Every finding on record at Centerville Post Acute

Based on record review, staff interview, and transportation interview, the facility failed to properly discharge a resident. This affected one (Resident #117) out of three reviewed for discharge. The facility census was 111.Findings include:Review of Resident #117's medical record revealed an admission date of 11/18/25 and a discharge date of 04/25/26 with diagnoses of paraplegia, complete, other acute osteomyelitis, right ankle and foot, neuromuscular dysfunction of bladder, and chronic pulmonary embolism. Further review revealed Resident #117's wounds to the bilateral heels were healed. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had moderate cognitive impairment with no behaviors documented. Resident required assistance with eating, required partial assistance with oral hygiene, required substantial assistance with bathing, personal hygiene, and was dependent on staff assistance with toileting hygiene, dressing, bed mobility, transfers, and wheelchair mobility.Review of the Care Plan dated 04/25/26 revealed Resident #117 was at risk for decline in activities of daily living (ADLs) with interventions including the resident required two person assist with all (ADLs) and care due to behaviors and fabrication of false allegations towards staff. Further review of the Care Plan revealed Resident #117 exhibits physical and verbal behaviors towards staff, throwing items, hitting staff and cursing at staff with interventions of medications as needed, encourage resident to verbalize feelings, and psych consult as needed. Review of the nurse's note dated 04/25/26 at 7:30 P.M. revealed Resident #117 became physically aggressive towards staff.Review of the nurse's note dated 04/25/26 at 11:42 P.M. revealed at 7:29 P.M. Resident #117 had physically assaulted a nurse at the facility, threw a soiled brief torn up at the nurse, and spit on the nurse. The police was called. Police arrived, took witness statements, and was going to arrest Resident #117. Upon resident voicing concerns of wounds, the resident requested to go to the emergency room (ER). Further review of Resident #117's progress notes revealed no documented behaviors prior to this incident. Additionally, there was no documentation to support the resident had been offered mental health services. Review of the ER note dated 04/26/26 at 1:35 A.M. revealed the ER nurse called the facility and spoke with Licensed Practical Nurse (LPN) Supervisor #282 and informed her that Resident #117 would not be going to jail and would be returning to the facility.Review of the Run Report from Transportation Company (TC) #500 revealed Resident #117 left the hospital on [DATE] at 1:41 A.M. and returned to the facility. Upon arriving at Centerville Post Acute, nursing staff met transport outside at the door, and refused Resident #117. Centerville Post Acute staff reported they refused Resident #117 because they didn't feel safe and reported they would clock out and go home if Resident #117 came into the facility. At this point, the resident was taken to his previous residence, his mother's home.Further review of the medical record revealed no evidence a discharge notice was given to Resident #117. Interview on 05/19/26 at 3:46 P.M. with the Director of Nursing (DON) confirmed Resident #117 was not given discharge paperwork from LPN Supervisor #282 on 04/25/26. Interview confirmed Resident # 117 was sent out the hospital due to assault on a staff member on 04/25/26 and the facility did not feel the hospital did a thorough psych evaluation, so the facility sent the resident back to the hospital. Interview confirmed Resident #117 was a paraplegic. The DON reported the resident had become upset on 04/25/26 because the facility initiated two staff present for care due to behaviors. Telephone call received on 05/20/26 at 11:36 A.M. from LPN Supervisor #282 confirmed she was the nurse on duty 04/26/26 at 1:35 A.M. when the Registered Nurse (RN) from the hospital called reporting Resident #117 was not going to jail and was returning to the facility. Interview also confirmed when Resident #117 returned to the facility on [DATE] around 3:35 A.M. she refused for the resident to readmit. Interview confirmed LPN Supervisor #282 felt the facility did not have the means to care for Resident #117 due to his behaviors. Interview confirmed she felt since Resident #117 assaulted a staff member, he should not be at the facility. Interview confirmed the DON told her not to allow the resident to readmit to the facility and to tell the squad to take him back to the hospital.Interview on 05/20/26 at 2:47 P.M. with the DON confirmed on 04/26/26, Resident #117 was brought back to the facility from the hospital and the facility wanted him sent back to the hospital since they felt the hospital didn't evaluate him for psych. Interview confirmed the facility does not have paperwork where they sent Resident #117 back to the hospital on [DATE]. Interview confirmed Resident #117 was not allowed back in the facility. Interview confirmed the emergency room paperwork dated 04/26/26 listed he was seen for behaviors and wounds. Interview also confirmed the facility did not contact their psych services for a review for Resident #117.Interview on 05/20/26 at 3:23 P.M. with Director of TC #500 confirmed on 04/26/26 when Resident #117 was returned from the hospital, the nurse at Centerville Post Acute said, she would clock out and leave if Resident #117 was brought into the facility. TC #500 staff called the police to have assistance with the situation and resident was taken to his mother's home.This deficiency represents non-compliance investigated under Complaint Number 296858.

Based on observations, record review, and resident and staff interview, the facility failed to ensure a clean and sanitary environment. This had the potential to affect all 92 residents residing in the facility. Findings include:Review of quote summary for facility hallways dated 09/18/25 with an expiration date upon 30 days notice, revealed there was an estimate to replace the flooring throughout the facility. The facility was unable to provide any other quote summaries for replacement of the flooring. Observation on 09/19/25 at 10:21 A.M. revealed widespread soiling, staining and wear throughout the facility's carpeted areas. Carpet tiles, each measuring 20 in length by (x) 20 inches in width, were found in poor condition with extensive dark brown discoloration, water damage, bright yellow blotches and sticky adhesive residue. The overall appearance of carpet was grimy and heavily trafficked, with visible signs of neglect, staining and deterioration. Observation on 09/19/25 at 10:24 A.M. revealed hallway 200-218 (431 Hall), approximately measuring 81 tiles in length by five in width, totaling around 405 tiles. Of these, 52 tiles were visibly soiled. Stains varied in size from small two x two-inch spots to full-tile coverage. The carpet displayed irregularities such as hardened adhesive buildup, deep-set wear patterns and fiber pilling. Many stains appeared dark, crusted and dried into the fibers, with a heavy concentration in the first part of the hallway, giving the impression of long-term accumulation. Interview on 09/19/25 at 10:24 A.M. revealed Housekeeping Staff Member (HSM) #386, who stated she worked at the facility for years, confirmed the carpets were extremely stained throughout and have been in this condition for some time. Interview on 09/19/25 at 10:26 A.M. revealed Registered Nurse #174 stated the carpets have always been dirty and worn. She noted that the flooring was consistently soiled throughout the hallways in the entire facility and mentioned hearing from management that floor replacement was being considered. Observation on 09/19/25 at 10:30 A.M. revealed hallway 219-232 (437 Hall), measuring 64 tiles in length by five in width, totaling 320 tiles. A total of 37 tiles were soiled. Cart track marks and shadowing formed visible linear patterns, with six tiles on the left, three on the right and another three on the left again. The largest stain, located about a quarter of the way down the hallway, affected four corner tiles and appeared dark, greasy and oil-like, covering roughly 25% of each tile. Smaller stains were scattered and sticky, resembling dried glue or adhesive. The carpet showed signs of wear, fiber breakdown and embedded grime. Interview on 09/19/25 at 10:31 A.M. revealed HSM #142 reported that due to reduced staffing hours, carpets were no longer cleaned regularly. HSM #142 described the flooring as being covered in random stains and admitted that despite efforts to maintain cleanliness, the condition has worsened over time. Observation on 09/19/25 at 10:34 A.M. revealed hallway 233-241, measuring 44 tiles in length by five in width, totaling approximately 220 tiles. Nine tiles were soiled, primarily with small splatter-like stains scattered across the surface. The carpet showed signs of adhesive residue, wear staining and fiber pilling, giving the area a patchy and unkempt appearance. Observation on 09/19/25 at 10:40 A.M. revealed hallway 325 near the elevator had a large, dark stain measuring approximately nine feet by four feet, leading toward the nurses' station. Five additional stains of varying sizes were present, ranging from small splatters to larger patches covering some of the tiles. A dark trail extended from the elevator along the right-hand side, with scattered blotches and heavy discoloration that suggested frequent foot traffic and liquid spills. Observation on 09/19/25 at 10:42 A.M. revealed the area outside the downstairs' main dining room had 10 carpet tiles with visible water damage and six with signs of wear and tear. A particularly egregious stain, dark and irregular in shape, stretched approximately eight feet by two feet, appearing as if liquid had been repeatedly spilled and left to soak into the fibers. Observation on 09/19/25 at 10:45 A.M. revealed severe staining outside the nurses' station. The carpet was heavily discolored with dirt, shadowing and water stains in various shades of brown and gray. A four by one-foot dark stain was located near the nurses' cart, with ripple-like water stains extending beyond its edges. Near the water fountain, a dark blotch measuring approximately three by two feet was observed. The flooring in front of the nurses' station was deeply worn and appeared saturated with soil. The area measured eight tiles in length and four tiles in depth. Observation on 09/19/25 at 10:44 A.M. revealed hallway 338, measuring 74 tiles in length by five in width, totaling approximately 370 tiles. A total of 43 tiles were soiled with shadowing, dark patches and embedded grime. The carpet showed signs of adhesive buildup and fiber breakdown, contributing to a dull and dirty appearance. Observation on 09/19/25 at 10:47 A.M. revealed hallway 332, measuring 65 tiles in length by five in width, totaling approximately 325 tiles. A total of 115 tiles were soiled. The carpet was scattered by widespread staining, adhesive residue and worn fibers. Observation on 09/19/25 at 10:49 A.M. revealed hallway 333, measuring 67 tiles in length by five in width, totaling approximately 335 tiles. A total of 69 tiles were soiled. The stains were varied in size and shape, with many appearing as dark blotches or sticky patches. The carpet was visibly worn and discolored. Observation on 09/19/25 at 10:50 A.M. revealed the front lobby area had a high-traffic zone around the desk with shadowing on the carpet measuring approximately two feet by eight feet. The discoloration was consistent with prolonged wear and heavy foot traffic. Interview on 09/19/25 at 10:58 A.M. revealed Maintenance Director #189 confirmed the facility was working on replacing the carpets. He could not specify when quotes were first requested but stated bids were currently being collected. He acknowledged the carpets were covered in numerous stains scattered throughout the facility. Interview on 09/19/25 at 10:59 A.M. revealed the Director of Nursing confirmed that all carpeted areas in the facility, including the main entrance, hallways 332, 333, 325, 338, 431 and a currently closed hallway, were stained throughout. The DON confirmed the facility had been working on getting new carpets throughout the facility since acquisition in February of 2025. Interview on 09/19/25 at 11:26 A.M. revealed HSM #661 confirmed the carpets were soiled. Interview on 09/19/25 at 11:42 A.M. revealed Certified Nursing Assistant (CNA) #184, who stated she has worked at the facility for three months, stated that many items were dropped on the carpets during meal service and other tasks. She noted that housekeepers try to clean the carpets, but they were in such poor condition they cannot be salvaged. Interview conducted 09/19/25 at 1:38 PM with Resident #64 confirmed carpets in the hallway were very soiled, they have may stains and look very dirty. Resident #64 voiced significant soiling outside the elevator stating the floor looks black. Review of the facilities homelike policy dated 02/2021 revealed residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include: a clean, sanitary and orderly environment. This deficiency represents non-compliance investigated under Complaint Number 2609903.

Based on medical record review, staff interview, and policy review, the facility failed to assess residents with new diagnoses and medications to treat serious mental illness for eligibility for Level II pre-admission screening and resident review (PASARR) services. The affected four (#19, #34, #55, And #63) of five residents sampled for PASARR. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, stage II chronic kidney failure, unspecified bipolar disorder, and paranoid schizophrenia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 34 had moderately impaired cognition, had no behaviors, did not wander , and did not reject care. Review of care plan dated 12/10/2023 revealed Resident # 34 had an Activity of Daily Living (ADL) Self-care/mobility/ functional ability/performance deficit. Interventions included limited to extensive assistance with bathing, and additional staff assistance with ADL's as needed to ensure needs were met. Review of PASARR dated 01/09/23 revealed Resident #34 was assessed and had anxiety and depression and had no antipsychotic. antidepressant, anti-anxiety, or mood stimulator medications ordered. Review of the medical record revealed Resident #34 was diagnosed with paranoid schizophrenia and borderline personality disorder on 01/06/23 and unspecified bipolar disorder on 11/28/22. Review of the medical record revealed Resident #34 had active orders for psychotropic medications including Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule by mouth two times a day for depression; buspirone HCl Oral Tablet 10 milligrams (mg), Give 1 tablet by mouth one time a day for anxiety; buspirone HCl Oral Tablet 15 mg, Give 1 tablet by mouth one time a day for anxiety; Quetiapine Fumarate Oral Tablet 100 mg, Give 1 tablet by mouth one time a day for depression and Give 2 tablet by mouth at bedtime for depression: and Sertraline HCl Oral Tablet 100 mg (Sertraline HCl) Give 1 tablet by mouth one time a day for anxiety. Interview on 03/26/25 at 10:18 A.M., Business Office Manager (BOM) #138 verified she had not completed a significant change PASARR after Resident #34 had new diagnoses and medications were initiated to treat serious mental illness. BOM #138 stated she was not clinical and did not attend clinical staff meetings where this information was shared. 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified chronic kidney disease, unspecified anxiety disorder, unspecified convulsions, and delusional disorders. Review of the most recent Minimum Data Set (MDS) assessment dated revealed Resident #55 had moderately impaired cognition, had occasional verbal behaviors, did not wander, and did not reject care. Review of PASARR Screening dated 01/22/21 revealed Resident #55 had no diagnoses or active medications orders which indicated Serious Mental Illness (SMI). Review of the medical record revealed Resident #55 was diagnosed with delusional disorders on 03/08/21, Major depressive disorder, single episode, severe with psychotic features on 11/12/24, and unspecified anxiety disorder on 02/23/21. Review of the drug summary revealed Resident #55 had active orders for psychotropic medications including: Ativan 0.5 mg by mouth twice daily (03/08/2025), Buspirone 10 mg one tablet once daily and two tablets once daily (10/30/24), Duloxetine 60 mg by mouth once daily (05/13/24), and Duloxetine 20 mg by mouth once daily (10/30/24). Interview on 03/26/25 at 9:56 A.M., with BOM #138 stated if nursing told her there had been a change in diagnosis or new medications she would do a new PASARR, but she was not clinical and would not otherwise know to do one. BOM #138 verified Resident # 55 had no new PASARR completed since admission. 37447 3. Review of the medical record for Resident #19 revealed she was admitted [DATE] with diagnoses to include type 2 diabetes, vascular dementia, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, hypothyroidism, gastro-esophageal reflux disease, dysphagia, delusional disorder and schizoaffective disorder. Review of her Minimum Data Set (MDS) annual assessment dated [DATE] revealed her Brief Interview of Mental Status (BIMS) score was 10 indicating she was moderately cognitively impaired. She required set-up for eating and moderate assistance for her activities of daily living (ADLs). Review of her Pre-Admission Screening and Resident Review (PASARR) dated 07/21/18 revealed a diagnosis of mood disorder. Review of her current diagnosis list revealed a diagnosis of delusional disorder dated 07/15/22. Interview on 03/26/25 at 10:00 A.M., with the Business Office Manager (BOM) #138 verified the diagnosis of delusional disorder was not documented on the PASARR for Resident #19 and an updated PASARR should have been completed to include the delusional diagnosis. BOM #138 stated she was not a clinical staff person so did not attend the clinical meetings and new diagnosis were not relayed to her. 4. Review of the medical record for Resident #63 revealed she was admitted [DATE] with diagnoses to include chronic obstructive pulmonary disease, encephalopathy, mood disorder, schizoaffective disorder, anxiety disorder, morbid obesity, hypertension, carpal tunnel syndrome, gastro-esophageal reflux disease, peripheral vascular disease, and bariatric surgery status. Review of her Minimum Data Set (MDS) quarterly dated 01/24/25 revealed her Brief Interview of Mental Status (BIMS) score was 15 indicating she was cognitively intact. She required set-up with eating and supervision with activities of daily living (ADLs). Review of her Pre-Admission Screening and Resident Review (PASARR) dated 10/31/23 revealed she took anti-psychotic and anti-depressant medication. Review of her current physician list revealed an anti-anxiety medication Buspar 5 milligrams (06/03/24) and a mood stabilizer Depakote 125 milligrams twice daily (05/12/24) which were not documented on her PASARR. Interview on 03/26/25 at 10:00 A.M., with the Business Office Manager (BOM #138) verified the anti-anxiety and mood stabilizing medication was not reflected on her PASARR and should have been added. BOM #138 stated she was not a clinical staff person so did not attend the clinical meetings, and new medications were not relayed to her. Review of the undated policy titled, PASARR (Pre-Admission Screening and Resident Review) revealed the policy was to ensure each resident was screened for a mental disorder or intellectual disability prior to admission and that residents identified with those diagnoses are evaluated and received care and services in the most integrated setting appropriate to their needs. If a resident's condition changed significantly after admission and there was reason to believe the resident may now have newly developed symptoms of a mental disorder or intellectual disability, the facility must reassess and if appropriate, re-submit the screening and coordinate with the state-designated authority to ensure a Level II PASARR is completed in a timely manner.

Based on observation, staff and resident interviews, and policy review, the facility failed to provide mechanically alter diet as ordered. This affected one (23) of the two residents reviewed for food texture. The facility identified seven residents on a pureed diet. The facility census was 96. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE] with medical diagnoses of hypertensive heart disease with heart failure, chronic kidney disease, congestive heart failure, diabetes mellitus, and dysphagia. Review of the medical record for Resident #23 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/07/25, which indicated Resident #23 was cognitively intact and was independent with transfers, toileting, and set-up assist with eating. The MDS indicated Resident #23 received a mechanically altered diet. Review of the medical record for Resident #23 revealed a physician order dated 03/24/25 for carbohydrate control, no added salt, pureed texture diet with thin liquids. Observation and interview with Resident #23 on 03/24/25 at 11:50 A.M., stated he does not receive meals as ordered at times and it is difficult to swallow some items. The observation of Resident #23's lunch tray revealed mashed potatoes, pureed vegetable, and pork loin. The observation of the lunch tray revealed individual shreds of pork loin were visible and the pork was easily flaked apart. Interview on 03/24/25 at 11:56 A.M., with Licensed Practical Nurse (LPN) #35 confirmed Resident #23's pork loin appeared minced and was not a pureed consistency. LPN #35 confirmed the mashed potatoes and vegetables on Resident #23 had a texture consistent with a pureed diet. Interview on 03/27/25 at 9:34 A.M., with Dietary Technician (DT) #191 stated she was notified on 03/24/25 that Resident #23 did not want his lunch tray. DT #191 stated she went to Resident #23's room and confirmed the pork loin that was provided on his lunch tray was not a pureed texture and she went to the kitchen and brought him a bowl of pureed pork loin. Review of the undated policy titled, Therapeutic Diets and Mechanically Altered Diets, stated puree foods are blenderized to a pudding-like texture that clings together and does not require chewing.

Based on medical record review, staff interviews, and policy review, the facility failed to investigate a resident elopement. This affected one (#22) of one resident reviewed for elopement. The facility census was 96. Findings included: Review of the medical record for Resident #22 revealed an admitted [DATE] with medical diagnoses of major Depression, diabetes mellitus, congestive heart failure, history of suicidal ideations, and hypertension. Review of the medical record for Resident #22 revealed a Minimum Data Set (MDS) assessment, dated 01/27/25, which indicated Resident #22 had severely impaired cognition and required set-up assistance with eating, toileting, bathing, bed mobility and transfers. The MDS did not indicate Resident #22 had behaviors. Review of the medical record for Resident #22 revealed a physician order dated 02/18/25 for wanderguard to check placement to left ankle and function every shift. Review of the medical record for Resident #22 revealed an elopement care plan dated 01/10/25 which stated Resident #22 was at risk for elopement/exit seeking/wandering related to altered cognitive status, exit seeking behaviors, expresses feeling unhappy with placement, and unsafe wandering. An intervention was to check wanderguard placement every four hours. Review of the medical record for Resident #22 revealed an elopement assessment dated [DATE] which indicated Resident #22 was at risk for elopement. Review of the medical record for Resident #22 revealed documentation on 01/10/25 Resident #22 was hospitalized at a psychiatric hospital for suicidal ideation, on 02/07/25, Resident #22 was hospitalized due to increased aggressive behaviors, exit seeking and cutting off his wanderguard, and on 02/19/25, Resident #22 was hospitalized for verbalizing suicidal ideations. Review of the medical record revealed a nurses note dated 03/02/25 at 11:33 A.M., stated Resident #22 voiced he was wanted to leave the facility and threatened to go play in traffic. The note stated the police were notified and deemed not suicidal by the police. The note continued to state Resident #22 later went on leave of absence (LOA) with his sister and upon return Resident #22 would continue one-on-one supervision. Review of the nurses note, dated 03/02/25 at 7:33 P.M. stated Resident #22 returned from LOA with sister at 6:00 P.M. The note stated Resident #22 attempted to get out of the facility and was redirected several times. The note stated the nurse went to assist another resident and upon return to the nurse's station noted Resident #22 was not sitting there any longer. The note stated the aide that was sitting with Resident #22 had gone to assist another resident also. The note indicated the nurse went to look for Resident #22 he was found being brought back into the facility through the front door by the night shift nurse and another aide. Interview on 03/26/25 at 9:15 A.M., with Registered Nurse (RN) #51 confirmed she was the nurse who took care of Resident #22 on day shift 03/02/25. RN #51 stated the aide on the unit went to assist another resident and left Resident #22 alone at the nurse's station. RN #51 stated when she returned to the nurse's station Resident #22 was no longer sitting there. RN #51 stated she went to look for Resident #51 and found the night shift nurse and aide bringing Resident #22 in the building through the front door. RN #51 stated Resident #22 was found in the front parking lot and had not gotten off the facility property. RN #51 stated she could not confirmed if Resident #22 had a wanderguard in place or if the door alarm was sounding. Interview on 03/26/25 at 1:59 P.M., with Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #241 confirmed the facility had not completed an investigation into how Resident #22 got out of the building, if Resident #22 had his wanderguard in place, or if the front door alarm was sounding upon Resident #22's exit from the facility. Administrator confirmed Resident #22 is at risk for elopement and has been on one-on-one supervision 24 hours per day since 03/04/25. Review of the policy titled, Elopement, revised December 2007, stated staff shall investigate and report all cases of missing residents. The policy stated staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON. The policy stated when a departing individual returns to the facility, DON or Charge Nurse shall: examine the resident for injuries, notify the attending physician, notify the resident's legal representative of the incident, complete and file Report of Incident/Accident and document the event in the resident's medical record.

Based on medical record review, observation, staff interview, resident interview, and review of policies, the facility failed to accurately assess a wound and timely initiate a treatment for new skin area. This affected one (#41) residents of four residents reviewed for wound care. The facility census was 96. Findings include: Review of the medical record revealed Resident # 41 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, morbid obesity, unspecified gout, and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 41 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of care plan dated 06/17/24 revealed Resident # 41 had potential for alteration in skin integrity related to incontinence. Interventions included diet as ordered, lotion for dry skin, Braden scale quarterly and as needed, avoid elevating head of bed greater than 30 degrees when in bed, keep lines dry and wrinkle free, monitor skin folds for signs of irritation, pressure redistributing devices as indicated, offload heels as tolerated, monitor nutritional status, turn and reposition as needed, and position with pillows as needed for support. Review of progress note dated 03/23/25 at 11:50 A.M. revealed Resident #41 asked Licensed Practical Nurse (LPN) #21 to check his upper thigh under his buttocks and noted a wound which measure 0.1 cm x 0.1 cm. The nurse cleansed the area with soap and water, applied cream, and applied a 3 x 3 gauze pad. Review of Wound assessment dated [DATE] revealed Resident #41 had a new abrasion in-house acquired, no location documented, which measured 0.4 cm x 1 cm x 0.6 cm with 100% granulation. Review of the medical record revealed Resident #41 had an order dated 03/25/25 to start 03/27/25 for wound care to the left gluteal fold: clean and cover with bordered foam three times a week and as needed every day shift every Tuesday, Thursday, and Saturday. Interview on 03/24/25 at 2:07 P.M., with Resident #41 stated he had an open area on back of his left thigh that had been there one week. He was not sure when or how he got it. Resident #41 stated it felt like something was pinching his thigh. Interview on 03/26/25 at 7:04 A.M., with LPN #21 stated she was giving medications and Resident #41 stated he felt something back there. The nurse rolled him over and saw a reddened area on the left thigh that looked like shearing, like a rug burn, where the skin was starting to break. The nurse stated when a new area was found, the nurse measured it and put a note in risk management for the wound team to check it out. LPN #21 stated she notified the wound manager and left a note in the book for the nurse practitioner. The LPN #21 stated she did not call the on-call practitioner to get a new order for wound care because she had looked at it, and the wound was not bleeding or deep. Interview on 03/26/25 at 7:55 A.M., with the DON stated when a nurse finds a new area, it goes into risk management, call the provider, get a new order, place new order in, and the wound nurse would see on next wound round day. Interview on 03/26/25 at 11:05 A.M., with Resident # 41 stated after the nurse put a dressing on it Sunday night, no one came and looked at the wound or changed the dressing placed on 03/23/25, until Tuesday morning, 03/25/25, when the wound team came in. Resident #41 stated he was unaware of any dressing currently in place. Observation on 03/26/25 at 1:03 P.M., revealed LPN #26 performed incontinence care. Resident #41 had an open area to left buttock/anterior thigh with no dressing in place approximately the size of a nickel. The skin surrounding the wound was covered with white paste. LPN #26 cleansed the peri-area with wipes, applied zinc paste to the skin surrounding the wound, placed a clean brief, positioned the resident in bed with pillows for comfort, doffed her gloves, and sanitized her hands before leaving room. During a concurrent interview, LPN #26 stated she normally did not have this hall. LPN #26 stated she was unaware Resident #41 had an open area or had a wound treatment in place. Interview on 03/26/25 at 2:44 P.M., with Registered Nurse (RN) #173 stated Resident # 41 was seen on weekly wound rounds for vascular ulcers on his lower extremities. There was a new wound on his buttocks. RN #173 verified the team became aware of the wound on Monday 03/24/25, but did not see it until wound rounds on Tuesday, 03/25/25. The RN stated for any new wound, nurses were expected to fill out a risk management and call the on-call to notify and receive new orders. RN #173 verified staff identified Resident #41 had a wound on 03/23/25 and the wound did not have an active treatment order placed until 03/25/25. Review of policy titled, Pressure Injury Risk Assessment, dated March 2020, revealed if a new skin alteration was noted, staff documented characteristics of the wound, provider notification, new orders for wound care, revision(s) to the care plan, and family notification. Review of the policy titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, stated the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressing, (occlusive, absorptive, etc.) and application of topical agents if indicated for type of skin alteration. This deficiency represents non-compliance investigated under Complaint Number OH00163742 and OH00162757.

Based on record review, staff interviews; resident interviews, and policy review, the facility failed to ensure quarterly care conferences were conducted with residents and resident representatives. This affected three (#16, #41, and #73) of three residents sampled for care planning. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident # 41 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, morbid obesity, unspecified gout, and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of care conference note dated 03/07/23 revealed Resident #41 and his father (via telephone) had a care conference with the social worker, dietary, and activity staff in attendance. Interview on 03/24/25 at 2:02 P.M., with Resident #41 stated he had not had a care conference in at least six months. Interview on 03/26/25 at 4:48 P.M., with the Director of Nursing (DON) verified Resident #41 has not had a care conferences since 03/07/24. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, obesity, and end stage renal disease with dependence on dialysis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, did not wander, and did not reject care. Interview on 03/24/25 at 11:48 A.M., with Resident #16 stated it had been at least four to five months since his last care conference. Review of Care Conference Note dated 10/23/24 revealed Resident #16 met with Social Worker #180 and discussed care plans, dietary orders, and concerns with care. Interview on 03/26/25 at 4:48 P.M., with the DON verified Resident #16 has not had a care conferences since 10/23/24. 25908 3. Review for Resident #73's medical record revealed an admitted [DATE]. Diagnoses included aphasia, diabetes, anxiety and stroke. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive assistance for dressing, toileting, and personal hygiene. Review of the care conference notes revealed care conferences were held 03/14/24, 05/23/24 and 08/06/24 with family in attendance. No further care conferences were noted. Interview on 03/26/25 at 4:48 P.M., with the Director of Nursing (DON) revealed Resident #73 did not have any more care conferences. Review of the policy titled, Resident Participation - Assessment/Care Plans, dated 02/2021, revealed the facility staff held quarterly care planning meetings at times when residents were functioning at their best and family members/representatives could attend.

Based on medical record review, observation, staff interview, and family interview, the facility failed to ensure gastrostomy tube dressings were changed as ordered. This affected one (#301) residents of four residents reviewed for wound care. The facility census was 96. Findings include: Review of the medical record for Resident #301 revealed an admitted [DATE], with medical diagnoses of aftercare following surgery for neoplasm, squamous cell cancer of skin on face, encounter for attention to gastrostomy, malignant neoplasm of mouth, dysphagia, and anemia. Review of the medical record for Resident #301 revealed an admission evaluation, dated 03/11/25, which indicated Resident #301 was cognitively intact and admitted with cancer biopsy site to right jaw, and a gastrostomy tube (g-tube). Review a physician order dated 03/12/25 revealed to cleanse g-tube site with normal saline and cover with a t-drain dressing daily. Review of the March 2025 Treatment Administration Record (TAR) which had documentation to support Resident #301's g-tube care was completed 03/12/25 to 03/25/25. Interview with observation on 03/24/25 at 2:23 P.M., with Resident #301's family stated staff were not changing Resident #301's g-tube dressing as ordered. Observation revealed Resident #301's family pulled up Resident #301's t-shirt and revealed a dressing to Resident #301's g-tube site dated 03/21/25. Interview on 03/24/25 at 2:26 P.M., with Licensed Practical Nurse (LPN) #206 confirmed the g-tube dressing for Resident #301 was dated 03/21/25 and that the dressing had not been changed daily as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00162757.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure a resident was being transported in a wheelchair in a dignified manner. This affected one (#34) of four residents sampled for dignity. The facility census was 96. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, stage II chronic kidney failure, unspecified bipolar disorder, and paranoid schizophrenia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had moderately impaired cognition, had no behaviors, did not wander , and did not reject care. Review of care plan dated 12/10/23 revealed Resident #34 had an Activities of Daily Living (ADL) Self-care/mobility/functional ability/performance deficit. Interventions included limited to extensive assistance with bathing, and additional staff assistance with ADL's as needed to ensure needs were met. Observation on 03/24/25 at 2:14 P.M., revealed Certified Nurse's Assistant (CNA) #8 pulled Resident #34 backwards in a shower chair in the hallway from the resident's room to the shower room. Interview on 03/24/25 at 2:14 P.M., with CNA #8 verified she pulled Resident #34 backwards in shower chair and stated she was unaware it was a dignity issue. Review of policy titled Dignity dated February 2021, revealed demeaning practices and standards of care that compromised dignity were prohibited.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record reviews, review of Self-Reported Incident (SRI), staff and guardian interviews and review of facility policy, the facility failed to ensure resident was free from abuse. This affected one (#102) out of the three residents reviewed for abuse. The facility census was 110. Findings include: Review of the medical record for Resident #102 revealed an admitted [DATE] with medical diagnoses of chronic respiratory failure, [NAME]-[NAME] Syndrome (multisystem disorder characterized by developmental delay and impaired cognition), hypothyroidism, obesity, and mild intellectual disabilities. Review of the medical record for Resident #102 revealed an admission Minimum Data Set (MDS) assessment, dated 08/14/24, which indicated Resident #102 had severe cognitive impairment and was dependent upon staff for toileting, bathing, bed mobility, and transfers. The MDS indicated Resident #102 did not ambulate. Review of the medical record for Resident #102 revealed a Social Service note, dated 09/12/24 at 2:57 P.M., which stated the Social Work staff called Resident #102's guardian and informed him about inappropriate behavior happening to Resident #102. The note stated the facility was handling the behavior by increasing staff monitoring and the guardian was happy with the outcome and appreciated the notice. Further review of the medical record for Resident #102 revealed a nurse's note, dated 09/14/24 at 2:56 P.M., which stated per the Administrator's request a complete head to toe assessment was completed for Resident #102 which showed no evidence of bruising or trauma noted externally. Review of the medical record for Resident #115 revealed an admitted [DATE] with medical diagnoses of diabetes mellitus, atrial fibrillation, peripheral vascular disease, and depression. Review of the medical record for Resident #115 revealed a discharge date of [DATE]. Review of the medical record for Resident #115 revealed a Social Service note, dated 09/11/24 at 2:04 P.M. which stated Social Work staff received report from staff that Resident #115 was being verbally inappropriate. The note stated Social Work staff spoke with Resident #115 and Resident #115 agreed to he would try to refrain from unacceptable behaviors directed towards staff and residents. The note stated Resident #115 had been counseled many times by different facility staff regarding his behaviors. Review of the medical record for Resident #115 revealed a Social Service note, dated 09/14/24 at 5:13 P.M., which stated Resident #115 had been sent out for a psychiatric evaluation for risk of harm to self and others per the Administrator's request. Review of the facility SRI, dated 09/14/23, revealed an investigation was completed for allegation of sexual abuse against Resident #102 by Resident #115. Resident #102 alleged that Resident #115 touched her inappropriately. The investigation included staff and resident interviews, staff education on abuse, resident physical assessments, and notification to Resident #102's guardian, the police, and physician. Interview on 10/10/24 at 9:54 A.M. with Resident #102's guardian stated he was notified on 09/14/24 by the Administrator that Resident #102 had been inappropriately touched by Resident #115. Resident #102's guardian stated he was informed that Resident #115 had been touching Resident #102 with his fingers, maybe even penetrating Resident #102 and was kissing her. Resident #102's guardian stated Resident #102 informed him that Resident #115 touched her, and she did not like it. Resident #102's guardian stated the police were notified and the incident was being investigated but he was informed by the police that charges would probably not be filed due to lack of evidence. Resident #102's guardian stated he did not believe Resident #102 would be able to understand the meaning of consent or even sexual intercourse. Resident #102's guardian stated Resident #102 was not sent out to the hospital for a physical examine per his request because he did not want to put Resident #102 through the experience since there was not any evidence of sexual intercourse. Interview on 10/10/24 at 10:16 A.M. with Administrator stated she was informed by the facility staff on the morning of 09/14/24 that Resident #102 had reported to staff that Resident #115 kissed her and that they were in a relationship which included sexually inappropriate touching and kissing. Administrator stated she immediately started an investigation and notified the police department. Administrator stated she interviewed Resident #115 who admitted to kissing Resident #102, putting his penis on her mouth and touching her inappropriately. Administrator stated she interviewed Resident #102 who stated Resident #115 put his penis in her mouth and touched her private area. Administrator stated Resident #102 denied having sexual intercourse with Resident #115. Administrator stated Resident #102 and Resident #115's stories had inconsistencies regarding the number of times they were together or what actually occurred between them. Administrator stated no staff reported ever seeing Resident #102 or Resident #115 together in a private area but only in therapy gym. Administrator stated a few days prior to the incident on 09/14/24, the staff were made aware that Resident #102 had a crush on Resident #115 who she met in therapy. Administrator stated Social Work staff notified Resident #102's guardian of Resident #102's infatuation with Resident #115 and he asked that the two residents' only see each other in public common areas. Administrator stated Resident #115 had no history of sexual abuse but would make lewd comments to staff. Administrator stated staff never observed Resident #115 in Resident #102's room. Administrator stated Resident #115 was put on one-on-one supervision on 09/14/24 until he discharged on [DATE] and had no further contact with Resident #102. Interview on 10/10/24 at 11:16 A.M. with Social Service designee (SS) #208 and Social Service Director (SSD) #209 revealed SS #208 stated Resident #102's guardian was notified that Resident #102 and Resident #115 were in a relationship on 09/12/24 and that Resident #102's guardian did not approve of the relationship but stated they could be together in public viewing areas. SSD #209 stated the facility was not aware of any inappropriate contact between the two residents at that time but wanted to make Resident #102's guardian aware of the relationship. SS #208 stated the facility intervention to ensuring Resident #102 and Resident #115 were not together in a private area was to increase staff rounds on Resident #102's hall since she required staff assistance for transfers and wheelchair mobility. SS #208 stated Resident #102 has not had any behaviors, crying, or withdrawal because of the interaction between her and Resident #115. Review of the facility policy titled, Abuse, reviewed 11/20/23, stated all residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The policy stated abuse included verbal, sexual, physical, and mental abuse. The deficient practice was corrected on 09/15/24, when the facility implemented the following corrective actions: On 09/14/24, Resident #115 was put on one-on-one supervisor. On 09/14/24, Administrator initiated SRI and investigation which included interviews with residents and staff. On 09/14/24, Administrator notified the local police department, Resident #102' guardian, and Medical Director. On 09/14/24, Regional Clinical Service Manager provided education to Administrator and Director of Nursing (DON) regarding abuse. On 09/14/24, facility nurse completed head to toe assessment for Resident #102 and had no negative findings. On 09/14/24, DON/Social Service completed interviews with all residents and no concerns were voiced about abuse except for Resident #102. On 09/14/24, Administrator, DON, and unit managers educated all staff on abuse. Education was completed by 09/15/24. On 09/14/24, Resident #115 was sent to the hospital for a psychiatric evaluation and returned to the facility 09/15/24. On 09/14/24, Quality Improvement Performance Assurance (QAPI) meeting conducted with Medical Director, DON, and Administrator. On 09/14/24, Unit Managers to audit three residents weekly for four weeks. No additional abuse concerns were identified. On 09/14/24, DON to interview three staff members weekly for four weeks on the facility abuse policy. No additional abuse concerns were identified. On 09/15/24, DON and floor staff completed head to toe assessments on all residents. No additional abuse concerns were identified. This deficiency represents non-compliance investigated under Complaint Number OH00158222.

Based on record review, observations, staff interviews and review of facility policy, the facility failed to ensure fall interventions were implemented per the residents care plan. This affected two (#10 and #12) of three residents reviewed for falls. The facility census was 96. Findings include: 1. Review of medical record for Resident #10 revealed admitted [DATE]. Diagnoses included heart attack, stage four kidney disease, congestive heart failure, peptic ulcer and anxiety. The resident remains at the facility. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed he required extensive two person assistance for bed mobility, transfers, toileting and supervision for eating. Resident #10's Brief Interview Mental Status (BIMS) was not assessed. Review of Resident #10's care plan revealed the resident was at risk for falls. There was an intervention initiated 08/23/23 for a low bed. Review of Resident #10's progress notes dated 08/28/23 revealed the resident was found on the floor, laying on his right side after sliding from the bed. Review of Resident #10's fall investigation dated 08/28/23 fall revealed an intervention for low bed was initiated. Observation on 12/11/23 at 11:50 A.M. revealed Resident #10's bed was not in the lowest position. This was verified at 11:54 A.M. by State tested Nursing Assistant (STNA) #35. 2. Review of medical record for Resident #12 revealed admitted [DATE]. Diagnoses included hemiplegia following stroke, heart failure, depression, and anemia. The resident was remains in the facility. Review of Resident #12's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating impaired cognition. He required set up for eating, maximum assistance for toileting, bed mobility and no documentation of transfers. Review of Resident #12's care plan revealed the resident was a fall risk due to history of falls with an intervention initiated on 09/25/23 to have the bed in lowest position while in bed. Observation on 12/11/23 at 8:42 A.M. revealed Resident #12 appeared to be sleeping and laying on his back. Further observations of Resident #12 revealed the bed was not in the lowest position. This was verified with Registered Nurse (RN) #27 at 8:45 A.M. Review of the facility fall policy last reviewed 06/08/22 documented Staff would identify pertinent interventions to try and prevent subsequent falls. This deficiency represents non-compliance investigated under Complaint Number OH000148920.

Based on record review, observations and staff and resident interviews, the facility failed to accurately assess, monitor and/or document resident with bruising. This affected two ( #10 and #11) of three residents reviewed for skin breakdown. The facility census was 96. Findings include: 1. Review of medical record for Resident #10 revealed admitted [DATE]. Diagnoses included heart attack, stage four kidney disease, congestive heart failure, peptic ulcer and anxiety. The resident remains at the facility. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed he required extensive two person assistance for bed mobility, transfers, toileting and supervision for eating. Resident #10's Brief Interview Mental Status (BIMS) was not assessed. Observation and interview on 12/12/23 at 1:20 P.M. of Resident #10 revealed multiple, scattered bruising on both of the resident's arms. Resident #10 stated the bruises were due to his blood thinners and old, thin skin. Review of Resident #10's progress note dated 12/06/23 revealed both arms were assessed to have healing bruises which were attributed to compression sleeves. Resident #10 was documented to have no concerns. Review of 12/03/23 and 12/10/23 skin assessment revealed no documentation or assessment of bruising. 2. Review of medical record for Resident #11 revealed admitted [DATE]. Diagnoses included hemiplegia non-dominant following stroke, asthma, malignant breast cancer with bone metastasis and dementia. The resident remains at the facility. Review of Resident #11's admission Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 12 indicating impaired cognition. She required supervision for bed mobility, moderate assistance for transfers, and eating. Review of Resident #11's progress notes and skin assessments from 11/28/23 to 12/07/23 revealed no documentation of bruising. Observation on 12/11/23 at 10:24 A.M. of Resident #11 revealed a healing circular bruise to the upper, proximal aspect of her right arm. Further observations revealed three small, healing bruises were noted to Resident #11's left forearm. Interview on 12/12/23 at 2:52 P.M. with Unit Manager (UM) #32 verified he observed bruising of both arms of Resident #10, and there was no documentation or assessment of bruising on the 12/03/23 or 12/10/23 skin assessment. UM #32 acknowledged there was no accurate description or measurement of the bruises for Resident #10. UM #32 also verified he observed bruising of Resident #11, and there was no documentation or assessment of bruising on the 11/28/23 to 12/07/23 skin assessment. UM #32 acknowledged there was no accurate description or measurement of the bruises for Resident #11. UM #32 shared the facility had a policy for skin care management but did not have a policy for skin assessments or wound management. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review and staff and resident interviews, the facility failed to provide assistance with activities of daily living by not offering a resident showers. This affected one (#10) of three residents reviewed for personal hygiene. The facility census was 96. Findings include: Review of medical record for Resident #10 revealed admitted [DATE]. Diagnoses included heart attack, stage four kidney disease, congestive heart failure, peptic ulcer and anxiety. The resident remains at the facility. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed he required extensive two person assistance for bed mobility, transfers, toileting and supervision for eating. Resident #10's Brief Interview Mental Status (BIMS) was not assessed. Review of Resident #10's care plan for Activities of Daily Living Deficit initiated 05/25/23 documented intervention to provide extensive assistance with bathing. Further review of Resident #10's electronic medical records revealed no documentation of showers/bed baths being offered/ provided. Interview on 12/11/23 at 1:20 P.M. with Resident #10 revealed he did refuse showers, but not bed baths. Resident #10 stated the staff did not offer them (bed baths) to him and added he would like one. Interview on 12/12/23 with the Administrator revealed staff had attempted to give Resident #10 a shower, however he refused due to anxiety of having water pouring on his head due to past occurrences in the military. The Administrator acknowledged water would not cascade over Resident #10's head during a bed bath. The Administrator verified there was no documentation bed baths/showers had been offered or refused. This deficiency represents non-compliance investigated under Complaint Number OH00148920.

Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure resident's medications were handled in a sanitary manner to decrease the potential for infection. This affected two residents (#95 and #22) of the four residents observed for medication administration. Facility census was 108. Findings include: 1. Review of the medical record for Resident #95 revealed an admitted [DATE] with diagnoses included, but not limited to, absence of right leg above the knee ([NAME]), rheumatoid arthritis, asthma, chronic obstructive pulmonary disease (COPD), type two diabetes, and gastroesophageal reflux disease (GERD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #95 revealed an intact cognition. Resident #95 required supervision for bed mobility, transfers, eating and toileting. Review of the January 2023 active physicians orders for Resident #95, revealed orders for Aspirin (Antipyretic/pain) low dose tablet delayed release 81 milligrams (mg) by mouth daily, Loratadine (allergies) oral tablet 10 mg one tablet by mouth daily, Losartan Potassium (high blood pressure) tablet 25 mg one tablet daily, Vitamin D 3 (supplement) oral tablet 125 micrograms (mcg) by mouth daily, Isosorbide (Nitrate for heart) 30 mg one tablet daily, Clopidogrel (anti-coagulant) 75 mg one tablet by mouth daily, and Morphine Sulfate (narcotic pain) extended released (ER) tablets give three tablet by mouth two times a day. Observation on 01/24/23 at 8:47 A.M. revealed Licensed Practical Nurse (LPN) #92 prepared medications for Resident #95. Prior to the preparation, LPN #92 had not preformed any hand hygiene or cleaned the medication cart surface before removing the chewable Aspirin, Loratadine, Losartan, Vitamin D 3, Isosorbide, Clopidogrel, and Morphine Sulfate from the medication cart. LPN #92 handled the medication cart keys, medication cart drawers, touched the medication cart, the computer keyboard and touched the medication boxes for each medication. While emptying the Morphine tablet from the narcotic card, the pill landed on the medication cart. LPN #92 picked up the Morphine tablet from the medication cart with her bare hands/fingers and dropped it into the medication cup along with the other medications. Interview on 01/24/23 at 8:59 A.M. with LPN #92, surveyor questioned if the facility policy allowed medications to be administered after they were handled with bare hands/fingers and when the medications had fallen onto the contaminated top surface of the medication cart. LPN #92 stated the medication carts were cleaned by the third shift nurses and no one ever told her she was not allowed to handle medications with my bare hands. Observation on 01/24/23 at 9:07 A.M. with LPN #92 administered the prepared medication to Resident #95. Interview on 01/24/23 at 9:13 A.M. with LPN #92, verified she picked up the Morphine pill after it fell on to the contaminated medication cart surface using her bare hands/fingers and placed it into the medication cup along with the other medications for Resident #95. LPN #92 verified she did not complete any hand hygiene prior to the preparation of medications for Resident #92. Interview on 01/24/23 at 2:09 P.M. with Director of Nursing (DON) verified medication should not be handled with bare hands and then administered to a resident. 2. Medical record review for Resident #22, revealed an admitted [DATE] with diagnoses that included, but not limited to, heart failure, hypertension, anxiety disorder, schizoaffective disorder, and GERD. Review of the comprehensive MDS assessment for Resident #22, revealed an intact cognition. Resident #22 required extensive assist with activities of daily living. Review of the January 2023 active physician orders for Resident #22, revealed Aspirin 81 mg chewable tablet by mouth daily, Docusate Sodium (stool softener) capsule 100 mg by mouth daily, Januvia (diabetes) tablet 100 mg one tablet by mouth daily, Metoprolol Tartrate (blood pressure) tablet 25 mg give one half tablet by mouth daily, Omeprazole (acid reflux) capsule delayed release 20 mg tablet by mouth daily, Calcium Carbonate tablet (anti-acid) chewable 500 mg one tablet by mouth daily, Duloxetine (pain/depression) capsule 60 mg one tablet two times a day, Geodon (antipsychotic) capsule 80 mg tablet by mouth two times a day, and Risperidone (atypical antipsychotic) one mg tablet by mouth two times a day. Observation on 01/24/23 at 9:20 A.M. of LPN #92 placed a medication cup directly on top of the medication cart surface without a barrier between the two surfaces and prepared the following medications for Resident #22: Aspirin, Docusate Sodium capsule, Januvia, Metoprolol Tartrate, Omeprazole capsule, Duloxetine Capsule, Geodon capsule, and Risperidone tablet by placing the medications in the medication cup. LPN #92 then placed a second medication cup on top of the cart and prepared a Calcium Carbonate chewable by placing the tablet into the cup. LPN #92 then picked up the first medication cup with the prepared medications and placed it on top of the medication cup containing the calcium carbonate chewable tablet. The bottom of the first medication cup was sitting on the calcium carbonate chewable tablet without any type of barrier. Interview on 01/24/23 at 9:25 A.M. with LPN #92 confirmed this was an acceptable form of administration storage and administered medications to Resident #22. Interview on 01/24/23 at 2:09 P.M with the DON verified the medications cups should not have been stacked on top of each other allowing the bottom of the cup to contaminate the medication in the other cup. DON also indicated the medications should not have been administered to the residents. Review of the facility skill and techniques evaluation titled Medication Management, dated 04/2022 revealed the facility did not implement the policy as written. Policy indicated removal of medication from containers without contamination.

Based on observation, staff and resident interview, and policy review, the facility failed to ensure staff wore Personal Protective Equipment (PPE) appropriately. This had the potential to affect all 88 residents who reside in the facility. The facility census was 88. Findings Included: 1. Observation on 06/13/22 at 12:24 P.M. with Registered Nurse (RN) #31 who worked on the skilled hall, came out of Resident #326 room wearing a yellow procedure gown, and gloves. RN #31 had an N95 mask and a face shield on. RN #31 walked from room [ROOM NUMBER] to room [ROOM NUMBER] to retrieve a straw for Resident #326. RN #31 walked back to Resident #326's room after retrieving a straw from medication cart located in the hall. At no time was RN #31 observed removing her yellow protective gown or gloves. There was no observed hand hygiene completed after leaving he residents room or returning to the room of Resident #326. Interview on 06/13/22 at 12:27 P.M., RN #31 verified she came out of Resident #326's room with a yellow procedure gown and gloves on. RN #31 said she had not touched anything in Resident #326's room; and was why she had not doffed her Personal Protective Equipment (PPE). Interview on 06/13/22 at 12:35 P.M., with Infection Preventionist Registered Nurse #58 said the staff would need to doff their PPE before leaving a room, if a resident requested an item to take back into their room. The Infection Preventionist Registered Nurse #58 stated the staff should have doffed the PPE, completed hand hygiene, then retrieved the item the resident requested. The staff should not walk in the hall with potentially contaminated PPE, after being in a quarantined or Covid positive resident's room. Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed that the donning and doffing of gowns are removed at the exit of the patient care area; gown to be deposed of or placed in a leak-proof laundry bag at the exit area for re-processing and washing (reusable). 2. Observation on 06/13/22 at 12:45 P.M. with Maintenance Director #109 who was wearing his surgical mask hanging from one ear, and his mouth and nose was exposed on the Medbridge unit, in a resident care area standing near room [ROOM NUMBER]. Observation on 06/13/22 at 12:50 P.M. the Health and Safety Consultant Surveyor toured the facility with Maintenance Director #109 who had not worn his mask. The Maintenance Director was observed not wearing his mask correctly or not wearing it at all while in a resident hallway number two. Maintenance Director #109 was not wearing his mask while testing the fire alarm at 3:14 P.M. while he was at the nurse's station on the 2nd floor. Observation on 06/13/22 at 3:40 P.M. Maintenance Director #109 walked down to the Heritage nursing station with his mask hanging from his left ear and not covering his nose and mouth. Interview on 06/16/22 at 4:28 P.M., the Maintenance Director #109 said he had not worn his surgical mask correctly when it was hanging on his ear while in the patient care area. Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed face masks that are specified in the usage guide lists procedure mask, N-95 respirator, face shield, goggles, safety glasses with protectant to guard eyes, gown (disposable or cloth), and surgical gloves. As of 03/26/20, all Senior Care service lines (SNF, AL, Home Health, Hospice, Palliative Care) are under universal masking criteria. Community-based staff entering a Senior Care center are also required to follow universal masking criteria as well as escalate Personal Protective Equipment use based on the following employee guidance. Donning and doffing at skilled nursing facility and assisted living: the masks are donned at the beginning of shift and only removed during scheduled breaks out of the patient care areas. Masks are removed outside of the patient care area. They are discarded when visibly soiled and in no case should they be worn beyond the end of the individual's shift. 3. Observation on 06/14/22 at 9:14 A.M. RN #56 took her black cloth mask off at the resident's room and placed a N95 mask on her face to enter a Covid quarantine room. Interview on 06/14/22 at 9:15 A.M., RN #56 said she was wearing a cloth mask, but not into Covid positive or Covid quarantine resident's room. RN #56 said she would take off the black cloth mask, change into a N95 and the rest of the PPE at each resident's door. RN #56 said she just left her cloth black mask on her nurse's cart next to the resident's room door. Observation on 06/14/22 at 9:36 A.M. Resident #332 activated the call light and asked for anxiety medication. RN #56 answered the call light at 9:38 A.M. wearing a black cloth face mask. RN #56 deactivated the call light and exited the room. At 9:40 A.M. RN #56 returned to the room wearing a black cloth mask and administered medication to Resident #332 and spoke to the resident less than two feet away. Interview on 06/15/22 at 2:38 P.M., the Administrator said employees were to wear a surgical mask or higher, and not a cloth mask. Interview on 06/15/22 at 3:50 P.M., Resident #332 said RN #56 wore a cloth mask her entire shift while working at the facility. Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed in no where stated in the guide that a cloth mask was allowed to be worn as an employee. Masks that are specified in the usage guide lists procedure mask, N-95 respirator, face shield, goggles, safety glasses with protectant to guard eyes, gown (disposable or cloth), and surgical gloves. 4. Observation on 06/15/22 at 3:50 P.M. with State tested Nursing Assistant (STNA) #120 standing near the nurse's station talking to Certified Nurse Aide (CNA) #33 who was sitting at the nurse's station charting on the computer. STNA #120 and CNA #33 wore face shields on but their surgical masks were at their chin resting, with their mouth and nose exposed to the air. Resident #57 was sitting less than four feet in a chair next to the next to the nurses' station with another unknown resident sitting on the other side. Resident #57 was not wearing a face mask nor the other unknown resident. Both STNA #120 and CNA #33 were observed not wearing their surgical mask correctly for over five minutes. Interview on 06/15/22 at 4:25 P.M., the STNA #120 said her and the other aide CNA #33 were wearing their surgical mask at their chin. STNA #120 said she knew two residents were sitting next to the nurse's station. STNA #120 verified there was two residents in the area, and said she was hot and needed air. Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed face masks that are specified in the usage guide lists procedure mask, N-95 respirator, face shield, goggles, safety glasses with protectant to guard eyes, gown (disposable or cloth), and surgical gloves. As of 03/26/20, all Senior Care service lines (SNF, AL, Home Health, Hospice, Palliative Care) are under universal masking criteria. Community-based staff entering a Senior Care center are also required to follow universal masking criteria as well as escalate Personal Protective Equipment use based on the following employee guidance. Donning and doffing at skilled nursing facility and assisted living: the masks are donned at the beginning of shift and only removed during scheduled breaks out of the patient care areas. Masks are removed outside of the patient care area. They are discarded when visibly soiled and in no case should they be worn beyond the end of the individual's shift. 5. Observation on 06/15/22 at 4:55 P.M. CNA #90 came out of room [ROOM NUMBER], where a newly admitted resident resided, with only a face shield and a surgical mask on. On the resident's door was signs posted for Covid-19 Quarantine. Interview on 06/15/22 at 4:59 P.M., the CNA #90 said she came out of the room [ROOM NUMBER] who was quarantined for Covid-19. CNA #90 said she was not aware she had to wear an N95 mask into a quarantine room, because she was fully vaccinated. CNA #90 was not aware their was two Covid positive cases on the unit. Interview on 06/15/22 at 5:00 P.M., the Licensed Practical Nurse (LPN) #114 verified CNA #90 only had a surgical mask on, when exiting the room. LPN #115 said the aide should have worn an N95 mask because she was in a Covid-19 quarantine room. Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed when to use N-95 respirators are to be used when providing care or services within six feet of patient with suspected or confirmed Covid-19, during aerosol-generating procedures, or during nasopharyngeal specimen collection. When donning and doffing of N-95 mask, the respirators are to be seal tested every time the respirator was donned. They are discarded when visibly soiled and changed in between patients.

Based on medical record review, observation, staff and resident interview and policy review, the facility failed to ensure residents had access to call lights. This affected three residents (#71, #31, and #47) out of 24 residents sampled for call lights. The facility census was 88. Findings include: 1. Review of the medical record revealed Resident #71 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #71 required two-person physical assistance and required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene; total assistance with transfers; and supervision with eating. Observation on 06/14/2022 at 7:30 A.M. revealed Resident #71's call light was laying across the top of the nightstand and out of the reach of the resident. During an interview on 06/14/2022 at 7:30 A.M., Resident #71 said he was not sure where his call light was and was unable to locate it. During an interview on 06/14/2022 at 7:35 A.M., State tested Nurse Assistant (STNA) #10 verified Resident #71's call light was laying across the nightstand out of the resident's reach. 2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS five day assessment dated [DATE]. Resident #31 had a Brief Interview for Mental Status (BIMS) score of eight indicating he had moderate cognitive impairment. He needed extensive assistance of two staff for bed mobility, transfer, toilet use, and personal hygiene. He did not walk. He required extensive assist of one staff for eating. He was totally dependent on one staff for bathing. He had functional limitation in range of motion on one side in the upper and lower extremity. Observation on 06/14/22 at 8:59 A.M. Resident #31 was lying in bed. His call light was on the floor out of reach. On 06/14/22 at 10:49 A.M., Nurse Aid in Training #33 verified the call light was out of reach and on the floor. 3. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent annual MDS assessment dated [DATE] revealed Resident #47 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Observation on 06/14/22 at 12:30 P.M. revealed Resident #47's call light was not within reach or near him. Resident #47's call light was on the floor and partly under the bedside table. During an interview on 06/14/22 at 12:30 P.M., Registered Nurse (RN) #40 verified Resident#47's call light was on the floor. Review of facility policy titled Call Light Policy, updated 10/2020 revealed to always position call light correctly for use and within reach. A clip may be used to secure the light.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure physician orders for oxygen therapy were implemented. This affected one resident (#30) of three residents reviewed for oxygen. In addition, the facility failed to obtain physician orders for oxygen use. This affected one resident (#73) of three residents reviewed for oxygen. The facility census was 88. Findings Included: 1. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum data set (MDS) quarterly assessment dated [DATE] revealed the Brief Interview of Mental Status was not completed. Resident #30 was alert and not able to answer questions in the interview. The resident required extensive two-person physical assistance for bed mobility, and transfers. The resident required total dependence of one-person physical assistance for dressing, and bathing. Resident #30 required extensive one-person physical assistance for personal hygiene, and toilet use. Review of the plan of care dated 05/03/22 revealed Resident #30 was at risk for [CONDITION(S)] for fluid volume overload. Interventions included check breath sounds and monitor for labored breathing, monitor lab work, give oxygen therapy as ordered, vitals as needed, and weight monitoring. Review of the physician order dated 08/06/2021 revealed Resident #30 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 06/15/22 at 4:50 P.M. with Licensed Practical Nurse (LPN) #114 verified Resident #30's oxygen concentrator was set on 1.5 L/m. LPN #114 said she was not sure how many liters the physician ordered for oxygen use. 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS quarterly assessment dated on 05/11/22 revealed Resident #73 had a Brief Interview of Mental Status (BIMS) score of an 11 indicating she was mildly cognitively impaired. Resident #73 required extensive two-person assistance for bed mobility, toilet use, and dressing. Resident #73 required total dependence two-person physical assist for all transfers. Review of the plan of care dated 06/15/22 revealed Resident #73 was at risk for altered cardiovascular status related to [CONDITION(S)] and [CONDITION(S)]. Interventions included assess for shortness of breath, encourage low fat and low salt intake, monitor and report to physician changes in lung sounds on auscultation, and monitor and report to physician chest pain or pressure. Resident was also at risk for altered respiratory status and difficulty in breathing related to recovering from Covid and [CONDITION(S)]. Interventions included administer medications and inhalers as ordered, provide oxygen at four liters via nasal cannula to maintain oxygen saturation above 90 percent. Review of the physician orders revealed Resident #73 had no order for oxygen use. Observation on 06/13/22 at 3:05 P.M. revealed Resident #73 was on 3.5 liters of oxygen via nasal cannula delivered by an oxygen concentrator. During an interview on 06/13/22 at 3:13 P.M., the Director of Nursing (DON) verified Resident #73 had no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation and interview on 03/13/22 at 3:20 P.M. the DON verified Resident #73 was receiving 3.5 liters of oxygen via nasal cannula delivered by a concentrator in the resident's room. Review of policy titled Oxygen Administration last updated 07/2017 revealed oxygen was administered by a licensed nurse according to physician order.

Bases on medical record review, family and staff interview and review of electronic mail (email) communications, the facility failed to invite residents and/or representatives to quarterly care conference meetings. This affected two (#10 and #11) out of three residents reviewed for care conferences. Facility census was 87. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Resident #10 had a recent hospitalization from [DATE] to 08/04/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) of 15 out of 15, no behaviors or moods documented, and required supervision with set up for activities of daily living (ADL). Review of Resident #10's medical record revealed the only documented care conference was dated 08/18/21. Further record review revealed there were no documented attempts to invite the resident or representative to a care conference. Review of the medical record for Resident #11 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's significant change MDS dated [DATE] revealed the resident had short and long term memory problem, was severely impaired cognition, required extensive assist of two staff for ADL's and had no concerns for mood or behaviors. Further review of Resident #11's medical record revealed there were no documented care conferences or attempts to invite the resident or representative to a care conference. Interview on 08/30/21 at 9:17 interview with Resident #10's daughter revealed she had a care conference 08/18/21. She further shared the previous care conference was in February of 2020. Interview with Social Services Designee (SSD) #40 revealed the staff member had a start date at the facility on 07/13/21. SSD #40 believed the facility had been without a social worker for one month to six weeks prior to his start date. SSD #40 could not answer if care conferences were done in a timely manner. SSD #40 continued to share he had initiated a care conference calendar and had been working on calling families to inform them of the dates of the conferences. A second interview on 08/30/21 at 2:24 P.M. with SSD #40 revealed there was no documentation for a care conference for Resident #11. SSD #40 stated the only care conference documented for Resident #10 was 08/18/21. Review of an email communication received on 08/31/21 from the Director of Nursing (DON) confirmed there was no documentation for a care conference for Resident #11 and the only care conference documented for Resident #10 was dated 08/18/21. Review of email communication received on 09/01/21 from the Administrator revealed the facility had a social worker from 03/30/21 to 05/25/21 and was without a replacement until 07/19/21. She shared it was quickly determined care conferences were not being done correctly and a correction plan was put in place. However, the Administrator confirmed care conferences were still in process and the schedule was set through 10/30/21. This deficiency substantiates Complaint Number OH 087.

Based on review of the facilities bed capacity, staff interview and personnel file review, the facility failed to employ a qualified social worker. This had the potential to affect all 87 residents residing in the facility. Facility census was 87. Findings include: Review of the facility's bed capacity revealed the facility was certified for 140 beds. Interview on 08/30/21 with Social Services Designee (SSD) #40 revealed he is not currently a Licensed Social Worker (LSW) and he does not meet the qualifications to be a qualified social worker. SSD #40 further shared that he has been in this position for six weeks and he assisted families with care conferences, discharges as well as family concerns. Review of SSD #40's personnel file revealed the staff member had a hire date of 07/13/21. SSD #40 was not a LSW and was not a qualified social worker. This deficiency substantiates Complaint Number OH 087.

Based on medical record review, review of facility investigation, review of facility policy, and staff interviews, the facility failed to report an allegation of potential resident to resident sexual abuse in a timely manner. This affected two Residents (#62 and #64) of five reviewed for abuse reporting. The facility census was 84. Findings include: 1. Review of the medical record for Resident #64 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. 2. Review of the medical record for Resident #62 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS assessment dated [DATE], revealed the resident had moderately impaired cognition. Review of the facility investigation revealed a witness statement dated 03/16/21 at 3:25 P.M., completed by State tested Nurse Aide (STNA) #2 revealed she was not sure of the date she entered Resident #64's room and observed the resident in a chair with Resident #62 standing near with his pants down. His penis was exposed and near Resident #64's face. The statement further revealed Resident #62 left the room with her at that time. Review of a witness statement dated 03/16/21 revealed Licensed Practical Nurse (LPN) #20 entered Resident #64's room on 03/05/21 and discovered Resident #64 lying flat on the bed with her head to the side. Resident #62 was standing at the bedside with his penis exposed and in Resident #64's mouth. The investigation revealed the Director of Nursing (DON) was notified on 03/12/21 at 9:30 A.M. during a staff meeting of the sexual encounter between Residents #62 and #64. Interview on 03/16/21 at 11:09 A.M. with LPN #20 revealed on 03/05/21 she had entered Resident #64's room and observed Resident #62 in the room with his pants down and penis exposed. LPN #20 stated when the residents saw her, they stopped, and she separated the residents. LPN #20 stated she notified the unit manager. She also stated the family and physician were notified. The intervention was to keep the residents separated. LPN #20 stated she had written a witness statement and gave it to the unit manager. Interview on 03/16/21 at 11:13 A.M. with Unit Manager #1 revealed LPN #20 walked into Resident #64's room (date not specified), saw something unusual, walked out of the room and notified her. Unit Manager #1 stated she had investigated the incident and turned the witness statements over to the DON. Interview on 03/16/21 at 4:35 P.M. with the DON confirmed there had not been a self-reported incident (SRI) filed for the incident which occurred on 03/12/21 because there had been no contact between Residents #62 and #64. The DON stated the alleged incident on 03/05/21 was never reported to her. Review of the facility policy titled, Patient Protection, Abuse, Neglect, Exploitation, Mistreatment, & Misappropriation Prevention, dated 11/16, revealed all allegations of abuse were to be reported to the appropriate agencies (State Survey Agency and Adult Protective Services) with in two hours of the incident, to be thoroughly investigated, and results of investigation to be reported to the State Survey Agency within five days of the incident.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the National Weather Forecast, review of the facility's investigation, observations, staff interviews and review of facility's policy on Missing Person Locator, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at high risk for elopement from the facility and with exit seeking behaviors, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #63 was placed at risk for serious harm and injury when the resident eloped from the facility without staff knowledge and exited a door near a steep hill and near a busy four-lane road. The resident was missing for two hours before being found outside the facility lying face down on the sidewalk in hot weather. This affected one (#63) of four residents (#07, #12, #21 and #63) reviewed for elopement. The facility identified 07 current residents (#07, #12, #21, #22, #35, #45 and #79) to be at risk for elopement. The facility census was 93. On 07/28/20 at 2:30 P.M., the Administrator was notified that Immediate Jeopardy began on 07/17/20 at 5:15 P.M. when Resident #63 exited the secured memory care unit through a stairwell door activating the door alarm, which State tested Nursing Assistant (STNA) #70 turned off without initiating a resident search. The resident then exited another door to the outside, which malfunctioned and did not alarm as it should have. Resident #63 was found on the sidewalk outside the facility lying face down two hours later. The ambient air temperature outside was 91 degrees Fahrenheit on 07/17/20. The resident was placed at potential risk of falling down a steep hill which was near the door the resident exited and/or being hit by a vehicle due to the facility resided on a four-lane road. At the time of discovery, Resident #63 was found to have physical injuries, including an abrasion to her forehead, measuring three centimeters (cm.) in length by three cm. in width, an abrasion to her right knee measuring 7.5 cm. by 7.5 cm. and a skin tear to her left elbow measuring 1.5 cm. by one cm. The Immediate Jeopardy was removed and the deficient practice corrected on 07/23/20 when the facility implemented the following corrective actions: · On 07/17/20 at 7:25 P.M. Resident #63 was assessed by Licensed Practical Nurse (LPN) #21. The LPN found new injuries on the resident to her forehead, an abrasion to her right knee and a skin tear to her left elbow. · On 07/17/20 at 7:50 P.M., the Administrator notified the Medical Director of the incident and actions taken. · On 07/17/20 at 8:00 P.M., Resident #63 was placed continuous one-to-one staff supervision. The resident will remain on one-to-one supervision indefinitely for the resident's protection. · On 07/17/20 at 9:00 P.M., Environmental Service Director #88 completed all door audits to ensure all exterior doors met safety regulations. All other facility doors were functioning correctly. The exterior door from the stairwell to the outside from the dementia unit did not alarm at the nurse's station. At 9:30 P.M., Environmental Service Director fixed the door for it to alarm at the nurse's station when opened without a door code. · On 07/17/20 at 9:30 P.M., the Administrator verified all facility doors were functioning. · On 07/17/20 at 9:45 P.M., the Administrator began all staff education on the facility's policy on Missing Patient and door alarm responses. · On 07/17/20 at 10:30 P.M., all eight residents with secure care bracelets (a bracelet type device worn to alert staff of unauthorized exits through doors equipped with an alarming system) were validated for placement and functioning by LPN #21. · On 07/17/20 at 11:00 P.M., the Administrator reviewed and updated the facility's Center Watch Binders and Boards. The Center Watch Binders and Boards provide identification information for the residents at risk for elopement. · On 07/17/20 at 11:16 P.M., the facility began an investigation into Resident #63's elopement from the facility. · On 07/18/20, the Director of Nursing (DON) reviewed and updated care plans as necessary for the eight residents with exit seeking behaviors (Resident #07, #12, #21, #22, #35, #45, #63 and #79). · On 07/18/20, missing patient and door alarm drills were initiated two times per day for five days by the Department Managers, Nursing Managers and/or Nursing Supervisor. · On 07/20/20, Unit Manager #7 reviewed the residents with exit seeking behaviors utilizing the Exit Seeking Quality Assurance and Performance (QAPI) Audit Tool. · On 07/22/20 at 4:30 P.M., all 140 staff members were educated on the facility's policy on Missing Patient and door alarm responses. · On 07/23/20, the missing patient and door alarm drills were completed two times per day for five days by the Department Managers, Nursing Managers and/or Nursing Supervisors. · On 07/27/20, the medical records for Resident #07, #12 and #21, identified at risk for elopement, were reviewed with appropriate assessments and plans of care in place. There were no other identified elopement events. · On 07/27/20 at 1:25 P.M., observations of the doors on the dementia unit revealed all four doors alarmed when opened without a door code. Staff were observed to respond quickly to the door alarms. · Interviews on 07/27/20 with LPN #21, Registered Nurse (RN) #72, RN #7, STNA #49, #38 and #53 revealed the staff had knowledge of proper procedures for resident elopement, and what to do if a door alarms. Findings include: Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the exit seeking risk assessment, dated 05/19/20, revealed Resident #63 was at a high risk for elopement. Review of the physician's orders [REDACTED]. Review of the plan of care for wandering, dated 07/06/20, revealed the resident was at risk for elopement/wandering related to dementia, cognitive deficits and impaired safety awareness. Resident #63 resided on a secure unit to maintain safety. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/06/20, revealed the resident had severe cognitive deficits and had exit seeking behaviors. The resident also required supervision with locomotion on the unit and limited assistance with locomotion off the unit. Review of the nursing note, dated 07/17/20 at 6:45 P.M., documented LPN #21 was notified by STNA#49 that Resident #63 was not observed in her room, bathroom or the dining room when she went to assist the resident with eating. Unit Manager #7 was notified. The resident was last seen at 4:00 P.M. lying on her bed. A head count was conducted, and the facility was searched. Resident #63 was observed outside the facility laying on the ground at 7:20 P.M. Resident #63 was assessed for injuries. Neurological checks were initiated. Resident #63 was found to have physical injuries, including an abrasion to her forehead, measuring three centimeters (cm.) in length by three cm. in width, an abrasion to her right knee measuring 7.5 cm. by 7.5 cm. and a skin tear to her left elbow measuring 1.5 cm. by one cm. Review of the National Weather Service Report for the evening of 07/17/20 revealed the outside temperature was 91 degrees F. Review of the facility's investigation, dated 07/17/20, revealed Resident #63 exited the building undetected. STNA #70 reported the door alarm to the door leading to a stairwell was alarmed at an unknown time on 07/17/20. When she heard the door alarm, STNA #70 checked the landing, which lead to a stairwell and another door which lead to the outside, and she saw no residents on the landing or down the first stairwell. STNA #70 stated she returned to her work duties without checking further down the stairs or outside the second door. On 07/17/20 at 6:45 P.M., STNA #49 was picking up resident meal trays. STNA #49 noted Resident #63's tray was untouched. STNA #49 went to the resident's room she checked in the bathroom, hall and dining room for the resident. STNA #49 could not locate Resident #63 on the unit and then reported this to LPN #21. LPN #21 notified Unit Manager #7 and a head count and a facility search were initiated. Interview on 07/27/20 at 10:00 A.M. with the Administrator revealed Resident #63 left the facility through the stairwell door. The stair well door sounded, and STNA #70 responded. STNA #70 looked down the steps and when no residents were seen, STNA #70 reset the door and returned to her duties. STNA #70 never looked outside. The Administrator verified the facility's policy was not followed. The Administrator noted the staff should have did a head count to make sure all residents were accounted for. Observations of Resident #63 on 07/27/20 at 1:30 P.M. revealed she was lying on her bed watching television. An STNA was sitting in the room with her. Resident #63 did not verbalize when spoken too. Interview with Unit Manager #7 on 07/27/20 at 1:50 P.M. revealed the resident walks very fast around the unit. Resident #63 walks up to the doors and looks out without opening them. Interview with RN #72 on 07/27/20 at 2:00 P.M. revealed she saw the resident outside on the ground lying on her stomach from a window when they were conducting the whole facility search. RN #72 assessed the resident for injury and brought her back inside for further assessment. Interview with STNA #49 on 07/27/20 at 2:10 P.M. revealed she was assisting the residents with their evening meal. She noted Resident #63 had not eaten and she went to find the resident. Resident #63 was not in her room or bathroom. This alarmed STNA #49 and she began looking in other resident rooms. STNA #49 reported to LPN #21 she could not locate the resident. Interview with the Maintenance Supervisor (MS) #88 on 07/27/20 at 3:00 P.M. revealed the door to the stairwell alarmed, however, the door to the outside did not alarm. He verified the door to the outside should have alarmed. He noted the door has a plug in the ceiling that came loose and broke the connection to the outside door causing it to malfunction, which allowed Resident#63 to leave the facility without staff knowledge. Interview with the Administrator via telephone on 07/28/20 at 10:00 A.M. revealed the facility cameras recorded Resident #63 went out the stairwell door at 5:15 P.M. on 07/17/20. The recording revealed STNA #70 responded at 5:16 P.M. STNA #70 opened the door and looked down the steps and reset the door and returned to work. Interview with LPN #21 on 07/28/20 at 9:00 A.M. revealed STNA #49 reported the resident missing. LPN #21 noted STNA #70 did not report the door alarm to her when it went off at 5:15 P.M. on 07/17/20. Interview with STNA #70 on 07/29/20 at 10:00 A.M. revealed she responded to the door alarm but could not remember the time. She stated only the stair well door was alarming. STNA #70 stated she opened the door and looked down the steps and saw no one. She thought it was a staff member who did not reset the door, so she returned to her work duties. Review of the facility's policy on Missing Person Locator, dated 04/2009, revealed if an employee discovered a sounding door alarm, the staff are to conduct an internal search of the immediate area. The staff should perform a face to face head count. If a resident is found missing, a more thorough search shall ensue. This is an incidental finding during the course of the complaint investigation.