Every finding on record at Colonial Nursing Center of Rockford

Based on medical record review, observations, staff and resident interviews, review of facility documentation and review of facility policy, the facility failed to implement enhance barrier precautions as required. This affected one (#1) of five residents reviewed for infection control. The facility also failed to document Legionella prevention control measures were documented. This had the ability to affect all 33 residents residing in the facility. The facility failed to ensure a resident's urinary collection bag was stored in a manner to reduce the chance of infection. This affected one (#35) of two residents reviewed for urinary catheters. The census was 33. Findings include: 1.Review of Resident #1's medical revealed an admission date of 04/29/21. Diagnoses listed included hemiplegia, diabetes mellitus, irritable bowel syndrome, pathological fracture, depressive disorder, hypertension, and schizophrenia. Review of an annual Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had moderately impaired cognition and received nutrition through a feeding tube. Review of physician orders revealed and order dated 06/06/25 for EBP related to percutaneous endoscopic gastrostomy (PEG) tube. Observation of Resident #1's medication administration on 12/30/25 at 4:12 P.M. revealed EBP were not implemented. Licensed Practical Nurse (LPN) #52 administered medications per Resident #1's PEG tube and rectally. LPN #52 was assisted by Certified Nurse Aide (CNA) #27. Incontinence care was also provided to Resident #1 after administration of a rectal medication. Neither LPN #52 nor CNA #27 downed gowns while performing any of the care. Interview with LPN #52 on 12/30/25 at 4:24 P.M. confirmed neither herself or CNA #27 had downed gowns during Resident #1's medication administration and incontinence. LPN #52 confirmed Resident #1 should have been on EBP because of her PEG tube. LPN #52 also confirmed there was not any signage at the entrance of Resident #1's door to inform staff that Resident #1 was on EBP. Interview with the DON on 12/31/25 at 8:00 A.M. confirmed Resident #1 was on EBP due to her PEG tube. The DON confirmed there was not any signage at the entrance of Resident #1 rooms to inform staff of EBP. Review of the facility's policy titled Enhance Barrier Precautions dated 03/01/25 revealed EBP refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employees targeted gown and gloves use during high contact resident activities. High-contact resident care activities include: dressing; bathing; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central lines, urinary catheters; feeding tubes; tracheostomy/ventilator tubes; hemodialysis catheters; peripherally inserted central catheters (PICC); midline catheters; and wound care: any skin opening requiring a dressing. 2. Review of the facility's Legionella Prevention documentation binder revealed control measures listed to be completed were hot water heaters would be flushed and cleaned monthly, faucets would be cleaned monthly and aerators replaced as needed, shower heads would be cleaned monthly and replaced as needed, drinking fountains would be cleaned to remove scale monthly, and ice machines would be cleaned and sanitized quarterly. Further review of the facility's Legionella Prevention documentation binder revealed no documentation of any of the above listed control measures being completed. Interview with Maintenance Director (MD) #57 on 12/29/25 at 10:34 A.M. confirmed he had not been documenting any control measure checks. Review of the facility's policy titled Water Management Program dated 10/01/25 revealed based on the risk assessment control points will be identified. The list of identified points shall be kept in the water management program binder. Control measures will be applied to address potential hazards at each control point. Testing protocols and control limits will be established for each control measure. Individuals responsible for testing or visual inspections will document findings. 3.Review of medical record for Resident #35 revealed admission date of 04/06/23. The resident was admitted with diagnoses including peripheral vascular disease, chronic obstructive pulmonary disease, and congestive heart failure and depression, obstructive and reflux uropathy. The resident remained at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required set up with meals, bed mobility, transfers and moderate assistance with toileting hygiene. Observation on 12/30/25 at 8:23 A.M. revealed Resident #35 was sitting on the side of his bed. Resident #35's urinary catheter bag was observed laying uncovered on the floor towards the foot of the bed. Interview with Resident #35 at the time of the observation revealed a staff member came in to get his walker to clean it. Resident #35 stated the staff removed the urinary catheter bag off of his walker and placed it on the floor. Interview and observation on 12/30/25 at 8:28 A.M. with the Director of Nursing (DON) verified the urinary catheter was uncovered and laying on the floor. The DON stated the urinary catheter bag should be secured to an area below the bladder and should not be laid on the floor for infection prevention.

Based on review of infection control documents, staff interview, and review of facility policy, the facility failed to have a qualified infection preventionist. This had the potential to affect all 33 residents residing in the facility. The census was 33. Findings include: Review of the facility's infection control program documentation revealed no evidence of any current staff member being certified infection control and prevention. Interview with the Director of Nursing (DON) on 12/20/25 at 9:50 A.M. revealed she had not received specialized training in infection prevention and had not obtained any infection control and prevention certification. The DON had been responsible for the facility's infection control program since 10/20/25. Interview with Administrator on 12/30/25 at 11:09 A.M. confirmed the DON had not received specialized training in infection prevention and had not obtained any infection control and prevention certification. The Administrator stated Contracted Registered Nurse (CRN) #36 had been certified in infection prevention. During a follow-up interview on 12/30/25 at 1:40 P.M. the DON stated the CRN #36 was not actively overseeing her infection control program. The DON stated CRN #36 had not been in the facility to review or infection control logs or to audit any findings. Review of the facility's policy titled Infection Prevention and Control Program dated revised 05/01/25 revealed the designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases.

Based on observations, staff interviews and policy review, the facility failed to ensure the dishwasher was adequately sanitizing dishes. This had the potential to affect all 33 residents residing in the facility who receive meals from the kitchen. The facility census was 33. Findings include: Observation with Dietary Aid (DA) #39 of the dishwasher on 12/29/25 at 8:12 A.M. revealed the dishwasher contained a manufactures label that read Minimum Temperature 120 degrees Fahrenheit (F) and sanitizer at 50 parts per million (ppm). The temperature observed during operation was observed three times with the maximum temperature for the wash at 110 degrees F and rinse was 115 degrees F. Testing of the sanitizer did not result in a color change of the strip. Interview with DA #39 at the time of the observation revealed he did not test the temperature of the dishwasher or sanitizer during this shift. Interview on 12/29/25 at 8:28 A.M. with DA #39 revealed he set up the dishwasher that morning and was able to demonstrate how to turn the dishwasher on. DA #39 stated he had not checked the water temperature or the sanitizer and was unsure how. Interview on 12/29/25 at 10:32 A.M. with the Administrator acknowledged she was aware of an issue with the water temperature of the dish machine prior to the survey. The Administrator explained the required part was already ordered and awaiting delivery for repair. Review of the Dishwasher Temperature policy dated 10/01/25 revealed all items cleaned in the dishwasher will be washed in water that is sufficient to sanitize. For low temperature dishwashers (chemical sanitation), the temperature shall be 120 degrees F and the sanitizing solution shall be 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse. The chemical solution shall be tested on ce per shift and water temperatures shall be checked after each meal and recorded. This deficiency represents non-compliance investigated under Complaint Number 2697542 and 2626706.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a medication as administered as ordered. This affected one (#05) resident out of five residents reviewed for medication administration. The facility census was 33.Findings include: Review of the medical record for Resident #05 revealed an admission date of 04/02/24 with medical diagnoses of schizoaffective disorder, suicidal ideations, hypertension, diabetes mellitus, depression, post-traumatic stress disorder, and anxiety. Review of the medical record for Resident #05 revealed a quarterly Minimum Data Set (MDS) assessment, dated 10/01/25, which indicated Resident #05 was cognitively intact, required supervision with bathing and was independent with bed mobility and transfers, and required set-up with eating and toileting. Review of the medical record for Resident #05 revealed a physician order dated 09/20/25 for losartan potassium 50 milligram one tablet by mouth daily, hold if systolic blood pressure <100. Review of the medical record for Resident #05 revealed the December 2025 Mediation Administration Record (MAR) indicated Resident #05 received losartan potassium on 12/07/25 with blood pressure of 98/62, on 12/20/25 with a blood pressure of 94/54 and on 12/21/25 with blood pressure of 99/66. Interview on 12/31/25 at 10:21 A.M. with Administrator confirmed Resident #05 was administered losartan potassium on 12/07/25, 12/20/25, and 12/21/25 and that the medication should have been held due to Resident #05's blood pressure was outside of the parameters ordered. Review of the facility policy titled, Medication Administration, revised 10/01/25, stated medications are to be administered by licensed nurses, or other staff who are legally authorized to so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination of infection. The policy stated to obtain and record vital signs, when applicable per physician orders, when applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to provide cares/services to prevent falls. The facility also failed to investigate and initiate interventions to prevent further falls. This affected one (#20) out of three residents reviewed for falls. The facility census was 33. Findings include: Review of the medical record for Resident #20 revealed an admission date of 04/19/25 with medical diagnoses of Parkinsonism, chronic obstructive pulmonary disease, schizophrenia, dementia, and depression. Review of the medical record for Resident #20 revealed a quarterly Minimum Data Set (MDS) assessment, dated 10/24/25, which indicated Resident #20 was cognitively intact and required supervision with eating, toilet hygiene, and transfers, and was independent with bed mobility and ambulation. Review of the MDS indicated Resident #20 did not have any recent falls. Review of the medical record for Resident #20 revealed an at risk for falls care plan indicated an intervention for staff to walk with resident when feeling weak, resident needs one staff assistance for transfers when feeling weak, and resident was encouraged to lower self to floor on knees to prevent falls. Review of the activities of daily living deficit care plan, stated Resident #20 had lack of coordination and unsteady on feet. Interventions included staff to assist resident with wheeled walker for mobility. Review of the medical record for Resident #20 revealed a nurse's note, dated 12/21/25 at 5:44 P.M. which stated resident was very weak today, dropping to his knees several times throughout the AM, this nurse gave resident wheelchair to use and found him several times without his wheelchair trying to use his walker again and going to his knees. The note stated the physician was notified. Review of the nurse's note dated 12/22/25 at 12:11 P.M, stated neurology group was notified that since Resident #20's Sinemet was decreased the resident had increased tremors, shakes and weakness and stated Resident #20 went down on his knees several times over the weekend. Lastly, review of the nurse's note, dated 12/30/25 at 8:43 A.M., stated visualized Resident #20 ambulating with his walker and went down onto one knee to prevent falls. The note stated the nurse encouraged Resident #20 to request assistance with ambulation due to increased weakness noted this morning. Observations on 12/30/25 at 8:25 A.M. revealed Resident #20 ambulating independently down the hall with his walker and was noted to have uncoordinated and unsteady gait. Continued observation revealed resident went down to his knees while his hands remained on the walker. Approximately 30 seconds later, Resident #20 was observed to stand back up and continued his uncoordinated gait down the hall. The observation revealed Resident #20 dropping to his knees and getting back up a total of five times. The observation revealed the Director of Nursing (DON) had observed Resident #20 ambulating and lowering self to the floor. Interview on 12/30/25 at 1:33 P.M. with Registered Nurse (RN) #71 stated Resident #20 had increased weakness since the neurologist discontinued his Sinemet but stated the medication was recently restarted. RN #71 confirmed Resident #20 would lower to his knees with ambulation at times and that it was not considered a fall. RN #71 stated Resident #20 was independent with ambulation and was care planned to lower self to floor. Interview on 12/31/25 at 1:00 P.M. with Administrator confirmed Resident #20's nursing notes on 12/21/25, 12/22/25, and 12/30/25 indicated Resident #20 had fallen to his knees several times due to weakness and the staff did not complete fall investigations or initiate interventions to prevent further falls. Administrator also confirmed Resident #20's care plan did not stated Resident #20 lowered himself to his knees as a behavior. Administrator also stated the incidents when Resident #20 dropped to his knees due to weakness, this should have been considered falls. Review of the facility policy titled, Fall Prevention Program, revised 10/01/25, stated each resident would be assessed for fall risk and would receive care/services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy stated a definition of a fall was an unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g. bed, chair, or bedside mat) or the result of an overwhelming external force (e.g. a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if they had not caught themselves or had not been intercepted by another person, this is still considered a fall. The policy stated if there is a loss of balance during supervised therapeutic interventions and the resident comes to resident on the ground, floor, or next level surface despite the clinician's effort to intercept the loss of balance, it is considered a fall. The policy stated to provide interventions to address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent changes in functional status. Lastly, the policy stated any resident who experiences a fall, the facility would: 1) assess the resident, 2) complete a post- fall assessment, 3) complete an incident report, 4) notify physician and family, 5) review the resident's care plan and update as indicated, 5) document all assessments and actions, 6) obtain witness statements in the case of injury. This deficiency represents non-compliance investigated under Complaint Number 1334906 (OH00166383).

Based on medical record review and staff interview, the facility failed to ensure laboratory work was completed as per physician orders. This affected one (#04) resident out of the five residents reviewed for unnecessary medications. The facility census was 33. Findings include:Review of the medical record for Resident #04 revealed an admission date of 06/29/22 with medical diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, Ogilvie syndrome, diabetes mellitus, depression, hyperlipidemia, and atrial fibrillation. Review of the medical record for Resident #04 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #04 was cognitively intact and was dependent upon staff for toilet hygiene, showering, transfers, and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #04 revealed a physician order dated 08/24/22 for the following laboratory values to be completed every June: thyroid-stimulating hormone (TSH), thyroxine (T4), triiodothyronine (T3), free T4 (FT4), lipid panel, complete blood count (CBC), comprehensive metabolic panel (CMP), hemoglobin blood (A1C) test, magnesium levels, B12 level, and Vitamin D level. Review of the medical record revealed no documentation to support the laboratory values had been completed in 2025. Interview on 12/30/25 at 3:37 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #04 did not contain any documentation to support the laboratory values ordered to be completed every June had been completed in 2025.

Based on observations and staff and resident interviews, the facility failed to have personal funds available after business hours. This affected three (#15, #9 and #35) out of three residents reviewed for availability of personal funds. The facility census was 33. Findings include: Interview on 12/29/25 at 9:27 A.M. with Resident #15 revealed the resident is unable to obtain money from personal funds after 4:00 P.M. after business office is closed during the week. Personal funds are not available on weekends or holidays. Interview on 12/30/25 at 1:40 P.M. with Register Nurse (RN) #71 revealed no personal funds are not kept in the medication cart for withdrawal when business office is closed. Interview on 12/30/25 at 1:50 P.M. with Business Office Manager (BOM) #11 revealed personal funds are not available in the evening or weekends. Business office has hours of Monday through Friday 8:00 A.M. to 4:00 A.M. BOM #11 stated, Everyone is in the route of doing that. Interview on 12/31/25 at 9:13 A.M. with Resident #9 revealed the resident did not know how much funds he has available or how to get to his funds. Resident #9 just knows someone comes to him to order clothes or other stuff when he needs to. Interview on 12/31/25 at 9:51 A.M. with Resident #35 revealed the resident is unable to get personal funds out during the evenings and weekends. Personal funds are only available Monday though Friday 8:00 A.M. to 4:00 P.M. if business office manager is working. Observation of posting outside of business office revealed banking hours of Monday through Friday 8:00 A.M. through 4:00 P.M. Observation of business office during survey revealed business office was closed on the Monday of survey, opened on Tuesday, and opened at 8:18 A.M., Wednesday then closed at Noon for the day. This deficiency represents non-compliance investigated under Complaint Number 2626703 and 2626706.

Based on medical record review, review of the facility optometrist visit log, and staff and resident interviews, the facility failed to ensure a resident was provided with the opportunity to see an optometrist. This affected one (05) out of four residents reviewed for ancillary services. The facility census was 33. Findings include: Review of the medical record for Resident #05 revealed an admission date of 04/02/24 with medical diagnoses of schizoaffective disorder, suicidal ideations, hypertension, diabetes mellitus, depression, post traumatic stress disorder, and anxiety. Review of the medical record for Resident #05 revealed a quarterly Minimum Data Set (MDS) assessment, dated 10/01/25, which indicated Resident #05 was cognitively intact, required supervision with bathing and was independent with bed mobility and transfers, and required set-up with eating and toileting. The MDS indicated Resident #05 had no vision issues with the use of glasses. Review of the medical record for Resident #05 revealed no documentation to support the resident was seen by an eye doctor since admission. Review of the facility's optometrist log revealed the last visit by an optometrist to the facility was on 03/14/24. Interview on 12/29/25 at 9:24 A.M. with Resident #05 stated she had not been provided with the opportunity to see an eye doctor since she was admitted to the facility. Resident #05 confirmed she wore glasses and that she thought her vision had worsened a little since admission, but it had not affected her ability to perform her activities of daily living. Interview on 12/30/25 at 12:18 P.M. with Social Service (SS) #74 confirmed Resident #05 had not been seen by an optometrist since prior to admission on [DATE]. SS #74 stated the facility had been working to get another optometrist to the facility but had not been successful in arranging the service at the facility. SS #74 stated some residents had gone out to their private optometrist and the facility had assisted with arranging the appointments.

Based on medical record review, resident and staff interviews, policy review, and review of the Centers of Disease Control (CDC) website, the facility failed to ensure a resident who tested positive for coronavirus (COVID-19) was monitored for changes in health status as per Center for Disease Control (CDC) guidelines. This affected one (#34) out of one residents reviewed for COVID-19. The facility census was 33. Findings include: Review of the medical record for Resident #34 revealed an admission date of 04/30/24 with medical diagnoses of gastroparesis, diabetes mellitus, hypertension, and depression. Review of the medical record for Resident #34 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #34 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #34 revealed a nurses' note, dated 12/25/25 at 2:15 P.M., which stated Resident #34 had returned from the hospital and tested positive for COVID-19 and was put into isolation. Review of the medical record for Resident #34 revealed a physician order dated 12/25/25 for airborne isolation for three days for COVID-19. The order was discontinued on 12/28/25. Review of the physician orders revealed an order dated 12/28/25 to recheck resident for COVID-19 one time only. Review of the medical record for Resident #34 revealed no documentation to support the facility staff had obtained Resident #34's temperature or oxygen saturation levels since 06/01/25. Further review of the medical record for Resident #34 revealed no documentation to support the facility staff had monitored Resident #34's clinical status since COVID-19 positive test or had documentation to support results of further COVID-19 tests. Interview on 12/30/25 at 1:29 P.M. with Resident #34 confirmed she tested positive for COVID-19 on 12/25/25 and the facility staff had completed a few more tests which came back negative. Resident #34 confirmed the facility staff have not completed any respiratory evaluations or obtained her vital signs since she tested COVID-19 positive on 12/25/25. Interview on 12/30/25 at 3:30 P.M. with Administrator confirmed the medical record for Resident #34 did not contain documentation to support the facility staff who had monitored Resident #34's respiratory status or obtained vital signs since Resident #34 tested COVID-19 positive on 12/25/25. Administrator also confirmed that the medical record for Resident #34 had no documentation to support further COVID-19 test results and Resident #34 did not have a current order for isolation in place. Review of the CDC website, https://www.cdc.gov/long-term-care-facilities/hcp/respiratory-virus-toolkit/index.html, stated staff should monitor the vital signs (temperature, respiratory rate, heart rate, blood pressure, oxygen saturations) for residents in a nursing home who are COVID-19 positive. Review of the facility policy, Covid-19 prevention, response, and reporting, revised 10/01/25, stated the facility would ensure appropriate interventions were implemented to prevent the spread of COVID-19 and to promptly respond to any suspected or confirmed COVID-19 infections. The policy stated staff would be alert to signs of COVID-19 and notify the resident's physician of any fever/chills, cough, shortness of breath or difficulty breathing, fatigue, muscle weakness, headache, new loss of taste or smell, sore throat, congestion, nausea or vomiting, and diarrhea.

Based on review of personnel records and staff interviews, the facility failed to complete performance reviews for Certified Nurse Aides (CNA) as required. This affected two (#13, and #18) of three CNA reviewed and had the potential to affect all 33 residents residing in the facility. The census was 33. Findings Include: Review of CNA #13's personnel file revealed a hire date of 04/25/23. Further review revealed no documentation of an annual performance review being completed in 2025. Review of CNA #18's personnel file revealed a hire date of 04/25/23. Further review revealed no documentation of an annual performance review being completed in 2025. Interview with Business Office Manager (BOM) #11 on 12/31/25 at 12:11 P.M. confirmed there were no annual evaluations for CNA #13 and CNA #18.

Based on observation, staff interview, policy review and review of local health department documentation the facility failed to ensure the kitchen was maintained in a safe and sanitary manner. This had the potential to affect all residents residing at the facility. The facility census was 27. Findings include: Observation on 04/17/25 at 7:58 A.M. of the kitchen revealed an uncovered trash can placed to the right side of the steel clean utensil cart. Food was observed splattered along the side of the cart. Food debris was noted encircling the clean utensil holders. A two layered steel cart was noted to have three open soda cans, with food debris and an uncovered plastic container of butter. A hooded sweatshirt was observed wadded up in the corner of the bottom shelf. The food service prep area had a pan of scrambled eggs and a second pan with bacon and seven over easy eggs. Food particles were observed on the steel cart where the clean plates were held encircling the clean plates. This was verified with [NAME] #25 at the time of the observation. Further observation of the kitchen on 04/17/25 at 8:07 A.M. revealed the following: a. The two-compartment sink had an approximate eight inch by 12 inch area coated with a cream colored powder b. Wired storage shelves had clean pans stored upside down on grease caked wire shelves. c. Food debris caked onto the glass plate of the microwave, with food splattered on all sides inside the microwave, including the inside of the door. d. The mixer on the microwave stand had dried food on both inside and on the outside of the bowl, as well as the mixing tool. e. Food debris was scattered on the floor throughout the kitchen as was a faint black unknown coating. f. The stove had burnt food pieces on each of the burners. g. The standing refrigerator had four pieces of cake uncovered and undated in styrofaom containers. h. Food was caked on the metal racks of the refrigerator as well as the bottom of the refrigerator. i. The [NAME] refrigerator contained a hard plastic container of an undated, unlabeled breaded product. j. An opened five pound hamburger roll was stored in a large steel container. The use/freeze by date was 04/02/25. The saran wrap was dated 04/12/25. The burger was observed to be a light grey color. k. A box containing a sealed plastic bag of apple slices had a best by date of 04/06/25. l. An open plastic bag of roast beef and turkey lunch meat was undated. m. An opened unlabeled, undated package of lunch meat. n. An open box of undated bacon in an open package. o. One open cardboard box containing unpasteurized eggs. p. The freezer had frozen hamburger patty's in an open plastic bag inside a cardboard box. Interview and observation on 04/17/25 at 8:47 A.M. with Dietary Manager #26 revealed the powder observed on the two-compartment sink was likely pancake mix, he acknowledged the wired shelf which stored clean pans had a sticky layer of grease, the microwave and mixer were unclean, and food particles were on the stand. Dietary Manager #26 acknowledged the floor of the kitchen was dirty, the stove top had burnt food, the refrigerator was not clean and contained undated, uncovered cake in styrofoam containers. The undated, unlabeled breaded meat was fish from a few days ago. He stated the opened lunch meat was an ongoing issue from nursing staff on the off shift making sandwiches and not properly labeling the meat when they were finished. He was unsure what one of the packages of meat was. Dietary manager #26 verbalized the hamburger and apple slices were outdated and the bacon and hamburger patty's had not been sealed properly. Further observation of the three-compartment sink revealed a brown/black substance was consolidated around the garbage disposal and a soiled dishtowel was tossed under the disposal. This was verified at the time of the observation. Interview on 04/17/25 at 1:17 P.M. with [NAME] #25 revealed she had used the unpasteurized eggs for the sunny side-up eggs she had cooked for breakfast. Review of the 03/19/25 Food Inspection Report completed by the local health department revealed the facility was marked as out of compliance with food contact surfaces cleaned and sanitized. Review of the facility policy, Food Safety Requirements last revised 01/01/25 documented food would be stored, prepared, distributes and served in accordance with professional standard of food service safety. Labeling, dating and monitoring of refrigerated food, including left overs, so its used by its use by date, or frozen by date. This deficiency represents non-compliance investigated under Complaint Number OH00164754.

Based on medical record review, review of facility investigation report, resident and staff interviews, and policy review, the facility failed to ensure medications were consumed at the time of administration. This affected one (#08) out of three residents reviewed for medication administration. The facility census was 25. Findings include: Review of the medical record for Resident #08 revealed an admitted [DATE] with medical diagnoses of acquired left below the knee amputation (BKA), chronic obstructive pulmonary disease, congestive heart failure, obsessive-compulsive disorder (OCD), major depression, and peripheral vascular disease. Review of the medical record for Resident #08 revealed an admission Minimum Data Set (MDS) assessment, dated 07/29/24, which indicated Resident #08 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene and bathing, supervision with transfers and set-up assistance with eating and bed mobility. The MDS indicated Resident #08 received antidepressant, anticoagulant, antibiotic, and opioid medications. Review of the medical record for Resident #08 revealed physician orders dated 07/24/24 for acetaminophen 650 milligram (mg) one tablet by mouth every four hours as needed, 07/25/24 for cholecalciferol (vitamin D3) 1000 units one tablet by mouth daily and oxycodone-acetaminophen (Percocet) 5-325 mg one tablet by mouth every four hours as needed, 07/26/24 for Colace (stool softener)100 mg one tablet by mouth two times per day, and 08/15/24 for gabapentin 100 mg one tablet by mouth every evening. Review of Resident #08's medical record revealed there was no physician order, assessment or care plan allowing the resident to self administer medications. Review of the medical record for Resident #08 revealed a nurse progress note dated 08/24/24 at 4:41 A.M. written by Licensed Practical Nurse (LPN) #75 which stated the nurse gave Resident #08 his morning medications, watched the resident take medications and left the room. The note stated a State tested Nursing Assistant (STNA) went into Resident #08's room to empty his catheter and saw Resident #08 putting medications into his pillowcase. The note stated LPN #75 and Director of Nursing (DON) went to into Resident #08's room and asked where he placed his medications. Resident #08 denied having the medications. The note stated LPN #75 checked in Resident #75's pillowcase and found a medication cup in a glove with two gabapentin tablets, one acetaminophen tablet, two stool softener tablets, four Vitamin D3 tablets, and ten Percocet tablets. The note continued to state the LPN educated Resident #08 on severe misuse of medications and how important it was to have his medications on him and to take them with compliance. Review of the facility investigation report, dated 08/24/24, stated Resident #08 was noted to hoard medications. The report stated Resident #08 was removed from the room by the floor nurse and DON. The report stated medications found were counted and destroyed. The investigation report stated Resident #08 was educated and the confirmed he took the medications but stated he didn't know why and wouldn't do it again. The report stated the facility notified the Administrator, Assisted Living waiver program representative, Resident #08's physician and representative of the incident. The report continued to state Resident #08 was alert and oriented to person, place, time, and situation and have no negative effects of the incident. Interview on 09/25/24 at 8:50 A.M. with Resident #08 confirmed he had previously kept medications in his mouth and would put in his pillowcase. Resident #08 stated he no longer kept his medications after the staff spoke to him about it. Interview on 09/25/24 at 8:57 A.M. with LPN #75 confirmed she was the nurse who administered medications to Resident #08 on 08/24/24. LPN #75 stated she observed Resident #08 consume his medications and left the room. LPN #75 stated she was notified by the STNA that Resident #08 had medications in his pillowcase. LPN #75 confirmed Resident #08 had medication in his pillowcase, and some were half dissolved. LPN #75 confirmed Resident #08 informed her he would pocket the medication in his cheek and then put in his pillowcase. Interview on 09/25/24 at 9:31 A.M. with DON confirmed Resident #08 had medications found in his pillowcase on 08/24/24. DON confirmed Resident #08 was educated on not keeping medications in his cheeks. DON stated Resident #08 has not had an incident of pocketing medications in his cheek since 08/24/24. Review of the facility policy titled, Medication Administration, revised 07/01/24, stated medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy stated the nurse was to observe resident consumption of medication. This deficiency represents non-compliance investigated under Complaint Number OH00157430.

Based on record review, staff interview, and review of the facility policy the facility failed to ensure resident funds were conveyed in a timely manner. This affected two residents (#20 and #23) of three reviewed for personal funds. The facility census was 19. Findings include: 1. Review of the medical record of Resident #20 revealed an admitted [DATE] and a date of death on [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia and hypoxia, hypotension, chronic obstructive pulmonary disease, anxiety disorder, emphysema, and quadriplegia C5-C7 incomplete. Review of the facility form titled, Transaction Report, dated [DATE] to [DATE] revealed Resident #20's account had a payment applied on [DATE] in the amount of $25,000.00. A second payment was applied on [DATE] in the amount of $7,000.00, and a third on [DATE] in the amount of $7,000.00. A refund of $7,500.00 was issued on [DATE]. There was a balance of $7,500. Interview on [DATE] at 10:30 A.M. with Business Office Manager (BOM) #150 and Director of Accounts Receivable (DAR) #151 revealed Resident #20 admitted under Medicare Part A with Michigan Blue Cross/Blue Shield as secondary payment. His insurance changed to Medicaid pending on [DATE], at which time he owed $1500.00 per day. Resident #20 expired on [DATE] for a total of $31,500.00 owed for the 21 days. The facility received a payment of $25,000.00 on [DATE], a payment of $7000.00 on [DATE], and $7000.00 on [DATE] totaling $39,000.00. At the time of his death Resident #20 had an outstanding balance of $6,000.00 as the facility was waiting on the co-insurance check to cover the $6,000.00 from [DATE] to [DATE]. This would leave a balance in the account of $1,500. A follow-up interview on [DATE] at 11:20 A.M. with BOM #150 and DAR #151 revealed Resident #20's estate should have received the $1,500.00 within the 30 days following his death. 2. Review of the medical record of Resident #23 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses include wedge compression fracture of T11-T12 vertebra and unspecified intellectual disabilities. Review of the payor sources revealed Resident #23 was private pay beginning [DATE] until discharged . Review of the, Transaction Report, dated [DATE] to [DATE] revealed Resident #23 had a positive balance of $226.00. The form revealed a refund check for the amount of $226.00 was issued on [DATE]. Interview on [DATE] at 1:07 P.M. BOM #150 verified Resident #23's refund check was not issued until [DATE]. Review of the facility policy titled, Resident Personal Funds, dated [DATE] revealed upon the death of a resident the facility will convey, within 30 days, the resident's funds to the resident's estate, in accordance with state law. This deficiency represents non-compliance investigated under Complaint Number OH00149946.

Based on observation, staff interview, and review of facility smoking contract, the facility failed to ensure cigarettes were lit outside the facility. Furthermore, the facility failed to ensure the resident smoking area was free from cigarette butts. This had the potential to affect all 19 residents residing in the facility. Additionally, the facility failed to ensure alcohol was stored properly. This affected one (Resident #11) of one resident reviewed for alcohol storage. The facility census was 19. Findings include: 1. Observation on 03/06/23 at 3:43 P.M. revealed State tested Nursing Assistant (STNA) #117 lighting the cigarettes of two male residents while they were inside the building, prior to them exiting to the courtyard patio. Observations of the courtyard revealed the presence of a large amount of cigarette butts on the ground, in the mulch, in the grass, and on the cement. STNA #117 verified the large amounts of cigarette butts throughout the courtyard. Interview on 03/06/23 at 3:45 P.M. with STNA #117 verified she lit cigarettes for residents inside the facility, prior to the resident exiting the facility. She added, all staff do this. Interview on 03/09/23 at 10:11 A.M. with the Administrator revealed he conducted walking observations numerous times throughout the day when at the facility, twice a week. The Administrator stated he was unaware staff were lighting cigarettes inside the building. He stated a resident knocked over a receptacle and spilled the cigarette butts and indicated staff cleaned the area yesterday. Observation on 03/09/23 at 10:20 A.M. of the patio courtyard area where the residents smoke, revealed cigarette butts lying in the mulch, in the grass, and on the cement area. Some of the butts appeared to be falling apart and discolored from excess moisture. Review of the, Tranquility of [NAME] Smoking Contract, revealed smoking was not permitted inside the facility. 41528 2. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included heart failure, high blood pressure, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the physician order dated 11/17/22, revealed Resident #11 may have one alcoholic beverage, daily every 24 hours as needed. Review of the care plan updated 11/17/22 revealed Resident #11 was care planned to have one alcoholic beverage per day. Observation on 03/06/23 at 11:17 A.M. revealed a liquor bottle of Kahlua on the floor by the resident's bedside. Interview on 03/07/23 at 1:25 P.M. with Licensed Practical Nurse (LPN) #110 verified a 750 milliliter (ml) bottle of Kahlua on the floor by Resident #11's bedside. The liquor bottle was open but mostly full with about 2.5 to 3 inches missing from the top.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the resident shower room provided adequate privacy. This had the potential to affect all 19 residents residing in the facility. The facility's census was 19. Findings include: Observation on 03/07/23 at 2:20 P.M. of the resident shower room revealed two separate shower suites for residents, with an open doorway to each suite. There were no doors or privacy curtains in place for resident privacy for either suite or near the shower itself. If a resident were to be receiving a shower, and a second resident or staff member entered, the first resident would be easily observed by the second resident and/or staff entering the shower room. Interview on 03/07/23 at 2:27 P.M. with State tested Nursing Assistant (STNA) #136 verified there were no doors or privacy curtains in place in the resident shower room. Interview on 03/07/23 at approximately 3:45 P.M. with the Director of Nursing (DON) verified all 19 residents utilized the resident shower room. Review of facility policy, Resident Rights, dated 02/01/23, verified the resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment, written and telephone communication, personal care, visits, and meetings of family and resident groups, but his does not require the facility to provide a private room for each resident.

Based on the facility's water management program information, staff interview, review of the Centers for Disease Control (CDC) guidance, and review of facility policy, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 19 residents in the facility. Findings include: Review of the facility's Legionella environmental assessment form dated 05/26/22 revealed the assessment was not fully completed and did not include all the required components. Further review revealed the facility did not complete a map/flow diagram of the facility and/or water temperature monitoring. Interview on 03/09/23 at approximately 1:50 P.M. with Maintenance Staff #128 revealed she had been working in the maintenance position since the end of November 2022. Maintenance Staff #128 admitted she was unaware what the requirements were for the water management program and verified she had yet to do anything regarding water management related to Legionella, including monitoring of water temperatures. Review of the undated CDC guidance titled, Overview of Water Management Programs, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: Establish a water management program team Describe the building water systems using text and flow diagrams Burden of Waterborne Disease Read about various illnesses, including Legionnaires' disease, in CDC's first estimates of the impact of waterborne disease in the United States. Identify areas where Legionella could grow and spread Decide where control measures should be applied and how to monitor them Establish ways to intervene when control limits are not met Make sure the program is running as designed (verification) and is effective (validation) Document and communicate all the activities Review of the facility's policy, Legionella Surveillance, undated, verified Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems.

Based on medical record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance for Coronavirus 2019 (COVID-19) vaccination and boosters, the facility failed to ensure residents were offered COVID-19 vaccines in a timely manner. This affected five (Residents #3, #6, #5, #8, and #11) of five residents reviewed for COVID-19 vaccination. This also had the potential to affect all residents residing in the facility. The facility census was 19. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included type two diabetes mellitus, borderline personality disorder, schizophrenia, hyperlipidemia, essential (primary) hypertension, nicotine dependence, major depressive disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of COVID-19 vaccine documentation dated 11/04/21 revealed Resident #3's responsible party declined the COVID-19 vaccine on 11/04/21. Further review of the medical record revealed there was no additional documentation showing the resident was offered the COVID-19 vaccine since 11/03/21. 2. Review of the medical record revealed Resident #6 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included unspecified convulsions, nicotine dependence, schizophrenia, cerebral cysts, benign neoplasm of brain, dementia, bipolar, and epilepsy. Review of the MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of COVID-19 vaccine documentation, dated 11/04/21, revealed Resident #6's responsible party declined the COVID-19 vaccine on 11/04/21. Further review of the medical record revealed there was no additional documentation showing the resident was offered the COVID-19 vaccine since 11/04/21. 3. Review of the medical record revealed Resident #5 was admitted on [DATE]. Diagnoses included schizophrenia, cerebral infarction, cerebrovascular disease, bipolar disorder, hyperlipidemia, type two diabetes mellitus, and essential primary hypertension. Review of the MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the immunization record revealed Resident #5 last received the COVID-19 vaccine booster Moderna 07/14/22. Further review of the medical record revealed no additional documentation showing the resident was offered an updated COVID-19 booster from 07/14/22 to March 2023. 4. Review of the medical record revealed Resident #8 was initially admitted on [DATE] with re-entry on 10/21/21. Diagnoses included Parkinson's, major depressive disorder, essential primary hypertension, restless leg syndrome, psychotic disorder with hallucinations, and schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the immunization record revealed Resident #5 last received the COVID-19 vaccine booster Moderna 07/14/22. Further review of the medical record revealed no additional documentation showing the resident was offered an updated COVID-19 booster from 07/14/22 to March 2023. 5. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included heart failure, high blood pressure, and chronic kidney disease. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the immunization record revealed Resident #5 last received the COVID-19 vaccine booster Moderna 07/14/22. Further review of the medical record revealed no additional documentation showing the resident was offered an updated COVID-19 booster from 07/14/22 to March 2023. Interview on 03/08/23 at 1:50 P.M. with the Director of Nursing (DON) verified the facility had not offered COVID-19 booster vaccines to current residents. Interview on 03/09/23 at 9:05 A.M. with the DON verified Resident #3 and #6 had not been re-offered the COVID-19 vaccine since 11/04/21. Review of the CDC guidance titled, Stay Up to Date with COVID-19 Vaccines Including Boosters, dated 03/02/23 revealed the CDC recommended people stay up to date with the COVID-19 vaccine for their age group. The CDC recommends one updated vaccine for everyone 5 years and older. Updated boosters are called updated because they protect against both the original virus that causes COVID-19 and the Omicron variant. Two COVID-19 vaccine manufacturers, Pfizer and Moderna, have developed updated COVID-19 boosters. Updated COVID-19 boosters became available on 09/22/22 for people aged [AGE] years and older. Review of the facility policy, COVID-19 Vaccination, dated 09/28/22 verified it is the policy of the facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice.

Based on review of a facility list of residents identified as smokers, review of the facility assessment, staff interview, and review of facility policy, the facility failed to identify smoking residents. Additionally, the facility assessment failed to address the facility's smoking population's needs. This had the potential to affect eight (Residents #2, #3, #6, #10, #11, #12, #14, and #19) identified by the facility as smoking residents. The facility's census was 19. Findings include: Review of a facility provided list of residents identified as smokers, revealed eight residents (#2, #3, #6, #10, #11, #12, #14, and #19) smoked out of the 19 residents residing in the facility, equaling 42 percent (%) of the facility population. Review of the facility assessment dated [DATE] revealed the assessment did not identify the facility's resident smoking population, nor did it identify needed services and care for smoking residents. Further review revealed the assessment indicated the facility would provide person-centered, directed care for psycho, social or spiritual support. The specific care or practices listed included to support helpful coping mechanisms. Interview on 03/08/23 at 3:00 P.M. the Administrator and Director of Nursing (DON) claimed the facility assessment covered smokers under the, Support helpful coping mechanisms, section. However, further review of the assessment revealed the smoking population was not addressed anywhere in the assessment. Interview on 03/09/23 at 3:30 P.M. with the DON revealed 42% of the facility's population were identified as smoking residents, which was a high amount. Review of the facility policy titled, Facility Assessment, reviewed 10/21/22 revealed the facility would conduct a facility-wide assessment to determine what resources are necessary to care for residents. The facility assessment will include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity and other pertinent facts that are present within the population.

Based on medical record review, employee file review, and staff interview, the facility failed to complete Behavioral Health training upon hire for new employees. This affected two State tested Nurse Aides (STNAs #106 and #117) of four STNAs review for Behavioral Health training. Additionally, this affected four (Residents #2, #5, #20, and #1) of four residents reviewed for mental health diagnoses. The facility identified 16 residents with mental health diagnoses (Residents #1, #6, #2, #5, #12, #123, #18, #15, #7, #174, #3, #11, #20, #175, #8, and #10). The facility's census was 19. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with medical diagnoses of schizoaffective disorder and paranoid schizophrenia. Review of the medical record for Resident #5 revealed an admitted [DATE] with medical diagnoses of schizophrenia, bipolar disorder, and depression. Review of the medical record for Resident #20 revealed an admitted [DATE] with medical diagnoses of post traumatic stress disorder (PTSD), anxiety, hallucinations, depression, schizoaffective disorder, and insomnia. Review of the medical record for Resident #1 revealed an admitted [DATE] with medication diagnoses of schizophrenia, depression, and psychosis. Review of the employee file for STNA #106 revealed a hire date of 11/23/22. Further review revealed no did not documentation to support STNA #106 received specialty care training for residents with mental health. Review of the employee file for STNA #117 revealed a hire date of 12/07/22. Further review revealed no did not documentation to support STNA #117 received specialty care training for residents with mental health. Interview on 03/09/23 at 11:30 A.M. with Business Office Assistant #146 confirmed STNAs #106 and #117) did not receive specialty care training for residents with mental health. Interview on 03/09/23 at 3:30 P.M. with the Director of Nursing (DON) confirmed all but three (Residents #4, #14, and #19) out of the 19 residents in the facility had psychiatric diagnoses. Review of the policy titled, Behavioral Health Services, stated all facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of the residents.

Based on record review, staff interview, and policy review, the facility failed to ensure an accurate Preadmission Screen and Resident Review (PASRR) was completed and failed to ensure the PASRR Review Results were obtained timely. This affected five (Residents #01, #05, #20, #08, and #10) of five residents reviewed for PASRRs. The facility census was 19. Findings include: 1. Review of the medical record for Resident #01 revealed an admitted [DATE] with diagnoses of residual schizophrenia, major depression, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #01 was cognitively intact. Resident #1 required supervision with bed mobility, transfers, locomotion, and eating. Resident #01 required limited assistance with toileting and extensive staff assistance with bathing. Further review of the medical record revealed a PASRR screen was completed on 05/11/18. The Review Results indicated Resident #01 had no indications of serious mental illness nor a developmental disability. Continued review of the PASRR screen revealed the form did not indicate the mental health diagnoses of psychosis and did not state that due to the mental disorder the individual experienced a limitation in maintaining personal hygiene. 2. Review of the medical record for Resident #05 revealed an admitted [DATE] with diagnoses of schizophrenia, bipolar disorder, and major depression. Review of the MDS assessment dated [DATE], indicated Resident #05 had moderate cognitive impairment. Resident #05 required extensive assist with bed mobility, dressing, toileting, and personal hygiene. Resident #05 was dependent upon staff for transfers and bathing and was non-ambulatory. Further review of the medical record revealed a PASRR screen completed on 05/10/19 revealed the form did not include the mental health diagnoses of schizophrenia or major depression. Further review of the medical record revealed no documentation to support the facility received the PASRR Review Results prior to Resident #05 admitting to the facility on [DATE]. 3. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses of post-traumatic stress disorder (PTSD), anxiety, hallucinations, major depression, schizoaffective disorder, and insomnia. Review of the MDS assessment dated [DATE], indicated Resident #20 was cognitively intact. Resident #20 required supervision with bed mobility, transfers, eating, and toileting. Resident #20 required extensive assistance with bathing. Further review of the medical record revealed a PASRR screen, dated 12/02/22, which did not indicate Resident #20 had schizoaffective disorder or post-traumatic stress disorder (PTSD). Further review of the medical record revealed no documentation to support the facility received the PASRR Review Results form prior to Resident #20's admitted [DATE]. 35031 4. Review of the medical record of Resident #08 revealed an admitted [DATE]. Diagnoses included major depressive disorder, anxiety disorder, psychotic disorder with hallucinations due to known physiological condition, other hallucinations, schizoaffective disorder, and psychotic disorder with delusions due to known physiological condition. Review of the MDS assessment dated [DATE] revealed Resident #08 had severe cognitive impairment. Review of the PASRR Identification Screen dated 08/02/21, signed by Social Service #115, revealed the form lacked documentation of Resident #08's mental health diagnoses. Further review of the medical record revealed no documentation to support the facility received the PASRR Review Results prior to Resident #08 admitting on 07/30/21. 5. Review of the medical record of Resident #10 revealed an admitted [DATE]. Diagnoses included anxiety disorder, major depressive disorder, and bipolar type schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of the PASRR Identification Screen dated 06/28/22 revealed the form lacked documentation of Resident #10's mental health diagnoses. Further review of the medical record revealed no documentation to support the facility received the PASRR Review Results prior to Resident #10 admitting to the facility on [DATE]. Interview on 03/08/23 at 4:13 P.M. with Social Service #115 verified the lack of accuracy of the PASRR Identification Screen forms for Residents #01, #05, #08, #10, and #20. She further confirmed no PASRR review results had been received for Residents #05, #08, #10, and #20 prior to their admission to the facility. Review of the policy titled, Resident Assessment-Coordination with PASRR Program, revised 10/01/22, stated all applicants to the facility would be screened with the PASARR program under Medicaid to ensure the individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on medical record review, staff interview, policy review and review of information from the National Pressure Ulcer Advisory Panel, the facility failed to assess, notify the physician and/or monitor a skin wound when it was reported by a [MEDICAL TREATMENT] center. This resulted in actual harm when the skin wound went untreated, worsened developing into a Stage III pressure ulcer (open sore that extends into the tissue beneath the skin and may expose fat) and required emergency room (ER) intervention. This affected one (#1) of three residents reviewed for pressure ulcers. The facility identified four residents in the last 60 days with skin issues. The facility census was 28. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE], re-admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. to an infection throughout the body), [MEDICAL CONDITION], end stage [MEDICAL CONDITION], gastrostomy (artificial opening into the stomach) tube, dependence on respirator, rectal hemorrhage, ileus (blockage of bowel), [MEDICAL CONDITION] (trach), diabetes mellitus type II, obstructive sleep apnea, [MEDICAL CONDITION], pressure ulcers and [MEDICAL CONDITION]. Review of a 14-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was in a persistent vegetative state, was totally dependent on staff for activities of daily living, always incontinent of bowel and bladder, and was short of breath. The resident was fed through a tube feeding, had no weight loss and no pressure ulcers. He had required the use of oxygen, suctioning, [MEDICAL CONDITION] care and received [MEDICAL TREATMENT]. Review of physician orders [REDACTED]. Review of [MEDICAL TREATMENT] Communication Form dated 10/17/18 revealed the [MEDICAL TREATMENT] center notified the facility the resident had open wounds on the right side of his neck from [MEDICAL CONDITIONS]. [MEDICAL CONDITION] were saturated and filthy. The [MEDICAL TREATMENT] center cleansed and applied gauze sponge underneath to absorb some moisture. The resident did have facial grimacing while the facility cleaned the area. A [MEDICAL TREATMENT] Communication Form dated 10/26/18 revealed the resident now had a pressure area approximately eight centimeters (cm) long by 0.5 cm wide and 0.2 cm deep to the posterior neck under [MEDICAL CONDITION] and had a strong odor. It revealed the resident was sent to the ER for an evaluation per the [MEDICAL TREATMENT] center physician and returned with the pressure ulcer closed with suture glue, [MEDICAL CONDITION] and an order for [REDACTED]. Review of Emergency Medical Services run sheet dated 10/26/18 revealed the resident had been to [MEDICAL TREATMENT] and was sent to the ER for [MEDICAL CONDITION] complications. Once the issue was resolved the resident was returned to the [MEDICAL TREATMENT] center for [MEDICAL TREATMENT] and returned to the extended care facility. Review of Patient Visit information from the hospital dated 10/26/18 revealed Resident #1 was seen at the facility for [MEDICAL CONDITION] care. Instructions were provided to suction regularly, [MEDICAL CONDITION] device regularly and apply padding to the neck to avoid pressure to the neck. The ER note further documented the wound was described as being malodorous, on posterior (back) neck area, was 12 cm in length and required glue to repair the area. Review of a Skin Grid Pressure 3.0 assessment dated [DATE] revealed a new pressure ulcer that was not present on admission. The original noticed date was 10/26/18. The area was on the right side of the neck, described as a cut eight cm long by 0.1 cm wide and no depth. It was staged as a Stage III pressure area due [MEDICAL CONDITION] elastic straps. The area was dark in color and had no odor. The physician was notified. Review of new physician orders [REDACTED]. Review of physician orders [REDACTED]. The area was to be washed before the dressing was applied and the area was to be measured weekly. Review of a Skin Assessment Weekly dated 10/30/18 revealed the resident had an area to the right side of the neck with treatments in place and was documented as a non-pressure area. Interview with the Director of Nursing (DON) on 11/05/18 at 10:15 A.M. revealed she had received a call from the hospital on [DATE] the resident had been sent to them to evaluate an open area on the resident's neck. She stated the hospital told her they thought it was due to the green ties from the trach. She stated she had seen a small area on the right side of his neck from where she had cleaned him and scrubbed him. Interview with the Administrator on 11/05/18 at 4:00 P.M. revealed she had spoken to Resident #1's family and had received permission to transfer the resident to a facility closer to his [MEDICAL TREATMENT] center and arrangements were made. Further interview with the DON on 11/06/18 at 1:00 P.M. verified the nursing staff did not always read the [MEDICAL TREATMENT] communication forms. She verified the [MEDICAL TREATMENT] center notified the facility of an open area on the resident right neck on 10/17/18 on the communication form and there was no follow up, including treatment or notification to the physician or responsible party. She further verified no treatment was initiated until 10/26/18 when the resident was sent to the ER by the [MEDICAL TREATMENT] center for an open wound. She verified on return to the facility on [DATE] the resident's physician was notified but had not documentation the resident's responsible party had been notified of the new open area. Further interview on 11/06/18 at 2:30 P.M. with the Administrator verified the facility had been notified of a new open area to the resident's neck by [MEDICAL CONDITION] area on 10/17/18 and no treatment had been initiated. She further verified the resident was sent to the ER by the [MEDICAL TREATMENT] center on 10/26/18 and the wound had worsened and required being closed with suture glue. She stated the facility should have observed the area during their routine observations. She further verified the facility should have read the [MEDICAL TREATMENT] communication form, assessed the open area, started treatment and notified the resident's physician and responsible party on 10/17/18 when they were notified. The Administrator further verified by the time the facility acted on the information from the [MEDICAL TREATMENT] center on 10/26/18, the area on the neck was then considered a stage III pressure ulcer and required intervention from the ER. Review of facility policy Notification of change policy and procedure dated 01/16/18 revealed the physician and responsible party must be notified timely of any change of condition, falls, new skin areas, elopement, medication errors, new orders by consulting physicians, and other concerns warranted by the [MEDICATION NAME] nurse. Review of information from the NPUAP revealed a Stage III pressure ulcer is defined as full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The NPUAP further indicated to assess pressure points, such areas beneath medical devices and consider placing a thin foam or breathable dressings under medical devices. This deficiency substantiates Complaint Number OH 920.

Based on medical record review, observations, staff interview, resident interview, medical director interview, policy review, review of Google Maps and review of the Weather Underground report, the facility failed to provide adequate supervision to Resident #12 who was cognitively impaired, independently mobile, and assessed to be at risk for elopement and wandering. This resulted in Immediate Jeopardy when one resident (#12) was placed at risk for serious harm when he eloped from the facility, without staff knowledge, on two separate occasions. This affected one (#12) of five residents reviewed who were cognitively impaired, and independently mobile. The facility identified a total of five (#3, #7, #12, #13 and #15) residents who were cognitively impaired, independently mobile, and at risk for elopement. The facility census was 20. On 06/01/16 at 4:08 P.M., the Executive Director (ED) and Director of Nursing (DON) were notified that Immediate Jeopardy began on 05/24/16 at approximately 11:18 P.M. when Resident #12 reported to Licensed Practical Nurse (LPN) #205 he had exited the facility but got scared and returned inside. LPN #205 reported Resident #12 did not have the WanderGuard (device which activates a door alarm when it passes through) device in place at the time of the incident and subsequently LPN #205 applied the WanderGuard; however, Resident #12 was assessed on 01/21/16 as requiring a WanderGuard at all times due to being an elopement risk. The Immediate Jeopardy continued on 05/26/16 at approximately 4:30 P.M. when Resident #12 eloped from the facility again, without staff knowledge, and was found at a local gas station. The gas station was located across town, and Resident #12's path of travel would have crossed eight streets and traveled along a United States (U.S.) Highway. According to a review of Google Maps, the local gas station was located 0.8 miles from the facility and it would take the average person approximately 16 minutes to walk from the facility to the gas station location. On 05/26/16 at approximately 5:00 P.M., Resident #12 was observed by a community member who recognized the resident in the vicinity of the local gas station and, this community member returned the resident back to the facility. The Immediate Jeopardy was removed on 06/02/16 when the facility implemented the following corrective actions: · On 06/01/16 starting at 3:00 P.M., the ED and DON began in-service training regarding the facility's policy and procedure for Elopement including identification of which doors alarm and the increased supervision of residents identified as being at high risk for elopement. All staff were also in-serviced regarding Resident #12's every 15 minute checks. On 06/01/16, all staff education was completed except LPN #202, who was on vacation during the in-service training. · On 06/01/16 at 4:00 P.M., the ED and DON re-assessed Resident #12 and implemented every 15 minute checks to ensure safety from elopement. The DON reviewed and updated Resident #12's care plans to reflect the identified elopement risks. Based on Resident #12's assessment, the DON received an order for [REDACTED].#12 which was scheduled on 06/06/16 with the facility's consultant psychiatrist. · On 06/01/16, the ED and DON updated the resident Sign-Out Sheets to identify resident's whereabouts in the event of a possible elopement. · On 06/01/16, the ED and DON implemented an on-going monitoring tool to review incidents of wandering behaviors, exiting seeking behaviors and elopements. This will be reviewed Monday through Friday at the morning meetings indefinitely. · On 06/02/16, the ED and DON re-assessed all cognitively impaired and independently mobile residents for elopement risk and determined there were no other elopements. · On 06/02/16, the ED and DON recognized a need to update the Elopement policy and procedure and re-educated staff on the revised policy and procedure for Elopement. · On 06/02/16, the ED implemented a tracking log for a twice weekly WanderGuard door alarm check to ensure proper functionality of the Wander Guard system. · On 06/02/16, the ED implemented a placement and functionality check of residents who wear WanderGuard devices. The checks will occur on every shift and will be documented in the treatment administration record on an on-going basis. · On 06/02/16, the surveyor reviewed the medical records of four (#3, #7, #13 and #15) additional residents who were identified by the facility as being cognitively impaired, independently mobile, and at risk for elopement. There were no additional concerns identified. · On 06/02/16 between 9:58 A.M. and 10:30 A.M., interviews were conducted with Housekeeper #206, Dietary Staff #207, State tested Nurse Aide (STNA) #204, STNA #208, and Housekeeper #209. All were knowledgeable regarding the facility's procedures for an elopement. An interview was conducted with LPN #201 who thought the doors lock and are inaccessible when a resident wearing a WanderGuard was near the door. LPN #201 could not recall what specific facility doors are equipped with the WanderGuard alarm system, and LPN #201 did not know what to do in the event of an elopement of a resident without a WanderGuard in use. On 06/02/16 at 10:47 A.M., the DON was informed of LPN #201's interview responses and the DON immediately re-educated LPN #201 on the elopement procedures. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility had to complete in-service training with LPN #202 and they are still in the process of implementing their corrective actions to ensure they are effective and being monitored for on-going compliance. Findings include: Review of Resident #12's medical record revealed the resident was admitted on [DATE] and had a psychiatric hospital re-admission on 05/24/16. [DIAGNOSES REDACTED]. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a three out of 15 on the brief interview for mental status (BIMS) indicating the resident is severely cognitively impaired. Further review of the MDS revealed Resident #12 has delusions, the resident wanders daily and is capable of walking in his room and corridor with staff supervision. Review of Resident #12's medical record revealed an elopement risk assessment dated 10/22/15 which revealed Resident #12 is capable of leaving the facility with no history of elopement; and the resident is pleasant and cooperative. A second elopement risk assessment dated 01/21/16 revealed Resident #12 is physically capable of leaving the facility, wanders, roams or paces, is pleasant and cooperative, and has a WanderGuard on at all times. A wandering risk assessment dated 01/21/16 revealed Resident #12 is disoriented to three spheres (person, place, and time), and exhibits or expresses fear and or anxiety. Further review of the wandering risk assessment revealed Resident #12 has had a recent change in caregiver or staff, is independently mobile, and takes antipsychotics, anti-anxiety or hypnotic medications. Resident #12 is a known wanderer or had a history of [REDACTED].#12 is physically capable of leaving the facility, wanders, roams or paces, and has a history of elopement. Review of Resident #12's care plan initiated a focus area on 03/01/16 identifying the residents risk for elopement/wandering related to unaware of safety needs. The goals included there will be no elopements from the facility and the resident will be able to wander safely within his environment. The interventions listed were created on 03/01/16 including one-to-one and allowing Resident #12 to vent feelings, 15 minute checks and attempt to involve resident in decision making. Additional interventions initiated on 06/01/16 were to redirect the resident during times of restlessness with activities that calm him, music, chores, and supervised outside walks as well as one-to-one talks about his family. Review of the care plan revealed an intervention was created on 06/01/16 which identified the application of a WanderGuard device which was actually initiated on 05/23/16. Review of nurses' progress notes dated 05/05/16 at 7:15 P.M. revealed Resident #12 went outside, followed by staff. When staff reached Resident #12, he was in the field by the facility and was escorted back inside by staff and an assessment was completed. Review of the progress note dated 05/07/16 at 4:06 P.M. revealed Resident #12 was in sight of nursing staff at the time of the incident and every 15 minute checks were initiated. Review of the medical record revealed there was no documentation of every 15 minutes checks being implemented for Resident #12. Review of the initial reentry care plan following a psychiatric hospital stay for Resident #12 dated 05/23/16 revealed a goal of no exit from the facility unassisted, a wander risk assessment would be completed, and to apply an exit alert device, as needed. Under the title of altered behavior the goal was to have fewer episodes of elopement and the interventions were to redirect as needed, maintain calm and relaxed environment, and encourage diversional activities. Review of progress notes dated 05/24/16 at 11:18 P.M. revealed Resident #12 informed LPN #205 he had went outside and got scared, so he came back in. After LPN #205 questioned Resident #12 about leaving the facility, he said he walked out the front door on his own. LPN #205 discovered Resident #12 was not wearing a WanderGuard device at this time so it was subsequently applied to Resident #12. LPN #205 was unaware of why Resident #12's WanderGuard device was not in place. According to a progress note dated 05/27/16 at 10:26 A.M., LPN #205 was made aware by second shift LPN #202 of Resident #12 leaving the facility on his own on Thursday 05/26/16. According to the progress notes there were no exit seeking behaviors noted throughout the night. A nurse's note dated 05/27/16 at 11:20 A.M. revealed Resident #12 had increased anxiety and increased pacing with encroachment to the doors. Resident #12 was also verbalizing a desire to leave the facility. Review of Resident #12's medical record revealed no documentation of the elopement incident occurring on 05/26/16. Further review of Resident #12's medical record revealed no physician notification of the incident. The review also revealed there was no documentation and/or discontinuation of the every 15 minute checks for Resident #12 as described in the 05/07/16 progress note. Interview on 06/01/16 at 10:37 A.M. with the DON and ED confirmed Resident #12's care plan did not reflect the current intervention regarding the use of a WanderGuard device. The ED further stated there have been no elopements in the past three months. Interview on 06/01/16 at 2:15 P.M. with STNA #203 revealed she was on duty on 05/26/16 when Resident #12 was found at the local gas station by the community member. STNA #203 stated the staff heard the alarm going off. STNA #203 stated there were two staff members on duty which included herself and LPN #202. STNA #203 stated the two of them looked for Resident #12 in the building once they discovered the alarm was sounding. STNA #203 stated she recalls the alarm was sounding for approximately two to three minutes at the point when she heard it. STNA #203 stated the incident happened between 4:30 P.M. and 5:00 P.M. or around supper time. STNA #203 stated they also went outside and didn ' t see Resident #12 so they returned to conduct a better search inside the facility. STNA #203 stated at some point, a community member called and informed LPN #202 she was bringing Resident #12 back to the facility from the local gas station. STNA #203 confirmed the local gas station where Resident #12 was found, is across town. STNA #203 confirmed Resident #12 has a history of exit seeking behaviors and the local police department was not notified Resident #12 was missing on 05/26/16. STNA #203 stated when the community member returned Resident #12 to the facility, the resident apparently told the community member he wanted to buy some pop and chips. Interview on 06/01/16 at 4:19 P.M. with the ED revealed she was present in the building when Resident #12 eloped on 05/26/16. The ED stated the alarm went off for quite a while on 05/26/16. At no time did the ED mention joining in the search for Resident #12. The ED further stated when Resident #12 was readmitted from the psychiatric hospital on [DATE], the WanderGuard device was not in place and this was discovered when Resident #12 reported he left the faciity on [DATE]. However, the ED stated when Resident #12 was admitted to the psychiatric hospital on [DATE] she believes he left with the WanderGuard device in place so she's not sure who removed the WanderGuard device. The ED stated when the community member returned Resident #12 to the facility on [DATE], the resident did not have any money or personal belongings and the community member reported he wanted to purchase pop and chips. The ED confirmed the facility did not investigate the incident on 05/26/16 to determine if Resident #12 walked out the doors with someone or if he held the doors' panic release hardware until it released. The ED was interviewed regarding having no elopements in the past three months and she stated the facility considered the incident involving Resident #12 on 05/26/16 as exit seeking behavior and not actually an elopement. Interview on 06/02/16 at 8:25 A.M. with Resident #12 revealed Resident #12 had flights of ideas. Resident #12 talked about Daddy built Mommy's house, 3,000 acres of Daddy's and 400 acres across the road, the big grocery store across the street. Resident #12 did not finish any sentence subjects. Resident #12 stated he grew up a distance from the facility but was unsure of where. Observations were conducted on 06/02/16 at 12:35 P.M. with the ED and the Administrator of the functionality of the facility's WanderGuard system. The observations revealed the facility's exit doors secured with the WanderGuard system will lock upon the approach of a WanderGuard device. The observations further revealed if an exit door is already opened, the alarm will sound until the code is entered to silence it. The WanderGuard device must be within five feet of the sensor to activate the system. During the observations, the ED and Administrator confirmed the facility does not have an elopement kit and an elopement notebook, per the facility's policy, and there is no tracking log in place to check the functionality of the WanderGuard door alarm system. During an interview on 06/02/16 at 3:46 P.M. with Medical Director (MD) #300 revealed he is also Resident #12's physician. MD #300 stated he did not have knowledge of Resident #12's elopement that occurred on 05/26/16. MD #300 did feel Resident #12 was physically capable of walking to the gas station but was unable to verify if Resident #12 was cognitively able to know or could meaningfully know the location of the gas station in order to purchase pop and chips. Interview on 06/02/16 at 3:57 P.M. with LPN #210 revealed on 05/05/16 Resident #12 had exited the building unaccompanied; the staff saw him exit the facility and immediately went out to redirect the resident. LPN #210 stated Resident #12 was returned easily and we watched him closely for the rest of the shift with no further episodes. LPN #210 stated Resident #12 has a history of wandering and exit seeking behavior. According to a review of Google Maps, the local gas station was 0.8 miles from the facility and would take the average person approximately 16 minutes to walk from the facility to the gas station location. Review of the Weather Underground report for May 26, 2016 revealed at 4:53 P.M., the temperature was 80.1 degrees Fahrenheit (F) with a heat index of 82.1 degrees F. The humidity level was 62% and the wind speed was 11.5 miles per hour (mph). The facility policy titled Elopement: Missing Resident Policy & Procedure dated 01/01/16 revealed to report a missing resident to the charge nurse or DON immediately. Staff should search the areas and then report to the Administrator. A Code E and unit name will be announced. The elopement notebook which should contain a current photo of all residents assessed to be at risk for elopement will be used. An elopement kit, kept in a centralized location, should contain flashlights, communication devices and laminated maps of the area highlighting high risk areas such as water, highways and woods, which should be checked first. All searchers are to report in every 15 minutes until found. Document the incident in the medical records and closely observe the resident and notify the family/guardian and the physician. The facility provided a revised copy of the Elopement: Missing Resident Policy and Procedure dated June 02, 2016 to reflect the deletion of the elopement notebooks and the elopement kits. The policy included an addition of the time frame of 15 minute searches before notifying the local police department for assistance. The policy further revealed to notify the physician and to document in the resident's medical record the episode and notifications made. This deficiency substantiates Complaint Number OH 700.