Every finding on record at Community Skilled Healthcare

Based on closed record review, review of an Emergency Medical Services (EMS) Run Report, review of the American Heart Association (AHA) 2025 guidance for adult Cardiopulmonary Resuscitation (CPR), review of the facility CPR policy and interview, the facility failed to promptly and correctly provide basic life support (BLS) including Cardio-Pulmonary Resuscitation (CPR) to Resident #92, (a resident with advance directives for a Full Code status), when the resident was found unresponsive and absent of vital signs. This resulted in Immediate Jeopardy and actual serious life-threatening harm and subsequent death of Resident #92 on 03/07/26 at approximately 9:00 A.M. when Transportation Aide (TA) #873 identified Resident #92 was unresponsive. TA #873 alerted Licensed Practical Nurse (LPN) #915 Resident #92 was not responding/needed help and LPN #915 refused to help stating that's not my resident and told TA #873 to go get Registered Nurse (RN) #815. Instead of providing immediate care, RN #815 stated to TA #873 I'll get to it when I can. TA #873 then utilized the facility overhead paging system to summon assistance. LPN #824 responded from another unit and initiated CPR (chest compressions) after a five to 10 minutes delay; however, at no time were artificial respirations provided to Resident #92. When Emergency Medical Services (EMS) arrived at 9:24 A.M., Resident #92 was absent from pulse/respiration and was transported to the hospital emergency room with unchanged presentation arriving at 9:48 A.M. and declared deceased in the hospital emergency room on [DATE] at 9:50 A.M. This affected one resident (#92) of two residents reviewed for death. The facility census was 83.On 04/09/26 at 3:58 P.M. the Administrator, the [NAME] President of Nursing (VPN) #802, Director of Nursing (DON) #801, and the Assistant Director of Nursing (ADON) #803 were notified Immediate Jeopardy began on 03/07/26 at approximately 9:00 A.M. when facility staff failed to respond to and provide timely and adequate basic life saving measures/CPR to Resident #92 per the resident's advance directive. EMTs arrived and took over CPR and transported the resident to the hospital where he was pronounced deceased on [DATE]. The Immediate Jeopardy was removed on 04/10/26 when the facility implemented the following corrective actions:On 04/09/26 the facility (Administrator, Director of Nursing (DON) #801, and [NAME] President of Nursing (VPN) #802) initiated an internal investigation. As a result of the investigation corrective actions were put into place to ensure resident safety and prevent further risk related to delayed emergency response and CPR. On 04/09/26 at 5:30 P.M. DON #801 and VPN #802 completed a review of all CPR events within the past six (6) months were reviewed. On 04/09/26 a full house audit of 81/81 residents (to include 80 in house residents and one on a leave of absence) code status to include validation of code status, code status order, and signed documents, and advance directive care plans was initiated. All were validated by DON #801, and Assistant Director of Nursing (ADON) #803, to ensure accuracy and accessibility of code status. On 04/09/26 ADON #803 placed laminated signage on all crash carts identifying the location of the automatic external defibrillator (AED). The facility has three (3) crash carts located on unit one, unit three, and unit four. On 04/09/26 VPN #802 developed a Medical Emergency Response Policy addressing timely response and notification of licensed nursing staff during a change of condition or unresponsive episode. On 04/09/26 at 7:15 P.M. a root cause analysis was completed by DON #801, VPN #802, ADON #803 and the Administrator. On 04/09/26 from 7:15 A.M. until 7:32 P.M. an Ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the root cause analysis (RCA) and the abatement plan. The meeting included DON #801, VPN #802, ADON #803, the Administrator, and the Medial Director via phone. The Ad Hoc QAPI reviewed the abatement plan to remove immediacy of jeopardy to include an implementation of a new policy to specify unlicensed staff role in alerting licensed personnel and timely response, review of prior CPR events in the past six months, education on high quality and CPR response with all licensed nursing staff, and implementation of mock code drills, The medical director was informed and updated on the facility plan. The QAPI committee accepted the plan and would continue oversight monitoring Beginning on 04/09/26 at 4:30 P.M. and continuing through 04/10/26 at 3:20 P.M. DON #801 provided education (verbally in person) to licensed nursing staff (20/21 LPNs, 5/6 RNs, 2/2 nurse practitioners), including the nurses who were involved in the CPR care on 03/07/2. Education topics included immediate CPR response, Code Blue activation, high-quality CPR (30:2 ratio), Ambu bag use and the new Medical Emergency Response policy. 1/21 LPNs and 1/6 RNs were educated verbally via phone and would sign in person prior to their next working shift. Beginning on 04/09/26 at 4:30 P.M. and continuing through 04/10/25 at 3:20 P.M. ADON #803, LPN #805 LPN #806 and Physical Therapy Assistant (PTA) #807 provided (verbally in person) education to non-licensed staff (29/37 Certified Nursing Assistants), 2/2 transportation Aides, 1/3 activities staff, 7/7 administrative staff, 13/13 food service staff, 15/15 environmental/maintenance staff, 4/7 therapy staff) on recognition of an unresponsive resident and the requirement to immediately notify nursing staff, clearly stating this is an emergency and the resident's location , to include the new Medical Emergency Response policy. 8/37 CNAs, 2/3 activity staff, 3/7 therapy staff were educated verbally via phone and would sign in-person prior to their next working shift. Beginning on 04/09/26 the facility implemented a plan for general orientation to include education on the facility Medical Emergency Response Policy and CPR policy. All newly hired staff would be educated by DON #801 or ADON #803 prior to assuming independent resident care responsibilities. On 04/10/26 at 2:00 P.M. Human Resources (HR) #804 completed an audit of licensed nurses (21 LPNs, six RNs, and two NPs) for current CPR certifications. Beginning on 04/13/26 the facility implemented a plan to host CPR mock code drills for licensed nurses led by certified CPR instructors Respiratory Therapist (RT) #808 and RT #809. These drills would be conducted on first, second, and third shift on 04/13/26 and on first and second shift on 04/14/26. Any licensed nursing staff who had not participated in a mock code drill by 04/14/26, would complete a drill with DON #801, RT #809 or ADON #803 prior to their next scheduled shift. The facility implemented a plan for the DON/designee to conduct mock code drills twice weekly for four (4) weeks, then monthly for two (2) months with emphasis on timely response and high-quality CPR. The facility implemented a plan for the DON/designee to complete an audit of all crash carts to validate inventory and CPR readiness; additionally, an audit would be conducted on all new admission/readmission to validate code status order, accuracy, and care plan weekly for four weeks, then monthly for two months. The facility implemented a plan for all CPR/emergency events to require DON lead investigations, reviewed by Regional VPN #810 evaluating timeliness of response and adherence to CPR standards. This review would be expected to be completed within 24 to 48 hours following any CPR event. All findings would be reviewed by the QAPI Committee. The QAPI committee would meet monthly and as needed. Although the Immediate Jeopardy was removed on 04/10/26 the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Review of the closed medical record for Resident #92 revealed an admission date of 02/07/26 with diagnoses including atrial fibrillation, type two diabetes, congestive heart failure (CHF), end stage renal disease (ESRD), anxiety, dementia, left kidney cancer, anal fistula, hypertension and dependency on renal dialysis. Resident #92 was discharged from the facility on 03/07/26 and expired at the hospital on [DATE].Review of Resident #92's physician order dated 02/08/26 revealed the resident was a full code (all life-saving measures/interventions including but not limited to cardiopulmonary resuscitation (CPR)). The resident also had a physician order for oxygen (O2) at two liters per minute via nasal cannula as needed for shortness of breath and an order for (hemo)dialysis treatments at 10:15 A.M. at an outside dialysis center every Tuesday, Thursday, Saturday.Review of the care plan initiated 02/13/26 revealed Resident #92 was at risk for ineffective breathing related to diagnoses of CHF and ESRD. Interventions included check breath sounds and monitor/document for labored breathing, monitor/document for the use of accessory muscles while breathing, oxygen therapy as needed, vital signs as needed, give cardiac medications as ordered and monitor lab work.Review of Resident #92's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had slight cognitive impairment, was independent with eating, dependent on staff for toileting, required partial to moderate assistance from staff with showers and substantial to maximum staff assistance with bed mobility. Resident #92 used intermittent oxygen therapy per the assessment.Review of Emergency Medical Services (EMS) (Run Number 26-22237) report, dated 03/07/26, revealed a call was received (on 03/07/26) at 9:18 A.M. with arrival to the facility at 9:24 A.M. Resident #92 was found unresponsive with facility staff performing CPR. Staff reported witnessing resident arrest. Staff instructed to pause. Resident was pulseless and apneic (not breathing). The resident was in pulseless electrical activity (PEA) and administered three doses of epinephrine (a drug administered to help restart effective circulation and improve chances of getting a pulse back) and given calcium. The resident was intubated and transport initiated. A fourth and fifth dose of epinephrine were given with no change in presentation. Care was transferred to the hospital staff at the emergency room (ER). Arrival at ER 9:48 P.M.Review of a facility progress note dated 03/07/26 at 9:55 A.M. and authored by Registered Nurse (RN) #815 revealed called to resident room at 09:14 per transportation aide to check resident. Resident was lying in bed on back unresponsive to verbal, tactile stimuli or to sternal rub. Resident pupils minimally responsive. Blood pressure (BP) 83/38 (hypotensive), heart rate (HR) 27 (bradycardic) with no respirations noted; unable to obtain pulse ox (oxygen saturation level). Skin warm and clammy. No palpable auscultated pulse. Bed flattened, CPR initiated at 09:15. Non-rebreather mask applied at 15 L (liters) per portable O2 (oxygen) tank. At 09:17 bed board applied CPR continue. EMS called and informed that resident in full arrest. AED called for. At 09:18 AED applied shock advised then prompts followed to continue CPR. At 09:20 EMS on site, status report given. IO (intraosseous line to deliver fluids) placed left knee per ambulance personnel. Epi and calcium given per squad who also placed their AED. 09:23 CPR continues. 09:25.Review of a facility progress note dated 03/07/26 at 10:11 A.M. authored by RN #815 revealed 09:25 continued EMS states that there is a disorganized rhythm on AED with HR of 94 but no palpable pulse. CPR continued. At 09:30 squad left facility. At 09:33 report called to hospital. At 09:36 brother notified of change in status and to call facility. At 10:00 phone call received from hospital ER stating the resident expired at 09:50 A.M.Review of a late entry progress note dated 03/07/26 at 11:27 A.M. authored by RN #815 revealed resident last known well time was when aide delivered breakfast tray at 8:45 A.M. Resident was sleeping and aide told him his tray was at the bedside and he mumbled oh, ok.An interview on 04/08/26 at 1:44 P.M. with Registered Nurse (RN) #815 revealed she was the assigned nurse for Resident #92 on 03/07/26. RN #815 stated Transportation Aide (TA) #873 was seeing if Resident #92 was going to dialysis on 03/07/26 in the morning and saw something was wrong with him. RN #815 then stated TA #873 came to her and said she needed to go see Resident #92 because there was something wrong with him. RN #815 stated she told TA #873 I'll be there when I can and proceeded to assist another resident she was working with. RN #815 stated TA #873 then stated, I don't think it can wait, and again RN #815 stated she told her OK, I'll be there when I can. RN #815 stated there was a three-to-four-minute delay from the time she was told there was an issue with Resident #92 to when she went to his room. RN #815 stated when she entered Resident #92's room he needed CPR, so she started compressions. RN #815 stated she could not remember who else was in the room and could not remember who called 911. An interview on 04/08/26 at 3:00 P.M. with ADON #803 revealed LPN #915 was working at the time of the incident. LPN #915 had stated that's not my resident, to Transportation Aide (TA) #873 when TA #873 first approached LPN #915 about Resident #92 needing help the morning of 03/07/26. ADON #803 confirmed LPN #915 did not help or assess the resident. ADON #803 revealed LPN #915 was terminated due to this incident/situation.Review of LPN #915's employee file revealed a hire date of 02/11/26 and a termination date of 03/19/26 for poor performance. There were no specific details in the termination documentation to illustrate the termination was related to LPN #915 refusing to provide nursing intervention to Resident #92 during a change of condition on 03/07/26.An interview on 04/08/26 at 3:10 P.M. with LPN #824 revealed she was working on the secured unit the morning of 03/07/26 and overheard a page requesting help in Resident #92's room because there was something wrong with him and no other nurse would go and assess him. LPN #824 stated when she entered the room no one else was in there and the resident was absent of vital signs. LPN #824 stated she began chest compression and yelled for help. LPN #824 stated RN #815 then entered the room with the crash cart and was attempting to insert an intravenous (IV) line. At this time no one was supporting the resident's respiration, as no one was supplying breaths via mouth or by Ambu bag. When asked if anyone was giving Resident #92 oxygen, LPN #824 stated no she did not believe anyone did. LPN #824 stated an AED was applied and a shock was advised and given and then EMTs arrived and took over the resident's care. LPN #824 stated Resident #92 was transported to the emergency room where he then expired.An interview on 04/09/26 at 10:00 A.M. with TA #873 revealed she was working on 03/07/26 and had gone into Resident #92's room and found the resident in distress. TA #873 revealed she immediately went and got LPN #915; however, LPN #915 would not come help Resident #92 stating LPN #915 said that's not my resident. LPN #915 also did not come in to help with CPR for Resident #92. TA #873 revealed she then went to RN #815 to try to get help for the resident and the RN stated, I'll get to it when I can. TA #873 told RN #815 it cannot wait, Resident #92 was in distress and again RN #815 stated I'll be there when I can. TA #873 stated that morning on 03/07/26 she had gone into the resident's room at approximately 9:00 A.M. to see if he was ready for dialysis and the resident was still in bed, he did not respond to her and just took a deep breath in and let it out and then was absent of respiratory effort. She stated she went over to the resident and tapped his leg and shouted his name with no response. She then went to the first nurse she saw who was LPN #915 who stated to her that is not my resident and told her to go get RN #815. She then went to RN #815 who also did not come to the resident's room. TA #873 stated she made an announcement over the PA system to get someone to come in and help. TA #873 stated LPN #824 came down from the secured unit to assist. TA #873 stated she was waiting outside Resident #92's room for approximately five to 10 minutes before anyone came to help Resident #92. RN #815 entered the room with the pulse oximeter and stated there was no heart rate and then said she needed to find out if the resident was full code or a Do Not Resuscitate (DNR). LPN #824 had entered and started chest compressions, but at no point did anyone provide artificial breaths to the resident with the use of an Ambu bag. TA #873 stated she was the one who called 911 and when they arrived, they stated to provide the resident with artificial respirations and took over CPR and transported the resident to the hospital.An interview on 04/09/26 at 10:48 A.M. with RN #815 verified no artificial respirations were provided to Resident #92 even though he was not breathing. She confirmed there was an Ambu bag available on the side of the crash cart. An interview on 04/09/26 at 11:15 A.M. with CNA #866 revealed on 03/07/26 she had taken Resident #92's breakfast tray to him between 8:15 A.M. and 8:30 A.M. and he was still in bed. CNA #866 revealed the resident replied Oh Ok when told his breakfast tray was there. CNA #866 stated the resident's breakfast tray remained untouched.An interview conducted on 04/09/26 at 1:30 P.M. with DON #801 revealed the facility did not do an internal investigation related to the CPR performed for Resident #92 at the time of the incident. The DON revealed it wasn't until the state surveyors started to question the quality and timeliness of the CPR provided during the annual survey that the facility initiated an investigation.An interview on 04/09/26 at 1:52 P.M. with the Administrator revealed Resident #92 and one other resident (Resident #98) had required CPR in the past 6 months. The Administrator confirmed there had been no investigation completed into the incident and subsequent death of Resident #92, and Resident #98 had also not been reviewed until after the concerns were brought forth by the state surveyors for Resident #92 during the annual survey.An interview on 04/09/26 at 3:00 P.M. with LPN #833 revealed (on 03/07/26) she entered Resident #92's room and jumped in to help with chest compressions. She was alerted to a situation going on by over hearing TA #873 yelling for RN #815 and went down to see what was going on. She also stated she called 911 as well and instructed the CNAs to go get the AED. She stated she was not aware of LPN #915 initially refusing to go and help and of the statement made by him that that was not his resident. She also confirmed at no time were artificial respirations given to the resident while she was in the room.Review of the American Heart Association (AHA) 2025 guidance for adult CPR included the following: Check for breathing, if the person is not breathing or only gasping, begin CPR; Chest compressions included to push down hard and fast at a rate of 100 to 120 compressions per minute; After every 30 compressions, give two rescue breaths; and make sure the person is on a firm surface. In 2008, after the publication of several studies looking at the rates of bystander CPR and public attitudes toward it, the AHA updated their guidance and decided to take out rescue breathing (mouth to mouth) for untrained or lay responders as a way to encourage and focus on hands only CPR. This updated guidance did not apply to trained healthcare professionals. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR) last revised 10/25/25 revealed it was the facility policy to adhere to residents' rights to formulate advanced directives. In accordance with these rights, this facility would implement guidelines regarding cardiopulmonary resuscitation (CPR).The facility would follow current American Heart Association (AHA) guidelines regarding CPR.If a resident experienced a cardiac arrest, facility staff would provide basic life support, including CPR, prior to the arrival of emergency medical services and:In accordance with the resident's advanced directives, [NAME] the absence of advanced directives or a Do Not Resuscitate order: andIf the resident does not show obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition).CPR certified staff would be available at all times.Staff would maintain current CPR certification for healthcare providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting I accordance with accepted national standards.This deficiency represents noncompliance investigated under Complaint Numbers 2977495.

Based on record review and interview, the facility failed to have a current transfer agreement with an area hospital. This had the potential to affect all residents residing in the facility. The facility census was 83. Findings include: Review of the facility document titled Transfer Agreement, revealed the transfer agreement was by and between Community Skilled Healthcare Center located at 1320 Mahoning Ave. N.W. [NAME], Ohio 44483 and Mercy Health Youngstown LLC doing business as Saint [NAME] Hospital located at 667 [NAME], [NAME], Ohio 44482. The document further revealed the agreement shall take effect on the date signed by both parties and continue for two years unless terminated by either party within 30 days written notice to the other party. The document was signed by Community Skilled Healthcare Center on 06/01/17. The document was signed by Mercy Health Youngstown LLC doing business as Saint [NAME] hospital on [DATE].An interview on 04/13/26 at 4:15 P.M. with the Administrator verified the signed date on the transfer agreement as finalized on 06/13/17. The Administrator stated he did not realize there was a limitation of two years of effect specified within the transfer agreement. The Administrator confirmed the transfer agreement had not been renewed with the hospital.

Based on record review and interview, the facility failed to thoroughly conduct a facility-wide assessment with active involvement of all required participants to determine what resources are necessary to care for the residents competently during day-to-day operations. This had the potential to affect all residents residing in the facility. The facility census was 83.Findings include: A review of the document titled Community Skilled Facility Assessment with a completion date of 02/15/26 and a revision date of 04/13/26 revealed the persons involved in making the assessment were the Administrator, the Director of Nursing and the Medical Director. There was no evidence a member of the governing body, or representatives of the direct care staff also participated in developing the assessment. The document indicated the facility provided care and services to individuals with certain medical and cognitive disabilities. The facility utilized information generated by the minimum data set assessment to determine the care required by the resident population. The document failed to define and address the on-site memory care unit. Further review of the document staffing plan revealed the facility staffing was based on resident population and acuity. The staffing plan did not contain information by unit. In particular, the staffing plan did not address the staffing needed on the memory care unit. Under the area of physical environment, the document failed to address and define the locked memory care unit. Under the area of services and care offered based on resident needs the facility did not ensure and define the locked memory care unit. The assessment also did not address the presence of an activity department. The assessment did not address the needs for specialized activities in the memory care unit.On 04/14/26 at 11:40 A.M. an interview with Regional [NAME] President of Nursing (RVPN) #810 revealed the original facility assessment given to surveyors was under review and revision. RVPN #810 stated it was the responsibility of the Administrator to ensure the accuracy of the facility assessment, but the document was under review and needed revision.On 04/14/26 at 3:00 P.M. an interview with RVPN #810 and [NAME] President of Nursing (VPN) #802 verified the facility assessment participants and that the assessment did not address staffing per unit. Both stated the staffing pattern within the assessment was based on a 24-hour period. Both acknowledged there was no staffing to directly address the memory care unit as the staffing pattern should be based on resident acuity as well. RVPN #810 and VPN #802 further verified the facility assessment did not address the presence or definition of the memory care unit. VPN #802 verified the facility assessment did not address the activity department as an additional service provided to the residents of the facility.

Based on observation, record review, job description review and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all residents who resided in the facility. The facility census was 83.Findings include:Review of the facility job description for Nursing Home Administrator revealed the Administrator signed the job description [DATE]. The document stated the nursing home administrator was responsible for the overall management, operation, and quality of care within a long-term care facility. This rule ensures compliance with all federal, state, and local regulations for maintaining a safe, supportive, and high-quality environment for residents, staff, and visitors. The administrator oversees clinical, financial, and operational functions and lead staff to deliver compassionate and efficient care. One of the key responsibilities listed was overseeing daily operations of the nursing home, including clinical services, staffing, and facility management. Further key responsibilities were stated as the licensed nursing home administrator will hire, train, and supervise and evaluate department heads and staff.Review of the facility job description for Director of Nursing revealed the director of nursing (DON) signed the job description on [DATE]. The document revealed that the director of nursing was responsible for the overall leadership, management, and direction of the nursing department within a nursing home or long-term care facility. This rule ensures the delivery of high-quality resident care in compliance with all regulatory standards while promoting a culture of compassion, safety, and clinical excellence. The director of nursing supervises nursing staff, coordinates care services, and collaborates with interdisciplinary teams to meet residents' medical and personal needs.Review of the Job Description of Activity Director revealed it was signed by Activity Director (AD) #876 on [DATE]. The document stated the activity director was a department head directly responsible for the planning, coordinating, supervising, and implementing a meaningful and ongoing activity program that fulfills the physical, social, mental, spiritual, and psychosocial well-being of all residents who choose to participate in a group setting, individually, or on a one-on-one basis. The program shall be in compliance with company policy, as well as with state and federal regulations. The activity director reports directly to the administrator. Professional qualifications included: successfully completed having at least one year activity experience in long term care, activity director certification (ADC) or working on process, MEPAP 1 (Modular Education Program for Activity Professionals 1), effective interpersonal and communication skills, and cardio pulmonary resuscitation preferred, but not required upon hire. Personal qualifications included must be dependable, flexible with work hours including evenings, holidays, and weekends, and possess a desire to learn and share. Essential functions included to keep the activity program in total compliance with all federal, state, and local laws and regulation and providing information and interacts with the survey team during the annual survey. Other essential functions within the job description included to supervise and delegate activity staff, participate in interdisciplinary team meetings, follow facility policy and procedures, maintain and promote all resident rights, train new personnel, and performs any related duties as specified by the administrator. Specific functions of the job were listed as planned outings in the community, inform, invite, and transport residents to and from activity area as needed, and assist resident with resident council meetings.During the annual and complaint survey, observations, record reviews and interviews resulted in concerns related to the overall operation of the facility including but not limited to resident council, residents rights conveyance, grievance processes, activities dedicated to the needs of all residents, qualifications of the activities director, quality of care, transfer agreements, a complete and thorough facility assessment to address all areas of the facility, and staff training. The facility failed to provide evidence administrative staff, including the Administrator, the DON and AD #876 had effective systems in place to timely identify and correct quality, care and other concerns as follows:A. The facility did not ensure reasonable steps were taken to ensure residents were assisted by a designated staff member for conducting resident council meetings, and residents were informed in advance of resident council meetings. Record reviews of the available Activity Calanders dated for 2025 and 2026 revealed resident council meetings were not advertised on the calendars. An interview on [DATE] at 10:40 A.M. with the Administrator revealed there were no resident council meetings held in February of 2026 and March of 2026 due to lack of a president for the meetings. The Administrator verified he had resident council meeting minutes for [DATE] only and handed the surveyor meeting minutes dated [DATE] that indicated five residents attended the meeting and staff attending included the Activity Director and the Director of Nursing. There was no future meeting date on the minutes. On [DATE] at 10:30 A.M. a resident council meeting was held with surveyors as part of the annual survey. Residents #15, #38 and #11 were in attendance. Resident #11 stated there had not been resident council meetings in February and March of this year due to no president. Resident #11 further stated, We were supposed to have one last week but, it was canceled. Resident #11 stated she was informed it was canceled, as there was no one to run the meeting. (see F565).B.The facility did not ensure residents were informed of their rights on an ongoing basis, and did not ensure all residents were informed on how to file a complaint with the state agency and the grievance filing process. Review of the resident council minutes dated [DATE] revealed there was no information presented to the council on resident rights. On [DATE] at 10:40 A.M. an interview with the Administrator revealed there were no Resident Council meetings held in February of 2026 and March of 2026 due to lack of a president for the meetings. The Administrator handed the surveyor one month of council meeting minutes dated [DATE]. On [DATE] at 10:30 A.M. a Resident Council meeting was conducted with Residents #11, #15 and #38. All stated resident rights were not reviewed at resident council meetings. All stated they had no knowledge of a grievance committee. They also stated they were unaware of how to file a grievance, and no information was shared or discussed on how to file a complaint with the state agency. All stated they did not know where to find this information in the facility (see F572, F574, F585).C.The facility did not ensure licensed nursing staff promptly and correctly provided basic life support (BLS) including Cardio-Pulmonary Resuscitation (CPR) resulting in Immediate Jeopardy and actual serious life-threatening harm and subsequent death of Resident #92 on [DATE] at approximately 9:00 A.M. when Transportation Aide (TA) #873 identified Resident #92 was unresponsive. TA #873 alerted Licensed Practical Nurse (LPN) #915 Resident #92 was not responding/needed help and LPN #915 refused to help stating that's not my resident and told TA #873 to go get Registered Nurse (RN) #815. Instead of providing immediate care, RN #815 stated to TA #873 I'll get to it when I can. TA #873 then utilized the facility overhead paging system to summon assistance. LPN #824 responded from another unit and initiated CPR (chest compressions) after a five to 10 minutes delay; however, at no time were artificial respirations provided to Resident #92. When Emergency Medical Services (EMS) arrived at 9:24 A.M., Resident #92 was absent from pulse/respiration and was transported to the hospital emergency room with unchanged presentation arriving at 9:48 A.M. and declared deceased in the hospital emergency room on [DATE] at 9:50 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented corrective actions. Although the Immediate Jeopardy was removed on [DATE] the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. (see F678).D. The facility did not ensure residents received a program of therapeutic activities and one-to-one activities for their highest practicable well-being and did not ensure a qualified activity professional held the position of activity director. Review of the facility document titled Job Description of Activity Director revealed it was signed by AD #876 on [DATE] and witnessed by Human Resources (HR). The position reported directly to the Administrator. The professional qualifications included successfully completed the MEPAP 1 (a foundational accredited course designed to qualify participants for the Activity Professional Certified designation through the National Certification Council for Activity Professionals), ADC (activity director certified) or working on progress, and has at least one year of activity experience in long-term care. Review of the personnel file for Activity Director (AD) #876 revealed there was no evidence in the personnel file of AD #876 completing the professional qualifications required for the position of Activity Director as specified in the job description. Observation was conducted on [DATE] between 5:50 P.M. to 6:20 P.M. on the secured memory care unit of the facility. Eight residents were observed lying in their beds. Five residents' rooms were noted with their doors closed so they were not disturbed during the observation period. There were 11 residents sitting in the dining room area not engaged in therapeutic visual, auditory, tactile or other sensory activities to occupy these residents. The observation further revealed that residents in the dining room were becoming increasingly restless and difficult to redirect while aides and nurses were tending to other residents' toileting needs after dinner. An interview with Licensed Practical Nurse (LPN) 807 during this observation revealed structured activities rarely happen on the unit especially at night after dinner. LPN #807 was unable to recall the last time an activity occurred on the memory care unit after dinner and stated there is no activity programming in general for the unit and she does not know why. An observation on [DATE] at 9:50 A.M. on the memory care unit revealed no structured, therapeutic activities were taking place on the memory care unit, and there were six residents sitting in the common area in front of a television.On [DATE] at 10:00 A.M. an interview with Registered Nurse (RN) #871 revealed there was no dedicated activity calendar for the dementia unit. RN #871 stated it was up to the nursing staff on the unit to do things for the residents, so the residents were going to have a movie at 3:00 P.M. that afternoon and she was the one who planned it and purchased the snacks for the activity. RN #871 further stated planned activities for the memory care unit are rare.On [DATE] at 10:45 A.M. an interview with AD #876 revealed she had been at the facility working for seven years in both housekeeping and activities. AD #876 stated she had started as activity director approximately [DATE]. AD #876 stated she received her activity certification in March of 2026 but did not have proof of the certification to show the surveyor. AD #876 stated she was never trained for the position as the activity director because the former activity director told her she was not going to show her anything. AD #876 also stated one-to-one visits were scheduled on the activity calendar at 6:00 P.M. and activity staff were scheduled to leave at 4:00 P.M. AD #876 stated on [DATE], for example, the one-to-one activity did not get done because staff left at 4:00 P.M. On [DATE] at 10:10 A.M. a follow up interview with AD #876 revealed she started her position as the AD in [DATE]. AD #876 stated she did not keep a record of activity calendars for the memory care unit and confirmed she had none to show from [DATE] through [DATE] of what activities were planned for the residents during that period on the memory care unit. On [DATE] at 11:00 A.M. an interview with AD #876 confirmed she signed the job description for the Activity Director position on [DATE]. AD #876 stated she was never trained for the position of Activity Director and stated she had no idea what was required of the position. On [DATE] at 9:50 A.M. an interview with Activity Assistant (AA) #878 revealed there were no dedicated activities for the memory care unit recently. AA #878 stated he felt it had been approximately two months since there were dedicated activities for the memory care unit. An observation of the memory care unit at the time of the interview revealed one resident (Resident #8) in the common area in a wheelchair with his head down on the table, two residents dozing in recliners in the common area, and two female residents coloring on coloring pages.On [DATE] at 3:20 P.M. an interview with Human Resource Director (HRD) #804 verified the facility had no evidence AD #876 had successfully completed the required professional certifications to hold the position of activity director and verified the absence of certification in the personnel file for AD #876. HRD #804 further stated she had been asking for the certification from AD #876 for over a month. An interview on [DATE] at 2:07 PM with AA #879 revealed the employee who was responsible for completing all one-on-one visits was no longer employed at the facility and had no knowledge if one-on-ones were being completed (see F679, F680). E. The facility did not ensure a current transfer agreement with a local hospital. Review of the facility document titled Transfer Agreement, revealed the transfer agreement was by and between Community Skilled Healthcare Center located at 1320 Mahoning Ave. N.W. [NAME], Ohio 44483 and Mercy Health Youngstown LLC doing business as Saint [NAME] Hospital located at 667 [NAME], [NAME], Ohio 44482. The document further revealed the agreement shall take effect on the date signed by both parties and continue for two years unless terminated by either party within 30 days written notice to the other party. The document was signed by Community Skilled Healthcare Center on [DATE]. The document was signed by Mercy Health Youngstown LLC doing business as Saint [NAME] hospital on [DATE].An interview on [DATE] at 4:15 P.M. with the Administrator verified the signed date on the transfer agreement as finalized on [DATE]. The Administrator stated he did not realize there was a limitation of two years of effect specified within the transfer agreement. The Administrator confirmed the transfer agreement had not been renewed with the hospital (see F843).F. The facility failed to thoroughly conduct a facility-wide assessment with active involvement of all required participants to determine what resources are necessary to care for the residents competently during day-to-day operations. A review of the document titled Community Skilled Facility Assessment with a completion date of [DATE] and a revision date of [DATE] revealed the persons involved in making the assessment were the Administrator, the Director of Nursing and the Medical Director. There was no evidence a member of the governing body, or representatives of the direct care staff also participated in developing the assessment. The document indicated the facility provided care and services to individuals with certain medical and cognitive disabilities. The facility utilized information generated by the minimum data set assessment to determine the care required by the resident population. The document failed to define and address the on-site memory care unit. Further review of the document staffing plan revealed the facility staffing was based on resident population and acuity. The staffing plan did not contain information by unit. In particular, the staffing plan did not address the staffing needed on the memory care unit. Under the area of physical environment, the document failed to address and define the locked memory care unit. Under the area of services and care offered based on resident needs the facility did not ensure and define the locked memory care unit. The assessment also did not address the presence of an activity department. The assessment did not address the needs for specialized activities in the memory care unit.On [DATE] at 3:00 P.M. an interview with RVPN #810 and [NAME] President of Nursing (VPN) #802 verified the facility assessment participants and that the assessment did not address staffing per unit. Both stated the staffing pattern within the assessment was based on a 24-hour period. Both acknowledged there was no staffing to directly address the memory care unit as the staffing pattern should be based on resident acuity as well. RVPN #810 and VPN #802 further verified the facility assessment did not address the presence or definition of the memory care unit. VPN #802 verified the facility assessment did not address the activity department as an additional service provided to the residents of the facility (see F838).G.The facility did not ensure direct care staff had specialized training to work on the memory care unit. Review of personnel files for Certified Nursing Assistants #844, #845, #846 and #860 who were hired between [DATE] to [DATE] had no evidence of specialized training for the memory care unit. An interview on [DATE] at 3:20 P.M. with Human Resource Director (HRD) #804 verified there was no documented evidence of training for the memory care unit for CNAs #844, #845, #846, and #860 within their personnel files. HRD #804 stated the facility did not conduct any specialized training for the memory care unit.On [DATE] between 12:14 P.M. and 12:21 P.M. interviews with CNAs #841, #855, and #866 revealed they had no specialized training for memory care unit (see F949).

Based on review of records and interviews, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all residents residing in the facility. The facility census was 83. Findings include:Review of the facility document titled Job Description of Activity Director revealed it was signed by AD #876 on 04/21/25 and witnessed by Human Resources (HR). The position reported directly to the Administrator. The professional qualifications included successfully completed the MEPAP 1 (a foundational accredited course designed to qualify participants for the Activity Professional Certified designation through the National Certification Council for Activity Professionals), ADC (activity director certified) or working on progress, and has at least one year of activity experience in long-term care. Review of the personnel file for Activity Director (AD) #876 revealed a date of hire as 09/09/2020 for the position of housekeeping. The file also contained a letter of resignation dated 08/23/21 from the position of activities. There were no job descriptions or payroll status changes in the record to indicate when AD #876 transferred to activities between 09/09/2020 to 08/23/21 or what department the employee may have changed to after 08/23/21. There was no evidence in the personnel file of AD #876 completing the professional qualifications required for the position of Activity Director as specified in the job description. On 04/08/26 at 10:45 A.M. an interview with AD #876 revealed she had been at the facility working for seven years in both housekeeping and activities. AD #876 stated she had started as activity director approximately 03/19/25. AD #876 stated she received her activity certification in March of 2026 but did not have proof of the certification to show the surveyor. AD #876 stated she was never trained for the position as the activity director because the former activity director told her she was not going to show her anything. On 04/09/26 at 11:00 A.M. a follow-up interview with AD #876 confirmed she signed the job description for the Activity Director position on 04/21/25. AD #876 stated she was never trained for the position of Activity Director and stated she had no idea what was required of the position. On 04/09/26 at 12:30 P.M. interview with the Administrator revealed he was unaware AD #876 worked in housekeeping prior to being the activity director. The Administrator stated AD #876 had approached him about the position, so the Administrator asked around about her to other staff then promoted her to Activity Director.On 04/09/26 at 1:38 P.M. interview with Human Resources Director (HRD) #804 revealed she could not verify the dates of when AD #876 went from housekeeping to the activity department between 09/09/2020 and 08/23/21 because there were no payroll changes or position changes in her employee file. HRD #804 stated she believed AD #804 went to housekeeping on 10/19/21 but could not verify the date with documentation. On 04/13/26 at 3:20 P.M. an interview with Human Resource Director (HRD) #804 verified the facility had no evidence AD #876 had successfully completed the required professional certifications to hold the position of activity director and verified the absence of certification in the personnel file for AD #876. HRD #804 further stated she had been asking for the certification from AD #876 for over a month.

Based on interview, record review and facility policy review, the facility failed to ensure all residents were informed on the grievance filing process. This had the potential to affect all 83 residents residing in the facility. The facility census was 83. Findings include:Record review of the facility document titled Grievance Committee Handbook, undated, revealed three residents, a fourth person (status unidentified) and two staff comprised the grievance committee. A note indicated a representative from the Ombudsman program will also be invited. This handbook was located on the bulletin board outside of the activity room. The handbook indicated in the event a grievance was filed, the above members would be contacted by the licensed social worker for a grievance meeting.Review of the resident council minutes dated 01/28/26 revealed there was no information presented to the council on how to file a grievance. Review of the facility document titled Grievance Committee Roster, with a review date of April 2026, revealed the grievance committee membership consisted of the Administrator, the Director of Nursing, Social Service #883, Infection Preventionist #803, Food Service Director #892 and Business Office Manager #881. There were no residents listed as committee members. An interview on 04/08/26 at 3:00 P.M. with the Administrator verified the updated grievance committee roster lacked inclusion of resident committee members on the document. An interview on 04/14/26 at 10:30 A.M. with Residents #11, #15 and #38 as part of the annual survey resident council meeting with the state surveyor revealed Resident #11, Resident #15 and Resident #38 all stated they had no knowledge of a grievance committee, and all were unaware of how to file a grievance. Resident #11 stated there had been no resident council meetings in February or March 2026 and the grievance process was not discussed at resident council when meetings were held. An interview on 04/14/26 at 11:00 A.M. with the Administrator revealed he had no knowledge of the grievance committee handbook that was hanging outside of the activity room. The administrator further stated the information in the grievance committee handbook was outdated.Review of the facility policy titled Resident and Family Grievances dated 01/01/25 revealed it was the policy of the facility to support each resident's and family members' right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. The policy further stated notices of residence rights regarding grievances will be posted in prominent locations throughout the facility. Finally, the policy stated information on how to file a grievance or complaint will be available to the resident. Information may include but is not limited to the contact information of the grievance official with whom the grievance can be filed, including his or her name, business address, and business phone number. The contact information of independent entities with whom grievances may be filed that is pertinent including the state agency, quality improvement organization, state survey agency, and state long term care ombudsman program or protection and advocacy system.

Based on record review and staff and resident interviews, the facility failed to inform the residents of their right to file a complaint with the State survey and certification agency. This had the potential to affect all 83 Residents in the facility.Findings include:On 04/08/26 at 10:40 A.M. an interview with the Administrator revealed there were no Resident Council meetings held in February of 2026 and March of 2026 due to lack of a president for the meetings. The Administrator handed the surveyor one month of council meeting minutes dated 01/28/26. The interview with the Administrator further revealed there was no evidence that Residents' Rights to file a complaint with the State survey and certification agency were discussed at the January 2026 Resident Council Meeting. Completion of the Resident Council portion of the annual survey on 04/13/26 between 10:30 A.M. and 10:52 A.M. with Residents #11, #15 and #38 revealed there was no information shared or discussed regarding the residents' right to file a complaint with the State survey and certification agency. Residents #11, #15 and #38 also stated they had no knowledge about where the information was posted in the facility.Review of the available Residents Council meeting minutes from January 2026 revealed no evidence that Residents' rights were reviewed during the resident council meeting. There were no additional Resident Council meeting minutes available for review.

Based on record review and staff and resident interviews, the facility failed to ensure residents were informed of their rights on an ongoing basis. This had the potential to affect all 83 residents currently residing in the facility.Findings include:On 04/08/26 at 10:40 A.M. an interview with the Administrator revealed there were no Resident Council meetings held in February of 2026 and March of 2026 due to lack of a president for the meetings. The Administrator handed the surveyor one month of council meeting minutes dated 01/28/26. Interview with the Administrator further revealed there was no evidence that Residents' Rights were discussed at the January 2026 Resident Council Meeting. Completion of the Resident Council portion of the annual survey on 04/13/26 between 10:30 A.M. and 10:52 A.M. with Residents #11, #15 and #38 revealed there was no ongoing review of Residents' Rights during the resident council meeting or in any other fashion at the facility.Review of the available Residents Council meeting minutes from January 2026 revealed no evidence that Residents' rights were reviewed during the resident council meeting. There were no additional Resident Council meeting minutes available for review.

Based on interview and record review, the facility failed to take reasonable steps to ensure residents were assisted by a designated staff member for conducting resident council meetings and residents were timely informed of meetings in advance. This had the potential to affect all 83 residents residing in the facility. The facility census was 83. Findings include:Record review of the facility Activity Calanders dated January 2025, February 2025, March 2025, April 2025, October 2025, November 2025, December 2025, January 2026, February 2026, March 2026, and April 2026 revealed there were no resident council meetings identified on the calendars. There were no available activity calendars to review for May of 2025, June of 2025, July of 2025, August of 2025, and September of 2025.An interview on 04/08/26 at 10:40 A.M. with the Administrator revealed there were no resident council meetings held in February of 2026 and March of 2026 due to lack of a president for the meetings. The Administrator verified he had resident council meeting minutes for January 2026 only and handed the surveyor meeting minutes dated 01/28/26 that indicated five residents attended the meeting and staff attending included the Activity Director and the Director of Nursing. There was no future meeting date on the minutes. An interview on 04/09/26 at 10:10 A.M. with Activity Director (AD) #876 revealed she was not aware she needed to save activity calendars and otherwise had no evidence to show when resident council meetings were held for the aforementioned months in 2025 and 2026. AD #876 stated her and her staff go and get residents for council meetings when they are due to be held. AD #876 stated resident council meetings are held monthly, and a meeting was going to be held this week. On 04/13/26 at 10:30 A.M. a resident council meeting was held with surveyors as part of the annual survey. Residents #15, #38 and #11 were in attendance. Resident #11 stated there had not been resident council meetings in February and March of this year due to no president. Resident #11 further stated, We were supposed to have one last week but, it was canceled. Resident #11 stated she was informed it was canceled, as there was no one to run the meeting.

Based on record review, interview and facility policy review, the facility failed to ensure care plans were revised in response to resident assessments and physician ordered interventions for Resident #10, Resident #49, Resident #71, and Resident #90. This affected four residents (#10, #49, #71,and #90) of 47 residents reviewed for care plans. The facility census was 83. Findings included:1. Review of the medical record for Resident #10 revealed an admission date of 09/17/22. Resident #10 was hospitalized from [DATE] to 01/13/26 due to a fracture of the right femur post-fall incident on 01/03/26. Further diagnoses included Alzheimer's dementia, hypertension, anxiety, insomnia, and chronic kidney disease.Review of Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition, was independent with eating, and required substantial to maximal assist for oral hygiene, toileting hygiene, showers, dressing. Resident #10 was dependent on staff for putting on and taking off shoes and bed mobility.Review of Resident #10's care plan, last revised 03/31/26, revealed the resident was at risk for falls related to dementia and Alzheimer's, anxiety, advanced age, and at times agitation with hands on care. Interventions included staff ensuring floor mat beside bed and a physical therapy screen dated 01/03/26. The care plan did not identify the fall that occurred on 01/03/26 or Resident #10's right femur fracture nor interventions to address care related to the fracture.An interview on 04/15/26 at 2:55 P.M. with Registered Nurse (RN) #811 revealed she verified Resident #10's care plan was not updated with her most recent fall and injury. 2.Review of the medical record for Resident #49 revealed an admission date of 10/01/25 with diagnoses including spinal stenosis, type two diabetes mellitus, chronic kidney disease (CKD) stage three and alcohol abuse.Review of the progress note dated 01/14/26 at 6:01 P.M. revealed Resident #49 contacted the hospice nurse regarding complaints of burning and itching upon urination. Resident #49 believed she had a Urinary Tract Infection (UTI). New orders for Macrobid (antibiotic for UTI) 100 milligram twice a day (BID) for seven (7) days. Resident #49 updated at bedside and family notified by Hospice nurse.Review of the order dated 01/15/26 revealed an order for Macrobid oral 100 mg capsule to administer one by mouth (PO) BID (twice a day) for seven days for symptoms of itching and burning.Review of the medication administration records (MARS) and treatment administration records (TARS) for January 2026 revealed Resident #49 received her antibiotic per physician orders.Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 had impaired cognition and was always incontinent of bladder and frequently incontinent of bowel.Review of Resident #49's care plan, last revised 04/09/26, revealed there was no revision made to add the diagnosis of UTI nor the physician ordered antibiotic from 01/15/26.An interview on 04/13/26 at 11:43 A.M. with the Director of Nursing (DON) confirmed there was no update to the care plan for UTI or antibiotic for Resident #49.An interview 04/13/26 at 1:04 P.M. with MDS Coordinator #811 confirmed there was no update to the care plan for UTI or antibiotic for Resident #49. 3. Review of Resident #71's medical record revealed an admission date of 01/07/25. Diagnoses included but not limited to spinal stenosis cervical region, lumbar region, impulse disorder, and adjustment disorder with mixed disturbance of emotions and conduct, mood affective disorder.Review of the MDS quarterly assessment dated [DATE] revealed Resident #71 had intact cognition and was occasionally incontinent of bladder and frequently incontinent of bowel.Review of the physician orders dated March 2026 revealed an order to cleanse right upper lateral back with normal saline, apply Medi honey and cover with a dry dressing and cleanse right upper medial back, apply Medi honey and cover with dry dressing.Review of the MARS and TARS for March 2026 and April 2026 revealed Resident #71 received treatments to cleanse right upper lateral back with normal saline, apply Medi honey and cover with a dry dressing and cleanse right upper medial back, apply Medi honey and cover with dry dressing except for refusals.Review of Resident #71's plan of care, date last revised 04/13/26, revealed the care plan had not been revised to specify Resident #71 had pressure injuries to right upper lateral back and pressure injury to right upper medial back. The care plan indicated has a pressure ulcer as of 03/12/26.An interview 04/13/26 at 11:43 A.M. with the DON confirmed there was no care plan for the pressure injury to right upper lateral back and right upper medial back for Resident #71.An interview 04/13/26 at 1:04 P.M. with MDS Coordinator # 811 confirmed there was no care plan for the pressure injury to right upper lateral back and right upper medial back for Resident #71. 4. Review of the medical record for Resident #90 revealed an admission date of 03/26/26. Diagnoses included unspecified severe protein-calorie malnutrition. Review of the admission MDS assessment dated [DATE] revealed Resident #90 had severely impaired cognition and was always incontinent of bowel and bladder.Review of the April 2026 physician orders revealed an order to change Peripherally Inserted Central Catheter (PICC) Line dressing weekly on day shift and as needed (PRN).Review of the April 2026 MARS and TARS revealed Resident #90's PICC Line dressing change was completed per physician orders. Review of Resident #90's care plan, last revised on 04/07/26, revealed there was no revision made to identify the PICC line dressing changes. An interview 04/13/26 at 11:43 A.M. with the DON confirmed there was no care plan for the PICC Line dressing change. An interview 04/14/26 at 12:23 P.M. with MDS Coordinator #811 confirmed there was no care plan for the PICC Line dressing change. Review of facility policy, Comprehensive Care Plans, revised 01/10/25, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will be prepared by an interdisciplinary team (IDT) and reviewed and revised by the IDT after each comprehensive and quarterly assessment.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #78 was provided one-to-one activities to meet personal needs, and failed to ensure all residents residing on the memory care unit (Residents #4, #5, #8, #10, #13 , #14, #16, #17, #23, #30, #40, #42 , #46, #47, #48, #50, #59, #64 , #65, #66, #68, #72, #83, and #84) received a program of therapeutic activities for their highest practical well-being. This affected 25 residents (Residents #4, #5, #8, #10, #13, #14, #16, #17, #23, #30, #40, #42 , #46, #47, #48, #50, #59, #64 , #65, #66, #68, #72, #78, #83, and #84) of 83 residents observed for activities. The facility census was 83. Findings include: A review of the facility activity calendar labeled February 2026 Dementia Unit revealed on 02/01/26 there were no activities on the calendar. The latest activity scheduled for each day on the dementia unit was at 2:00 P.M. unless it was a holiday, then the latest activity was scheduled at 3:00 P.M. There were no special function activities. Beginning on 02/02/26 per this calendar, the following activities were scheduled daily at 10:00 A.M. and 2:00 P.M. : Morning Stretch at 10:00 A.M. and Music Time at 2:00 P.M. every Monday. Beachball Toss or Coloring at 10:00 A.M. and Snack and Chat at 2:00 P.M. every Tuesday. Sensory Time or Coffee Time at 10:00 A.M. and Snack and Chat at 2:00 P.M. every Wednesday. Memory Game or Guess the Song at 10:00 A.M. and Snack and Chat at 2:00 P.M. every Thursday. Nails at 10:00 A.M. and Nails at 2:00 P.M. every Friday. Exercise at 10:00 A.M. and Coloring at 2:00 P.M. every Saturday. On 02/14/26 there was a holiday celebration at 3:00 P.M. Church on TV at 10:00 A.M. and I Spy at 2:00 P.M. every Sunday. Review of the facility activity calendar labeled March 2026 (for the dementia unit) revealed the activity schedule (10:00 A.M. and 2:00 P.M.) remained the same as the February 2026 calendar. There were no special function or evening activities listed except for a Celebration activity added at 3:00 P.M. on 03/17/26 for the holiday. Review of the facility activity calendar labeled April 2026 revealed the facility had one activity calendar and no longer had one specifically designated for the residents residing on the memory care (dementia) unit. The following activities were scheduled daily as follows: Coffee and News at 9:00 A.M., Church on TV at 10:00 A.M., Coloring Packet at 2:00 P.M. and Ice Cream at 3:00 P.M. on Sunday. Coffee and News at 9:00 A.M., Exercise at 9:30 A.M., Gardening at 10:00 A.M., Bingo at 1:30 P.M. and Water Cart at 3:00 P.M. on Monday. Coffee and News at 9:00 A.M., Uno at 10:00 A.M., Puzzles at 1:30 P.M. and Juice Cart at 3:00 P.M., Residents Choice at 4:00 P.M. and 1:1 Room Visits at 6:00 P.M. on Tuesday. Coffee and News at 9:00 A.M., Trivia at 10:00 A.M., Bingo at 1:30 P.M. and Water Cart at 3:00 P.M., Movie at 4:00 P.M. and 1:1 Room Visits at 6:00 P.M. on Wednesday. Coffee and News at 9:00 A.M., Exercise at 9:30 A.M., Nails at 10:00 A.M., Nails at 1:30 P.M. and Water Cart at 3:00 P.M. on Thursday. Coffee and News at 9:00 A.M., Board Games at 10:00 A.M., Bingo at 1:30 P.M. and Juice Cart at 3:00 P.M. on Friday. Coffee and News at 9:00 A.M., St 4 Coffee at 10:00 A.M., [NAME] Baptist 2:00 P.M. and Water Cart at 3:00 P.M. on Sunday. A review of the facility document titled Job Description of Activity Director revealed it was signed by Activity Director (AD) #876 on 04/21/25. The document indicated the Activity Director was a department head directly responsible for the planning, coordinating, supervising, and implementing a meaningful and ongoing activity program that fulfills the physical, social, mental, spiritual, and psychosocial well-being of all residents who choose to participate in a group setting, individually, or on a one-on-one basis. The program shall be in compliance with company policy, as well as with state and federal regulations. Observation was conducted on 04/07/26 between 5:50 P.M. to 6:20 P.M. on the secured memory care unit of the facility. Eight residents were observed lying in their beds. Five residents' rooms were noted with their doors closed so they were not disturbed during the observation period. There were 11 residents sitting in the dining room area not engaged in therapeutic visual, auditory, tactile or other sensory activities to occupy these residents. The observation further revealed that residents in the dining room were becoming increasingly restless and difficult to redirect while aides and nurses were tending to other residents' toileting needs after dinner. An interview with Licensed Practical Nurse (LPN) 807 during this observation revealed structured activities rarely happen on the unit especially at night after dinner. LPN #807 was unable to recall the last time an activity occurred on the memory care unit after dinner and stated there is no activity programming in general for the unit and she does not know why. On 04/08/26 at 8:09 A.M. an interview with LPN #816 revealed that she sometimes works in the memory care unit. LPN #816 stated there are no activities being held in the memory care unit. On 04/08/26 at 9:50 A.M. an interview with LPN #832 revealed the facility was working on activities for the memory care unit. LPN #832 further revealed that sometimes the activity department will bring the residents in the memory care unit ice cream. An observation on 04/08/26 at 9:50 A.M. on the memory care unit revealed no structured, therapeutic activities were taking place on the memory care unit, and there were six residents sitting in the common area in front of a television. On 04/08/26 at 10:00 A.M. an interview with Registered Nurse (RN) #871 revealed there was no dedicated activity calendar for the dementia unit. RN #871 stated it was up to the nursing staff on the unit to do things for the residents, so the residents were going to have a movie at 3:00 P.M. that afternoon and she was the one who planned it and purchased the snacks for the activity. RN #871 further stated planned activities for the memory care unit are rare. On 04/08/26 at 10:45 A.M. an interview with Activity Director (AD) #876 verified on Tuesday, specifically 04/07/26, one-to-one visits were scheduled on the activity calendar at 6:00 P.M., however, the activity staff were scheduled to leave at 4:00 P.M. so those one-to-one visits were not actually done. On 04/08/26 at 1:30 P.M. bingo was observed in the main activity room. An interview with AD #876 and Assistant Director of Nursing (ADON) #803 at the time of the observation revealed there were no residents from the memory care unit present for the bingo activity. Subsequent observation of the memory care unit directly following this observation revealed no activities taking place on the memory care unit. There were four residents sitting in front of the television. On 04/09/26 at 9:45 A.M. there was no activity taking place in the activity room. Per the calendar, the Thursday, 9:30 A.M. activity was exercise. On 04/09/26 at 10:00 A.M. observation of the memory care unit revealed one resident in the common area working with an abacus. An interview with RN #871 at the time of the observation revealed no exercise had taken place in the memory care unit this morning. RN #871 further stated activities did not come down to the unit to take residents to the activity room to participate in the exercise activity as scheduled. On 04/09/26 at 10:10 A.M. an interview with AD #876 revealed she started her position as the AD in March 2025. AD #876 stated she did not keep a record of activity calendars for the memory care unit and confirmed she had none to show from May 2025 through January 2026 of what activities were planned for the residents during that period on the memory care unit. On 04/13/26 at 9:50 A.M. an interview with Activity Assistant (AA) #878 revealed there were no dedicated activities for the memory care unit recently. AA #878 stated he felt it had been approximately two months since there were dedicated activities for the memory care unit. An observation of the memory care unit at the time of the interview revealed one resident (Resident #8) in the common area in a wheelchair with his head down on the table, two residents dozing in recliners in the common area, and two female residents coloring on coloring pages. On 04/13/26 at 1:30 P.M. observation was conducted of four residents from the memory care unit who were observed participating in bingo in the main activity room. Subsequent observation directly following in the memory care unit revealed four residents watching television. An interview with LPN #824 at the time of the observation revealed she worked on the memory care unit often. LPN #824 further stated there have been no planned activities for the memory care unit. LPN #824 stated the memory care unit was going to have root beer floats this afternoon and that activity was planned by the staff of the memory care unit because the activity staff had no activities planned for the unit. LPN #824 stated the memory care staff will try to plan activities and purchase the needed items for the activities. On 04/14/26 at 9:47 A.M. an interview with AA #879 revealed she was the only full-time activity staff person. AA #879 further stated she used to spend a lot of time back in the memory care unit but now she only gets back to the unit when she can. AA #879 stated she was the one who primarily made the activity calendars and she tried to incorporate activities for the memory care unit within the main calendar. AA #879 stated she has had no formal dementia training from the facility and what she knows she has been self-taught by videos or online training. AA #879 stated it has been at least two months since there were dedicated activities in the dementia care unit. On 04/14/26 at 2:00 P.M. residents were observed playing video bowling in the main activity room. There were no residents from the dementia unit per Environmental Service Supervisor #905. Subsequent observation immediately following in the memory care unit revealed there were no activities taking place in the memory care unit. On 04/15/26 at 10:45 A.M. a group activity was taking place in the main activity room. There were no residents from the memory care unit which was verified at the time of the observation by AA #879. On 04/15/26 at 10:57 A.M. an interview with LPN #818 revealed there have been no scheduled activities or dedicated activity staff for the memory care unit. LPN #818 stated the staff in the memory care unit do the best they can for the residents and often plan their own activities for the unit. An observation at the time of the interview revealed two female residents sitting at a table coloring, one resident using an Abacus, and two residents utilizing tactile boards. A review of the facility policy titled, Dementia Care, dated 01/01/25, with the revision date of 11/11/25, revealed it is the policy of the facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. The policy further stated individualized, non-pharmacologic approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. 2. Record review for Resident #78 revealed an admission date of 07/10/23 with diagnoses including Parkinson's Disease, fibromyalgia, hallucinations, stage four pressure ulcer, protein-calorie malnutrition, chronic viral hepatitis C, generalized anxiety disorder, restlessness and agitation. Review of Resident #78's Minimum Data Set (MDS) assessment dated [DATE] revealed a Basic Interview of Mental Status (BIMS) score 03 which indicated severe cognitive impairment. Review of the MDS further indicated Resident #78 was dependent on staff for all Activities of Daily Living (ADLs), bed mobility and transfers. Review of Resident #78's care plan dated 01/13/26 revealed she had little or no activity involvement due to her physical limitations and required one-on-one visits from activity staff. Interventions included Resident #78 was to receive one to three one-on-one visits per week.Review of one-on-one activity logs for the last month through 04/13/26 revealed Resident #78 did not receive any one-on-one visits for that look back period. On 04/08/26 at 10:45 A.M. an interview with AD #876 verified one-to-one visits were scheduled on the activity calendar at 6:00 P.M. and activity staff were scheduled to leave at 4:00 P.M. AD #876 stated on 04/07/26, for example, the one-to-one activity did not get done because staff left at 4:00 P.M. An interview on 04/14/2026 at 2:07 PM with AA #879 revealed she did not complete any one-on-one visits for this resident and further stated the employee who was responsible to complete all one-on-one visits was no longer employed at the facility and had no knowledge if one-on-ones were being completed. The facility was unable to provide a policy related to activities during the survey.

Based on employee personnel file review, review of the facility assessment, review of the facility policy and interview, the facility failed to ensure staff had specialized training for the memory care unit. This had the potential to affect all residents (Residents #4, #5, #8, #10, #13, #14, #16, #17, #23, #30, #40, #42, #46, #47, #48, #50, #59, #64, #65, #66, #68, #72, #83, and #84) residing in the memory care unit The facility census was 83.Findings include: A review of the personnel file for Certified Nurse Aide (CNA) #844 revealed a date of hire as 01/28/26. Further review revealed CNA #844 had no specialized training for the memory care unit.A review of the personnel file for CNA #845 revealed a date of hire as 02/25/26. Further review revealed CNA #845 had no specialized training for the memory care unit.A review of the personnel file for CNA #846 revealed a date of hire as 07/31/25. Further review revealed CNA #846 had no specialized training for the memory care unit.A review of the personnel file for CNA #860 revealed a date of hire as 02/25/26. Further review revealed CNA #860 had no specialized training for the memory care unit.An interview on 04/13/26 at 3:20 P.M. with Human Resource Director (HRD) #804 verified there was no documented evidence of training for the memory care unit for CNAs #844, #845, #846, and #860 within their personnel files. HRD #804 stated the facility did not conduct any specialized training for the memory care unit.On 04/14/26 between 12:14 P.M. and 12:21 P.M. interviews with CNAs #841, #855, and #866 revealed they had no specialized training for memory care unit.A review of the document titled; Facility Assessment, with a revision date of 04/13/26, revealed the facility routinely serves residents with clinical and functional needs including, but not limited to, cognitive impairment, dementia, and behavioral health diagnoses. The assessment also revealed nurse aides will receive the following core training including dementia management training and resident abuse prevention training, care of the cognitively impaired, and at least 12 hours of training per year to ensure continuing competence.A review of the policy titled; Luxor Dementia Unit Placement Criteria Policy, dated 01/01/25, revealed residents may be considered for placement on the secured dementia/ memory care unit when clinical assessment and interdisciplinary team review determined the resident would benefit from the specialized environment, programming, and supervision provided on the unit.A review of the policy titled; Dementia Care, with a review date of 11/11/25, revealed the facility will provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. The policy further stated all staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies, and skill sets to ensure resident safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure residents were free from physical restraints. This affected one resident (Resident #66) of one resident reviewed for physical restraints. The facility census was 83.Findings include:Review of Resident #66's medical record revealed an admission date of 11/20/25. Diagnoses included moderate protein-calorie malnutrition, dementia, hyperlipidemia, mood disorder, urinary retention, age related osteoporosis, Alzheimer's disease, and anxiety disorder.Review of Resident #66's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition but was able to make needs known. Resident #66 required partial to moderate assist with all Activities of Daily Living (ADLs) including eating, showers, personal hygiene, dressing, and bed mobility.Review of Resident #66's care plan dated 02/01/26 revealed the resident was at risk for fluctuations and/or decline with ALDs due to multiple health issues and she was at risk for falls due to impaired safety awareness, age related debility, and potential for side effects of medications. Staff were to anticipate the resident's needs, follow facility fall protocol, medication review with hospice, ensure proper footwear is on when out of bed, and staff were to ensure wheelchair breaks were locked when not in use.Review of Resident #66's physician orders dated April 2026 revealed she was to have a body pillow to left side of bed for body positioning.Observation on 04/06/26 at 9:48 A.M. of Resident #66 revealed she was lying in bed on her back, right side of bed was against the wall, she had two pillowss along her left side tucked under the fitted sheet. Resident #66 was calm at this time and not trying to get out of bed.An interview on 04/06/26 at 9:50 A.M. with Certified Nursing Assistant (CNA) #841 revealed the pillows were placed under the fitted sheet along the left side of the resident to keep the resident in the bed. CNA #841 stated the resident was a high risk for falls and climbs out of bed. They were instructed to put the pillows under the fitted sheet due to resident pulling at them and wanting to hold the pillows if they are above the sheet and they are meant to keep the resident in bed. CNA #841 confirmed the pillows were under the fitted sheet and that the resident was unable to remove them and that there was not a fall mat on the floor next to her bed.An interview on 04/08/26 at 9:45 A.M. with the Assistant Director of Nursing (ADON) #803 revealed she verified Resident #66 was only to have the body pillow alongside her and not under the fitted sheet and stated that was a restraint.Review of the facility policy titled Restraint Free Environment, last revised 10/06/25, revealed it was the policy of the facility that each resident shall attain and maintain his or her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use in circumstances in which the resident has medical symptoms that warrant the use of such restraint. Under the definition of Physical Restraint it referred to any manual method or physical, or mechanical device, material or equipment attached or adjacent to resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: Applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove, using bed rails to keep the resident from voluntarily getting out of bed, tucking in a sheet tightly so that the resident cannot get out of bed, or fastening fabric or clothing so that a resident's freedom of movement is restricted.

Based on observation, interviews and record reviews, the facility failed to secure smoking materials for Resident #52. This affected one Resident (#52), who was identified as the facility's only smoker, of one resident reviewed for smoking and had the potential to affect all residents in the facility. The facility's census was 83.Findings include:A review of Resident #52's medical record revealed an admission date of 09/13/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus type II with hyperglycemia, atherosclerotic heart disease, depression, hypertension (HTN), myocardial infarction (MI), and lesion of the ulnar nerve of the left upper limb.A review of Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. Further review of the MDS also revealed Resident #52 required set-up/supervision with all activities of daily living and required supervision with shower transfers and mobility.A review of Resident #52's lone smoking assessment dated [DATE] revealed education was conducted with the resident on safety of smoking including designated smoking areas, designated smoking times, no cigarettes, e-cigarettes or lighters would be kept in resident's room. The smoking assessment further revealed all smoking items were to be kept in a secure location with staff access only.A review of the facility's Resident Sign-Out log on 04/07/26 at 1:15 P.M. revealed Resident #52 signed himself out to smoke several times per day over approximately the last nine months.An interview with Resident #52 on 04/07/26 at 1:29 P.M. revealed he went out to the sidewalk to smoke and signed himself out each time per the facility's policy. The resident further stated he kept his cigarettes and his lighter on his person in his room and had not been instructed to store them locked up at the nurses station.An observation with Resident #52 on 04/07/26 at 1:30 P.M. confirmed his cigarettes and his lighter were stored in a coat pocket in the closet in his room. This observation was confirmed by Certified Nursing Assistant (CNA) #868 on 04/07/26 at 1:31 P.M.An interview with the Administrator on 04/08/26 at 12:30 P.M. revealed the facility's only smoking policy in place was for a Smoke Free Facility. The Administrator further stated there was no current policy in place or available for smoking residents who were grandfathered in before the building became a smoke-free facility.An interview with Regional [NAME] President of Nursing #810 on 04/15/26 at 9:00 A.M. revealed the facility was smoke-free since 01/01/25.

Based on record review, interview and observation the facility failed to ensure call lights were within reach for Residents #13, #76, and #84. This affected three (Residents #13, #49, and #84) of three residents reviewed for call lights. The facility census was 83.Findings include:1. Review of Resident #84's medical record revealed an admission date of 01/10/26. Diagnoses included malignant breast cancer, hypothyroidism, hypertension, adult failure to thrive, unspecified dementia, schizophrenia, and age-related osteoporosis.Review of Resident #84's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Resident #84 required setup or clean up assistance with eating, partial to moderate assistance with toileting hygiene, oral hygiene, and showering.An observation on 04/06/26 at 10:40 A.M. of Resident #84's call light revealed it was clipped to the privacy curtain out of reach of the resident.An interview on 04/06/26 at 10:41 A.M. with Resident #84 revealed if she had her call light, she would not have to walk down to the nurses' station to tell them what she needed.An interview with Registered Nurse (RN) #861 on 04/06/26 at 10:42 A.M. revealed she verified the call light was clipped to the privacy curtain and not where Resident #84 could reach it.2. Review of Resident #13 medical record revealed an admission date of 08/12/25. Diagnoses included Alzheimer's disease late onset, generalized anxiety, folate deficiency, cognitive communication deficient, hypokalemia, and dementia insomnia.Review of Resident #13's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had impaired cognition, required set-up assistance with eating, supervision or touching assistance with oral hygiene and partial to moderate assistance with toileting and personal hygiene.Observation on 04/06/06 at 10:43 A.M. revealed Resident #13's call light was lying on the over the bed light and not within reach of the resident.An interview on 04/06/26 at 10:45 A.M. with Certified Nursing Assistant (CNA) #839 verified the call light was not within reach of Resident #13 and verified if the call light was within reach, the resident would use it. She then placed the call light within reach of the resident.3. A review of Resident #49's medical record revealed an admission date of 10/01/25 with diagnoses including spinal stenosis, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, congestive heart failure (CHF), obstructive sleep apnea, atrial fibrillation, major depressive disorder, generalized anxiety disorder, and pulmonary hypertension.Further review of Resident #49's medical record and MDS 3.0 dated 03/01/26 revealed a Brief Interview of Mental Status (BIMS) score of 08 which indicated moderate cognitive impairment. Resident #49 required moderate assistance with bathing and dressing, was dependent for toileting and required moderate assistance with bed mobility and transfers.An observation and interview on 04/06/26 at 10:00 A.M. revealed Resident #49's call light was hanging from the outlet in the wall, and the cord was stuck between the bed and the wall. The resident stated she could not reach her call light from her lying position in the bed.An interview on 04/06/26 at 10:02 A.M. with Environmental Services Worker #911 and Maintenance Worker #919 confirmed the finding that Resident #49 was unable to reach her call light which was stuck between her bed and the wall.A review of the facility's policy titled Call Lights: Accessibility and Timely Response, revised 12/31/25, revealed the staff would ensure the call light was within reach of residents and secured as needed. The policy also stated the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on interview, record review and facility policy review the facility failed to provide written notice of room changes to the resident and family representative. This affected one resident (#79) out of one resident reviewed for room change. The facility census was 83.Findings includeRecord review for Resident #79 revealed an admission date of 07/31/25 with diagnoses including unspecified intellectual disabilities, other seizures, unspecified psychosis not due to a substance or known physiological condition. Effective 03/11/26 Resident #79's brother was listed as Power of Attorney (POA).Review of Resident #79's progress notes revealed on 03/11/26 a social services entry stated, notified resident of room change. Resident is ok with room change. There was no documentation of evidence that Resident #79 received prior written notice of room change and that Resident's POA was provided written prior notice of room change.Review of a nursing note dated 03/17/26 revealed Resident #79 had a room change done, all personals moved and resident's brother aware.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment. Resident #79's speech was clear, usually made self-understood, understood others, and had adequate vision.An interview on 04/06/26 at 3:15 P.M. with Resident #79's POA revealed he was notified verbally in person three days after the room change for Resident #79 that occurred on 03/17/26 and was provided nothing in writing about the room change. An interview on 04/14/26 at 9:05 A.M. with Resident #79 revealed he could not recall receiving written notice prior to his room changes or reasons why he changed rooms. An interview on 04/15/26 at 9:15 A.M. with Social Service Designee (SSD) #883 confirmed written notice was not provided to Resident #79 or his POA prior to resident's room changes on 03/11/26 and 03/17/26. SSD #883 stated she did not have a Room Change Notice form to provide residents and family representatives prior to room changes. SSD #883 confirmed the Room Change Policy, date revised 03/16/2026, stated written notice was to be provided to residents and family representatives prior to room changes. Review of the facility policy Change in Room or Roommate, date revised 03/16/26, revealed prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. The notice of a change in room or roommate will be provided in writing; in a language and manner the resident and representative understand and will include the reason(s) why the move or change is required.

Based on record review and interview the facility failed to ensure residents were notified of bed hold information prior to discharge to the hospital and failed to notify the Ombudsman of hospitalizations. This affected two residents (Residents #2 and #5) of two residents reviewed for hospitalizations. The facility census was 83. Findings include:1.Review of the medical record for Resident #2 revealed an admission date of 08/24/23 with diagnoses including bipolar disorder, gender identity disorder, and borderline personality disorder.Review of the census data within the medical record revealed Resident #2 was hospitalized from [DATE] and returned to the facility on [DATE]. There was no evidence in the record of a bed hold notice. 2.Review of medical record for resident #5 revealed an admission date of 10/14/25 with diagnoses including unspecified dementia.Review of the census data within the medical record for Resident #5 revealed Resident #5 was hospitalized from [DATE] through 04/10/26. There was no evidence in the record of a bed hold notice. On 04/09/26 at 10:05 A.M. an interview with the Administrator revealed there were no bed hold notices for Residents #2 and #5. The administrator further revealed there was no Ombudsman notification for Residents #2, and the Ombudsman had not been notified yet for Resident #5.On 04/09/26 at 3:52 P.M. an interview with Ombudsman #920 revealed she does not receive notification from the facility for residents going to the hospital.Review of the facility document titled Authorization for Admission, undated, revealed residents receiving Medicaid assistance are entitled to 30 bed hold days per year. These bed hold days are paid by Medicaid and are used for hospital stays or therapeutic leave days. If all 30 bed hold days are exhausted prior to the year's, end, it will be the resident and or residence responsible parties' option to pay the facilities current rate for the bed to be held. The resident and or responsible party will be notified before the charge takes effect so a decision may be made to hold the bed.

Based on record review and interview the facility failed to ensure a care plan was developed to include discharge planning for Resident #77. This affected one resident (#77) of 47 residents reviewed for care plans. The facility census was 83.Findings include: Review of the medical record for Resident #77 revealed an admission date of 01/22/26. Diagnoses included chronic respiratory failure chronic obstructive pulmonary disease, type two diabetes mellitus without complications, and obesity.Review of the modification of admission MDS assessment dated [DATE] revealed Resident #77 was cognitively intact, had adequate hearing, was able to make himself understood, and understood others. Review of progress notes in Resident #77's medical record revealed on 02/06/26 a nursing note indicated Resident #77 wanted to return to his assisted living and he wanted to stay at the facility until renovations were completed. An additional nurse progress note dated 02/20/26 revealed a mini care conference took place in Resident #77's room. Discharge planning was not documented as discussed in this note.An interview on 04/06/26 at 9:54 A.M. with Resident #77 revealed he moved temporarily to the facility after his assisted living (AL) experienced water damage in December 2025, and he was just waiting for the repairs to be finished at the AL so he could return to the AL. Resident #77 stated his discharge plans have not changed and he wanted to return to his AL as soon as the repairs were done.Review of the care plan for Resident #77, last revised on 04/05/26, revealed a care plan had not been developed to address discharge planning.An interview on 04/13/26 at 2:15 P.M. with Social Services Designee (SSD) #883 confirmed Resident #77's discharge plans were to return to his AL once the water damage was repaired. SSD #883 confirmed a discharge plan of care had not been developed for Resident #77. Review of facility the policy titled, Comprehensive Care Plans, revised 01/10/25, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The care plan will include the residents preferences for future discharge.Review of facility policy, Comprehensive Care Plans, revised 01/10/25, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will be prepared by an interdisciplinary team (IDT) and reviewed and revised by the IDT after each comprehensive and quarterly assessment. The care plan will address the residents' preferences for future discharge and discharge plans.

Based on record review, observation, interview and facility policy review, the facility failed to administer a proper dose of acetaminophen (analgesic) to Resident #60. This affected one (Resident #60) of six residents observed for medication administration. The facility also failed to address x-rays in a timely manner for Resident #10. This affected one (Resident #10) of two residents reviewed for falls. The facility census was 83.Findings include:1.A review of medical records for Resident #60 revealed the date of admission of 01/22/26. Significant diagnosis included osteoarthritis of the knee, unspecified, and pain in unspecified knee. Significant orders included acetaminophen 500 milligrams, give two tablets by mouth two times a day for pain. An admission minimum data set assessment (MDS) dated [DATE] revealed a brief interview for mental status with a score of 13 indicating Resident #60 was cognitively intact. The assessment also revealed Resident #60 received scheduled pain medication. The pain was rated as occasional with a pain scale rating of two (minor or mild pain). A care plan dated 04/01/26 revealed resident #60 had a history of osteoarthritis to the knees. Interventions included give analgesics (medications for pain) as ordered by the physician and monitor for effectiveness. An observation of medication administration on 04/08/26 at 8:09 A.M. revealed Licensed Practical Nurse (LPN) #819 remove a bottle of acetaminophen from the medication cart. The bottle of acetaminophen was noted to be 325 milligrams. LPN #819 removed 2 tablets from the bottle. LPN #819 then dispensed the medication to Resident #60. Upon return to the medication cart LPN #819 was asked to read the dosage on the acetaminophen bottle. LPN #819 verified the dosage given was 325 milligrams, two tablets. LPN #819 further verified resident #60 was to receive two 500 milligram tablets of acetaminophen two times daily. A review of the facility policy titled; Medication Administration dated 04/09/25 revealed medications are administered by licensed nurses or other staff who are legally authorized to do so in this state. Medications are administered in accordance with professional standards of practice. The policy further revealed medications are administered utilizing the six right of medication administration which included right resident, right drug, right dosage, right route, right time, and right documentation. 2. Review of the medical record for Resident #10 revealed an admission date of 09/17/22 with diagnoses including Alzhiermer's dementia, hypertension, anxiety, insomnia, and chronic kidney disease. Review of Resident #10's admission MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. She was independent with eating and required substantial to maximal assistance for oral hygiene, toileting hygiene, showers, and dressing. She was dependent on staff with bed mobility and putting on and taking off shoes. Review or Resident #10's care plan, last revised on 03/31/26, revealed the resident was at risk for falls related to dementia and Alzheimer's, anxiety, advanced age, and agitation with hand on care. Further review of Resident #10's care plan revealed to minimize risk for falls through the next review date staff were to ensure a floor mat beside (01/03/26) the bed and a physical therapy (PT) screen (07/07/25). Review of Resident #10's progress notes dated 01/03/26 to 01/07/26 revealed Resident #10 had an unwitnessed fall in her room on 01/03/26, skin tears to left forearm, left buttocks and thumb were cleansed, and dressing applied. Range of motion assessment was completed with no abnormal findings. A fall report, neurological checks and monitoring was initiated. Family and physician were updated. Resident #10 was given Tylenol for discomfort and follow up pain scale was zero. On 01/07/26 an X-ray of the left hip and shoulder was ordered due to complaints of low to moderate (three to five on scale of one to ten) pain in the left hip area which was relieved to zero pain with Tylenol. The X-ray was negative. Review of the fall incident and related investigation revealed on 01/03/26 Resident #10 had an unwitnessed fall in her room at 7:00 A.M., non-skid socks were on, no contributing environmental factors, no recent medication changes, vitals were normal, skin tears noted to left arm and left buttocks, and thumb. There was no reported pain with range of motion assessments and no abnormal findings upon assessment. Intervention was fall mat to side of bed. Further review of progress notes revealed on 01/08/26 Resident #10 complained of low to moderate (two to five) pain this time on her right hip which was relieved to zero pain with Tylenol. At 12:27 P.M. a right hip, right knee, left shoulder X-ray was ordered. Review of the X-ray results for Resident #10 revealed the results were completed on 01/08/26 at 2:33 P.M. and resulted to the facility on [DATE] at 3:11 P.M. revealing a right femur fracture. Review of progress notes and pain scales dated 01/09/26 revealed Resident #10 was treated with Tylenol at 8:19 A.M. for moderate pain with good effect (follow up pain level two) and was sent to the hospital as noted at 10:09 A.M. An interview on 04/09/26 at 2:40 P.M. with the X-ray company verified the X-ray results for Resident #10 were made available to the facility on [DATE] at 3:11 P.M. An interview on 04/13/26 at 4:47 P.M. with the Director of Nursing (DON) revealed Resident #10's X-ray results were sent to the facility electronically on 01/08/26 at 3:13 P.M. on their communication dashboard in Point Click Care (PCC) and they were not reviewed until the DON noticed they were unreviewed on their electronic dashboard during morning meeting on 01/09/26 at 10:00 A.M. and notified the floor nurse of the results and to send Resident #10 to the hospital because the X-ray results were positive for a fracture. The DON stated X-ray results should have been reviewed on 01/08/26 and promptly notified the physician of the results. Review of the facility policy titled Radiology and other Diagnostic Services and Reporting, last revised 12/02/25, revealed the facility must promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside the clinical reference range.

Based on record review, observation, facility policy review and interview, the facility failed to ensure Resident #9's nasal spray was stored in a safe manner. This affected one (Resident #9) of six residents observed during medication administration. In addition, the facility failed to date a multi-dose vial of Tubersol (a liquid that is used to test if someone has been exposed to tuberculosis) in a manner to preserve efficacy. This had the potential to affect all residents who may require tuberculin skin testing using multi-dose vials. The facility census was 83.Findings include:1. A review of medical records for Resident #9 revealed the date of admission as 02/25/26. Significant diagnoses included chronic diastolic congestive heart failure. Significant orders included Fluticasone (corticosteroid nasal spray) 50 micrograms suspension, use one spray in each nostril daily for allergies. There were no orders to leave medications at the bedside of Resident #9.An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating Resident #9 was cognitively intact.An observation of medication administration on 04/07/26 at 9:22 A.M. for Resident #9 revealed her Fluticasone nasal spray was located in the top drawer of her bedside table. Licensed Practical Nurse (LPN) #832 verified the nasal spray was located in the top drawer of the bedside table at the time of the observation. LPN #832 stated Resident #9 did not have an order to keep medication at her bedside, nor did Resident #9 have an order for self-administration of the nasal spray.2. An observation of the low three medication storage refrigerator on 04/07/26 at 9:25 A.M. revealed a one milliliter multi-use vial of Tubersol (10 doses) that was opened. The Tubersol vial was not labeled as to when it was opened. LPN #832 verified the opened, undated Tubersol vial at the time of the observation.A review of the manufacturer's package insert for Tubersol revealed vials in use for more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.A review of the facility policy titled; Medication Storage, dated 03/31/25, revealed it is the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy further stated all drugs and biologicals will be stored in locked compartments.

Based on observation, medical record review, review of hospital records, review of information from the National Pressure Injury Advisory Panel (NPIAP), review of facility policy, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the development of, worsening of and promote the healing of a facility acquired pressure ulcer for Resident #44, a resident who was at risk for pressure ulcer development and dependent on staff for all activities of daily living (ADLs) including bed mobility, turning and repositioning, incontinence care for both bowel and bladder, showering, and dressing. This resulted in Immediate Jeopardy and actual harm when the facility failed to implement effective interventions to prevent the development of and timely and adequately treat a facility acquired pressure ulcer. On [DATE] Resident #44 was seen by a wound care team for moisture associated dermatitis (MASD) (MASD is a general term for skin inflammation or erosion caused by exposure to moisture and its contents) on the sacrum that had progressed from MASD measuring 0.3 cm in length by 0.4 cm width with 0.2 cm depth to a Stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) pressure ulcer measuring 2.4 cm long by one cm wide with 0.3 cm depth. On [DATE] the ulcer deteriorated with an increase in size and measured 3.8 cm long by 1.8 cm wide with 0.7 cm depth. On [DATE] at 2:25 P.M. the resident was documented to have a change in condition with increased lethargy, no food intake at lunch, minimal fluid intake, abnormal vital signs including an elevated temperature of 101 degrees Fahrenheit, elevated heart rate of 90 and decreased blood pressure of ,d+[DATE]. The resident had an elevated white blood cell count of 12.51 (indicative of infection) at this time. However, wound cultures ordered on this date were not obtained until [DATE]. On [DATE] the resident was transferred to the hospital and admitted for treatment of sepsis secondary to decubitus/pressure ulcer. In addition, a concern that did not rise to Immediate Jeopardy but did result in Actual Harm occurred to Resident #10, who was at risk for pressure ulcer development and/or alteration in skin integrity when the facility failed to provide the necessary care and services for the prevention and development and then worsening of a Stage III pressure ulcer. On [DATE] Resident #10 was assessed to have a new in-house acquired Stage III pressure ulcer measuring 1.8 cm long by 1.8 cm wide with 0.1 cm depth to the left lower buttock. The pressure ulcer deteriorated when assessed on [DATE] with an increase in size measuring 2.5 cm long by three cm wide with 0.1 cm depth and an increase in exudate drainage. Actual harm also occurred to Resident #72 on [DATE] when the facility failed to provide the necessary care and services for the prevention and development and then worsening of a Stage III pressure ulcer. Resident #72 was assessed to have an in-house acquired Stage III pressure ulcer to the sacrum measuring 3.5 cm long by 4.5 cm wide with 0.1 cm depth. The pressure ulcer deteriorated when assessed on [DATE] with an increase in size measuring four cm long by 4.5 cm wide with 0.3 cm depth with documentation the wound progress was exacerbated due to new damaged skin around the wound. This affected three residents (#10, #44, and #72) of six residents reviewed for pressure ulcers. The facility identified 10 residents with pressure ulcers (#7, #10, #44, #45, #46, #49, #58, #61, #65 and #72) The facility census was 78. On [DATE] at 12:35 P.M. the Interim Administrator and the Director of Nursing were notified Immediate Jeopardy began on [DATE] when Resident #44 was seen by wound care team including Wound Care Physician (WCP) #700 who identified a wound to the resident ' s sacrum had progressed from MASD to an in-house acquired Stage III pressure ulcer. In addition to failing to prevent the ulcer from developing, following the identification of the pressure ulcer, the facility failed to implement adequate and necessary care and treatment resulting in a deterioration in the pressure ulcer and acute change in resident condition resulting in hospitalization (on [DATE]) for treatment of sepsis related to the pressure/decubitus ulcer. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] Director of Nursing (DON) #804 began staff education for licensed nurses and State tested Nursing Assistants (STNAs) on the need to ensure that all pressure relieving interventions were in place in accordance with the plans of care and that incontinence care, turning and repositioning, and showers/bed baths were implemented timely and in accordance with the plan of care for all residents, including those with wounds. All nursing staff were also in-serviced on the need to inform the nurse if wound dressings become soiled with urine or stool so they can be changed. Staff training/education was provided between [DATE] and [DATE]. Any staff not In-serviced by [DATE] would be in-serviced prior to their next working shift. On [DATE] Resident #44 was readmitted to the facility from the hospital. Licensed Practical Nurse/Wound Nurse (LPN/WN) #800 re-assessed the resident ' s sacral wound and a new order to cleanse with normal saline, apply Santyl nickel thick and cover with bordered gauze was obtained. The resident ' s care plan was reviewed and included interventions of turn and reposition side to side, lay down after meals, and Chamosyn to buttocks after incontinence episodes was initiated. All necessary physician orders including medication orders and wound care orders were reviewed to ensure accurately reflected in the care plan. Between [DATE] and [DATE] LPN/WN #800 initiated review of care plans for all residents who had existing wound, Resident #7, #10, #44, #45, #46, #49, #58, #61, #65 and #72. On [DATE] LPN/WN #800 again reviewed all necessary physician orders for Resident #44 and the facility implemented a plan to review these orders daily to ensure they were accurately reflected in the resident ' s care plan. The resident was also scheduled to see the wound care physician on [DATE]. On [DATE] and [DATE] Director of Nursing (DON) #804 began in-service with all licensed nurses on the need to ensure the physician was timely notified of all wound changes, treatments were implemented in accordance with orders, and all orders for cultures and labs were obtained timely and orders for antibiotics were implemented timely. Any staff not educated by [DATE] would be educated would be educated prior to their next working shift. On [DATE] Licensed Practical Nurse/Wound Nurse (LPN/WN) #800, LPN #801, LPN #802, and LPN #803 completed skin sweeps and new Braden Scales on all facility residents. No new pressure ulcers or infections were identified. All resident care plans would be reviewed by [DATE] to ensure appropriate preventative interventions were in place and appropriate treatments were in place if appropriate. On [DATE] DON #804 posted the STAT phone number for the lab at all nurse ' s stations to ensure staff had access and were calling the correct number when STAT labs need to be drawn, and in-serviced all nurses on the number as well as the need to contact the DON or Administrator if the lab cannot be reached. On [DATE] LPN/WN #800 checked all culture containers (urine and swabs) and discarded all expired items and contacted the lab to request non-expired culture containers be provided. LPN/WN #800 would then check culture containers monthly and discard expired containers. On [DATE] DON #804 in-serviced all licensed nurses on the process for monthly checking of culture containers for expired containers and on the need to check all containers, including swabs for expiration prior to use. On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON #804, LPN/WN #800, and Medical Director (MD) #900 to review the plan. MD #900 was notified of the Immediate Jeopardy on [DATE] at the QAPI meeting. The meeting included a discussion of skin issues identified with the skin/wound CQI report. The facility implemented a plan for LPN/WN or designee to complete observations of at least five random residents per day for four weeks to ensure pressure relieving interventions were being implemented in accordance with the plan of care, including offloading, incontinence care provided timely, and showers completed in accordance with the plan of care and shower schedule. The observation/audits would include residents with and without wounds. All audits would be reviewed by the QAPI committee. The facility implemented a plan for LPN/WN or designee to complete observations/audits of at least three residents with wounds per day to ensure wound treatments were being implemented as ordered, dressings were changed if soiled, and new orders for labs or cultures are implemented timely. The audits/observations would be completed for four weeks, and all audits would be reviewed by the QAPI committee. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 3 (Actual Harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1.Review of Resident #44 ' s medical record revealed the resident had diagnoses including cerebral palsy, type two diabetes mellitus, overactive bladder, urinary incontinence, unspecified intellectual disabilities, hypertension and pressure ulcer of sacral region. Review of Resident #44 ' s care plan revised [DATE] revealed Resident #44 was at risk for alteration in skin integrity related to decreased mobility. Interventions included to be laid down after breakfast to promote skin integrity, bariatric bed for positioning, body check nightly, bath days and as needed, cushion to chair with non-skid above and below, keep linen dry and wrinkle free every shift, maintain pressure relief mattress, provide skin care every morning and night and as needed, reposition on rounds and as needed, resident preferences on baths/showers and side to side turns while in bed. Review of Resident #44 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference Review of Resident #44 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and required substantial to maximal assistance by staff for eating and dressing. The assessment revealed Resident #44 was dependent on staff for all other activities of daily living (ADLs) including oral hygiene, toileting, showers, personal hygiene, and bed mobility. Resident #44 was always incontinent of bowel and bladder. Review of the physician orders for Resident #44 ' s revealed the following orders: initiated [DATE] Chymosin Ointment 0.45%-20% apply to coccyx and right buttock topically every shift for incontinence and apply heavily with episodes of incontinence. Initiated on [DATE] side to side turns while in bed, reposition on rounds and as needed, Low Air Loss (LAL) mattress to bed at all times initiated on [DATE], resident in bed after all meals. Weekly Skin Assessments every night shifts every Wednesday for health maintenance initiated [DATE], cleanse sacral wound with normal saline (NS), apply collagen sheet and bordered gauze three times a week and as needed on Tuesday, Thursday, and Saturday, initiated on [DATE]. Review of the shower schedule for Resident #44 revealed the resident was to receive showers twice a week. Review of shower sheets for Resident #44 from the date range of [DATE] to [DATE] revealed Resident #44 had only received a shower on [DATE], [DATE], [DATE] and [DATE] during this time period. Review of a Wound Evaluation and Management Summary dated [DATE] by WCP #700 revealed Resident #44 had Moisture Associated Dermatitis (Site #3) noted as healing, measuring 0.3 cm length by 0.4 cm width with 0.2 cm depth. The treatment plan consisted of Chymosin twice daily for nine days. Review of a Wound Evaluation and Management Summary dated [DATE] by WCP #700 revealed Resident #44 ' s MASD to the sacrum exacerbated due to multifactorial events which was noted to have deteriorated to a Stage III pressure ulcer and was measuring larger in size at 2.4 cm long by one cm wide with 0.3 cm depth, with drainage of light serous (a clear to pale yellow watery fluid). On [DATE] WCP #700 changed the treatment plan to Collagen gel/paste three times per week for 30 days and cover with gauze island with border apply this as well three times per week for 30 days. Record review revealed the resident was assessed by WCP #700 on [DATE] at which time the Stage III pressure ulcer to Resident #44 ' s coccyx/sacrum measured 2.1 cm long by one cm wide with 0.7 cm depth, with light serosanguinous (a thin watery fluid, pink in color due to small amounts of red blood cells) drainage. The wound bed consisted of 20% thick adherent devitalized necrotic (dead) tissue, 20% slough (dead tissue separating from living tissue), and 60% granulation (new) tissue. There were no changes made to the wound treatment orders at this time. Review of Resident #44 ' s care plan updated [DATE] revealed Resident #44 was at risk for alteration in skin integrity related to decreased mobility. Interventions included Resident #44 was to be laid down after breakfast to promote skin integrity on buttocks, bariatric bed for positioning, bilateral heel protectors, body check nightly, bath days, and as needed, Chymosin ointment to buttocks every shift, cushion to chair with non-skid above and below, keep linen dry and wrinkle free every shift, maintain pressure relief mattress, and notify the physician with any changes. The plan indicated staff were to provide skin care every A.M. and P.M. and as needed. Resident #44 was unaware of bowel and bladder urges, unable to transfer to toilet due to total dependence on staff for transfers. The goals listed in the care plan were that the resident would remain as dry as possible without skin breakdown. Interventions included staff to administer overactive bladder medication per physician orders, change the resident as needed, assist the resident to ensure peri care after each incontinent episode to prevent skin breakdown, and check the resident every round for incontinence. The care plan indicated the resident was to receive showers twice a week. Review of Resident #44 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference Further review of the Wound Evaluation and Management Summary dated [DATE] by WCP #700 revealed the Stage III pressure wound to Resident #44 ' s coccyx/sacrum had deteriorated again with exacerbation due to multifactorial issues including poor incontinence care, poor turning and reposition, and not off-loading pressure by turning the resident every two hours and as needed to ensure direct pressure was not on the resident ' s coccyx/sacrum. On [DATE] WCP #700 measured the wound to be 3.8 cm long by 1.8 cm wide with 0.7 cm depth, with light serous drainage, 20% thick adherent devitalized necrotic tissue, 20% slough, and 60% granulation tissue. There were no changes to treatment orders at this time by WP #700. Review of Resident #44 ' s progress notes revealed a change in condition was noted on [DATE] with the resident having increased lethargy, no food intake at lunch, minimal fluid intake record throughout the day and (abnormal) vital signs with a temperature of 101.0 Fahrenheit (F)(elevated), pulse 90 (elevated), blood pressure (BP) ,d+[DATE] (hypotensive). Notification was made to Resident #44 ' s Nurse Practitioner (NP) who gave orders for a STAT Complete Blood Count (CBC), Complete Metabolic Panel (CMP), urinalysis with culture and sensitivity (UA C&S), wound cultures, and a chest x-ray. There was a delay in obtaining the laboratory work, and wound cultures due to expired wound culture collection swabs and no one contacting the appropriate number for STAT lab draws. The NP was updated on the delay and gave further orders to start Resident #44 on the antibiotic, Rocephin 1 gram (gm) intramuscularly (IM) for five days on [DATE] at 10:52 A.M. The antibiotics were not scheduled to be given until [DATE] but should have been started immediately per facility policy for antibiotic administration. Review of Resident #44 ' s wound culture results, ordered on [DATE], which was not collected until [DATE] due to all the wound culture swabs at the facility being expired, resulted on [DATE] revealed the cultures were positive for Escherichia coli. (E. Coli). On [DATE] at 11:45 A.M. Resident #44 ' s Primary Care Physician (PCP), Medical Director (MD) #900 was informed of the change in condition and the recommendations of the NP. MD #900 gave orders to send the resident to the emergency room for evaluation and treatment. Consequently, review of hospital records revealed Resident #44 was admitted to the hospital for treatment of the Stage III pressure injury of the sacral region. Resident #44 was hospitalized from [DATE] to [DATE] with treatment provided for sepsis including fluid resuscitation per hospital protocol for severe sepsis, along with two intravenous (IV) antibiotics of Cefepime and Flagyl. Resident #44 returned to the facility on [DATE] with continuation of antibiotics including Cephalexin and Flagyl by mouth. During an interview on [DATE] at 3:22 P.M. with State tested Nursing Assistant (STNA) #808, the STNA indicated she believed the facility was short staffed most of the time, showers were not completed due to the facility getting rid of the shower aide position, and residents (including Resident #44), were not provided with timely incontinence care, or turned and repositioned when they should be. Observations made on [DATE] at 9:45 A.M. and 11:00 A.M. with STNA #809 and on [DATE] at 4:45 P.M. with LPN/WCN #800 of Resident #44 ' s positioning while in bed revealed Resident #44 was in the same position on her right side with positioning wedges used that were flat. The resident did not appear to be positioned properly on the positioning wedge pillows and pressure was not reduced from sacral wound at the time of these observations. Interview on [DATE] at 10:00 A.M. with LPN/WN #800 revealed Resident #44 ' s sacral wound had worsened from MASD to a Stage III pressure ulcer due to staff not providing her with timely incontinence care, staff not turning the resident per her plan of care, staff not repositioning the resident timely when she was in her wheelchair, and staff not providing showers or giving the resident a bed bath per her plan of care. LPN WN #800 also revealed staff were unable to collect the wound cultures ordered on [DATE] due to all the wound culture swabs being expired, and they would not receive new ones until Monday [DATE] when the lab brought them to the facility. Observation made on [DATE] at 2:03 P.M. of wound care for Resident #44 by LPN/WN #800 with assistance for turning and repositioning from STNA #809 revealed when removing the top sheet from the resident to perform wound care there was a strong odor of urine present, the resident ' s brief was dry, however when they rolled the resident over the dressing to sacral wound dated [DATE] had feces on the outside of the dressing and underneath the dressing in the wound. They provided incontinence care to the resident, removed the old dressing, washed hands and changed gloves and cleansed the wound with normal saline. Upon assessment of the wound, LPN/WN #800 found new necrotic tissue. While providing wound care LPN/WN #800 stated when she did the treatment last on [DATE] the center of the wound had white granulation tissue in the center of the wound and now there was necrotic tissue the approximate size of a quarter, with redness around the peri wound edges, indicating possible infection. The wound had a foul odor present. The wound was dressed per physician ' s orders with no concerns identified with wound care technique. The resident was turned onto her right side and positioning wedges used. Resident #44 was on a low air loss mattress. She had orders for a tilt and space wheelchair with a pressure reducing cushion in the chair which was present in the hallway. Interview via phone on [DATE] at 10:53 A.M. with WCP #700 revealed he stated MASD should never progress to a pressure ulcer. He stated the facility staff do not turn and reposition or provide timely incontinence care. WCP #700 stated Resident #44 ' s wound deterioration was a direct result of staff not caring for the resident appropriately and per her care plan. Interview on [DATE] at 11:40 A.M. with DON #804 and with LPN/WN #800 confirmed they were able to provide only four shower sheets for Resident #44 for the time frame requested of [DATE] to [DATE]. Interview on [DATE] at 12:30 P.M. with DON #804 confirmed Resident #44 developed an in-house Stage III pressure ulcer due to a lack of proper care, including staff not turning and repositioning the resident every two hours or as needed, staff not providing timely incontinence care, showers/bed baths, or providing proper care for the resident. Interview on [DATE] at 1:45 P.M. with DON #804 revealed when asked what the expectation was for antibiotic administration, DON #804 stated antibiotics should be scheduled to be given as soon as possible as they have a starter box in the medication room with antibiotics in them. She stated the nurse should have started Resident #44 ' s ordered Rocephin immediately on [DATE] and not scheduled it for [DATE]. 2. Review of Resident #10 ' s medical record revealed an admitted [DATE] with diagnoses including unspecified dementia with mild agitation, hypertension, chronic kidney disease stage II, and Stage III pressure ulcer of left buttock ([DATE]). Review of Resident #10 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required set up help or clean up help only for eating, he was independent for bed mobility, supervision, or touching assistance for oral hygiene, partial to moderate assistance for toileting, and substantial to maximal assistance for showers, dressing, and personal hygiene. Review of Resident #10 ' s care plan dated [DATE] revealed the resident had the potential for pressure ulcer development and or alteration in skin integrity related to decreased mobility and side effects related to medications. The goal was Resident #10 would have intact skin free of redness, blisters, or discoloration by or through the review date. Interventions included administering medications as ordered, monitor and document for side effects, administering treatments as ordered and monitor for effectiveness and staff will encourage the resident to turn and reposition on care rounds and as needed. Review of the shower schedule for Resident #10 revealed he was to receive showers twice a week. Review of progress notes for Resident #10 from [DATE] to [DATE] revealed there were no notes stating the resident refused care such as incontinence care, repositioning and or showers. Review of Resident #10 ' s physician orders revealed pressure reduction mattress to bed at all times initiated on [DATE], cushion to chair with non-skid above and below cushion initiated on [DATE], reposition on rounds and as needed initiated on [DATE], weekly skin assessments every day shift every Monday initiated on [DATE], pad and protect left buttock with foam dressing every day shift every Monday, Wednesday, and Friday initiated on [DATE]. Review of Resident #10 ' s Initial Wound Evaluation and Management Summary dated [DATE] revealed the resident had an inhouse acquired Stage III pressure ulcer to the left lower buttock measuring 1.8 cm long by 1.8 cm wide with 0.1 cm depth with light serous drainage, 80 % granulation tissue. Treatment recommendations at this time were for Leptospermum honey, apply three times per week for 30 days and cover with dry dressing three times per week for 30 days, other recommendations were to off-load the wound, and reposition per facility protocol. Review of Resident #10 Wound Evaluation and Management Summary dated [DATE] revealed the wound deteriorated as the wound was larger in size measuring 2.5 cm long by three cm wide with 0.1 cm depth with moderate serous drainage, 20% thick adherent devitalized necrotic tissue, 10% slough, 50% granulation tissue and 20% other viable tissue including the dermis and subcutaneous tissue. Wound progress was noted to be not at goal. There were no changes made to the treatment plan at this time, and recommendations were to off-load the wound, and reposition per facility policy which was every two hours and as needed. Interview on [DATE] at 10:00 A.M. with LPN/WN #800 revealed Resident #10 developed a Stage III in-house acquired pressure ulcer that subsequently deteriorated due to the resident not being repositioned timely and per facility policy by facility staff. Additional review of Resident #10 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference. For the date range of [DATE] to [DATE] there were no shower sheets to evidence the resident had been given any showers in that time period. Interview on [DATE] at 3:22 P.M. with STNA #808 indicated she believed the facility was short staffed most of the time, showers were not completed due to the facility getting rid of the shower aide position, and residents (including Resident #10), were not provided with timely incontinence care, or turned and repositioned when they should be. Observations made on [DATE] at 10:00 A.M. and 2:03 P.M. with STNA #808, and on [DATE] at 12:45 P.M., and 2:00 P.M., with STNA #809 of positioning for Resident #10 revealed Resident #10 was laying on his back with no pillows supporting his weight to offload the pressure to his left buttocks. Interview via phone on [DATE] at 10:53 A.M. with WCP #700 confirmed Resident #10 ' s wound deteriorated due to the resident not being repositioned timely and per facility policy to off load the pressure from the wound. Wound care observations were attempted on [DATE] at 10:00 A.M. and 1:00 P.M., however the resident refused to allow the State surveyor to watch his wound care. Interview on [DATE] at 11:30 A.M. with Resident #10 revealed he was alert and could answer questions. When asked about his showers, repositioning, and incontinence care he stated staff help but stated he had not had a shower in long time. The resident also stated he did not receive timely incontinence care or timely repositioning. Interview on [DATE] at 11:40 A.M. with DON #804 and with LPN/WN #800 confirmed they could not produce shower sheets for Residents #10. 3. Review of Resident #72 ' s medical record revealed an admitted d of [DATE] with diagnoses including Parkinson ' s disease, disease of spinal cord, Stiff-Man syndrome, hypertension, and an in-house acquired Stage III pressure ulcer to the sacrum as of [DATE]. Review of Resident #72 ' s care plan dated [DATE] revealed the resident was at risk for alteration in skin integrity related to Parkinson ' s disease. The goal was Resident #72 would have skin remain dry and intact through target date, interventions included air mattress to bed for skin preventions, body check nightly on bath days and as needed, chair cushion when in wheelchair or bedside chair, Chymosin ointment to buttocks as ordered by the physician, Resident #72 was to be laid down after breakfast to promote skin integrity on buttocks, keep linen dry and wrinkle free every shift, moisturizer daily to dry skin, barrier cream to buttocks, apply after each episode of incontinence. Review of Resident #72 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required supervision or touching assistance for eating, and was dependent on staff for all other ADLs including oral hygiene, showers, toileting, dressing, personal hygiene, and bed mobility. Review of the shower schedule for Resident #72 revealed he was to receive showers twice a week. Review of progress notes for Resident #72 from [DATE] to [DATE] revealed there were no notes stating the resident refused care such as incontinence care, repositioning and or showers. Review of Resident #72 ' s physician ' s orders revealed orders for Chymosin Ointment to buttocks/peri-area topically every shift for incontinence episodes initiated [DATE], Pommel Cushion to wheel chair with Dycem above and below, for positioning initiated [DATE], Bariatric bed for positioning initiated [DATE], check and change on rounds and as needed for incontinence care initiated [DATE], body pillow while in bed for positioning every shift initiated [DATE], Resident to be laid down in bed after all meals every shift for prevention initiated [DATE], weekly skin assessments evening shift on Wednesdays initiated [DATE], Cleanse stage III pressure ulcer to sacrum with normal saline apply Medi honey topically and cover with border gauze change three times a week and as needed every day shift on Tuesday, Thursday, and Saturday initiated on [DATE]. Review of Resident #72 ' s Initial Wound Evaluation and Management Summary dated [DATE] revealed Resident #72 was being seen due to a new in-house acquired Stage III pressure ulcer to his sacrum measuring 3.5 cm length by 4.5 cm width with 0.1 cm depth, with light serous exudate, 50% granulation tissue, 20 % other viable tissue including dermis and subcutaneous (Sub Q) tissue, and 30% skin. Treatment orders at this time were for leptospermum honey applied three times per week for 30 days and cover with dry dressing three times per week for 30 days. Further recommendations were to offload the wound, and to reposition per facility protocol. Review of Resident #72 ' s Wound Evaluation and Management Summary dated [DATE] revealed Resident #72's Stage III pressure ulcer measured two cm length by 2.5 cm width by 0.1 cm depth with light serous drainage, 70 % granulation tissue, 10 % slough, and 20% other viable tissues including the dermis and Sub Q. There was no change to the treatment orders, or recommendations. Review of Resident #72 ' s Wound Evaluation and Management Summary dated [DATE] revealed Resident #72 ' s Stage III pressure ulcer to his sacrum deteriorated as evidenced by an increase in size with the ulcer measuring four cm length by 4.5 cm width by 0.3 cm depth, moderate serous drainage, 70 % granulation tissue, 10 % slough, 20 % other viable tissues such as dermis and sub-q. Wound progress had exacerbated due to new damaged skin peri (around) the wound. New treatment orders were obtained to include Santyl apply once daily for 30 days, and cover with dry dressing. Recommendations continue to off-load wound and reposition per facility policy. Additional review of Resident #72 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident, or showers being completed timely per the resident ' s care plan and preference. For the date range of [DATE] to [DATE] there were no shower sheets to evidence the resident had been given any showers in that time period. Interview on [DATE] at

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of a Police Report, review of the facility Elopement Policy and Procedure and interviews, the facility failed to provide adequate supervision and failed to respond and act appropriately when a door alarm sounded to prevent Resident #43, who was cognitively impaired, required a front wheeled walker for mobility with stand by assist (SBA) for ambulation, and demonstrated previous exit seeking behaviors, from eloping. This resulted in Immediate Jeopardy and the potential for actual harm, injury, or death on [DATE] at approximately 11:00 A.M. when Resident #43 left the facility via an alarmed emergency exit door without staff knowledge. Although, the door Resident #43 exited did alarm as designated, Licensed Practical Nurse (LPN) #600 opened the door and because she did not see any resident(s) in the immediate vicinity, she reset the alarm without investigating further and/or completing a facility head count. LPN #600 also failed to check on Resident #43 despite having previous knowledge Resident #43 was on her assigned unit and had demonstrated exit seeking behaviors. On [DATE] at 11:08 A.M. a community member found Resident #43 approximately 0.3 miles from the facility at a park which he would have had to cross a heavily trafficked road to get to. The community member contacted the police to report Resident #43 was at a park by the tennis court stumbling around with an ankle bracelet to his ankle. Police Officer #618 responded and documented in his report that Resident #43 had multiple injuries and he contacted emergency rescue service (EMS) to transport Resident #43 to the hospital. Police Officer #618 contacted the facility, and they were unaware Resident #43 had eloped from the building. On [DATE] at 4:53 P.M. the Administrator was notified Immediate Jeopardy began on [DATE] at approximately 11:00 A.M. when Resident #43 who displayed exit seeking behaviors, exited the facility via an alarmed emergency exit door without staff knowledge. The door to the 100-Mahoning Hall had a key code and a 15-second delayed push release with keypad to override the alarm. LPN #600 heard the alarm and responded by opening the door but while holding the door open viewed only the immediate surroundings. LPN #600 did not see any resident(s); therefore, shut the door and reset the alarm. She then proceeded with her work; failed to complete a resident head count, investigate further and/or follow the facility policy and procedure regarding a missing person. Resident #43 was subsequently found located at a park down the street, sent to the hospital for evaluation and was found to have an abrasion to his left lower leg. The Immediate Jeopardy was removed, and the deficiency corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 12:12 P.M. the Administrator was notified by phone on of Resident #43's elopement by Interim Director of Nursing (DON) #601 who stated that the police notified the facility that Resident #43 was at the park and then brought to the hospital. On [DATE] the Administrator and Interim DON #601 initiated an immediate investigation with timeline of incident. On [DATE] at 12:33 P.M. the Administrator instructed Maintenance Director #609 to report to the facility for immediate audit/testing of all doors. Environmental Director #610 was currently onsite and assisted the Maintenance Director #609 to complete. On [DATE] from 12:58 P.M. to 1:05 P.M. Maintenance Director #609 and the Environmental Director #610 tested the exit doors by exercising for both locking mechanism intact and to initiated audible alert while in the open position without negative findings. On [DATE] from 1:20 P.M. to 1:45 P.M. Environmental Director #610 tested all wanderguards for placement and response without negative findings. Wanderguard(ankle bracelet that triggers alarms and can lock monitored doors to prevent residents leaving unattended) checks were completed weekly prior to the elopement with the last one conducted by Medical Records #611 on [DATE] without negative findings. On [DATE] from 1:20 P.M. to 1:45 P.M. in-servicing with all onsite staff on Door Alarms was completed by Maintenance Director #609. On [DATE] from 1:50 P.M. to 1:51 P.M. Maintenance Director #609 and the Environmental Director #610 completed a door alarm testing drill with random residents at risk for staff response without negative findings. The alarm was answered by LPN #602 on [DATE] at 1:51 P.M. On [DATE] from 12:20 P.M. to 6:46 P.M. the Administrator in-serviced Department Heads on Elopement and Addendum to Elopement (Door Alarms) via phone. On [DATE] at 12:43 P.M. the Administrator googled the walking distance and time to park from the facility with a finding of 0.3 miles, six minutes with mostly flat terrain, and a road to cross. The Administrator also googled the weather for the area with findings of a temperature range from 76 degrees to 83 degrees Fahrenheit at 11:00 A.M and it was partly cloudy. On [DATE] at 1:44 P.M. facility staffing was reviewed by Human Resources (HR)/Payroll Coordinator #612 and the Administrator. They reconciled actual staffing hours of Licensed Nursing and State tested Nurse Aides (STNAs) for [DATE] which noted there were 3.13 hours per resident and the facility census was 84. On [DATE] from 4:35 P.M. to 10:38 P.M. Environmental Director #610, HR/ Payroll Coordinator #612, Chief Financial Officer (CFO) #613, Activity Director #614 and Rehabilitation Director #615 in-serviced licensed nursing staff, STNA's, maintenance staff, housekeeping staff, activity staff, dietary staff, office staff, therapy staff, and laundry staff on the facility Elopement and Addendum to Elopement (Door Alarms). On [DATE] at 5:10 P.M. Maintenance Director #609 checked camera locations for video. There was no designated camera to the 100-Mahoning Hall. On [DATE] at 5:47 P.M. Resident #43's hospital record was reviewed by the Administrator which noted the resident was at his baseline and would be returning to the facility. On [DATE] at 6:41 P.M. the resident's wife was contacted and informed upon return, the resident would be moved to the facility secured unit. The resident continued to also have a Wanderguard device in place. A Quality Assurance/ Performance Improvement (QAPI) update of timeline/abatement plan was held with department heads including the Administrator, Social Service Designee (SSD) #622, Dietary Manager #623, Environmental Director #610, Maintenance Director #609, Medical Records #611, Rehabilitation Director #615, Wound/ LPN #624, CFO #613, [NAME] #625, RN/ Interim Minimum Data Set (MDS) Coordinator #617, RN/ MDS Coordinator #619, Admissions #626, HR/ Payroll Coordinator #612, Business Office Manager #627, and Medical Director #605 on [DATE] at 9:15 A.M. and on [DATE] at 9:15 A.M. On [DATE] at 10:30 A.M. RN/ Interim Minimum Data Set (MDS) Coordinator #617 revised Resident #43's Wander Elopement Risk care plan to reflect diagnoses and that the resident was unaware of own safety needs (decreased safety awareness). The care plan goals were updated to reflect the need to keep the resident safe by not leaving facility unattended. On [DATE] Medical Records #611 updated the facility Elopement Book to include Resident #43 and ensured that like residents assessed for risk of elopement were updated. All residents with assessed elopement risk were audited to ensure residence on Secured Care Unit. On [DATE] at 3:10 P.M. Medical Records #611 reached out to Police Department to inquire their first immediate needs in the case of an elopement to aid in updating the facility elopement book. Based on this conversation Medical Records #611 ensured photos were current, highlighted contact phone numbers, notated that resident's name were in the collar and/or waist band of their clothing on the face sheet, and labeled the Wanderguard strap with the facility name on one side of the transmitter and labeled the Wanderguard strap with the telephone number to the facility on the other side of the transmitter. A pair of Resident #43's worn socks were added via Ziplock packaging on [DATE] at 3:50 P.M. as they were told this would be helpful for their search dogs to locate if needed. On [DATE] at 5:09 P.M. an order was obtained to verify placement of alert ankle bracelet every shift for Resident #43 and like residents by Interim Director of Nursing #601 from Medical Director #609. This was verified on [DATE] at 9:20 A.M. as completed. Interviews on [DATE] from 11:00 A.M. to 1:09 A.M. and [DATE] from 1:01 P.M. to 1:40 P.M. with Registered Nurse (RN) #644, LPN #600, #637, #639, #641, #646, STNA #630, #633, #636, #638, #640, Activity Assistant #608, Housekeeping #634, #635, #642, Occupation Therapy Assistant (OTA) #632 and Physical Therapy Asssiatnt (PTA) #631 verified they received the training and were knowledgeable regarding the facility elopement and Addendum to Elopement (Door Alarms) policy. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, dementia with psychotic disturbances, hallucinations, cerebrovascular disease, and hypertension. Review of the Elopement Evaluation dated [DATE] and completed by LPN #600 revealed Resident #43 was not at risk for elopement. There was no other elopement evaluation completed until after an incident of elopement that occurred on [DATE] at which time revealed Resident #43 was at risk for elopement. Review of the admission/ Medicare five- day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition as his Brief Interview for Mental Status (BIMS) score was an eight (out of 15). The assessment revealed the resident had wandering, verbal, and physical behaviors one to three days during the seven-day assessment reference period. He required extensive assistance of two-staff for bed mobility, and transfers and extensive assistance of one-staff with ambulation and locomotion per the MDS assessment. Review of the nursing note dated [DATE] at 6:30 P.M. and completed by LPN #649 revealed Resident #43 was alert with confusion as he tried to hit staff with a walker and a tray table. The note revealed Resident #43 escaped from the facility front door and when approached by staff, he picked up a brick and attempted to hit staff with it. The note revealed the resident was brought back in the facility and was then sent to the emergency room for evaluation due to behaviors. Review of the care plan dated [DATE] revealed Resident #43 was a wander/ elopement risk as he had diagnoses that included dementia, previous attempts to leave the facility, and decreased safety awareness. Interventions included assist in orientation to facility with verbal cues, be observant around doorways, frequent observations to make sure the resident was accounted for, intervene if seen trying to leave, wanderguard to ankle, check every shift and as needed, and put familiar items to assist in identifying his room. Review of a nursing note dated [DATE] at 5:55 P.M. and completed by Agency RN #650 revealed the nurse contacted the family regarding Resident #43 getting out of the facility. The note revealed the staff brought Resident #43 back into the facility and Interim DON #601 had the staff place a wanderguard to his ankle. Review of the activity documentation dated [DATE] at 9:54 A.M. revealed Activity Assistant #608 documented she had completed a one-on-one activity with Resident #43. Review of Police Report #,d+[DATE] dated [DATE] at 11:08 A.M. and completed by Officer #618 revealed emergency dispatch received a call from a community member on [DATE] at 11:06 A.M. that there was an older adult male stumbling around at the park wearing a hospital bracelet to his ankle. The report revealed Resident #43 had multiple injuries from falling and EMS transported him to the hospital. Review of a nursing note dated [DATE] at 11:35 A.M. and completed by LPN #600 revealed at approximately 11:30 A.M. she received a call from emergency dispatch stating Resident #43 was found down the street at a park. The dispatch informed the facility Resident #43 was going to be sent to the hospital as he sustained injuries. The note revealed Resident #43's door had been closed all morning because he was on COVID-19 isolation and that the last time she had seen him was when she provided his breakfast tray. The note revealed on [DATE] at 11:00 A.M. she had heard the side door alarming and when she checked she did not see anyone around the door as she even stepped outside and looked. The note revealed Primary Care Physician (PCP)/Medical Director #605 and Interim DON #601 were notified. Review of the facility SRI, tracking number 237796, dated [DATE] revealed the facility filed a report for emotional/verbal abuse. The SRI revealed on [DATE] at 11:57 A.M. the hospital emergency department reported Resident #43 was found at a park sleeping by the police department and was transported to the hospital. The resident was wearing a Wanderguard to his right lower leg and had a small abrasion to his left lower leg. Review of a witness statement dated [DATE] (untimed) and completed by LPN #600 revealed STNA #636 stated she was going on break and a minute later she was at the nursing station and heard an alarm sounding and went down to open the 100-Mahoning Hall side door. She revealed she opened the door and did not see anything. The statement revealed she presumed it was STNA #636 going out that door so put the code in to stop the alarm and proceeded to go to a resident's room. The statement revealed at approximately 11:30 A.M. to 11:35 A.M. she received a call from emergency dispatch that they had found Resident #43 at the park. Review of a witness statement dated [DATE] (untimed) and completed by STNA #636 revealed she had seen Resident #43 on [DATE] at approximately 7:50 A.M. when she dropped off his breakfast tray and did not see him any further until she had heard he was found at the park. Review of Google map documentation, dated [DATE] at 12:43 P.M. revealed the park was approximately 0.3 miles and a six-minute walking distance from the facility. Review of Hospital Discharge paperwork dated [DATE] and completed by emergency room (ER) Physician #651 revealed Resident #43 was found at the park sleeping by the police department, and EMS were called to transport him to the hospital for evaluation. ER Physician #651 revealed the resident was alert but confused and upon arrival was wearing shorts, t-shirt, and slippers. Resident #43 was found to have a small abrasion to his left lower leg/ shin area. ER Physician #651 discharged the resident back to the facility in stable condition. Review of a Physical Therapy Discharge Summary dated [DATE] and completed by Physical Therapist #607 revealed Resident #43 was discharged from therapy as he ambulated with a front wheeled walker with stand by assist (SBA) up to 300 feet and stairs were listed as not applicable. On [DATE] at 8:26 A.M. Resident #43 was observed on the facility secured memory care unit sitting in the lounge area with a front wheeled walker next to him. He was wearing a Wanderguard to his right ankle. The resident was noted to be cognitively impaired, and during the interview he stated he and his wife never made it to the park. He stated, Guess I got turned around, so I started but then turned around and now back here. He was unable to provide any other information regarding the incident on [DATE]. Interview on [DATE] at 8:36 A.M. with the Administrator revealed on [DATE] at approximately 11:00 A.M. LPN #600 responded to the 100-Mahoning Unit side emergency exit door alarm and when she looked out the door, she did not see any resident(s) or a visible reason why the door alarm sounded. She revealed LPN #600 shut off the alarm by entering a code into the keypad and then proceeded assisting another resident (Resident #82) to discharge from the facility. She revealed LPN #600 should have conducted a head count to ensure all residents were accounted for, but she did not. She revealed at approximately 11:30 A.M. LPN #600 received a call from emergency dispatch that the police department had found Resident #43 down the street at the park, and the police department had EMS transport him to the hospital for evaluation. Interview on [DATE] at 9:25 A.M. with Maintenance Director #609 revealed the 100-Mahoning Hall side door was an emergency exit only with a 15-second door release and was alarm activated. He revealed once the bar on the door was pushed it activated an alarm to notify staff of a person exiting the facility. He stated to shut off the alarm, a code had to be placed into a keypad on the side of the door. He revealed on [DATE] the door alarm sounded appropriately, and LPN #600 shut off the alarm by entering the code into the keypad. Interview on [DATE] at 11:00 A.M. with LPN #637 revealed she was assigned to Station One (the unit Resident #43 resided on) with LPN #600 and STNA #636. She revealed she had administered the resident medication on [DATE] at approximately 8:00 A.M. She revealed she had not seen Resident #43 any further nor heard any door alarms sound after that. Interview on [DATE] at 11:09 A.M. with LPN #600 revealed she was assigned Station One and she was working on Resident #82's discharge from the facility. She revealed on [DATE] at approximately 10:55 A.M. she heard a faint alarm and finished grabbing the discharge paperwork off the printer and then checked to see where the alarm was coming from. She revealed the alarm was coming from the 100-Mahoning Hall Emergency exit door and that the keypad had lights flashing on it. She revealed she opened the door and while holding the door opened looked outside but did not see anyone in the vicinity. She revealed she thought it was possibly a family member for the resident that she was discharging that had accidentally pushed on the door or STNA #636 that was assigned on the unit as she had stated just prior, she was going on break. She revealed she placed the code into the keypad that silenced the alarm and proceeded to go back to working on the discharge that she was previously working on. She verified she had not asked the family or STNA #636 if they had set the alarm off, investigated further into the reason why the door alarmed and/ or conducted a head count to ensure all residents were accounted for. She revealed on [DATE] at approximately 11:30 A.M. she received a call from emergency dispatch stating Resident #43 was down the road at a park and that they were having him transported to the hospital for possible injuries. She revealed she was aware Resident #43 had demonstrated exit seeking behaviors prior to the incident as she stated he had made previous comments when she had worked: I am waiting for the bus, I need a car and that he had packed his bags in his room previously but verified she did not check on Resident #43 [DATE] after the door alarm sounded despite having knowledge he had exit seeking behaviors. Interview on [DATE] at 11:46 A.M. with LPN #641 revealed she was aware Resident #43 was displaying exit seeking behaviors a few weeks ago as he was outside but that she was not aware of the details. Interview on [DATE] at 12:14 P.M. with STNA #636 revealed she was assigned on [DATE] Station One with LPN #600 and LPN #637. She revealed she only saw Resident #43 on [DATE] at 8:00 A.M. as he peeked his head out the door but that she reminded him he was on isolation and to stay in his room and keep the door closed. She revealed she had not checked on him after that and went to lunch at approximately 11:00 A.M. and was not aware he exited the facility until LPN #600 stated she received a call from the police department, and he was at the park. Interview on [DATE] at 1:09 P.M. with RN #644 revealed Resident #43 demonstrated exit seeking behaviors prior to the event on [DATE] as one night she revealed he was at the front entrance door and stated, he was late to his plane trip as he was attempting to leave. Interview on [DATE] at 1:18 P.M. with Activities Assistant #608 revealed on [DATE] at approximately 8:45 A.M. she was passing water and newspapers. She stated she spoke briefly with Resident #43 and that she shut his door as he was on respiratory isolation. On [DATE] at 12:50 P.M. the surveyor walked from the facility to the park. Resident #43 would have had to ambulate down four concrete stairs from the 100-Mahoning Hall emergency exit to the sidewalk. The sidewalk to the park was cracked and uneven. The park was located on the other side of the street from the facility; therefore, at some point Resident #43 would have had to cross a heavily trafficked road with a posted 35 mile per hour speed limit. The distance was verified as 0.3 miles and was approximately a six-minute walk. Interview on [DATE] at 1:32 P.M. with Interim DON #601 verified the only elopement evaluation for Resident #43 prior to the incident on [DATE] was completed on admission on [DATE] when he was assessed as not at risk for elopement. She verified in the nursing notes on [DATE] and [DATE] the resident had demonstrated exit seeking behaviors. She revealed on [DATE] she was present and the resident was adamant on exiting the facility on [DATE] as he was trying all the doors in the facility trying to leave and instead of escalating his agitation, she had walked with him around the facility to attempt to decrease his agitation. She revealed he had a Wanderguard placed because of his exit seeking behaviors and he should have been reassessed, including completing an elopement assessment. Interview on [DATE] at 1:25 P.M. with Physical Therapy Assistant (PTA) #631 revealed she worked with Resident #43 frequently until he was discharged on [DATE] and his functional ability fluctuated day to day. She revealed on [DATE] he could only ambulate 15 to 30 feet with SBA, tolerated two to four minutes of standing and had balance issues. She revealed other days such as [DATE] he was able to ambulate 300 feet with his wheeled walker and 15-minutes balance tolerance without losing his balance. She revealed they had not attempted stairs due to his balance issues. The PTA revealed she did not feel the resident was safe to independently ambulate out in the community especially due to his severe impaired cognition, balance issues, impaired safety awareness, and high risk for falls. Review of the facility policy titled Missing Resident Policy dated [DATE], revealed the policy was to ensure the safety and protection of all residents that resided at the facility. The policy revealed the first person who was aware of a possible missing person must make the nurse of the station aware. The policy revealed the nurse would request all staff members involved immediately begin looking for the resident within the unit and if not located then the entire grounds should be searched. The policy revealed if the resident was not located then the Administrator, physician, family, and police department would be notified. The policy did not include if a door alarm sounded the procedure that would be followed such as conduct a head count immediately if there was no visible explanation for the alarm. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00145286 and Complaint Number OH00145185.

Based on observation, interview and record review, the facility failed to ensure interventions to prevent the developement of a pressure ulcer were in place for residents who were identified at high risk to develop a pressure ulcer. This resulted in actual harm for Resident #37 who developed an avoidable unstageable pressure ulcer to the left buttock. In addition, the facility failed to ensure pressure ulcer treatments were provided as ordered by the physician for Resident #28. This deficient practice affected two (Resident #37 and #28) of five resident reviewed for pressure sores. The facility census was 108. Findings include: 1. Resident # 37 was originally admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received all nutrition through a feeding tube. Review of the most recent minimum data set (MDS) assessment dated [DATE] revealed the resident was in a persistent vegetative state, was totally dependant on staff for all aspects of daily living, was incontinent of bowel and bladder and was at risk to develop pressure sores. At the time of the MDS assessment, the resident had no pressure ulcers. Review of a care plan initiated on 07/25/12 revealed the resident had a potential for pressure ulcer development and skin breakdown related to incontinence and immobility. The care plan indicated the resident had an open area on the the left gluteal fold that healed on 01/04/13. The interventions included to apply a dressing to the left gluteal fold, check and change on rounds (every two hours) and as needed, a cushion to her chair, a pressure relief mattress and turn and reposition on rounds and as needed. The care plan was updated on 12/02/13. The update stated the resident had developed an unstageable pressure ulcer on her left ischium related to immobility and incontinence. Review of a nurses note dated 11/21/13 at 8:00 A.M. revealed old scar tissue to left gluteal fold was open and measured 1.8 centimeters (cm) long, by 1.0 cm wide, by 0.01 deep. White/ purple macerated tissue surrounded the dark purple wound bed. The doctor was notified. Review of the wound assessment tool dated 11/21/13 revealed the resident developed an unstageable pressure ulcer and the wound bed was 100% yellow slough (stringy/dead tissue) with bloody drainage. Review of physician orders [REDACTED]. Start to cleanse left gluteal fold with saline, Apply Algisite (a soft absorptive wound dressing), cover with Allevyn foam and change every Monday, Wednesday and Friday. The resident was observed lying in bed on 12/11/2013 at 11:22 A.M. on a defined perimeter mattress. There was a foul odor in room. Licensed practical nurse (LPN) # 13 entered the room with this surveyor. LPN # 13 rolled the resident onto her right side to examine the resident's left ischial/buttock dressing. LPN # 13 removed the resident's incontinence brief and there was no dressing in place. The wound was an open, deep unstageable pressure ulcer with yellow/tan slough tissue at the base and black eschar surrounding the base. The wound rested directly on the incontinence brief and there was wound drainage on the brief. LPN # 13 was interviewed at the time and stated she was unaware there was no dressing in place LPN # 13 stated she was not notified the dressing was off, she walked out for the room after she reapplied the resident's brief and continued to do medication pass. LPN #13 did not attempt to apply a dressing or notify the wound nurse the dressing was not in place. State tested nursing assistant (STNA) # 15 was interviewed on 12/11/2013 at 11:36 A.M. STNA # 15 verified she was assigned to care for Resident # 37 that day. STNA # 15 stated the resident did not have her dressing in place at 7:00 A.M., when she started her shift. STNA # 15 stated she provided incontinence care to the resident at 7:00 A.M. and again at 9:30 A.M., when the resident was incontinent again. STNA # 15 stated no one from the midnight turn staff reported the resident's dressing was off, so she did not know how long it had not been in place. STNA # 15 stated she did not inform the wound care nurse the resident's dressing was not in place. The wound care nurse, licensed practical nurse (LPN) # 16, was interviewed on 12/11/13 at 11:45 A.M. This surveyor informed the wound nurse there was no dressing in place to the resident's pressure ulcer. LPN # 16 promptly entered the resident's room to do the dressing change. Wound care was observed and the nurse measured the wound. The wound was 3.5 cm long by 3.1 cm wide, by 1.2 cm deep to base. LPN #16 also found wound tunneling of 0.5 cm at 6:00 and 0.3 at 9:00. The base of the wound was tan with black eschar surrounding the base. There was foul smelling drainage on the wound. LPN #16 proceeded to do the dressing change. LPN #16 stated she felt the resident's wound had deteriorated since the last time she had done the dressing change on 12/09/13. Review of a nurses note dated 12/11/13 at 1:45 P.M. revealed the doctor was faxed measurementsof the wound. The wound was larger in size and slightly deeper and had some tunneling noted at 6:00 and 9:00 o'clock. Wound bed covered 100% by yellow slough and brown/black necrotic tissue. Tan exudate (drainage) present. The LPN # 17 was interviewed on 12/12/13 at 10:10 A.M. LPN # 17 was interviewed concerning the resident's mattress. LPN # 17 stated the resident received the mattress she was currently on, on 07/10/13. Review of the information provided by the facility revealed the mattress was a pressure redistribution reactive mattress, not a pressure relief mattress as listed on her care plan interventions. This was verified with LPN # 17. LPN # 17 also verified the wound was discovered unstageable on 11/21/13. 2. Review of Resident #28's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE] at 6:10 P.M. revealed Resident #28 had a 0.9 centimeter (cm) x 0.8 cm scabbed over ulcer on top of the right foot and a two cm by one cm ulcer open on the left heel. Review of Resident #28's physician orders [REDACTED]. The order did not indicate where the Santyl was to be applied. Santyl ointment is active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level. Review of the treatment administration record (TAR) and nursing notes for July revealed no evidence that dressings were done for the left heel ulcer or the right lateral ankle ulcer daily for Resident #28's heel and ankle pressure ulcers on 07/04/13, 07/06/13 and 07/07/13. Review of a physician order [REDACTED]. This physician order [REDACTED]. Algisite is a calcium-alginate dressing which forms a soft, gel that absorbs when it comes into contact with wound exudate. Review of the TAR and the nursing notes for July 2013 revealed no evidence that daily dressing were applied to the left heel ulcer or the right ankle ulcer on 07/13/13, 07/14/13, 07/21/13, 07/27/13, and 07/28/13. Interview with Licensed Practical Nurse (LPN) #50 on 12/12/13 at 1:04 P.M. revealed Resident #28 was admitted on [DATE] with two wounds located on the residents feet that were unstageable pressure ulcers. Both pressure ulcers were ordered Santyl and dry dressing changes daily from 07/03/13 through 07/09/13. LPN #50 confirmed the physician order [REDACTED]. LPN #50 verified dressings were not done to both wounds on 07/04/13, 07/06/13, or 07/07/13. LPN #50 revealed the medication nurses were responsible for completing the dressing changes on the weekends. LPN #50 verified the dressing changes were not done to both wounds on 07/13/13, 07/14/13, 07/21/13, 07/27/13, and 07/28/13. This citation substantiates complaint # OH 823.

Based on record review, interview and observation, the facility failed to provide care and services to prevent an unstageable pressure ulcer and a Stage III pressure ulcer for Resident #2, and failed to accurately complete pressure ulcer assessments for Resident #180. This affected two of three residents reviewed for pressure ulcers. The facility census was 121 residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #2 had severely impaired cognition for decision making. The MDS assessment identified Resident #2 at risk for the development of pressure ulcers. The same MDS assessment revealed Resident #2 was totally dependent on staff for all care, including bed mobility. The Wound Assessment Tool dated 01/26/12 identified a new pressure area of deep tissue injury that measured 4.0 centimeters (cm) by 4.0 cm. on Resident #2's left heel. A Pressure Ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). The wound was described as a "red/purple fluid filled blister." The Wound Assessment Tool dated 05/02/12 revealed the area of deep tissue injury opened and measured 4.0 cm by 4.0 cm with a depth of 0.2 cm and a "very moist wound base with 30 percent yellow slough." Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy (at times). The presence of slough made the wound unstageable, since the wound bed was not visible. The Wound Assessment Tool dated 07/11/12 revealed the wound had deteriorated to a stage three pressure ulcer measuring 4.8 cm by 8.4 cm with a depth of 1.2 cm. The wound bed was described as pink with yellow slough. The 09/19/12 Wound Assessment Tool identified the left heel wound as a Stage Three pressure ulcer that measured 5.0 cm by 4.0 cm with pink granulation tissue. The surveyor was present in the room on 09/19/12 and the depth of the wound was not measured on that date. A Stage III pressure ulcer is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Nurse's Notes dated 08/02/12 at 11:30 P.M., revealed that a new open area was noted to Resident #2's left outer calf that measured 9.3 centimeters (cm) by 5.2 cm. The center of the wound was described as sloughy, with the remainder of the wound described as beefy red tissue. The Nurse's Note indicated wound treatment was initiated and was signed by Licensed Practical Nurse (LPN) #8. The corresponding Wound Assessment Tool was dated 08/03/12. The assessment indicated the left lateral leg (calf) wound was an unstageable pressure ulcer that measured 9.3 cm by 5.2 cm with a yellow slough center and remainder of the wound beefy red. The assessment referenced bloody exudate. The Wound Assessment Tool dated 09/19/12 revealed the unstageable pressure ulcer had deteriorated measuring 10.0 cm by 3.0 cm, with a 4.0 cm by 2.0 cm brown slough center with scant yellow exudate. Necrotic (dead) or devitalized tissue presents frequently as brown or black and has lots its usual physical properties and biological activity. On 09/19/12 at 09:35 A.M., the wound nurse, LPN #7, was observed providing wound care for Resident #2. A deep, Stage III left heel wound was observed that measured 5.0 cm by 4.0 cm. The depth of the wound was not measured by the nurse. The wound bed was deep pink. The nurse indicated the wound was Stage III due to the depth of the wound. LPN #7 verified Resident #2 was a quadriplegic and acknowledged she was totally dependent on staff for all care including bed mobility. LPN #7 provided wound care for Resident #2's left calf wound. The nurse measured the wound as follows: the overall, irregularly shaped ulcer measured 10.0 cm by 3.0 cm, with a 4.0 cm by 2.0 cm black center at the proximal end, surrounded by deep red tissue. The distal end of the wound had a linear section of yellow slough, surrounded by deep, red tissue. During an interview on 09/19/12 at 3:40 P.M., the director of nursing (DON) explained that the facility's wound nurse, LPN #9, was on a medical leave of absence. The DON reported that she telephoned LPN #9. LPN #9 recalled that before 7:00 AM on 08/02/12 she completed wound care for Resident #2's left heel wound and there was no skin alteration noted on Resident #2's left lower calf at that time. LPN #9 revealed to the DON that twelve hours later there was a linear mark on Resident #2's left lateral calf that she believed was caused by the catheter tubing. During an interview on 09/19/12 at 4:40 P.M., LPN #8 indicated that on the evening of 08/02/12, two state tested nurses aides (STNAs) reported the newly opened area on Resident #2's left calf, which they discovered while turning the resident. LPN #8 recalled the heel elevator (foam, circular pad) was stuck to the wound. She indicated she removed the heel elevator from Resident #2's calf, and there was blood and drainage on it. LPN #8 indicated Resident #2's leg was not lying on the catheter tubing when she first observed the wound, but acknowledged the STNAs had just turned her prior to her entry into the room. LPN #8 indicated that she looked for a treatment order for the wound, but there was none. LPN #8 reported she telephoned the wound nurse, LPN #9, at home. LPN #9 indicated she had not observed the wound earlier that morning when wound care was provided for the left heel wound. LPN #8 verified the left calf wound measured 9.3 cm by 5.2 cm with a yellow slough center and was unstageable at the time of discovery. LPN #8 verified Resident #2 was a quadriplegic and was totally dependent on staff for all care, including bed mobility. 2. Resident #180 was admitted to the facility on [DATE] with [MEDICAL CONDITION], melanoma and [MEDICAL CONDITION] and was on Hospice services. On 09/9/12 Resident #180 developed a pressure ulcer on her coccyx which measured 3 cm long by 1.5 cm wide. The boxes on the form for depth measurement and staging only read DTI, deep tissue injury. The wound base was documented as being red with necrotic /slough with a brown center. A DTI is used to describe a pressure ulcer in which the tissue damage is below intact skin and presents as dark purplish or maroon in color. The description of the wound base with necrotic, slough and brown tissue indicates the skin is not intact and is unstageable as it is covered with devitalized, dead tissue. The assessment completed by the wound nurse, licensed practical nurse (LPN) #7 was not accurate. The wound assessments were reviewed with the director of nursing (DON) on 09/20/12 at 9:25 A.M. and she verified that the assessment was not accurate and would provide the resource used by the facility staff to assess and stage pressure ulcers. The DON returned with LPN #7 at 9:45 A.M. with the facility staging document. The facility utilizes the staging system published by the National Pressure Ulcer Advisory Panel. LPN #7 verified she had inaccurately staged and described Resident #180's pressure ulcer as a DTI.