. A wander guard monitor device was visible on his left ankle. Interview on [DATE] at 1:55 P.M. with Resident #49 revealed on [DATE] there were two staff at the resident smoke break, but he did not tell the staff he was leaving. The resident stated, after the smoke break, he went to the store to get snacks because he didn't like the snacks at the facility. He stated he took Resident #35 with him because she had money and knew the store location. He stated he took Resident #35 down the sidewalk in the back and made a right turn. Resident #49 stated Resident #35 fell out of the wheelchair, and he tried to find someone to help. He stated he went to [NAME], came back, and went to the facility. The facility was locked so he walked the rest of the night until the staff found him. Interview on [DATE] at 3:10 P.M with STNA #34 revealed at the 8:00 P.M. smoke break, STNA #36 assisted STNA #34 with opening the door and passing cigarettes. STNA #34 verified Resident #35 stayed inside the facility, as the resident did not have any cigarettes. Resident #49 went outside to the courtyard, attended the smoke break and returned inside the facility. STNA #34 revealed at the 9:00 P.M. smoke break, she did not observe Resident #35 or Resident #49. STNA #34 stated STNA #36 was in attendance to assist with the 9:00 P.M. smoke break. STNA #34 stated the smoke break was very chaotic with multiple residents going in and out of the facility doors. There were more than ten residents in the smoke break area. It was well lit and there was no precipitation. STNA #34 verified the courtyard is surrounded with a wall without a secured gate. Interview on [DATE] at 1:30 P.M. STNA #36 revealed on [DATE] he observed Resident #49 on the first-floor units and was unsure if Resident #49 attended the 9:00 P.M. smoke break. He stated he observed Resident #35 at 8:00 P.M. near the smoke break area. He was unsure if Resident #35 attended the smoke break as there were multiple residents at the smoke time. He verified Resident #35 did not have cigarettes. STNA #36 revealed it was difficult to keep track of residents coming in and out of the smoke door into the facility. STNA #36 verified the back area of the smoke patio was not visible to the facility smoke door. STNA #36 stated he thought Residents #35 and #49 exited the smoke area on the pathway through the ungated brick wall. Interview on [DATE] at 2:38 P.M. with the Administrator revealed local detectives reported a store, visited by Residents #35 and #49 on [DATE], had a video camera. The video camera showed the residents were in the store, and purchased items on [DATE] at 9:26 P.M. Interview on [DATE] at 3:53 P.M. with the DON revealed she entered the facility on [DATE] at approximately 9:00 P.M. She was approached by RN #67 regarding Residents #35 and #49 missing at about 9:55 P.M. The DON stated internal and external searches began immediately and the external searches lasted through 2:00 A.M. on [DATE] and began again on [DATE] from 7:00 A.M through 8:30 P.M. The DON stated she obtained statements from STNAs #34 and #36, who were witness to the missing residents, and RN #67. The DON verified the statements had inconclusive information regarding how the residents exited the facility. The DON stated when STNA #36 returned Resident #49 to the facility on [DATE] at 9:00 A.M., the resident still had a wander guard monitoring device on the left ankle, and the wander guard functioned correctly at the front door, by sounding the alarm. The DON indicated staff must respond to the front door and all other doors to silence the alarm. The DON stated no door alarms were sounding when she arrived at the facility at 9:00 P.M. The DON then clarified she could not determine how Residents #35 and #49 exited the facility, whether during the smoke break through the courtyard, after smoke break and/or which doors were used to exit the facility. The facility had no exterior cameras. Observation and interview on [DATE] at 8:40 A.M. revealed Resident #49 was finishing up his breakfast and he had a wander guard on the left ankle. Resident #49 stated he gets his cigarettes donated. Resident #49 did walk with the surveyor and MDS Nurse #52 to the front door and the alarm went off and staff had to reset the alarm. The door does not lock, it only sets off an alarm. Resident #49 stated the alarm goes off because he had his bracelet on, and staff come to turn off the alarm. He stated he goes to the front desk area once a week to check out a book. The surveyor then asked Resident #49 to show surveyor where he goes to smoke. Resident #49 was confused as to which hall to go down but did find the way after two tries. Resident #49 stated he used to go out the door until they changed the code. He stated he knew the code before but did not know the code now. He denied going out any other doors by himself except the door to the smoke area and stated staff lets the residents out into the smoke area at smoke time. Observation and interview on [DATE] at 9:20 A.M. revealed Maintenance Director #18 was actively working on the dining room door (that was in same vicinity as door that leads to smoke area), the latches were removed and there was a key code box next to the door. Maintenance Director #18 stated he started employment at this facility about three weeks ago. He stated he was not requested to change to a new doorknob until two days ago by the Administrator. He stated this door previously functioned as a closed door and locked from the outside and was not asked to secure the door by key code. He stated before, the dining room door could be exited but not able to re-enter from the courtyard. He stated that the keypad has not been attached. He stated he was now adding a lock so the door can be entered from the courtyard with a key by staff only and would check to see if he can get the key code alarm added to the door. He stated he never saw anyone go out except the dietary staff to take the trash out but never had to pay attention to the door function since only staff used it and he verified he knew the door did not have a key code alarm functioning. He verified residents could get out this dining room door without an alarm sounding because it was not hooked up. He stated he checks the functions of the doors, alarm, and ensures it is working properly. He stated he has not documented the door checks since he was hired. He stated that he has no form to document door monitoring. Interview on [DATE] at 10:15 A.M. with Resident #49 revealed he got the smoke area door code from watching the staff put in the code. He stated the night he went to go to the store ([DATE]), after the staff had residents in from the 9:00 P.M. smoke break, he used the code and went out the door to the courtyard. He stated Resident #35 was in the courtyard and they took the paved walkway to the street, then to the store. He stated Resident #35 had the money and he knew the area because he used to work in the area and that Resident #35 knew of the store. He stated that he was not seen by staff because staff was gone from taking residents in from smoking. He denied ever trying or using any other door because they were alarmed with the wander guard system. A phone interview was conducted on [DATE] at 2:35 P.M. with Police Sergeant #150 who stated the detectives were unable to discuss the investigation due to clearance and they were still working on the reports. Police Sergeant #150 did verify they found Resident #35 at the corner of two avenues in a heavily wooded area and the cause of death was yet to be determined via autopsy; however, did appear to have been a fall and they did not suspect foul play. Observation on [DATE] from 9:15 A.M. through 9:25 A.M. revealed the dining room door was repaired and the door security was functioning. The door code leading to the smoke area was reset and functional. Observation on [DATE] at 10:32 A.M. revealed STNA #25 using a check form for residents returning to the 300 unit from smoke break. Observation on [DATE] at 10:34 A.M. of Resident #49 revealed he had a wander guard device on the left ankle. Resident #49 was unable to enter door codes to the smoke area and the dining room door. At the front door, Resident #49's wander guard device activated the security alarm and staff responded and had to reset the alarm at the alarm box. Interview on [DATE] at 10:34 A.M. with Resident #49 revealed the door codes had been changed last week and he had not tried to leave the facility since [DATE]. He stated the staff now watch to see if he returns to his second-floor unit after he completes each smoke break. Interviews on [DATE] from 11:55 A.M. through 12:08 P.M. with STNAs #25, #46, and #13, Housekeeping Aides #85 and 74 and LPN # 71 revealed no other residents had eloped since [DATE]. Additionally, the DON verified no other residents had eloped since [DATE]. Interview on [DATE] at 1:45 P.M. with Regional Maintenance Director #160 revealed that on [DATE] by 4:30 P.M., maintenance had repaired the dining room door to make it functional and the security company came in and repaired it to make it secure with a door code. Review of the facility's wandering and elopement policy dated [DATE] revealed staff would identify residents at risk of unsafe wandering and include in the plan of care interventions to maintain the resident's safety and prevent harm. Review of the facility undated policy titled, Resident Smoking revealed all residents require monitoring of their smoking cigarette use and shall receive direct supervision in the designated smoking area. Review of facility policy titled, Abuse, Neglect Exploitation or Misappropriation, dated [DATE] revealed all reports of neglect were immediately reported to the state licensing agency within two hours of allegation of suspected abuse and neglect that results in serious bodily injury. The reported incident will be thoroughly investigated by facility management. This deficiency represents noncompliance investigated under Master Complaint Number OH00143020 and Complaint Numbers OH00142899, OH00142929, OH00142926, and OH00142925.

Based on medical record review, review of hospital documentation, observation, interviews with staff, Certified Nurse Practitioner (CNP) #250 and family, review of facility policy, and review of medication information from Medscape, the facility failed to ensure residents were free from unnecessary medications when the facility failed to adequately monitor Resident #21's blood glucose level before administering insulin. This resulted in Actual Harm when staff administered insulin to Resident #21 without monitoring the residents blood glucose levels and the resident was subsequently found unresponsive by staff and was admitted to a local hospital for [CONDITION(S)]. This affected one (#21) of five residents reviewed for unnecessary medications. The census was 66. Findings include: Review of Resident #21's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as being cognitively intact with a Brief Interview Mental Status (BIMS) of 14 out of 15. Resident #21 required supervision with activities of daily living (ADL's) and received insulin injections. Review of a care plan dated initiated 12/07/20 revealed Resident #21 had potential for complications related to diabetes mellitus. Interventions listed included to administer medications per physician orders. Monitor for effectiveness and side effects. Monitor for signs and symptoms of [CONDITION(S)] such as: sweating, cold and clammy skin, numbness of fingers-toes-mouth, rapid heartbeat, nervousness, tremors, faintness, and dizziness. Review of Resident #21's physician orders revealed an order dated 08/02/21 for [MEDICATION(S)] solution (long-acting insulin) 100 units per milliliter (unit/ml). Inject 25 units subcutaneously (SQ) at bedtime related to type II diabetes mellitus without complications. An order dated 08/05/21 was for [MEDICATION(S)] solution (rapid acting insulin) 100 unit/ml. Inject 10 units SQ three times a day related to type II diabetes mellitus without complications. Resident #21's medical record contained no physician orders for blood glucose monitoring. Review of Resident #21's medication administration records (MAR's) revealed [MEDICATION(S)] was documented as being administered to Resident #21 on 07/11/22 at 9:00 P.M. [MEDICATION(S)] was documented as being administered to Resident #21 on 07/11/22 at 10:00 P.M. and on 07/12/22 at 6:00 A.M. Further review of Resident #21's MAR's revealed the scheduled administration times for [MEDICATION(S)] was changed from 8:00 A.M., 12:00 P.M., and 5:00 P.M. (before meals) to 6:00 A.M., 2:00 P.M., and 10:00 P.M. on 07/07/22. No blood glucose levels were documented before the administration of [MEDICATION(S)] on 07/11/22 at 9:00 P.M. or [MEDICATION(S)] on 07/11/22 at 10:00 P.M. and 07/12/22 at 6:00 A.M. Review of Resident #21's progress and vital signs recorded revealed no documentation of blood glucose levels were documented before the administration of [MEDICATION(S)] on 07/11/22 at 9:00 P.M. or [MEDICATION(S)] on 07/11/22 at 10:00 P.M. and 07/12/22 at 6:00 A.M. Review of hospital emergency room (ER) documentation dated 07/12/22 revealed Resident #21 was admitted for symptomatic low blood sugar. Resident #21 was given dextrose five percent (D5) 150 ml intravenously in route to the ER to treat [CONDITION(S)]. Resident #21's cognitive status had improved. Review of hospital documentation revealed Resident #21 was admitted for further treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #21 on 07/12/22 at 8:56 A.M. revealed she was unresponsive. Resident #21 was in her bed and not responding to staff. Staff members present in the room included Assistant Director of Nursing (ADON) #131, ADON #161, Licensed Practical Nurse (LPN) #200, Director of Therapy (DOT) #157, Occupational Therapist (OT) #105, and OT #189. ADON #131 checked Resident #21's finger stick blood sugar (FSBS) with a result of 37 milligrams per deciliter (mg/dl). ADON #161 administered [MEDICATION(S)] (medication to reverse [CONDITION(S)])-one milligram (mg) subcutaneously into Resident #21's abdomen. ADON #131 checked Resident #21's FSBS with a result of 44 mg/dl at 9:08 A.M. ADON #131 stated the emergency services had been called. At 9:18 A.M. Resident #21 remained unresponsive. Vitals were checked with on oxygen saturation of 97 percent on room air and a heart rate of 57. Emergency services personnel entered the room at 9:19 A.M. and took over care of Resident #21. Resident #21 was transported to a local hospital. During an interview on 07/12/22 at 9:21 A.M. State tested Nursing Assistant (STNA) #188 stated he told three to four facility staff members Resident #21 was on the floor in her room. STNA #188 stated STNA #180 went into Resident #21's room and gave her a pillow. During an interview on 07/12/22 at 2:23 P.M. ADON #131 stated STNA #180 told her Resident #21 was on the floor. Therapy staff had Resident #21 in the bed when she arrived. ADON #131 tried to get Resident #21's vital signs including FSBS. The result of the FSBS was 33. ADON #131 called Resident #21's physician and daughter. ADON #131 confirmed Resident #21 was provided [MEDICATION(S)] on 07/12/22 and breakfast was not provided. During an interview on 07/12/22 at 2:36 P.M. ADON #131 confirmed the lack of FSBS documentation before the administration of [MEDICATION(S)] on 07/11/22 at 9:00 P.M. or [MEDICATION(S)] on 07/11/22 at 10:00 P.M. and 07/12/22 at 6:00 A.M. ADON #131 was unable to explain the scheduled administration time changes for [MEDICATION(S)] on 07/07/22. ADON #131 would expect staff to check a residents FSBS before administering any insulin. During an interview on 07/12/22 at 2:41 P.M. STNA #180 stated STNA #188 told her Resident #21 was on the floor in her room. STNA #180 tried to wake Resident #21 up. STNA #180 stated Resident #21 wasn't responding. STNA #180 gave Resident #21 a pillow and covered with a blanket. STNA #180 reported Resident #21 being on the floor to LPN #200. During an interview on 07/12/22 at 3:26 P.M. with LPN #200 stated she was informed by a therapist that Resident #21 was in the floor. LPN #200 was never told by any STNA that Resident #21 was on her floor. During morning the night nurse did not report any concerns with Resident #21. LPN #200 called ADON #161 to assist with Resident #21. During an interview 07/13/22 at 9:16 A.M. with CNP #250 revealed she would expect a resident's FSBS to be checked before the administration of [MEDICATION(S)] insulin. CNP #250 stated [MEDICATION(S)] insulin should be administered before a meal. During a phone interview on 07/13/22 at 11:55 A.M. with Resident #21's family member revealed the resident was admitted to the hospital for [CONDITION(S)]. Resident #21's family stated the resident was now alert. Review of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus dated November 2020 revealed [CONDITION(S)] can lead to cognitive impairment, functional impairment, falls, fractures, and pain. The target range for older healthy adults is 90 to 139 mg/dl. For the resident receiving insulin who is well controlled: monitor blood glucose levels twice day if on insulin (example before breakfast and lunch as necessary), monitor three to four times a day if on intensive insulin therapy or sliding scale insulin. Review of Medscape revealed changes in insulin, insulin strength, manufacturer, type, or method of administration may affect glycemic control and predispose to [CONDITION(S)] or [CONDITION(S)]. Further review of Medscape revealed [MEDICATION(S)] should be administered within five to 10 minutes of a meal. Because [MEDICATION(S)] is fast-acting, do not use if the individual is unable to eat right after the injection or if you have low blood sugar.

Based on record review, staff interview, review of policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement interventions to prevent the development of pressure ulcers and failed to initiate prompt and timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm when Resident #33, was admitted to the facility with out pressure sores and being assessed as a moderate risk for the development of pressure ulcers. The facility failed to implement pressure ulcer prevention measures, subsequently, Resident #33 developed an avoidable stage four pressure ulcer (full-thickness skin and tissue loss has occurred, with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Rolled wound edges (epibole) and eschar may be present. Undermining and/or tunneling can often occur), and the facility failed to initially assess and timely initiate wound treatment. This affected one (#33) of three residents reviewed for pressure ulcer. The census was 67. Findings include: Review of Resident #33's medical record revealed an admitted [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #33, dated 04/03/22, revealed the resident was cognitively impaired and was totally dependent on the assistance of two staff with bed mobility and transfers. Further review of the MDS revealed the resident was coded as positive for the presence of a Stage IV pressure ulcer which was not present upon admission. Resident #33 was coded as being at risk for the development of pressure ulcers. Review of the pressure ulcer risk assessment for Resident #33 dated 12/01/21 revealed resident was at moderate risk for the development of pressure ulcers. Review of skin assessment for Resident #33 dated 12/08/21, revealed the resident's skin was intact. Review of the care plan for Resident #33 initiated 12/23/21, revealed the resident was incontinent of bowel and bladder and had the potential for impaired skin integrity related to mobility deficit. Interventions included the following: call light within reach at all times, answer call light promptly, check and change every two hours and as needed, observe for signs/symptoms of restlessness which may indicate the need to urinate/void. The care plan was updated on 03/16/22 to reflect skin breakdown was present and a low air loss mattress was initiated. Review of the care plan for Resident #33 initiated on 03/14/22 revealed resident had the potential for impairment of skin integrity, was at risk for skin breakdown due to poor tissue integrity, immobility, and incontinence. Interventions included the following: assist with hygiene and general skin care, keep skin clean and dry, apply protective cream after each incontinent episode, turn and reposition per protocol, consult Nurse Practitioner (NP) for evaluation and treatment as indicated. Review of the December 2021 Treatment Administration Record (TAR), the January 2022 TAR, and the February 2022 TAR for Resident #33 revealed there was no record of pressure ulcer prevention measures provided to resident. Review of weekly skin assessment dated [DATE], per Registered Nurse (RN) #286 revealed Resident #33 had an opened red area to her coccyx and on the list of possible interventions, the nurse had checked wound nurse referral. Under the section of the assessment titled Treatment Ordered the box was blank. Review of the February 2022 TAR for Resident #33 revealed it did not include any treatment orders for the opened red area identified by RN #286 on 02/23/22. Review of the nurse progress notes for Resident #33 dated 02/23/22 through 03/09/22 revealed the notes were silent regarding the opened red area to resident's coccyx identified on 02/23/22. Review of the record for Resident #33 revealed it did not include a detailed description of the of the opened red area noted during the skin assessment dated [DATE]. Review of nurse progress note for Resident #33 dated 03/10/22, revealed RN #286 observed an area on the resident's upper right gluteal fold and coccyx area. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2022 TAR for Resident #33 revealed an order to cleanse coccyx area and right gluteal fold area with normal saline, pat dry, apply medi-honey, cover with bordered dressing every night shift was ordered on 03/10/22 and was documented as administered until the treatment was discontinued on 03/14/22. Review of the wound assessment for Resident #33 dated 03/14/22, documented by RN #286, revealed the resident had a Stage IV pressure ulcer (full-thickness skin and tissue loss has occurred, with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Rolled wound edges (epibole) and eschar may be present. Undermining and/or tunneling can often occur) to her sacrum which measured 4.0 centimeters (cm) in length by 2.8 cm in width by 1.6 cm in depth. Undermining to the wound was noted at 10 to 12 o'clock with depth of undermining of 4.2 cm at its deepest point. There was a scant amount of serosanguinous drainage/bleeding noted. Wound treatment orders were in place and new pressure ulcer prevention orders for low air loss mattress and Roho cushion to wheelchair were noted to be in place. Review of the wound assessment for Resident #33 dated 03/14/22 per the wound NP revealed resident had a Stage IV pressure ulcer to her sacrum which measured 4.0 cm in length by 2.8 cm in width by 1.6 cm in depth. Further review of note revealed the 03/14/22 consult was the wound NP's initial consult with Resident #33. Review of the March 2022 TAR for Resident #33 revealed an order dated 03/14/22, to cleanse sacrum with Normal Saline, pat dry, lightly pack with Vashe moist gauze, and cover with bordered foam dressing every night shift. The TAR documented the dressing completed from 03/14/22 to 03/31/22. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 06/03/22 at 5:57 P.M., with the Director of Nursing (DON), verified RN #286 had completed a skin sweep sometime near the end of February 2022. DON verified the opened area to Resident #33's coccyx identified by RN #286 on 02/23/22, was probably observed during the skin sweep. DON verified there was no full assessment of the wound and wound treatment orders were not implemented until 03/14/22. Resident #33's pressure ulcer to her sacrum was first identified on 03/14/22, when it was already at a Stage IV. DON further verified Resident #33 was at risk for the development of pressure ulcers but did not have adequate pressure ulcer prevention measures implemented until 03/14/22. Interview on 06/07/22 at 9:43 A.M., with the DON stated she had additional information regarding the pressure ulcer to Resident #33's sacrum. DON verified RN #286 had actually observed and identified an open area to Resident #33's coccyx on 03/04/22, but the electronic medical record (EMR) had saved the assessment as occurring on 02/23/22. DON stated the facility wound NP assessed Resident #33's skin on 03/07/22, but did not pick resident up because she observed an old area which had healed. DON verified Resident #33's representative was at the bedside during the observation and stated the resident had a wound to her bottom in the past which had healed prior to admission. DON verified a treatment to the open area for Resident #33 was not implemented until 03/10/22 and a full wound assessment was not completed until 03/14/22 at which time the resident presented with a Stage IV wound to her sacrum. Review of the policy titled Prevention of Pressure Injuries dated April 2020, revealed the facility should develop the resident's care plan and identify the risk factors for prevention of skin breakdown as well as the interventions designed to reduce or eliminate those considered modifiable. Further review revealed staff should inspect residents' skin on a daily basis when performing or assisting with personal care or ADLs, identify any signs of developing pressure injuries (i.e., non-blanchable [CONDITION(S)]) or for darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency, and should inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Staff should evaluate, report and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. Review of the guidance from the National Pressure Injury Advisory Panel (NPIAP) dated 2014, revealed staff should assess the pressure ulcer upon discovery and at least weekly thereafter and should implement appropriate wound care. Further review revealed with each dressing change, staff should observe the pressure ulcer for signs that indicate if a change in treatment is required (e.g., wound improvement, wound deterioration, signs of infection, or other complications). Wound status could change rapidly. Wound improvement or deterioration indicated by change in wound dimensions, change in tissue quality, an increase or decrease in wound exudate, signs of infection or other complications all provided indications of the effectiveness of the current management plan. The person responsible for dressing changes should be educated regarding signs and symptoms of complications that should be reported to the health professional. This deficiency substantiates Complaint Number OH 808

Based on medical record review, review of hospital records, review of a radiology report, staff interview, and review of email correspondence, the facility failed to provide timely and effective pain management for Resident #75 following a fall. Actual harm occurred when Resident #75 was not provided effective pain relief for roughly 15 hours after experiencing a fall with fracture on 12/30/21 at 10:45 A.M. This affected one (Resident #75) of three residents reviewed for pain management. The facility census was 75. Findings Include: Review of the medical record for Resident #75 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set assessment, dated 11/04/21, revealed Resident #75 had severe cognitive impairment and was rarely or never understood. The assessment further revealed Resident #75 required extensive assistance of one staff for bed mobility, transfers, and ambulation. Review of the assessments for Resident #75 revealed no pain assessments were completed. Review of the care plan for Resident #75 revealed pain management was not addressed in the care plan. Review of Resident #75's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. (ten hours after the resident's fall) for a pain level of five on a scale from one to ten with ten being the most severe pain. The medication was marked as effective. Review of the nurses note dated 12/30/21 at 3:33 P.M. revealed Resident #75 had an unwitnessed fall around 8:30 A.M. Resident #75 fell from the bed to the floor and landed on her left side. Resident #75 was found right away because staff heard the fall. Resident #75 was mostly non-verbal and was unable to explain what happened or if anything hurt. Resident #75's vital signs were taken and were within normal limits. Range of motion (ROM) exercises were performed, and Resident #75 did not show any signs of pain. No facial grimace or resistance to ROM exercises was noted. No bumps or bruises were noted on Resident #75's body. Resident #75's pupils were normal. When the staff assisted Resident #75 up, Resident #75 started to limp on the left side. Physician #110 was notified and ordered x-rays of Resident #75's left hip, knee, and ankle, and to monitor closely. Review of the radiology order dated 12/30/21 at 1:25 P.M. revealed bilateral x-rays of Resident #75's knees, hips, and ankles were ordered STAT (immediately) with a symptom of pain noted. Review of the x-ray results dated 12/31/21 at 1:24 A.M. revealed the examination date was 12/31/21 at 12:35 A.M. (13 hours after Resident #75's fall occurred). The x-ray results revealed findings of a right subcapital fracture with superior displacement (a fracture in the neck of the thighbone) with a conclusion of an acute right hip fracture. The x-ray was electronically signed by a physician on 12/31/21 at 1:23 A.M. (14 hours after Resident #75's fall occurred). Review of the nurses note dated 12/31/21 at 1:30 P.M. revealed the mobile x-ray provider arrived at the facility and completed x-rays of Resident #75's bilateral (both sides) hips, knees, and ankles. The results showed a right hip fracture. Physician #110 and Resident #75's representative were notified. Physician #110 ordered for Resident #75 to be sent to the hospital. Emergency Medical Services (EMS) was called and transported Resident #75 to the hospital. Review of the nurses note dated 01/04/22 at 7:40 A.M. revealed Resident #75's fall occurred around 10:45 A.M. on 12/30/21, not 8:30 A.M. Resident #75's family was notified, and neurological checks were started. Resident #75's left side was rechecked throughout the shift for bruising, and there was some redness noted in the hip area but there was no bruising and no bumps on Resident #75's head were noted. Review of the hospital records dated 12/31/21 at 3:12 A.M. revealed Resident #75 was seen and admitted to the hospital on 12/31/21 at 1:24 A.M. with a right closed fracture of the proximal end of her right femur (a right hip fracture). The assessment and plan included orthopedic and anesthesia consultation, pain management with [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] medications, and an ice compression, non-weightbearing, and consultation with cardiology for surgical clearance. The physician's notes stated, patient has severe dementia and is nonverbal. Information obtained from review of records. Patient was brought to the emergency room after a fall at the skilled nursing facility 20 hours ago. Images showing right proximal femur fracture. The physical examination noted, right lower extremity shorter compared to left. Resident #75 had an order started on 12/31/21 for [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]), a pain medication, 5-325 mg tablet with instructions to take one tablet by mouth every 12 hours as needed for up to seven days. The order had an end date of 01/07/22. Resident #75 underwent right cemented hip hemiarthroplasty surgery on 12/31/21. Resident #75 was discharged from the hospital on 01/04/22. Interview on 01/18/22 at 3:40 P.M. with the Director of Nursing (DON) revealed she was notified by the agency nurse, Licensed Practical Nurse (LPN) #111, that Resident #75 had a fall on 12/30/21 around 11:00 A.M. LPN #111 contacted Physician #110 who ordered x-rays for Resident #75 shortly after the fall occurred. The DON confirmed the x-rays were ordered STAT. The DON stated the x-ray was not completed until the evening because the mobile x-ray provider was short-staffed and had other facilities to visit before they arrived at the facility. The DON stated according to LPN #111, Resident #75 was not in any distress or pain and felt Resident #75 could wait for the x-ray technician to complete the x-rays instead of sending Resident #75 to the hospital. The DON stated, if it was me, I would have sent Resident #75 out to the emergency room and not waited for the x-ray, but the nurse decided not to do that. The DON stated the nurse completed a pain assessment and it should be in the Electronic Medical Record (EMR). Interview via telephone on 01/19/22 at 7:54 A.M. with LPN #111 revealed she and State tested Nurse Aide (STNA) #106 found Resident #75 on the floor around 10:45 A.M. on 12/30/21. Resident #75 fell out of the bed and landed on her side. LPN #111 could not recall which side Resident #75 landed on. LPN #111 assessed Resident #75, completed ROM exercises, and checked Resident #75's vital signs. Resident #75 did not appear to be in any pain when LPN #111 completed the ROM exercises. LPN #111 confirmed Resident #75 was non-verbal due to cognitive impairment. LPN #111 stated Resident #75 did not have any facial grimacing with ROM exercises. LPN #111 and STNA #106 assisted Resident #75 to stand and attempted to walk with Resident #75. LPN #111 stated Resident #75 had a limp when she walked. LPN #111 stated she parked her cart outside of Resident #75's room to monitor her. LPN #111 stated she started neurological checks, notified the physician, and the physician ordered x-rays. The x-ray technician had not arrived when LPN #111's shift ended at 7:30 P.M. LPN #111 stated she administered Tylenol to Resident #75 due to Resident #75's limp. LPN #111 stated, I figured she must have had a little pain if she was limping. LPN #111 stated based on her nursing judgement, she did not feel Resident #75 was in any distress and could wait for the x-ray technician to arrive instead of sending Resident #75 to the hospital. Resident #75 was still in the facility when LPN #111's shift ended at 7:30 P.M. (eight hours after Resident #75's fall). Telephone interview on 01/19/22 at 10:26 A.M. with LPN #105 revealed she was the night shift nurse on 12/30/21 and into 12/31/21. LPN #105 stated LPN #111 informed her Resident #75 fell out of bed in the morning. LPN #105 stated LPN #111's report to her was that LPN #111 and STNA #106 assisted Resident #75 up and walked her but it was obvious that she was in a lot of pain, so they put her back in bed where she stayed, and Resident #75 had a limp. LPN #105 stated I could tell Resident #75 was in pain. She showed facial grimacing, did not want to move at all, and declined a snack which was very unusual. She looked like she had a scream on her face but was not able to say anything. LPN #105 stated LPN #111 had given Resident #75 Tylenol at the end of her shift and Resident #75 was not due for anymore yet, so LPN #105 did not give Resident #75 any pain medication. LPN #105 stated she assessed Resident #75 for pain after she received the report and found Resident #75 was in excruciating pain. LPN #105 did not contact the physician or Nurse Practitioner (NP) to discuss Resident #75's pain level. LPN #105 could not recall when the x-ray technician arrived but stated it was at least 9:00 P.M. or later but the order had been made way earlier. LPN #105 stated when the x-ray technician notified her Resident #75 had a fractured hip, she immediately notified the physician and received an order to send Resident #75 to the hospital. Follow up interview on 01/19/22 at 11:30 A.M. with the DON revealed LPN #105 admitted to the DON she administered Resident #75 acetaminophen at 9:43 P.M. but she did not want to say that in the interview because she could not remember if she had documented it or not. The DON confirmed if LPN #111 administered acetaminophen to Resident #75, then LPN #111 did not document it. The DON confirmed there were not any pain assessments documented in Resident #75's medical record. The DON confirmed LPN #105 arrived at 7:30 P.M. on 12/30/21, stated Resident #75 was in excruciating pain and did not administer any pain medication until 9:43 P.M. Interview on 01/19/22 at 10:56 A.M. with STNA #106 revealed she and LPN #111 found Resident #75 on the floor after breakfast on 12/30/21 around 10:30 A.M. Resident #75 rolled out of bed. LPN #111 completed an assessment and checked Resident #75's pain level. When LPN #111 asked Resident #75 about pain, Resident #75 made a noise like a moan. When LPN #111 and STNA #106 assisted Resident #75 to stand, Resident #75 put all of her weight to one side, as if one side was hurting. Resident #75 was babying the side that ended up being broken. STNA #106 stated they asked another aide to assist, and Resident #75 limped to the dining room and sat in a recliner where she could be seen by staff. STNA #106 stated Resident #75 was resting in the recliner the last time she saw her on 12/30/21. Interview on 01/25/21 at 4:13 P.M. with Physician #110 revealed he was notified of Resident #75's fall at the end of December. Physician #110 stated x-rays were ordered and then later on, Resident #75 developed more pain and was sent out to the hospital. Physician #110 could not recall the time of day he received a call from facility staff regarding Resident #75's fall on 12/30/21. Physician #110 stated if Resident #75 was not in excruciating pain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician #110 stated he did not recall being informed that Resident #75 was in severe pain and did not recall any additional calls from the staff related to Resident #75's status or pain level. Review of email correspondence with the Administrator dated 01/25/22 at 5:50 P.M. revealed the facility did not have a policy regarding pain management. This deficiency substantiates Complaint Number OH 993.

Based on review of a closed medical record, interviews with residents, staff, local law enforcement, and the Coroner, review of a Self-Reported Incident (SRI) and facility policy review, the facility failed to ensure one resident (#82) was free from physical abuse by another resident. This resulted in Immediate Jeopardy and subsequent death when Resident #83 placed a pillow over his roommate Resident #82's face and suffocated him. This affected one of seven residents reviewed for abuse. The facility census was 80. On [DATE] at 4:15 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] during the morning shift change at approximately 7:00 A.M., when Resident #83 stated he had killed his roommate. Resident #82 was found lying in his bed, unresponsive, cool to touch and blue. Homicide Detective #101 stated the preliminary cause of Resident #82's death was identified as suffocation. She stated this was also confirmed by the statement she received from Resident #83. He gave a detailed statement of how he picked up a pillow from the wheelchair and held it over the face of Resident #82, suffocated, and killed him. He further stated to her Resident #82 had scratched Resident #83's neck and she confirmed Resident #83 had fresh scratches on his neck. She stated Resident #83 reported the devil made him do it. She stated nail scrapings were taken from Resident #82 and a Deoxyribonucleic Acid (DNA) swab was taken from Resident #83. She said the case was closed as a homicide. Finally, she stated there would be no trial as Resident #83 had hung himself in the local jail and expired. The Immediate Jeopardy was removed on [DATE] at 5:00 P.M., when the facility implemented the following corrective actions: · On [DATE] at approximately 7:30 A.M., the local law enforcement removed Resident #83 from the facility. Resident #83 was placed into custody and taken to the local county jail. · On [DATE], the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #64 reviewed both residents' records. There were no prior documented issues between the two residents. · On [DATE] time unspecified, Licensed Practical Nurse (LPN) #61 notified Medical Director (MD) #106 of the alleged abuse by Resident #83. LPN #61 also notified MD #106 of Resident #82's death. · On [DATE] at 9:00 A.M., the facility initiated an SRI for resident to resident abuse. · On [DATE] at approximately 9:30 A.M., Social Service Director (SSD) #68 completed wellness checks of all residents to ensure they felt safe and were completed on [DATE] at 5:00 P.M. · On [DATE] at approximately 5:00 P.M., the Administrator implemented a new procedure to no longer admit any resident with a history of homicidal ideation. · On [DATE] at 5:00 P.M., ADON #64 and Unit Manager (UM) #62 began educating all staff on behaviors including homicidal ideation. Part time, as needed staff, and Agency nursing staff will be educated prior to working their next scheduled shift. All in house staff will be educated by [DATE] at 5:00 P.M. · The Administrator, the DON and ADON #64 will continue to update and educate staff and residents on abuse monthly. The most recent abuse training was completed on [DATE] for all staff. · On [DATE] at 5:00 P.M., SSD #68 completed an audit of current residents with a psychiatric [DIAGNOSES REDACTED]. No residents were found with homicidal ideation. One resident (#61) was identified with a history of suicidal ideation, but no current ideations. · On [DATE], ADON #64, and UM #62 created a monitoring tool to review residents for signs and symptoms of abuse weekly, times four weeks, and then monthly thereafter. · Interviews on [DATE] from 8:45 A.M. to 6:47 P.M. and on [DATE] from 9:00 A.M. to 4:00 P.M. with the Administrator, the DON, Registered Nurse (RN) #37 and #39, LPN #61, State tested Nursing Assistant (STNA) #38, STNA #103, STNA #104, STNA #60, STNA #66, Activity Director #22, and Housekeeper #19 revealed they were knowledgeable of the abuse policy and indicated they would immediately report any allegations of abuse to the Administrator and/or to the DON. · On [DATE] at approximately 8:00 A.M., House Psychiatrist #100 completed a review all residents for homicidal ideation. No current residents were found with homicidal ideation. · On [DATE], a special Quality Assurance Performance Improvement (QAPI) meeting was held with MD #106 and House Psychiatrist #100 to discuss the incident that occurred between Resident #82 and Resident #83. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident #82 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed the resident had intact cognition, he required extensive assistance from one staff for bed mobility, transfer and ambulation. He had bilateral impairment of the upper and lower extremities and used a wheelchair. Review of the current plan of care revealed the resident had an alteration in mood and behavior related to anxiety and brain deterioration. The goal was to accept care and medication as ordered. Interventions included monitor mental status when new medications are added. Observe and report any changes in mental status. Review of the nurse notes dated [DATE] at 8:00 A.M., revealed the resident was found unresponsive at 7:05 A.M. Review of the closed medical record revealed Resident #83 was admitted to the facility on [DATE]. He was admitted from a local hospital where he had a stay in [DATE] due to bizarre behaviors, such as stripping naked and he expressed wanting to kill everyone at the homeless shelter. [DIAGNOSES REDACTED]. It may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning and can be disabling. People with [MEDICAL CONDITION] require lifelong treatment), [MEDICAL CONDITION] disorder, and diabetes. Review of the quarterly assessment dated [DATE] revealed the resident had moderate impaired cognition, he had trouble falling or staying asleep and he had not displayed any hallucinations or delusions. He required supervision for bed mobility, and transfer; however, he was independent in walking in his room. He also took antipsychotic medication. Review of the current plan of care revealed he had a potential to demonstrate physical behaviors related to poor impulse control and a history of suicidal and homicidal ideation. The goal was to not harm himself or others. Interventions included cognitive assessments, provide physical and verbal cues to alleviate anxiety, be able to verbalize the source of agitation, document observed behavior and attempted interventions in the behavior log. Monitor, document and report to the MD of danger to self and others. Review of the nurse notes revealed the last documented note was dated [DATE] which documented the resident had no behaviors. No further behavior documentation was in the progress notes from [DATE] to [DATE]. Review of a facility SRI, dated [DATE], and facility investigation revealed an allegation of physical abuse involving Resident #82 and Resident #83 occurred at 6:55 A.M., when Resident #83 claimed to have caused the passing of Resident #82. The local authorities were called and immediately arrived. Per the SRI, the local authorities and the facility management staff did not believe the allegation made by Resident #83. The investigation revealed the residents were immediately separated. As part of the facility's investigation, witness statements were taken from LPN #61, RN #37, Medical Records Staff #09, and UM #62 on [DATE]. LPN #61's witness statement documented she administered 5:00 A.M. medications and both residents were on their respective sides of the room. She checked Resident #83's blood sugar and noticed Resident #82 resting with his eyes closed and his chest was moving up and down. As she was completing her shift, Housekeeper #19 alerted her that Resident #83's head was hurting. Resident #83 was standing in the hallway. LPN #61 told the resident to wait so she could obtain equipment to check his vital signs. LPN #61 called UM #62 and told her Resident #83 did not seem like himself. UM #62 instructed her to ask him if he felt like hurting himself or others. Resident #83 told LPN #61 he had hurt Resident #82. LPN #61 observed Resident #82 unresponsive. She indicated Medical Records Staff #09 initiated cardiopulmonary resuscitation (CPR) while she called for emergency services and checked Resident #82's code status. After LPN #61 called emergency services, she went to the room to assist with the code. RN #37's witness statement documented she heard the calls for help and she and Medical Records Staff #09 came to assist. RN #37 stayed outside of the room with Resident #83 while the code was started. Medical Records Staff #09's witness statement documented she and RN #37 ran down the hall toward the calls for help. RN #37 remained outside with Resident #83 while she began chest compressions until emergency services arrived. UM #62's witness statement documented she received a call from LPN #61 on [DATE] at 7:01 A.M. LPN #61 inquired if Resident #83 had recently been acting weird or had been sick. LPN #61 informed UM #62 the resident was complaining his head hurt and he didn't feel right. UM #62 instructed LPN #61 to ask Resident #83 if he felt like he was going to hurt himself or someone else. Further review of the facility investigation revealed there were no other witness statements or interviews from other staff members who had worked on [DATE]. Interview on [DATE] at 10:42 A.M., Homicide Detective #101 stated the preliminary cause of Resident #82's death was identified as suffocation. She said this was also confirmed by the statement she received from Resident #83. He gave a detailed statement of how he picked up a pillow from the wheelchair and held it over the face of Resident #82, suffocated and killed him. He further stated to her Resident #82 had scratched Resident #83's neck and she confirmed Resident #83 had fresh scratches on his neck. She said Resident #83 reported the devil made him do it. She said nail scrapings were taken from Resident #82 and a Deoxyribonucleic Acid (DNA) swab was taken from Resident #83. She said the case was closed as a homicide. She said there would be no trial as Resident #83 had hung himself in the local jail and expired. Interview on [DATE] at 11:19 A.M., Coroner's Office Staff #102 stated they would not release any information at this time due to the matter was a homicide. Interview on [DATE] at 11:45 A.M., Housekeeper #19 stated she came in on [DATE] around 7:00 A.M., and Resident #83 was standing in the hallway, which was unusual for him. He told her he didn't feel well so she alerted LPN #61 who was getting ready to clock off. She observed LPN #61 talking to Resident #83 but could not hear what they were saying. LPN #61 ran out of the room and yelled he's (Resident #82) 'expletive' dead. All the nurses were in the hallway and Housekeeper #19 called her supervisor at 7:09 A.M., and again at 7:16 A.M. She said Resident #83 was calm standing in the hallway. Interview on [DATE] at 12:00 P.M., RN #37 stated she heard the call for help from the night shift nurse LPN #61. RN #37 said she stayed out in the hallway with Resident #83. LPN #61 went to the top of the hallway to call emergency services. Agency LPN #105 went into the resident's room while RN #37 waited in the hallway with Resident #83. The police came and took Resident #83 away. She said she never saw this coming, Resident #83 did not socialize and did not come out of his room. Interview on [DATE] at 4:18 P.M., LPN #61 stated she had finished up her morning medication pass. She was called back to the 100-hall because Resident #83 had a headache and wasn't acting himself. She called UM #62 and asked if the resident had been having any problems since LPN #61 had not worked in a few days. At the direction of UM #62, she asked Resident #83 if he felt like hurting himself or others and he stated he had killed Resident #82. She went into the room and Resident #82 looked unresponsive. She did not initiate CPR, instead she called nine-one-one (911) and stayed on the phone with the dispatcher. Medical Records Staff #09 initiated CPR while RN #37 was in the hallway with Resident #83. Interview on [DATE] at 4:32 P.M., the DON, ADON #64 and the Administrator stated the staff were not going to go in the resident's room after Resident #83 had just killed his roommate. Interview on [DATE] at 5:25 P.M., Resident #51 stated she was a friend of Resident #82 and the only thing she noticed was a few days before the incident, she observed Resident #83 rummaging through Resident #82's drawers. She asked Resident #83 what he was doing, and he said nothing. She observed Resident #82 asking Resident #83 what he was carrying, but Resident #83 indicated he had nothing and refused to show Resident #82 what he had. Interview on [DATE] at 12:17 P.M., House Psychiatrist #100 stated when she previously saw Resident #83, he denied command auditory hallucinations and he could not recognize the voices he was hearing. There was no indication he would escalate to this level. Interview on [DATE] at 11:17 A.M., Medical Director #106 stated he was informed of the incident approximately 24 hours later. He said Resident #83 was very protective and fixated on being the best friend of Resident #82. He further reported when Resident #82 began spending time with Resident #51 this may have set Resident #83 off. Review of the facility policy entitled Abuse, Neglect, and/or Misappropriation of Resident Funds or Property with a revised date [DATE] revealed if the resident was injured as a result of the alleged or suspected abuse or neglect, the facility shall take immediate action to treat the resident. Staff are not to leave a victim unless it was necessary to summon assistance. This deficiency substantiates the allegations in Complaint Number OH 601, Complaint Number OH 573, Complaint Number OH 540 and Complaint Number OH 291.

Based on review of the closed medical record, interviews with staff, review of the local fire department patient care record, review of the Self-Reported Incident (SRI) and facility policy review, the facility failed to assess, and immediately initiate Cardiopulmonary Resuscitation (CPR) for one Resident (#82) who was found unresponsive and was identified as a full code status. This resulted in Immediate Jeopardy and life-threatening harm when Resident #82 was not assessed nor provided timely CPR and expired in the nursing facility. This affected one of two residents reviewed for full code status and death. The facility identified five deaths in the facility. The facility census was 80. On [DATE] at 3:49 P.M., the Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #64, Social Service Director (SSD) #68, Unit Manager (UM) #62, Admissions Coordinator #85, Dietary Manager #36, Activity Director #22, and Minimum Data Set (MDS) Nurse #34 were notified Immediate Jeopardy began on [DATE] during the morning shift change at approximately 7:00 A.M., when Resident #82 was found by Licensed Practical Nurse (LPN) #61 to be unresponsive and CPR was not immediately initiated. LPN #61 ran out of the room and yelled he's ' expletive ' dead. Homicide Detective #101 stated the preliminary cause of Resident #82's death was identified as suffocation. She stated this was also confirmed by the statement she received from Resident #83. He gave a detailed statement of how he picked up a pillow from the wheelchair and held it over the face of Resident #82, suffocated and killed him. Interview on [DATE] at 4:32 P.M., the DON, ADON #64 and the Administrator stated the staff were not going to go in the room after Resident #83 said he had killed someone. They were making sure the scene was safe and they were safe. The Immediate Jeopardy was removed on [DATE] at 5:00 P.M., when the facility implemented the following corrective actions: · On [DATE] at approximately 9:00 A.M., ADON #64 and UM #62 began educating all nursing staff on what to do when finding a resident unresponsive, checking the code status, starting CPR immediately and having another person call nine-one-one (911) and to continue CPR until emergency services arrive. State tested Nursing Assistants (STNAs) were educated if a nurse yells for help they should respond to this type of event as anyone can get another nurse, check code status, or call 911. All full-time staff had completed education by [DATE] at 5:00 P.M. All part-time and as needed (PRN) staff will be educated by phone or in person prior to their next working shift by ADON #64 or UM #62. All training will be completed by [DATE]. All new employees will be trained on this procedure upon hire. · On [DATE] at approximately 9:30 A.M., SSD #68 reviewed all resident records to ensure code status was properly placed in the medical record. She also interviewed residents to ensure they felt safe in the building. · On [DATE] and [DATE] the DON, ADON #64 and SSD #68 held a town hall meeting (a meeting with staff and residents) to debrief residents and staff about the incident/alleged murder and the passing of two of their residents. · On [DATE] at approximately 8:00 A.M., Medical Director (MD) #106 was notified of the death of Resident #82. · The Administrator, the DON, ADON #64 and UM #62 will audit charts for code status and monitor any future deaths of residents who were full code status if they expired in the facility. This will be completed weekly times four weeks and then monthly thereafter. · On [DATE], a special Quality Assurance Performance Improvement (QAPI) meeting will be held with Medical Director #106 and House Psychiatrist #100 to discuss the incident in the building. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of the closed medical record revealed Resident #82 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the face sheet revealed he was a full code. He expired in the facility on [DATE]. Review of the quarterly assessment dated [DATE] revealed the resident had intact cognition, and he required extensive assistance from one staff for bed mobility, transfer and ambulation. He had bilateral impairment of the upper and lower extremities and used a wheelchair. Review of the current plan of care revealed the resident had an alteration in mood and behavior related to anxiety and brain deterioration. The goal was to accept care and medication as ordered. Interventions included monitor mental status when new medications were added. Observe and report any changes in mental status. He was a full code. Review of the local fire department patient care record dated [DATE] documented the emergency services were called to the facility at 7:07 A.M., they were dispatched at 7:09 A.M., they arrived at the facility at 7:17 A.M., and they were at Resident #82 at 7:19 A.M. The engine crew made contact with Resident #82 who was lying supine (on his back) in bed. It was reported Resident #82 was strangled by another resident who occupied the same room. The crew reported CPR was not initiated prior to their arrival and there was another (unknown) resident sitting on the other bed in the room with the door shut. The crew reported Resident #82 was pulseless, apneic (cessation of breathing), and warm to touch. CPR was initiated and the Automated External Defibrillator (AED) was applied as well as oxygen. They established an airway, an intravenous (IV) line and administered lifesaving medications. The resident was pronounced dead at 7:39 A.M., in the facility. The coroner's office was contacted and would be out to investigate. Review of the nurses notes dated [DATE] at 8:00 A.M. revealed the resident was found unresponsive at 7:05 A.M. Code was started at 7:05 A.M., and 911 was called. Review of a facility SRI dated [DATE] at 9:00 A.M. revealed the facility investigated an allegation of resident to resident physical abuse involving Resident #82 and #83 that occurred on [DATE] at 6:55 A.M., when Resident #83 claimed to have caused the passing of Resident #82. As part of the facility investigation, witness statements were taken from LPN #61, RN #37, Medical Records Staff #09, and UM #62 on [DATE]. LPN #61's witness statement documented she administered 5:00 A.M. medications and both residents were on their respective sides of the room. She checked Resident #83's blood sugar and noticed Resident #82 resting with his eyes closed and his chest was moving up and down. As she was completing her shift, Housekeeper #19 alerted her that Resident #83's head was hurting. Resident #83 was standing in the hallway. LPN #61 told the resident to wait so she could obtain equipment to check his vital signs. LPN #61 called UM #62 and told her Resident #83 did not seem like himself. UM #62 instructed her to ask him if he felt like hurting himself or others. Resident #83 told LPN #61 he had hurt Resident #82. LPN #61 observed Resident #82 unresponsive. She indicated Medical Records Staff #09 initiated CPR while she called for emergency services and checked Resident #82's code status. After LPN #61 called emergency services, she went to the room to assist with the code. RN #37's witness statement documented she heard the calls for help and her and Medical Records Staff #09 came to assist. RN #37 stayed outside of the room with Resident #83 while the code was started. Medical Records Staff #09's witness statement documented she and RN #37 ran down the hall toward the calls for help. RN #37 remained outside with Resident #83 while she began chest compressions until emergency services arrived. UM #62's witness statement documented she received a call from LPN #61 on [DATE] at 7:01 A.M. LPN #61 inquired if Resident #83 had recently been acting weird or had been sick. LPN #61 informed UM #62 the resident was complaining his head hurt and he didn't feel right. UM #62 instructed LPN #61 to ask Resident #83 if he felt like he was going to hurt himself or someone else. Further review of the facility investigation revealed there were no other witness statements provided or follow-up interviews with other staff who had worked on [DATE]. Interview on [DATE] at 11:45 A.M., Housekeeper #19 stated she came in on [DATE] around 7:00 A.M., and Resident #83 was standing in the hallway, which was unusual for him. He told her he didn't feel well so she alerted LPN #61 who was getting ready to clock out. She observed LPN #61 talking to Resident #83 but could not hear what they were saying. LPN #61 ran out of the room and yelled he's (Resident #82), 'expletive' dead. All the nurses were in the hallway and Housekeeper #19 called her supervisor at 7:09 A.M., and again at 7:16 A.M. She said Resident #83 was calm standing in the hallway. Interview on [DATE] at 12:00 P.M., RN #37 stated she heard the call for help from the night shift nurse LPN #61. RN #37 said she stayed out in the hallway with Resident #83. LPN #61 went to the top of the hallway to call emergency services. Agency LPN #105 went into the resident's room while RN #37 waited in the hallway with Resident #83. The police came and took Resident #83 away. She said she never saw this coming, Resident #83 did not socialize and did not come out of his room. Interview on [DATE] at 12:15 P.M., Medical Records Staff #09 stated she was in the building and heard screaming and saw LPN #61 was distraught. She walked briskly down to the area where she heard screaming, ran in the room and started chest compressions. She said she was the only person in the room, she knew LPN #61 was on the phone and RN #37 was outside of the room watching Resident #83. She reported Resident #82 was cool to the touch and his lips and face were blue. Interview on [DATE] at 4:18 P.M., LPN #61 stated she had finished her morning medication pass. She was called back to the 100-hall because Resident #83 had a headache and wasn't acting himself. She called UM #62 and asked if the resident had been having any problems since LPN #61 had not worked in a few days. At the direction of UM #62, she asked Resident #83 if he felt like hurting himself or others and he stated he had killed Resident #82. She went into the room and Resident #82 looked unresponsive. She did not initiate CPR, instead she called 911 and stayed on the phone with the dispatcher. Medical Records Staff #09 initiated CPR while RN #37 was in the hallway with Resident #83. Interview on [DATE] at 4:32 P.M., the DON, ADON #64 and the Administrator stated the staff were not going to go in the room after Resident #83 said he had killed someone. They were making sure the scene was safe and they were safe. Interview on [DATE] at 11:00 A.M., agency LPN #105 stated she had just arrived at work, around 7:05 A.M., and LPN #61 came to the 100-hall nurses station and said she had just asked Resident #83 if he had wanted to hurt himself or anyone. He said he had killed Resident #82. LPN #61 stated she went in the resident's room and he was dead as a doorknob and he was blue. She said LPN #61 called 911 and it took about seven minutes for the emergency services to arrive. When emergency services arrived, they asked for the nurse on duty and worked on Resident #82 for about 20 minutes. Agency LPN #105 said she never went down the hallway or saw Resident #82. Interview on [DATE] at 8:38 A.M., Environmental Manager #50 stated he received two phone calls from Housekeeper #19 on [DATE] and both were a little after 7:00 A.M. He said she called and reported to him that Resident #83 had killed Resident #82. He kept asking her what and to repeat herself, as he couldn't believe what she was saying. He arrived to work a few minutes after the calls, and the police had already taken Resident #83 into custody and the emergency personnel were working on Resident #82. During a follow-up interview on [DATE] at 8:05 A.M., Medical Records Staff #09 stated she was in the residents room completing chest compressions and she was told by RN #37 the emergency services personnel had arrived, so she stopped compressions and ran out of the room to the bathroom, because she was upset. She verified the emergency service personnel had not relieved her prior to her stopping chest compressions. Follow-up interview on [DATE] at 8:12 A.M., RN #37 verified she did not go in the residents ' room, she only kept her eyes on Resident #83. She did not recall alerting Medical Records Staff #09 of the arrival of the squad nor did she see her run out of the room. Her eyes were on Resident #83. Interview on [DATE] at 11:17 A.M., Medical Director #106 stated he was aware of the incident approximately 24 hours later. He stated he would expect the staff to call 911 and start CPR immediately if the resident was a full code. The only exception would be if they had clear clinical signs of death without reversal. Review of the facility policy titled Performance Guidelines of Cardiopulmonary Resuscitation (CPR) revised date [DATE] revealed the requirements to be met regarding CPR: Cardiac or respiratory arrest occurs for a resident who does not show obvious signs of irreversible death. A resident who has requested CPR in his/her advance directives. A resident who has not formulated an advance directive. A resident who does not have a valid Do Not Resuscitate (DNR) order. Procedure: Initial respondent reaches out to staff members for assistance, CPR is initiated based on Resident Code Status, staff member simultaneously calls 911/Emergency Medical Technicians (EMT's). This deficiency is an incidental finding discovered during Master Complaint Number OH 601, Complaint Number OH 573, Complaint Number OH 540 and Complaint Number OH 291.

Based on review of the medical record, interviews with staff, review of the Self-Reported incident (SRI) and facility policy review, the facility failed to ensure one resident (#83) who was diagnosed with [REDACTED]. This resulted in Immediate Jeopardy and life-threatening harm when Resident #83, who had a known history of homicidal ideation, reported he had killed his roommate (Resident #82), who was subsequently found unresponsive in his bed after being suffocated by Resident #83. On [DATE] at 3:49 P.M., the Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #64, Social Service Director (SSD) #68, Unit Manager (UM) #62, Admissions Coordinator #85, Dietary Manager #36, Activity Director #22, and Minimum Data Set (MDS) Nurse #34 were notified Immediate Jeopardy began on [DATE] during the morning shift change at approximately 7:00 A.M., when Resident #82 was found by Licensed Practical Nurse (LPN) #61 to be unresponsive and Resident #83 reported he had killed Resident #82. Homicide Detective #101 stated the preliminary cause of Resident #82's death was identified as suffocation. She stated this was also confirmed by the statement she received from Resident #83. He gave a detailed statement of how he picked up a pillow from the wheelchair and held it over the face of Resident #82, suffocated and killed him. He further stated to her Resident #82 had scratched Resident #83's neck and she confirmed Resident #83 had fresh scratches on his neck. She stated Resident #83 reported the devil made him do it. She said nail scrapings were taken from Resident #82 and a Deoxyribonucleic Acid (DNA) swab was taken from Resident #83. She said the case was closed as a homicide. Finally, she stated there would be no trial as Resident #83 had hung himself in the local jail and expired. The Immediate Jeopardy was removed on [DATE] at 5:00 P.M., when the facility implemented the following corrective actions: · On [DATE] at approximately 7:30 A.M., the local law enforcement removed Resident #83 from the facility. Resident #83 was placed into custody and taken to the local county jail. · On [DATE] the DON and ADON #64 reviewed both residents ' records. There were no prior documented issues between the two residents. · On [DATE] time unspecified, Licensed Practical Nurse (LPN) #61 notified Medical Director (MD) #106 of the alleged abuse by Resident #83. LPN #61 also notified MD #106 of Resident #82's death. · On [DATE] at 9:00 A.M., the facility initiated an SRI for resident to resident abuse. · On [DATE] at approximately 9:00 A.M., SSD #68 began wellness checks of all residents and anyone who saw a counselor she notified the case manager of the incident. This was completed on [DATE] at approximately 9:45 A.M. · On [DATE] at approximately 5:00 P.M., the Administrator implemented a new procedure to no longer admit any resident with a history of homicidal ideation. · On [DATE] at 5:00 P.M., ADON #64 and UM #62 began educating all staff on behaviors including homicidal ideation. Part time, as needed staff, and Agency nursing staff will be educated prior to working their next scheduled shift. All in house staff will be educated by [DATE] at 5:00 P.M. · The Administrator, the DON and ADON #64 will continue to update and educate staff and residents on abuse monthly. The most recent abuse training was completed on [DATE] for all staff. · On [DATE] at 5:00 P.M., SSD #68 completed an audit of current residents with a psychiatric [DIAGNOSES REDACTED]. No residents were assessed with [REDACTED].#61) was identified with a history of suicidal ideation, but no current ideations. · On [DATE] at 5:00 P.M., ADON #64, and UM #62 created a monitoring tool, to review residents for signs and symptoms of abuse/behaviors weekly times four weeks and then monthly thereafter. · Interviews on [DATE] from 8:45 A.M. to 6:47 P.M. and on [DATE] from 9:00 A.M. to 4:00 P.M. with the Administrator, the DON, Registered Nurse (RN) #37 and #39, LPN #61, State tested Nursing Assistant (STNA) #38, STNA #103, STNA #104, STNA #60, STNA #66, Activity Director #22, and Housekeeper #19 revealed they were knowledgeable of resident behaviors and knew what to do in the case of homicidal ideation and suicidal ideation. · On [DATE] at approximately 8:00 A.M., House Psychiatrist #100 completed a review all residents for homicidal ideation. No current residents were found with homicidal ideation. · On [DATE], a special Quality Assurance Performance Improvement (QAPI) meeting is scheduled to be held with MD #106 and House Psychiatrist #100 to discuss the incident that occurred between Resident #82 and Resident #83. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident #83 was admitted to the facility on [DATE]. He was admitted from a local hospital where he had a stay in [DATE] due to bizarre behaviors, such as stripping naked and he expressed wanting to kill everyone at the homeless shelter. [DIAGNOSES REDACTED]. It may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning and can be disabling. People with [MEDICAL CONDITION] require lifelong treatment), [MEDICAL CONDITION] disorder, and diabetes. Review of the counseling referral dated [DATE] revealed he had been offered counseling due to being depressed, being withdrawn, psychotic thinking, thought distortion, worries and history of homicidal ideation (which he reasonably denied at the time of the consult). He declined the offer for counseling and there was no other documented follow-up request for counseling services for the resident. Review of the psychiatric consultation dated [DATE] revealed he was seen due to history of mental illness and unable to care for himself, he had auditory hallucinations (hearing voices), anxiety, depression, and difficulty coping with the new placement. His mental status examination included that he was suspicious, had paranoia, delusions, he had fair insight and limited judgement. He was ordered an antipsychotic medication. He was to follow up in one to three months. Review of the psychiatric consultation dated [DATE] revealed a follow-up was requested by the medical doctor due to behavioral symptoms, and psychotic signs and symptoms. He was feeling persecuted and paranoid. He was suspicious, withdrawn, dysphoric, delusions, preoccupation, he reliably denied suicidal and homicidal thoughts. He was slowly responding with increased quality of life. He was to have follow-up in three months. Review of the psychiatric consultation dated [DATE] revealed a follow-up was requested by the medical doctor due to behavior symptoms, psychotic symptoms and depressive mood and therapeutic efficiency of medication. He reliably denied suicidal and homicidal thoughts and continued the same medication regimen. Review of the psychiatric consultation dated [DATE] revealed he had presented to the hospital for out of control blood sugar; however, he continued with paranoid thinking, feeling persecuted, delusions, auditory hallucinations, dysphoric and anxious. He reliably denied suicidal and homicidal thoughts. His antipsychotic medication was decreased at this time; however, the plan documented a gradual dose reduction was clinically contraindicated at this time. He was to follow-up in three months. Review of the behavior/intervention monthly flow record dated from ,[DATE] through ,[DATE] revealed the behavior being monitored was refusing medications and refusing care. The behavior monitoring was not documented consistently on each shift. There were no other specific targeted behavior monitoring for delusions, auditory hallucinations, or homicidal ideation. Review of the quarterly assessment dated [DATE] revealed the resident had moderate impaired cognition, he had trouble falling or staying asleep and he had not displayed any hallucinations or delusions. He required supervision for bed mobility, and transfer; however, he was independent in walking in his room. He also took antipsychotic medication. Review of the current plan of care revealed he had a potential to demonstrate physical behaviors related to poor impulse control and a history of suicidal and homicidal ideation. The goal was to not harm himself or others. Interventions included cognitive assessments, provide physical and verbal cues to alleviate anxiety, be able to verbalize the source of agitation, document observed behavior and attempted interventions in the behavior log. Monitor, document and report to the MD of danger to self and others. Review of the nurse notes revealed the last documented note was dated [DATE] which documented the resident had no behaviors. No further behavior documentation was in the progress notes from [DATE] to [DATE]. Review of a facility's SRI dated [DATE] and the facility investigation revealed an allegation of physical abuse involving Resident #82 and Resident #83 occurred at 6:55 A.M., when Resident #83 claimed to have caused the passing of Resident #82. The local authorities were called and immediately arrived. Per the SRI, the local authorities and the facility management staff did not believe the allegation made by Resident #83. The investigation revealed the residents were immediately separated. As part of the facility investigation, witness statements were taken from LPN #61, RN #37, Medical Records Staff #09, and UM #62 on [DATE]. LPN #61's witness statement documented she administered 5:00 A.M. medications and both residents were on their respective sides of the room. She checked Resident #83's blood sugar and noticed Resident #82 resting with his eyes closed and his chest was moving up and down. As she was completing her shift, Housekeeper #19 alerted her that Resident #83's head was hurting. Resident #83 was standing in the hallway. LPN #61 told the resident to wait so she could obtain equipment to check his vital signs. LPN #61 called UM #62 and told her Resident #83 did not seem like himself. UM #62 instructed her to ask him if he felt like hurting himself or others. Resident #83 told LPN #61 he had hurt Resident #82. LPN #61 observed Resident #82 unresponsive. She indicated Medical Records Staff #09 initiated cardiopulmonary resuscitation (CPR) while she called for emergency services and checked Resident #82's code status. After LPN #61 called emergency services, she went to the room to assist with the code. RN #37's witness statement documented she heard the calls for help and her and Medical Records Staff #09 came to assist. RN #37 stayed outside of the room with Resident #83 while the code was started. Medical Records Staff #09's witness statement documented she and RN #37 ran down the hall toward the calls for help. RN #37 remained outside with Resident #83 while she began chest compressions until emergency services arrived. UM #62's witness statement documented she received a call from LPN #61 on [DATE] at 7:01 A.M. LPN #61 inquired if Resident #83 had recently been acting weird or had been sick. LPN #61 informed UM #62 the resident was complaining his head hurt and he didn't feel right. UM #62 instructed LPN #61 to ask Resident #83 if he felt like he was going to hurt himself or someone else. Further review of the facility investigation revealed there were no other witness statements or interviews from other staff members who had worked on [DATE]. Interview on [DATE] at 10:42 A.M., Homicide Detective #101 stated the preliminary cause of Resident #82's death was identified as suffocation. She said this was also confirmed by the statement she received from Resident #83. He gave a detailed statement of how he picked up a pillow from the wheelchair and held it over the face of Resident #82, suffocated, and killed him. He further stated to her Resident #82 had scratched Resident #83's neck and she confirmed Resident #83 had fresh scratches on his neck. She said Resident #83 reported the devil made him do it. She stated nail scrapings were taken from Resident #82 and a Deoxyribonucleic Acid (DNA) swab was taken from Resident #83. She said the case was closed as a homicide. Finally, she stated there would be no trial as Resident #83 had hung himself in the local jail and expired. Interview on [DATE] at 12:00 P.M., RN #37 stated she heard the call for help from the night shift nurse LPN #61. RN #37 said she stayed out in the hallway with Resident #83. LPN #61 went to the top of the hallway to call emergency services. Agency LPN #105 went into the resident's room while RN #37 waited in the hallway with Resident #83. The police came and took Resident #83 away. She said she never saw this coming, Resident #83 did not socialize and did not come out of his room. Interview on [DATE] at 12:55 P.M., SSD #68 stated he had a history of [REDACTED]. She stated he had a psychiatric stay in May/[DATE] when he was running around the homeless shelter naked and acting bizarre. When they asked him if he wanted to hurt himself or others, he responded everyone. She verified there was no other attempt for counseling, and they did not monitor specific behavior daily of hearing voices, or homicidal ideation, because he just said it in the homeless shelter. He said he had seen the psychiatrist and reliably denied homicidal ideation. She further stated Resident #83 was protective of Resident #82 as he thought of him as a best friend. Interview on [DATE] at 4:18 P.M., LPN #61 stated she had finished up her morning medication pass. She was called back to the 100-hall because Resident #83 had a headache and wasn't acting himself. She called UM #62 and asked if the resident had been having any problems since LPN #61 had not worked in a few days. At the direction of UM #62, she asked Resident #83 if he felt like hurting himself or others and he stated he had killed Resident #82. She went into the room and Resident #82 looked unresponsive. Interview on [DATE] at 4:32 P.M., the DON, ADON #64 and the Administrator stated the staff were not going to go in the resident's room after Resident #83 had just killed his roommate. Interview on [DATE] at 5:25 P.M., Resident #51 stated she was a friend of Resident #82 and the only thing she noticed was a few days before the incident she observed Resident #83 rummaging through Resident #82's drawers. She asked Resident #83 what he was doing, and he said nothing. She observed Resident #82 asking Resident #83 what he was carrying, but Resident #83 indicated he had nothing and refused to show Resident #82 what he had. Interview on [DATE] at 12:17 P.M., House Psychiatrist #100 stated when she previously saw Resident #83, he denied command auditory hallucinations and he could not recognize the voices he was hearing. There was no indication he would escalate to this level. She further stated she decreased the antipsychotic medication due to him having [MEDICAL CONDITION]. She said she did not take him off completely and she decreased it slowly. She did not report why she had documented a gradual dose reduction was contraindicated on the [DATE] consultation when she decreased the medication. She also discussed the behavior plan with the nursing staff. She said for counseling they would attempt two times before they do not refer them again. Interview on [DATE] at 11:17 A.M., Medical Director #106 stated when Resident #82 started spending time with Resident #51 he thought this may have set off Resident #83. Resident #83 thought of Resident #82 as his best friend and fixated on this. Review of the facility policy titled Mental Health Services dated [DATE] revealed the facility will help residents maintain or improve their psychosocial conditions and will provide or arrange counseling, psychotherapy, or other mental health services when indicated. Monitor behavior using behavior monitoring tool on the Medication Administration Record [REDACTED]. This deficiency is an incidental finding discovered during Master Complaint Number OH 601, Complaint Number OH 573, Complaint Number OH 540 and Complaint Number OH 291.

Based on record review, observation, interview and review of policy and manufactures operation instructions for shower bed the facility failed to ensure a shower bed was properly maintained which resulted in actual physical harm to one resident (#3) when she fell during a shower and received a laceration to the lateral aspect of her right eye. This affected one Resident (#3) of three reviewed for falls. The facility identified 6 residents who used a shower bed. The facility census was 87. Findings include: Review of Resident #3's medical revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a fall assessment dated [DATE] revealed the resident was at high risk for falls. Review of the Minimum Data Set ((MDS) dated [DATE] identified Resident #3 with severe cognitive impairment, totally dependent for bathing and required one person physical assistance. Review of a nurses noted dated 07/14/16 at 11:00 A.M. indicated a state tested nursing assistant (STNA) had Resident #3 in the shower in a shower bed. The STNA rolled Resident #3 onto her side and Resident #3 rolled onto the floor out of the shower bed hitting her head. Resident #3 had a laceration to the right side of her face and pressure was applied until emergency medical services (EMS) arrived. Resident #3 was able to move all extremities, was kept awake by simple questions and remained alert. Resident was taken to the local hospital for treatment. The family and the physician were notified of the incident and of transfer to the hospital. Review of the fall investigation dated 07/14/16 at 11:13 A.M. revealed STNA #30 was interviewed and reported the shower bed rail had broken during the turning of Resident #3. STNA #30 reported in this interview the shower bed was not broken prior to Resident #3's shower on 07/14/16. Review of physician orders [REDACTED]. Another PO dated 07/14/16 indicated Norco (a narcotic pain medication) 5 milligram (mg)/325 mg by mouth every six hours as needed. Review of PO dated 07/15/16 indicated to remove eight sutures in seven days (07/21/16). Review of the Medication Administration Record (MAR) for 07/2016 revealed Resident #3 was medicated with the Norco on 07/14/16 at 11:30 P.M., 07/15/16 at 3:30 P.M., 07/15/16 at 9:30 P.M. and on 07/18/16 at 7:45 A.M. During an observation of Resident #3 on 08/11/16 at 10:35 A.M. revealed Resident #3 was resting in in bed with eyes closed. A healed scar to lateral aspect of right eye was observed. The resident was not interviewable. During an interview with the Administrator and the Assistant Director of Nursing (ADON) #40 on 08/11/16 at 11:30 A.M. the Administrator stated after Resident #3 fell out of the shower bed on 07/14/16 he sent Plant Director (PD) #50 to a local store to obtain metal pins and chains for the shower bed's rails. ADON #40 stated the metal pins should have been with the shower bed were frequently misplaced by staff. At the time of the interview an observation was made of the shower bed. Four pins total were observed in the shower bed rails. Two on each side of the rail, one pin in each end to hold the side rail in place and upright. These pins were attached to the shower bed with metal chains. The shower bed was constructed of polyvinyl chloride (PVC) tubing. The Administrator stated that he was unsure if the shower bed came with metal pins, but confirmed holes were present in the side rails for pin placement and none were added by PD #50. Both the ADON #40 and the Administrator confirmed there was only one shower bed present in the facility. The Administrator stated that he was unaware of any manual or instructions for the operation of the shower bed. During a phone interview on 08/11/16 at 11:35 A.M. with Representative #40 who was employed by the manufacturer of the shower bed revealed the shower bed was manufactured with 4 metal pins held to the bed with rubber lanyards. Representative #40 further revealed operation instructions were provided with each shower bed. The representative provided a copy of these instructions by email on 08/11/16. Review of these instructions and of the manufacturer's recommendations indicated to lock siderails in place at all time except for transfer. During an interview on 08/11/16 at 11:45 A.M. with PD #50 he revealed he attached four new metal pins and metals chains to the shower bed on 07/14/16 after Resident #3's fall. PD #50 was unsure the number of pins present in the bed before attaching the new ones. PD #50 stated there was maybe one pin, but he was unable to locate it. In a follow up interview at 12:08 P.M., PD #50 stated he was unaware of any manual or instructions for the shower bed and reported it had been at the facility for awhile. PD #50 confirmed that no regular inspections of the shower bed had been completed. During an observation and interview on 08/11/16 at 11:58 A.M. STNA #30 demonstrated and explained how Resident #3 fell from the shower bed on 07/14/16. STNA #30 stated that she rolled Resident #3 towards herself while the resident was on the shower bed and demonstrated the motion. STNA #30 stated Resident #3 rolled against the side rail and the rail fell open. STNA #30 demonstrated how the rail fell open with no pins in place in the side rails. STNA #30 stated she tried to prevent Resident #3 from hitting the floor, but was unable to do so because Resident #3 was slippery due to being soapy and wet. STNA #30 stated that pins were present in the shower bed rails that day, but she was unable to explain how the rails fell open. STNA #30 stated that maybe the old pins were shorter than what was currently in place. STNA #3 reported she was inserviced on the shower bed use. During interviews conducted on 08/11/16 at 12:35 P.M. and 2:05 P.M. ADON #40 revealed the shower bed pins were lost by staff and used to be held to the shower bed by plastic ties. ADON #40 revealed she did not think all four pins were in place in the shower bed side rails when Resident #3 fell on [DATE]. ADON #40 confirmed that no regular inspections of the shower bed had been completed. During an interview on 08/11/16 at 2:20 P.M. the Administrator revealed he did not believe any pins were in place in the shower bed rails when Resident #3 fell and sustained a head laceration on 07/14/16. During an interview on 08/11/16 at 2:35 P.M. Registered Nurse (RN) #10 revealed the pins were missing from the shower bed prior to Resident #3's fall and the shower bed should have been fixed. RN #10 stated this was the reason for Resident #3's fall. Review of the policy entitled Shower Bed Use and Safety dated April, 2002 revealed the purpose of the policy was to ensure the safe use of a shower bed. Procedures given to obtain this were monthly shower bed inspections by maintenance staff, STNA to ensure all pins are in place prior to shower use, STNA to ensure rails are locked for patient safety prior to use and shower bed to be cleaned after each usage per infection control guidelines. This deficiency substantiates Complaint Number OH 890.