Every finding on record at Concord Care Center of Toledo

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the environment was adequately maintained. This affected six (#66, #67, #78, #79, #80, and #81) of six residents reviewed for environment. In addition, the facility failed to ensure a clean and comfortable environment. This affected 35 (#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61 and #62) residents who resided on the Nurse Station One and Nurse Station Two halls. The facility census was 82.Findings include: 1. Observation on 03/20/26 at 8:40 A.M. revealed the ceiling in Resident #66 and Resident #67's room had an approximately four feet by three feet area of visually noticeable ceiling plaster repair from what appeared to be a previous water leak. The non-uniform repair resulted in unsanded spackling, with some of the area painted and some of the area the color of the spackling. Resident #67's bed was directly under the ceiling area. Further observation revealed what appeared to be additional water damage repairs on the resident room outside wall. Interview on 03/20/26 at 8:45 A.M. with the Administrator verified the below standard ceiling repair. Interview on 03/20/26 at 11:51 A.M. with Certified Nursing Assistant (CNA) #237 revealed Resident #67 preferred to remain in bed all day, under the ceiling repair, with the exception of meals. 2. Observation on 03/20/26 at 8:52 A.M. revealed Resident #78, Resident #79, Resident #80, and Resident #81 shared bathroom. Further observation of the bathroom revealed water stains approximately six to eight inches from the bottom of the door, a broken light switch plate, the baseboard heater was detaching from the wall, and an unknown hardened sand like material was around and under the baseboard heater. Interview on 03/20/26 at 8:55 A.M. with CNA #244 verified Resident #78, Resident #79, Resident #80, and Resident #81's bathroom was in disrepair. 3. Observation on 03/20/26 at 12:05 P.M. of Resident #66 and Resident #67's room revealed the baseboard heating vent had visible build-up of what appeared to be dust. Observation on 03/20/26 at 12:09 P.M. of Nurse Station One and Nurse Station Two's ceiling vents revealed the vents had a thick layer of dust. The dust on the ceiling vent at Nurse Station Two was thick and drooping off the vent. Additional observation of Nurse Station Two's baseboard heating vent revealed a thick layer of dust coating the baseboard vent inside and out.Interview on 03/20/26 at 12:11 P.M. with the Administrator verified the above findings. Review of the facility policy titled, Homelike Environment, dated February 2021, revealed residents were provided with a safe, clean, comfortable, and homelike environment. The characteristics included a clean, sanitary, and orderly environment. This deficiency represents non-compliance investigated under Complaint Number 2791098.

Based on observation, staff interview, resident interview, review of the activities calendar, and review of the facility policy, the facility failed to implement the activities calendar as scheduled. This affected all 62 (#10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, and #71) residents who resided on the first floor of the facility. The facility census was 79.Findings include:Review of the February Activities Calendar for 02/24/26 revealed the scheduled activities included Coffee Chat at 10:00 A.M. and Keep It Moving and Card Games were scheduled for 10:30 A.M.Observations on 02/24/26 from 10:15 A.M. to 10:59 A.M. revealed activities were offered to residents on the secured unit on the lower level of the facility but not to the 62 residents on the first floor. Interview on 02/24/26 at 10:50 A.M. with Resident #53 and an unidentified female resident revealed no morning activities were offered on the first floor. Interview on 02/24/26 at 11:00 A.M. with Activities Assistant (AA) #100 revealed activities were offered to residents on the secured unit on the lower level from 9:00 A.M. to 11:30 A.M. and residents on the first level were offered activities from 12:00 P.M. to 4:00 P.M. AA #100 verified activities were scheduled on the activities calendar for the residents on the first floor and those activities did not happen.Review of the facility policy titled, Activities, dated 2026, revealed the facility would provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. This deficiency represents non-compliance investigated under Complaint Number 2694103.

Based on observation, staff interview, and review of the facility policy the facility failed to ensure the shower rooms were maintained in a sanitary and safe condition. This affected all 55 (#10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #23, #25, #26, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #61, #62, #63, #64, #65, #67, #68, #69, #70, and #71) residents residing on the first floor who utilized the shower room. The facility census was 79.Findings include:Observation on 02/23/26 at 10:01 A.M. revealed the Unit One shower room had an attached wall heating source that was rusty in color, had holes, and had sharp edges. The shower area included a metal shower seat area that was rusty with sharp edges. Observation on 02/23/26 at 10:10 A.M. revealed the Unit Two shower room had approximately 19 tiles missing near the drain directly under the shower head. The area with the missing tiles was lower than the drain and standing water was observed. Interview on 02/23/26 at 12:49 P.M. with the Administrator and Maintenance Director (MD) #172 verified the findings in both the Unit One and Unit Two shower rooms. Review of the facility policy titled, Homelike Environment, dated February 2021, revealed residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The characteristics of the facility included being clean, sanitary, and orderly. This deficiency represents non-compliance investigated under Complaint Number 2694103.

Based on observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure effective pest control. This had the potential to affect all 17 (#72, #72, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, and #88) residents who resided on the secured lower level unit of the facility. The facility census was 79.Findings include:Observations on 02/23/26 at 9:00 A.M. revealed gnats throughout the secured unit on the lower level of the facility. Gnats were observed in the halls, common areas, and resident rooms.Interview on 02/23/26 at 9:18 A.M. with Certified Nursing Assistant (CNA) #147 verified there were gnats throughout the secured unit, including resident areas.Interview on 02/23/26 at 9:31 A.M. with CNA #163 verified there were gnats throughout the secured unit, including resident areas. Interview on 02/23/26 at 9:52 A.M. with Resident #77 revealed the gnats in her room were very bothersome. During an interview on 02/23/26 at 9:58 A.M., Resident #74 stated the gnats were everywhere. Concurrent observation revealed three gnats flying around the resident, who was lying in her bed.Review of the facility policy titled, Pest Control, dated 06/19/24, revealed the facility recognized the importance of pest and vermin control in providing a living environment of adequate health and safety for its residents. The Administrator or designee shall ensure scheduled inspections provided adequate treatment to address any existing infestation. Additional treatment may be required at times other than the scheduled visits. This was an incidental finding discovered during the complaint investigation.

Based on observation, staff interview, and policy review, the facility failed to ensure the facility was pest free. This had the potential to affect 29 residents (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43) who used the 100-hall shower. The facility identified one (#26) resident on the 100-hall who did not use the shower room. This deficient practice also affected four residents (#13, #44, #45, and #46) who shared a bathroom. The facility census was 78.1. Interview on 09/02/25 at 9:37 A.M. with Housekeeping Supervisor (HS) #501 confirmed she was aware of cockroaches and pests in the facility, particularly on the 100-hall. HS #501 stated the base of the toilet in the shower room on the 100-hall leaked and staff kept towels around the base of the toilet to contain the water. HS #501 stated bugs came from under the towel. Continued interview and observation on 09/02/25 at 9:41 A.M. in the 100-hall shower room revealed the toilet had a towel around the base and when the towel was moved by HS #501's shoe, two bugs crawled out from under it and crawled to the baseboard at the wall. The type of bugs could not be identified. 2. Interview on 09/02/25 at 11:25 A.M. with Housekeeper #512 revealed the bathroom shared by Resident #13, Resident #44, Resident #45, and Resident #46 had several bugs. Continued interview and concurrent observation of the bathroom revealed five to seven fruit flies around the base of the toilet. Housekeeper #512 stated the base of the toilet was not sealed and therefore attracted fruit flies. Additional observation revealed five to seven fruit flies flying around the room. Further observation of the ceiling revealed five to seven fruit flies on the ceiling and the water pipes hanging just below the ceiling. Housekeeper #512 stated the condition of the ceiling, which appeared to have suffered water damage, also attracted fruit flies. Housekeeper #512 confirmed there were fruit flies near the floor, flying around her head, and on the ceiling. Continued observation with Housekeeper #12, upon exiting the bathroom, revealed Resident #46 lying on his bed with his back facing the door. Housekeeper #512 confirmed two house flies were on the seat of Resident #46's pants. An attempt to interview Resident #46 was unsuccessful. Interview on 09/02/25 at 11:31 A.M. with Resident #13 revealed the bugs in the bathroom bothered him. Resident #13 stated he believed they were mosquitoes. Interview on 09/02/25 at approximately 1:35 P.M. with the Administrator revealed the facility was aware of the bathroom ceiling in need of repair. The facility planned to ensure the roof was repaired prior to fixing the bathroom shared by Resident #13, Resident #44, Resident #45, and Resident #46. Interview on 09/02/25 at 3:21 P.M. with HS #501 with concurrent observation of the ceiling in the bathroom shared by Resident #13, Resident #44, Resident #45, and Resident #46 revealed about one quarter of the ceiling appeared to have suffered water damage with the drywall paper layers hanging from the ceiling and discoloration of beige and dark grey throughout the damaged area. Review of the policy Pest Control Policy, dated 06/19/24, revealed the facility recognized the important of pest and vermin control in providing a living environment of adequate health and safety for its residents. This violation represents non-compliance investigated under Complaint Number 2602025.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, resident interview, staff interview, review of the facility's investigation, and review of facility policy, the facility failed to provide adequate supervision to prevent resident elopement. Actual Harm occurred on 06/26/25 at 11:15 P.M. when Resident #07 eloped from the facility without staff knowledge. Resident #07 was missing until 06/29/25 at 3:45 P.M. when Resident #07 called the resident representative for assistance. This affected one (#07) of four residents reviewed for elopement. The facility identified 32 (#2, #4, #7, #11, #13, #15, #17, #20, #21, #22, #24, #26, #28, #34, #36, #37, #40, #42, #45, #52, #53, #56, #57, #60, #63, #65, #66, #67, #68, #69, #74, and #78) residents at risk of elopement. The facility census was 78.Review of the medical record revealed Resident #07 was admitted on [DATE]. Diagnoses included schizoaffective disorder, bipolar type, major depressive disorder, recurrent, post-traumatic stress disorder, schizoaffective disorder, obsessive compulsive, kleptomania, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, 05/11/25, revealed the resident was moderately cognitively impaired. Review of the care plan, initiated on 8/05/19, revealed Resident #07 was at risk for elopement due to schizoaffective bipolar, depression, post-traumatic stress disorder, obsessive compulsive disorder, delusions, and history of elopement. Review of nursing progress note dated 06/27/25 at 12:30 A.M. revealed at approximately 12:30 A.M. staff notified the writer Resident #07 was not in her bed. A code brown was immediately called and a resident head count completed. The staff searched the entire facility. The protocol was initiated while staff continued to search inside and outside the premises and the surrounding neighborhood. The management, power of attorney, and physician were notified. Review of a nursing progress note dated 06/29/25 at 4:56 P.M. revealed Resident #07's family called to notify the facility a call was just received from Resident #07, requesting a ride, Resident #07 provided the family her location. The DON and Administrator immediately drove to the location that was provided, and Resident #07 was standing on the corner with a bag in hand. Resident #07 was assisted into the car and stated she was tired. The Administrator asked if she was hungry and the resident stated she had sausage and pancakes at the church. The Administrator asked if she was thirsty and noted a bottle of water in the bag. Resident #07 stated she wanted some cold water. The resident reported her feet hurt due to walking. Resident was taken back to the facility and a head-to-toe assessment was completed, Resident #07 complained of pain to bilateral feet but no other areas. Redness noted to bilateral arms and face, no noted peeling areas. Resident #07 stated the church provided sunscreen. Resident was showered and offered dinner. Resident #07 ate approximately half of the dinner, and stated she was not hungry. The guardian, family, and physician were provided an update. Ibuprofen was provided due to complaints of bilateral feet pain. Resident #07 placed on a one-on-one until further notice.Review of the social services note, dated 06/29/25, revealed the resident was observed and assessed for safety and overall well-being. No signs of distress, harm, or discomfort noted. The Resident was alert and oriented, stable mood, and affect. The resident denied any concerns or complaints at the time. No negative psychosocial effects or issues observed or reported. Review of the skin check evaluation, dated 06/29/25, revealed redness to the face, left arm, and right arm. Resident #07 had filled blisters to the right heel, left heel, left great toe, right lateral foot, and right great toe. There were non-filled blisters to the right toe and right foot back of toes. Review of wound assessment report, dated 06/30/25, revealed a right heel blister measuring 2.20 centimeters (cm), a right plantar foot blister measuring 1.5 cm x 1.7 cm, a left heel blister measuring 1.4 cm x 2 cm, left great toe blister measuring 2.5 cm x 2.6 cm, and left mid plantar foot blister 1.7 cm x 2.3 cm. Treatment orders were provided. Review of physician skin and wound note, dated 07/01/25, revealed the service was provided on 06/30/25. Resident #07 was readmitted back to the facility and presents with multiple nonthermal blisters to her feet. Review of wound assessment report, dated 07/09/25, revealed the right heel blister, right plantar foot blister, and left great toe blister all resolved. The left heel blister measured 1.0 cm x 1.9 cm and the left mid plantar foot blister measured 1.6 cm x 1.8 cm. Both were identified to be improving without complications. Review of the wound assessment report, dated 07/16/25, revealed the left mid planter foot blister measured 1.6 cm x 1.8 cm and the left heel blister measured 1.0 cm x 1.8 cm. The blisters were noted to be improving without complications. Review of the wound assessment report, dated 07/23/25, revealed the left mid plantar foot and left heel resolved. Review of the elopement incident, dated 06/27/25 at 12:30 A.M., revealed at approximately 12:30 A.M. LPN #246 was notified by CNA #247 that Resident #07 was not in her bed. A code brown was called immediately. Head count was completed, and the entire unit/facility was searched. The elopement protocol was initiated. Staff continued to search inside and outside the premises and surrounding neighborhood. Notification was made to management, the medical director, and the resident's guardian. Interview on 07/28/25 at 4:39 P.M. with Resident #07 revealed she had left the facility by foot and spent time in the downtown area (approximately five to six miles from the facility). Resident #07 stated she went out to smoke and was locked out of the building. Resident #07 claimed she knocked on the door but was unable to alert the staff. Resident #07 revealed she rode a city bus, and they had allowed her to ride for free. Resident #07 stated she received clothing, food, and water from a local church and had also found scissors and cut her hair. Someone had provided her a bag of coins and Resident #07 stated she bought a single cigarette, lighter, and a vape. Resident #07 stated she was not harmed or scared, but her feet hurt. Resident #07 stated she remembered her family members' phone number and called for a ride.Interview on 07/28/25 at 5:13 P.M. with Resident #07's family member stated Resident #07 had a history prior to admission to the facility of eloping and living in the downtown area for short periods at a time. The family member stated she had not had any elopement attempts and had been doing so well she received permission to take the resident out for her birthday the weekend of the elopement. Resident #07's family member stated Resident #07 has her phone number memorized and believes her feet began to hurt bad enough that she decided to call to return to the facility. The family member verified going to the facility to see the resident the day she returned and stated her feet were swollen and wrapped, but otherwise looked good. Interview on 07/29/25 at 6:12 A.M. with Certified Nursing Assistant (CNA) #233 verified on 06/26/25 slightly before 11:00 P.M. taking Resident #07 and three other residents out for the 11:00 P.M. resident supervised smoking time. CNA #223 verified supervising the residents the entire time during the smoking time and after all residents had one cigarette they went inside. CNA #233 verified the last time she saw Resident #07 was when they were coming inside from the smoke break at approximately 11:15 P.M. CNA #233 stated upon entering the facility she continued her routine duties. On 06/27/25 at approximately 12:30 A.M., an aide giving an orientation tour discovered Resident #07 was not in bed. CNA #233 stated she was sitting near Resident #07's door at the time and believed she was in bed. Interview on 07/29/25 at 6:32 A.M. with LPN #246 revealed on 06/26/25 she had worked from 11:00 P.M. to 7:00 A.M. Upon the beginning of the shift, she observed Resident #07 standing in the hall waiting to smoke. Resident #07 had asked her for a coat and LPN #246 had told the resident it was hot outside, and a coat would not be needed. Resident #07 was determined to wear coat, so she went to her room and obtained a coat. When Resident #07 went out to smoke she wore a pair of jeans, a nightgown, shoes, a coat, and a hat. When the residents were taken out to smoke by CNA #233 the nurse was completing medication count. LPN #246 stated she was notified at approximately 12:30 P.M. that Resident #07 was not in her room. LPN #246 stated she called a code brown (missing resident), and all facility staff began searching the inside and outside of the facility. The management staff were notified, and the Administrator, DON, and unit manager came in to search for the resident. Interview on 07/29/25 at 11:58 A.M. with the DON revealed on 06/26/25 sometime after 11:00 P.M. Resident #07 eloped, possibly on her way back into the building from the last smoking time. During the interview with CNA #233 she had stated she thought all the residents were in. The DON verified she was notified timely upon discovery and both she and the Administrator came in. The police were notified and came to the facility to take report. The facility had paid staff to work extra shifts for staff to drive around the area and into downtown as they suspected Resident #07 would be. On Sunday, 06/29/25 at approximately 3:45 P.M. Resident #07's family representative called to report Resident #07 had called her asking for a ride and provided the location that she was at in the downtown area. The DON and Administrator went to the location and picked up the resident. Resident #07 was observed to be in different clothing. Resident #07 reported she had received new clothing from the church and thrown away her clothes in addition to cutting her hair. The DON stated the resident reported she had not slept much because she was outside and excited. The resident could not state exactly where she had been other than to the church and baseball field and at times her story would change. Resident #07 was found to have a bag with two bottles of water. There were blisters to her feet and her skin was slightly pink but not red. The DON stated overall the resident was in good condition and did not need to go to the hospital. Review of policy, Resident Right to Freedom from Abuse, Neglect, and Exploitation policy and procedure, dated 2025, verified the facility's residents have the right to be free from abuse, neglect, and misappropriation of their property and exploitation as defined in the policy. The deficiency was corrected on 07/13/25 when the facility implemented the following corrective actions: On 06/27/25 at 12:30 A.M. Licensed Practical Nurse (LPN) #246 called a code brown (missing resident). On 06/27/25 at 12:30 A.M. facility staff searched the facility. On 06/27/25 at 12:35 A.M. facility staff searched the facility grounds. On 06/27/25 at 12:40 A.M. facility staff searched the surrounding community. On 06/27/25 at 1:06 A.M. the Administrator was notified. On 06/27/25 at approximately 2:00 A.M. the guardian, resident representative, and physician were notified. On 06/27/25 at 2:15 P.M. the local police were notified and took report. On 06/27/25 the Director of Nursing (DON) completed facility-wide elopement reassessments of all residents to identify the at-risk residents. The facility wide elopement reassessment identified 32 residents who are at risk for elopement. Beginning 06/27/25, identified residents were placed on safety checks. On 06/27/25, the elopement binder was updated with any resident identified as an elopement risk. On 06/27/25, the Medical Director was notified by the DON of the results of the assessments. On 06/27/25, the identified at-risk resident care plans were reviewed and revised by the DON/designee. On 06/27/25, the Administrator and DON reviewed the facility's policies related to elopement and supervision. The policy was determined to meet the standards of practice, and no revision was necessary. On 06/27/25, the Administrator and DON provided education to the nursing staff. The education provided was related to the policy with emphasis on redirecting wandering or exit seeking residents, to consult the residents care plan, and notify the DON/Administrator/Care Plan Nurse/Social Worker of any new worsening wandering or exit-seeking behaviors. The training included but was not limited to the staff's responsibility to provide adequate supervision to prevent elopement for a resident with a history of wandering, exit seeking, and assessed to be at risk for elopement. During smoking times, all staff were educated that a head count and environment check needed to be completed at each smoke assignment. On 06/27/25, the Administrator, DON, or designee provided the training identified above to all staff in the non-clinical departments. Any member of the staff who was not available at the time of the training was to be educated upon return to work. Agency staff not currently working in the facility will receive education upon return to work. The DON will ensure compliance. All staff hired after 06/27/25 would be educated at orientation on the elopement risk, what to report, and to whom. On 06/27/25, the Administrator and DON completed a root cause analysis using the fishbone diagram. It was identified that Resident #07 indicated that she wanted to smoke on 06/26/25. On 06/27/25, the DON or designee reviewed resident smoking assessments. On 06/27/25, an Ad-Hoc Quality Assurance Performance Improvement meeting was held with the interdisciplinary team (IDT) and Medical Director to discuss the alleged deficiency and corrective actions. On 06/27/25, the Administrator completed an elopement drill on every shift.o Elopement drills will be conducted weekly for four weeks and then quarterly. On 06/27/22, the Administrator, Maintenance Director, or designee checked all doors to ensure all doors were locked, secured, and functioning appropriately. No concerns were identified. o All doors will be checked daily, Monday through Friday, by the Administrator, Maintenance Director, or designee.o The manager on duty will complete door checks on the weekends. o Any concerns will immediately be addressed and reported to the Administrator or Maintenance Director. On 06/29/25 at approximately 3:45 P.M. the Administrator was notified of Resident #07's whereabouts and at approximately 4:10 P.M. the Administrator and DON located the resident. On 06/29/25 at 4:35 P.M. Resident #07 arrived at the facility. A full head-to-one assessment was completed in addition to receiving a shower and a meal. On 06/29/25, the Administrator completed a smoking assessment for Resident #07. On 06/29/25, Resident #07 was placed on a one-on-one observation with a plan to monitor for three days, if there are no exit seeking behaviors will be placed on fifteen-minute checks. On 06/29/25, the Administrator completed a trauma assessment and psycho-social assessment for Resident #07. On 06/30/25, the DON or designee ensured all units completed a resident head count for each smoking time daily for each smoke break. This will continue ongoing. On 06/30/25, the DON reviewed all elopement assessmentso The DON, or designee will review elopement assessments monthly for the three months, and then quarterly, and as needed, thereafter, to ensure any subtle resident changes are identified. Any new admits starting on 06/30/25 will be assessed for elopement risk upon admission, and then quarterly. On 06/30/25, the DON reviewed care planso Care plans will be reviewed by the DON, or designee monthly for three months. On 06/30/25, the DON reviewed the electronic medical record for three residentso The DON, or designee will review three residents weekly and will rotate residents weekly for four weeks, and then monthly for three months to identify new or worsening behaviors to include wandering/exit seeking behaviors. o Any concern will be addressed immediately. On 07/02/25, Resident #07 was placed on every 15-minute checks. On 07/03/25, a Quality-of-Life meetings was conducted by the IDT to discuss high risk residents, including but is not limited to residents with wandering and/or exit seeking behaviors. Quality of Life meetings will be weekly and continue ongoing.Review of the correction action from 06/27/25 through 07/13/25 verified actions had been taken; audits were completed and education conducted. Staff interviewed verified knowledge of residents at risk for elopement and further verified the recent education and steps implemented to adequately supervise residents identified at risk for elopement. This deficiency represents non-compliance investigated under Complaint Number 1254637.

Based on record review, observation, staff interview, resident interview, and policy review, the facility failed to ensure a safe, clean, homelike environment. This affected 16 residents (#3, #4, #6, #13, #14, #16, #27, #28, #31, #35, #37, #56, #65, #58, #64, and #74) of 16 residents reviewed for a safe, clean, homelike environment. The facility census was 78. Review of Resident #28's medical chart revealed an admission date of 12/27/24. Diagnoses included paranoid schizophrenia, anxiety, hypertension, and insomnia. Review of the quarterly Minimum Data Sat (MDS) assessment dated [DATE] revealed Resident #28 had severely impaired cognition. Further review of the MDS assessment revealed Resident #28 needed setup or clean-up assistance for personal hygiene. Review of Resident #28's care plan dated 07/01/25 revealed Resident #28's functional abilities were impaired as well as a self-care and mobility deficit. Furthermore Resident #28 required staff intervention to complete self-care and mobility activities. Observation on 07/28/25 at 10:54 A.M. of Resident #28's bathroom revealed the toilet in the shared bathroom contained urine, feces, and toilet paper that accumulated to the height of the toilet seat. Feces were noted to be on the back of the toilet seat in multiple areas. Urine and an adult brief were also noted to be on the bathroom floor. Furthermore, there was a small hole that was approximately four inches in width and height in the base of the door to the shared bathroom. Observation on 07/28/25 at 2:05 P.M. of Resident #28's bathroom revealed the toilet in the shared bathroom contained more feces, toilet paper, and urine. Resident #28's bedroom had a strong foul odor. Interview on 07/28/25 at 2:08 P.M. with Certified Nurse Assistant (CNA) #275 verified the feces, urine, and toilet paper in the toilet, the brief and urine on the bathroom floor, and the hole in the shared bathroom door. 2. Review of Resident #37's medical record revealed an admission date of 10/08/24. Diagnoses included generalized anxiety disorder, schizoaffective disorder, and hypertension. Review of the quarterly Minimum Data Sat (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. Observation on 07/30/25 at 8:32 A.M. of Resident #37's bedroom revealed a black substance on the windowsill. Furthermore, the wall was opened and the wood behind the wall was showing through. There was also a black substance on the exposed wood. Plaster was applied to the ceiling in an unsightly manner. Concurrent interview with Resident #37 revealed that the wall and windowsill bothered her as she thought it was unsightly. Interview on 07/30/25 at 8:35 A.M. with Housekeeper #222 verified the exposed wood with a black substance and the windowsill to have a black substance. She also verified the plaster to the ceiling to be unsightly. 3. Residents #31 and #4 are roommates. Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included major depressive disorder severe with psychotic features, Parkinson’s disease with dyskinesia, mixed hyperlipidemia, epilepsy, and bipolar disorder. Review of the MDS assessment, dated 05/23/25, revealed the resident was moderately cognitively impaired. Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included other specified intracranial injury without loss of consciousness, chronic obstructive pulmonary disease, hypoxic ischemic encephalopathy, dysphagia, muscle weakness, unspecified dementia, and other schizoaffective disorder. Review of the MDS assessment, dated 05/30/25, revealed the resident was moderately cognitively impaired. Observation on 07/28/25 at 2:36 P.M. of Resident #4 laying in bed and the room felt warm in temperature. The air conditioner unit in the room was above the resident’s bed and the cord was observed to be unplugged. Interview on 07/28/25 at 2:38 P.M. with the Administrator verified the air conditioner unit electrical cord was unplugged and did not appear to be long enough to plug into the wall. Upon taking temperature of the room the room tempted at 81.1 degrees Fahrenheit. The Administrator verified the temperature of the room. 4. Review of the medical record revealed Resident #6 was admitted on [DATE]. Diagnoses included unspecified dementia, cognitive communication deficit, chronic obstructive pulmonary disease, schizoaffective disorder, and major depressive disorder recurrent. Review of the MDS assessment, dated 08/16/18, revealed the resident was severely cognitively impaired. Observation on 07/28/25 at 2:40 P.M. of Resident #6’s room revealed the temperature was 81.9 degrees Fahrenheit. Subsequent interview with Resident #6 verified his room is always hot. Interview on 07/28/25 at 2:41 P.M. with the Administrator verified Resident #6’s room temperature. 5. Resident #14 and #56 are roommates. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses included paranoid schizophrenia, chronic obstructive pulmonary disease, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 07/12/25, revealed Resident #14 was severely cognitively impaired. Review of the medical record revealed Resident #56 was admitted on [DATE]. Diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, atherosclerotic heart disease of native coronary artery without angina pectoris, generalized anxiety disorder, major depressive disorder, essential hypertension, and hyperlipidemia. Review of the MDS assessment, dated 05/07/25, revealed the resident was moderately cognitively impaired. Observation on 07/28/25 at 2:43 P.M. of Resident #14 and Resident #56’s room revealed the resident room tempted at 77.9 degrees Fahrenheit. Resident #14 and Resident #56 were in the resident room and the air conditioner unit was on and the door had been closed. Subsequent interview with the Administrator verified the temperature of the room was 77.9 degrees Fahrenheit. Interview on 07/28/25 at 2:44 P.M. with Resident #56 stated his room is always hot. 6. Review of the medical record revealed Resident #65 was admitted on [DATE]. Diagnoses included heart failure, personality disorder, type two diabetes mellitus without complications, chronic obstructive pulmonary disease, dysphagia, major depressive disorder recurrent, and schizoaffective disorder. Review of the MDS assessment, dated 07/07/25, revealed the resident was cognitively intact. Review of the physician order, dated 04/25/24, revealed an order for oxygen at 2 liters per minute as needed to keep peripheral oxygen saturation (Sp02) above 90%. Observation on 07/28/25 at 2:48 P.M. of Resident #65 walking down hall calling out the Administrator. Resident #65 was observed telling the Administrator that her room is so hot and that she has respiratory issues and needs a cooler room. Observation on 07/28/25 at 2:50 P.M. of Resident #65’s room revealed the room tempted at 81.1 degrees Fahrenheit. Interview on 07/28/25 at 2:51 P.M. with the Administrator verified Resident #65’s room tempted at 81.1 degrees Fahrenheit. 7. Observation on 07/28/25 at 9:20 A.M. of the bathroom for room [ROOM NUMBER], shared by two residents (#16 and #35), revealed a brown substance scattered on the front of the raised toilet seat, rusty baseboards, and rust at the bottom of the door frame extending from the floor up approximately 12 inches. Observation on 07/28/25 at 9:50 A.M. of the bathroom between rooms numbered 31 and 32, shared by four residents (#13, #27, #64 and #74), revealed brown splatters on the front rim of the toilet bowl and rust at the bottom of both door frames extending from the floor up approximately 12 inches. Additionally, there was a missing section of door frame with a jagged rusted metal edge at floor level, approximately two inches by four inches, leading to room [ROOM NUMBER]. Interview on 07/28/25 at 11:23 A.M. with Resident #27 revealed the rust at the bottom of her bathroom door frame was unsightly and not homelike. Observation and interview on 07/28/25 at 5:00 P.M. with the Director of Nursing verified of the bathroom for room [ROOM NUMBER], shared by two residents contained a brown substance scattered on the front of the raised toilet seat, rusty baseboards, and rust at the bottom of the door frame extending from the floor up approximately 12 inches. Observation and concurrent interview on 07/28/25 at 5:07 P.M. with the Director of Nursing verified the bathroom between rooms numbered 31 and 32, shared by four residents contained brown splatters on the front rim of the toilet bowl and rust at the bottom of both door frames extending from the floor up approximately 12 inches. Additionally, there was a missing section of door frame with a jagged rusted metal edge at floor level, approximately two inches by four inches, leading to room [ROOM NUMBER]. Review of facility policy dated February 2021 and titled “Homelike Environment” revealed the facility would maintain a safe, comfortable, sanitary, and homelike environment for residents. This includes comfortable and safe temperatures (71 degrees Fahrenheit to 81 degrees Fahrenheit). This deficiency represents non-compliance investigated under Complaint Number 2570409.

Based on record review, observation, interview, and policy review, the facility failed to ensure residents could reach their call lights. This affected three residents (#51, #69, and #70) of three residents reviewed for call lights. The facility census was 78. 1. Review of Resident #51's medical record revealed an admission date of 01/21/21. Diagnoses included borderline personality disorder, major depressive disorder, bipolar disorder, and insomnia. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition. Observation on 07/28/25 at 9:52 A.M. of Resident #51's call light revealed the call light to be tangled underneath Resident #51's bed which was out of reach for Resident #51. Interview on 07/28/25 at 9:59 A.M. with Licensed Practical Nurse (LPN) #239 verified the call light was tangled under the resident's bed. 2. Review of Resident #69's medical record revealed an admission date of 03/14/25. Diagnoses included schizophrenia, asthma, and major depressive disorder. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69's cognition was moderately impaired. Observation on 07/30/25 at 7:50 A.M. of Resident #69's call light revealed it was underneath Resident #69's bed which was out of reach for Resident #69. Concurrent interview with Certified Nurse Assistant (CNA) #263 verified the call light to be underneath of Resident #69's bed and out of reach for Resident #69. 3. Review of Resident #70's medical record revealed an admission date of 04/01/22. Diagnoses included schizophrenia, major depressive disorder, and chronic obstructive pulmonary disease (COPD). Review of Resident #70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had moderately impaired cognition. Observation on 07/30/25 at 7:50 A.M. of Resident #70's call light revealed it was underneath Resident #70's bed which was out of reach for Resident #70. Concurrent interview with Certified Nurse Assistant (CNA) #263 verified the call light to be underneath of Resident #69's bed and out of the resident's reach. Review of the facility policy titled Call System, Residents with a last revision date of September 2022 revealed each resident is provided with a means to call staff directly for assistance from his/her bed or from the bathing/toileting facilities.

Based on medical record review, review of self-reported incidents (SRI), staff interview, and review of facility policy the facility failed to report incidents of resident elopement. This affected two (#7 and #13) of two residents reviewed for actual elopements. The facility census was 78. 1. Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included schizoaffective disorder bipolar type, major depressive disorder recurrent, post-traumatic stress disorder, schizoaffective disorder, obsessive compulsive disorder, kleptomania, and cognitive communication deficit.Review of the Minimum Data Set (MDS) assessment, 05/11/25, revealed the resident was moderately cognitively impaired. Review of nursing progress note, dated 06/27/25 at 12:30 A.M., revealed at approximately 12:30 A.M. staff notified the writer Resident #07 was not in her bed. A code brown was immediately called and head count completed. The staff searched the entire unit and facility. The elopement protocol was initiated. Staff continued to search inside and outside the premises and the surrounding neighborhood. Management, power of attorney, and physician were notified. Resident #07 returned to the facility on [DATE] at 4:35 P.M. after being picked up by facility staff in the downtown area (approximately five to six miles away) after being notified by family of Resident #07's location. 2. Review of the medical record revealed Resident #13 was admitted on [DATE] with re-entry on 11/25/24. Diagnoses included schizoaffective disorder depressive type, delusional disorders, mood disorder due to known physiological condition, chronic kidney disease stage 3, auditory hallucinations, essential hypertension, type two diabetes mellitus without complications, schizophrenia, chronic obstructive pulmonary disease, and unspecified systolic heart failure.Review of the Minimum Data Set (MDS) assessment, dated 06/04/25, revealed the resident was cognitively intact. The influenza vaccine was documented as offered and declined. Review of the nursing progress notes, dated 05/28/25 at 9:43 A.M., revealed during the morning change of shift staff noted during rounds Resident #13 was not in her room. A code brown was called and a facility search occurred. Resident #13 was found to be outside in front of the building attempting to cross the street. Review of self-reported incidents dated since 05/28/25 revealed no alleged neglect incidents had been reported for either resident elopement.Interview on 07/29/25 at 11:01 A.M. with the Administrator verified no Self-Reported Incident was completed for resident elopements.Review of policy, Resident Right to Freedom from Abuse, Neglect, and Exploitation policy and procedure, dated 2025, verified the facility's residents have the right to be free from abuse, neglect, and misappropriation of their property and exploitation as defined in the policy. The facility will ensure alleged violations of neglect are reported in the proper time frame pursuant to the policy.

Based on record review, staff interview, and policy review, the facility failed to obtain Preadmission Screening and Resident Review (PASARR) results for Resident #06. Furthermore, the facility failed to obtain a level two PASARR as indicated for Resident #21. This affected two residents (#06 and #21) of two residents reviewed for PASARR. The facility census was 78. 1. Review of Resident #06's medical record revealed an admission date of 01/14/25. Diagnoses included dementia, cognitive communication deficit, schizoaffective disorder, chronic viral hepatitis C, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #06 had severe cognitive impairment. Review of Resident #06's medical record revealed the results from the Preadmission Screening and Resident Review (PASARR) were not present in the chart. Interview on 07/30/25 at 9:48 A.M. with Human Resources (HR) #228 verified the results from the PASARR were not present in the medical chart. 2. Review of Resident #21's medical record revealed an admission date of 01/16/23. Diagnoses included bipolar disorder, depression, schizoaffective disorder, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #21 had intact cognition. Review of Resident #21's medical record revealed Resident #21 required a level two PASARR to be completed. Interview on 07/30/25 at 9:48 A.M. with Human Resources (HR) #228 verified the level two PASARR was not completed for Resident #21. Review of the undated facility policy titled Resident Assessment Policy and Procedure revealed residents with an intellectual disability should have a PASARR completed to determine the level of services needed.

Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to provide the necessary services related to grooming and personal hygiene. This affected one resident (#28) of two residents reviewed for grooming and personal hygiene. The facility census was 78. Review of Resident #28's medical record revealed an admission date of 12/27/24. Diagnoses included paranoid schizophrenia, anxiety, hypertension, and insomnia. Review of the quarterly Minimum Data Sat (MDS) assessment dated [DATE] revealed Resident #28 had severely impaired cognition. Further review of the MDS assessment revealed Resident #28 needed setup or clean-up assistance for personal hygiene. Review of Resident #28's care plan dated 07/01/25 revealed Resident #28's functional abilities were impaired as well as a self-care and mobility deficit. Furthermore Resident #28 required staff intervention to complete self-care and mobility activities. Observation on 07/28/25 at 10:52 A.M. revealed Resident #28 had a large amount of hair on her chin. Concurrent interview with Resident #28 revealed it bothered her to have facial hair. Resident #28 stated a staff person who she could not identify told her they would shave her face today if they had time. Observation on 07/28/25 at 2:05 P.M. revealed Resident #28's facial hair remained unshaven. Interview on 07/28/25 at 2:08 P.M. with Certified Nurse Aide (CNA) #275 verified Resident #28 had a large amount of hair on her chin and stated she would shave it. Review of the facility policy titled Activities of Daily Living (ADL), Supporting with a last revision date of March 2018 revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently which included grooming and personal hygiene.

Based on observations, staff interviews, resident interviews, and review of facility policy, the facility failed to ensure residents received services and equipment to adequately maintain vision. This affected two (Resident #09 and Resident #62) of two residents reviewed for vision. The facility census was 78. 1. Review of the medical record for Resident #62 revealed an admission date of 07/02/20. Diagnoses included glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder. Interview on 07/28/25 at 9:35 A.M. with Resident #62 revealed he had two pairs of glasses that were both broken. Concurrent observation revealed one pair of silver glasses had a missing temple arm on the left side and were ill-fitting due to being bent at the right temple arm. A second pair of black glasses was missing the left lens. Interview on 07/31/25 at 12:25 P.M. with the Director of Nursing confirmed there was no documentation available to confirm Resident #62 had seen an eye doctor. Continued interview revealed Resident #62 was not on the patient list as being seen at the last facility visit made by the eye doctor. The Director of Nursing declined to provide a copy of the patient list stating this was a directive from corporate. Interview on 07/31/25 at 2:15 P.M. with the Director of Nursing confirmed Resident #62 had two pairs of glasses that were broken. 2. Review of the medical record revealed Resident #09 was admitted on [DATE]. Diagnoses included schizoaffective disorder, bipolar disorder, muscle weakness, unspecified psychosis, essential hypertension, type two diabetes mellitus without complications, and muscle wasting and atrophy. Review of the MDS assessment, dated 06/23/25, revealed the resident was cognitively intact. Review of optical services documentation, dated 04/25/19, revealed Resident #09 received glasses. Interview on 07/28/25 at 10:57 A.M. with Resident #09 revealed he had previously had glasses but does not have them anymore. Resident #09 stated he needs glasses. Interview on 07/31/25 at 11:32 A.M. with Licensed Practical Nurse (LPN) #239 and Certified Nursing Assistant (CNA) #263 verified familiarity with Resident #09 and stated they have not seen him with glasses. Interview on 07/31/25 at 12:35 P.M. with the DON verified Resident #09 was not on the list to see the optometrist and did not see them at the last visit to the facility approximately six months ago. Review of policy, Hearing and Vision Services, dated 2025, verified all residents shall have access to hearing and vision services and receive adaptive equipment as indicated.

Based on record review, observation, staff interview, and policy review, the facility failed to administer oxygen per physician orders. This affected one resident (#37) of one resident reviewed for oxygen administration. The facility census was 78. Review of Resident #37's medical record revealed an admission date of 10/08/24. Diagnoses included chronic obstructive pulmonary disease, anemia in chronic kidney disease, and dependence on supplemental oxygen. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. Review of Resident #37's physician's orders revealed an order for oxygen at two to three liters per minute via nasal canula as needed for shortness of breath. Observation on 07/28/25 at 11:25 A.M. of Resident #37's oxygen concentrator revealed her oxygen to be running at four liters per minute via nasal cannula. Observation on 07/28/25 at 3:17 P.M. of Resident #37's oxygen concentrator revealed her oxygen to be running at four liters per minute via nasal cannula. Interview on 07/28/25 at 3:22 P.M. with Licensed Practical Nurse (LPN) #276 verified Resident #37's oxygen concentrator was running at four liters per minute via nasal cannula and the physician order is for three liters per minute via nasal cannula. Review of the undated facility policy titled Oxygen Safety revealed Licensed staff using oxygen will be trained upon hire regarding usage requirements.

Based on medical record review, staff interview, and review of facility policy the facility failed to obtain laboratory testing as ordered. This affected one (Resident #62) of one resident reviewed for laboratory testing. The facility census was 78. Review of the medical record for Resident #62 revealed an admission date of 07/02/20. Diagnoses included glaucoma, alcohol-induced dementia, altered mental status, and major depressive disorder. Continued review of this medical record revealed provider orders dated 05/08/25 for laboratory testing in January and June.Interview on 07/31/25 at 12:00 P.M. with [NAME] President of Clinical Services #301 confirmed Resident #62 had provider orders for laboratory testing to be completed in June and the testing had not been processed.Review of facility policy dated November 2018 titled Lab and Diagnostic Test Results - Clinical Protocol revealed staff would arrange for ordered laboratory testing.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy the facility failed to ensure residents had access to dental services. This affected one (#09) of two residents reviewed for dental services. The facility census was 78.Review of the medical record revealed Resident #09 was admitted on [DATE]. Diagnoses included schizoaffective disorder, bipolar disorder, muscle weakness, unspecified psychosis, essential hypertension, type two diabetes mellitus without complications, and muscle wasting and atrophy.Review of the Minimum Data Set (MDS) assessment, dated 06/23/25, revealed the resident was cognitively intact. Review of care plan, revised on 03/22/21, revealed Resident #09 has some/all missing natural teeth due to poor dental hygiene. The Resident wears upper and lower dentures. Interventions included to coordinate arrangements for dental care, transportation as needed and as ordered.Interview on 07/28/25 at 10:55 A.M. with Resident #09 revealed all of his teeth were missing and he would like to have dentures. Observation on 07/28/25 at 10:56 A.M. revealed Resident #09 opened his mouth to show that he had no teeth. Interview on 07/31/25 at 12:35 P.M. with the Director of Nursing (DON) verified Resident #09 had not seen the dentist and was not on the list to see the dentist. Review of policy, Dental Services, dated 2025, verified the facility shall assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location.

Based on medical record review, resident interview, staff interviews, and review of facility policy, the facility failed to accurately document in the medical record. This affected one (Resident #03) of one resident reviewed for accuracy of documentation. The facility census was 78. Review of the medical record for Resident #03 revealed an admission date of 06/03/25, diagnoses included hemiplegia and hemiparesis affecting the left side following cerebral infarction (stroke), depression, anxiety, heart disease, and bone density disorders.Further review of the medical record for Resident #03 revealed progress notes dated 06/03/25, 06/04/25, 06/06/25, 06/08/25, and 06/27/25 indicating Resident #03 participated in physical therapy. Review of provider orders for Resident #03 revealed there were no orders for physical therapy on admission, nor had physical therapy orders been initiated since admission.Interview on 07/28/25 at 10:00 A.M. with Resident #03 revealed she was not receiving physical therapy services.Interview on 07/30/25 at 10:35 A.M. with Physical Therapist #300 revealed Resident #03 had not received physical therapy.Interview on 07/30/25 at approximately 3:00 P.M. with [NAME] President of Clinical Services #301 confirmed the progress notes for Resident #03 dated 06/03/25, 06/04/25, 06/06/25, 06/08/25, and 06/27/25 indicated the resident participated in physical therapy. Continued interview confirmed Resident #03 did not have orders for physical therapy on admission, nor had physical therapy orders been initiated since admission.Review of facility policy dated July 2017 titled Charting and Documentation indicated documentation in the medical record would be accurate.

Based on medical record review, staff interview, resident interview, review of the admission packet and review of facility policy the facility failed to offer influenza vaccines as required. This affected one (#13) of five residents reviewed for influenza vaccinations. The facility census was 78.Review of the medical record revealed Resident #13 was admitted on [DATE] with re-entry on 11/25/24. Diagnoses included schizoaffective disorder depressive type, delusional disorders, mood disorder due to known physiological condition, chronic kidney disease stage 3, auditory hallucinations, essential hypertension, type two diabetes mellitus without complications, schizophrenia, chronic obstructive pulmonary disease, and unspecified systolic heart failure.Review of the Minimum Data Set (MDS) assessment, dated 06/04/25, revealed the resident was cognitively intact. The influenza vaccine was documented as offered and declined. Review of immunization documentation, dated 10/14/24, revealed the influenza vaccine was marked as refused. Review of Resident #13 census documentation revealed the resident was out to the hospital from [DATE] to 11/25/24. Review of Informed Consent for Influenza Vaccine, no date, revealed Resident #13 provided consent for the facility to administer the influenza vaccine. Review of Informed Consent for Influenza Vaccine, 11/26/23, revealed Resident #13 provided consent for the facility to administer the influenza vaccine. Interview on 07/31/25 at 8:35 A.M. with Assistant Director of Nursing (ADON) #226 revealed Resident #13 was manic at the time the influenza vaccine was offered in the fall and did not receive the vaccine. The ADON #226 verified there is no evidence it was offered again after readmission. Interview on 07/31/25 at 8:55 A.M. with Resident #13 revealed she would want the annual influenza vaccine. Review of the Resident admission Packet, dated, revealed the informed consent for influenza vaccine was included. The informed consent stated the resident is being offered the influenza vaccine because it is recommended by the Advisory Committee on Immunization Practices for your age group to prevent influenza. Vaccine Information Statement for influenza vaccine was also included. Review of the policy, Influenza Vaccine, dated March 2022, verified all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.

Based on record review and staff interview, the facility failed to ensure a physician was notiifed of a resident not receiving antipsychotic medications as ordered by the physician. This affected two (#36 and #53) of four residents reviewed for notification. The facility census was 79. Findings include: 1. Review of Resident #36's medical revealed an admitted [DATE], with diagnoses of schizophrenia, obesity, pseudobulbar affect (PBA), vitamin D deficiency, asthma, bipolar disorder, difficulty in walking, hypokalemia, constipation, and weakness. Review of Resident #36's orders revealed Clozapine (an antipsychotic medication) 100 milligrams (mg) was ordered by the physician to be administered two times a day (BID) by mouth (PO) beginning 01/15/19. Review Resident #36's electronic medication administration record (eMAR) for November 2024 revealed Resident #36 did not receive her physician-ordered dose of Clozapine 100 mg in the evening on 11/08/24, 11/09/24, or 11/10/24. Review of a progress note dated 11/15/24 at 4:24 P.M., which revealed the physician and guardian were aware that Clozapine 100 mg cannot be dispensed until a Patient Services Form (PSF) is completed. (A PSF is a form that is completed in the Clozapine Risk Evaluation and Mitigation (REMS) system to link a patient who is prescribed Clozapine with their prescribing provider to reduce the risk of occurrence or severity of an adverse event. If a resident is linked to a different prescribing provider in the REMS system, the pharmacy will not fill the prescription.) Review of the Pharmacy Manifest of Delivery, dated 11/27/24, revealed Resident #36 had 60 tablets (30-day supply) of Clozapine 100 mg delivered. Review of the eMAR for December 2024 revealed Resident #36 did not receive any of her physician-ordered doses of Clozapine 100 mg on 12/29/24, 12/30/24, and 12/31/24. Review of the eMAR for January 2025 revealed Resident #36 did not receive her ordered evening doses of Clozapine 100 mg on 01/01/25, 01/02/25, and 01/03/25. Concurrent review of the eMAR revealed Resident #36 did not receive her ordered morning doses of Clozapine 100 mg on 01/02/24 and 01/03/24. Review of the medical record revealed no evidence of the physician being notified of the medication not being administered per orders. Interview on 01/30/25 at 10:10 A.M., with Regional Director of Clinical Services (RDNC) #200 verified Resident #36 did not receive the missing doses of Clozapine listed above for the months of November 2024, December 2024, and January 2025. Interview on 02/05/25 at 1:00 P.M., with RDNC #200 verified there was no documentation of physician notification of Resident #53's not receiving medications as ordered. 2. Review of Resident #53's medical record revealed an admitted [DATE] with diagnoses including: cognitive social or emotional deficit following unspecified cerebrovascular disease, benign prostatic hyperplasia (BPH), vitamin D deficiency, tachycardia, morbid obesity, hypertension (HTN), pulmonary embolism, dysphagia, bipolar disorder, violent behavior, mild intellectual disabilities, other sexual dysfunction, anemia, personal history of diseases of the skin and subcutaneous tissues, personal history of COVID-19, paranoid schizophrenia, unspecified psychosis not due to a substance or known physiological condition, anxiety, and insomnia. Review of Resident #53's monthly physician orders for November, December 2024 and January 2025 revealed physician orders for Clozapine 100 mg by mouth every morning, for psychosis and Clozapine 200 mg by mouth every evening, for psychosis. Review of the eMAR for Resident #53 for November 2024 revealed he did not receive his physician-ordered 100 mg dose of Clozapine on 11/23/24 or 11/26/24. Concurrent review revealed he did not receive his physician-ordered 200 mg dose of Clozapine on 11/08/24, 11/09/24, and 11/10/24. Review of the eMAR for Resident #53 for December 2024 revealed he did not receive is physician-ordered 100 mg dose of Clozapine on 12/16/14 and 12/30/24. Concurrent review revealed he did not receive his physician-ordered 200 mg dose of Clozapine on 12/28/24, 12/29/24, and 12/30/24. Review of the eMAR for Resident #53 for January 2025 revealed he did not receive his physician-ordered 100 mg dose of Clozapine on 01/06/25 and 01/07/25. Review of the medical record revealed no evidence of the physician being notified of the medication not being administered per orders. Interview on 02/04/25 at 10:19 A.M. with RDNC #200 verified the medication was not administered per orders and there was no documentation of physician notification of Resident #53's not receiving medications as ordered.

Based on record review, review of policies, review of hospital records, and staff interviews, the facility failed to ensure the mental health of a resident was met when antipsychotic medications were not administered per physician orders. This affected two (#36 and #53) of four residents reviewed for behavioral services. The facility census was 79. Findings include: 1. Review of Resident #36's medical revealed an admitted [DATE], with diagnoses of schizophrenia, obesity, pseudobulbar affect (PBA), vitamin D deficiency, asthma, bipolar disorder, difficulty in walking, hypokalemia, constipation, and weakness. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 10/29/24, revealed a Brief Interview of Mental Status (BIMS) Score of 15, indicating Resident #36 was cognitively intact. Review of the most recent care plan for revealed Resident #36 used psychotropic medications related to schizophrenia. The goal was for the resident to remain free of psychotropic-related drug complications. Interventions include administering psychotropic medications as ordered by the physician. a. Review of Resident #36's orders revealed Clozapine (an antipsychotic medication) 100 milligrams (mg) was ordered by the physician to be administered two times a day (BID) by mouth (PO) beginning 01/15/19. Review Resident #36's electronic medication administration record (eMAR) for November 2024 revealed Resident #36 did not receive her physician-ordered dose of Clozapine 100 mg in the evening on 11/08/24, 11/09/24, or 11/10/24. Review of the electronic medical record (EMR) revealed no documentation on why the evening doses of Clozapine 100 mg for 11/08/24, 11/09/24, and 11/10/24 for Resident #36 was not administered. Review of the EMR for Resident #36 revealed a progress note dated 11/15/24, at 4:24 P.M. which revealed the physician and guardian were aware that Clozapine 100 mg cannot be dispensed until a Patient Services Form (PSF) is completed. (A PSF is a form that is completed in the Clozapine Risk Evaluation and Mitigation (REMS) system to link a patient who is prescribed Clozapine with their prescribing provider to reduce the risk of occurrence or severity of an adverse event. If a resident is linked to a different prescribing provider in the REMS system, the pharmacy will not fill the prescription.) rems Review of the eMAR for December 2024 revealed Resident #36 did not receive any of her physician-ordered doses of Clozapine 100 mg on 12/29/24, 12/30/24, and 12/31/24. Review of a progress note for Resident #36, dated 12/29/24 at 11:01 A.M., revealed Resident #36's morning dose of physician-ordered Clozapine 100 mg was not administered due to not having medication and medication will need to be ordered. Review of a progress note for Resident #36, dated 12/29/24 at 7:47 P.M., revealed Resident #36's evening dose of physician-ordered Clozapine 100 mg was not administered due to being on order. Review of a progress note for Resident #36, dated 12/30/24 at 11:08 A.M., revealed Resident #36's morning dose of physician-ordered Clozapine 100 mg was not administered due to waiting on pharmacy to fill the prescription. Review of a progress note for Resident #36, dated 12/30/24 at 8:39 P.M., revealed Resident #36's evening dose of physician ordered Clozapine 100 mg was not administered due to being on back order. Review of a progress note for Resident #36, dated 12/31/24 at 10:01 A.M., revealed Resident #36's morning dose of physician ordered Clozapine 100 mg was not administered as it had been re-ordered from the pharmacy and the facility was awaiting delivery. Review of a progress note for Resident #36, dated 12/31/24 at 7:58 P.M., revealed Resident #36's evening dose of physician ordered Clozapine 100 mg was not administered due to being on back order. Review of the eMAR for January 2025 revealed Resident #36 did not receive her ordered evening doses of Clozapine 100 mg on 01/01/25, 01/02/25, and 01/03/25. Concurrent review of the eMAR revealed Resident #36 did not receive her ordered morning doses of Clozapine 100 mg on 01/02/24 and 01/03/24. Review of a progress note for Resident #36, dated 01/01/25 at 11:49 A.M., Resident #36 is experiencing alter mental status, cannot answer what her name is or where she is. Review of the progress note for Resident #36, dated 01/01/25 at 7:36 P.M., revealed Resident #36's evening dose of physician-ordered Clozapine 100 mg was not administered due to being on back order. Review of the progress note for Resident #36, dated 01/02/25 at 1:02 P.M., revealed Resident #36's morning dose of physician-ordered Clozapine was not administered due to her having altered mental status and does not understand how to take this medication. Review of the progress note for Resident #36, dated 01/03/25 at 9:21 A.M. revealed Resident #36's morning dose of physician-ordered Clozapine 100 mg, was not administered due to not being available. Review of the progress note for Resident #36, dated 01/03/2/5 at 7:17 P.M., revealed Resident #36's evening dose of physician-ordered Clozapine 100 mg, was anticipated to be delivered to the facility on [DATE]. Review of Resident #36's EMR revealed no documentation the facility notified the physician on 01/01/25, 01/02/25 and 01/03/25, the doses of Clozapine 100 mg were not administered. b. Review of Resident #36's orders revealed Nuedexta (a medication used to treat PBA) 20-10 mg was ordered by the physician to be administered two times a day (BID) by mouth (PO) beginning on 01/15/19. Review of Resident #36's EMR revealed no documentation the facility notified the physician on 11/08/24, 11/09/24, or 11/10/24, the doses of Nuedexta 20-10 mg were not administered. Review Resident #36's eMAR for January 2025 revealed Resident #36 did not receive her physician-ordered dose of Nuedexta 20-10 mg in the evening on 01/02/25, and she did not receive any doses of this medication on 01/08/25. The MAR does not have any documentation for the evening of 01/02/25 and there are no progress notes as to why it was not administered. On 01/08/25, the morning dose was documented in the MAR as refused and there are no progress notes as to why this dose was not administered. On 01/08/25, the MAR does not have any documentation for the evening dose and there are no progress notes as to why it was not administered. Review of Resident #36's EMR revealed no documentation the facility notified the physician on 01/01/25, or 01/08/25, the doses of Nuedexta 20-10 mg were not administered. Review of a progress note, dated 01/02/25 at 11:49 A.M., revealed Resident #36 had altered mental status and was transported to the emergency room (ER) for further evaluation. Review of a progress note, dated 01/02/25 at 10:13 P.M., revealed Resident #36 would be returning from the ER at that time. Review of the hospital discharge records for Resident #36, dated 01/02/25, revealed at 6:42 P.M., the consulting neurologist determined the cause of Resident #36's current state was her not receiving her medications at the facility. At 9:24 P.M., psychiatry evaluated Resident #36 who was showing improvement after medications were administered, and at this time she was able to speak a few words at the time. At this time, psychiatry stated Resident #36's AMS and dystonia were secondary to PBA and her not having her medications. At 9:28 P.M., Resident #36's medication dosing was reviewed with the pharmacies who recommended titrating Resident #36's Clozapine 25 mg twice a day for the first three days; then 50 mg twice a day for the next three days; then 75 mg twice a day for three days and finally back to 100 mg twice a day. Review of a progress note, dated 01/02/25 at 11:28 P.M., revealed Resident #36 returned to the facility via stretcher with a flat facial effect and stated she was glad to be home. Review of the eMAR for January 2025 revealed Clozapine administration was documented in the eMAR as follows: on 01/03/25: both doses were not available; on 01/04/25: AM dose: spit out meds, PM dose: refused; on 01/05/25: both doses were administered; on 01/06/25: AM dose: refused, PM dose: administered on 01/07/25: AM dose: administered, PM dose: refused; and on 01/08/25: AM dose: refused, PM dose: no documentation of administration. Review of progress note for Resident #36 dated 01/06/25 at 4:20 P.M., documented Resident #36 is confused and walking around, and she had never been like this before. Review of progress note, dated 01/08/25 at 5:30 P.M., revealed Resident #36 was refusing to take her medications and is currently taking off her clothes, yelling, and standing on one leg in the hall with no clothes in a statues position staring. Due to Resident #36's changing mental status, causing these behaviors, it was decided at this time to send Resident #36 to the ER again for evaluation. At 6:26 P.M., the progress notes documented transportation arrived to pick up Resident #36 to go to the ER. Review of hospital discharge summary dated 01/09/25 revealed Resident #36 was admitted due to not eating or drinking, carrying for herself and appeared internally stimulated. Resident #36 was observed to be exit seeking, disrobing and non-verbal. Resident #36 has history of Catatonia. Resident #36 was seen a week ago, stabilized and discharged . It was noted Resident #36 progressively decompensated, due to non-availability of her medications for being on back order. At this time of this interview, Resident #36 presents as disorganized, irritable, notably nonverbal and uncooperative with assessment, noted that Resident #36 was nonsensical, yelling and screaming out loud at the emergency department. She was very incoherent, and noncompliance with evaluation. Resident #36 paces the hallway appears somewhat lethargic and irritable. Unable to fully assess due to Resident #36's refusal to engage. Requested medical consultation and a higher level of care to evaluate possible neurological co-mobility. Interview on 01/20/25 at 7:30 A.M., with the Regional Director of Nursing Compliance (RDNC) #200 revealed the facility has a plan for Resident #36's missing doses of Clozapine. Concurrent interview with RDNC #200 verified Resident #36 was transferred to the ER and returned to the facility on [DATE] and was again transferred to the ER [DATE]. Further interview with RDNC #200 revealed Resident #36 had not returned to the facility after her transfer to theER on [DATE]. Interview on 01/30/25 at 10:10 A.M., with RDNC #200 verified Resident #36 did not receive the missing doses of Clozapine and Nuedexta listed above for the months of November 2024, December 2024, and January 2025. Interview on 01/30/25 at 11:35 A.M., with Registered Nurse (RN) #202 revealed he worked the morning shift (6:30 A.M. - 2:30 P.M.) on 01/08/25 and verified Resident #36 was sent to the ER that day as she was walking around the halls naked and was unable to be redirected. Interview on 01/30/25 at 11:50 A.M., via telephone, with the Director of Nursing (DON) revealed that on 01/08/25 Resident #36 was not behaving at her baseline. Concurrent interview with the DON revealed Resident #36 had not returned to her baseline since 01/02/25 ER encounter. Interview on 01/30/25 at 1:07 P.M., with the Administrator revealed Resident #36 was no longer at The University of [NAME] Medical Center (UTMC) and was at an inpatient psychiatric facility in Lorain, OH. Interview on 01/30/25 at 3:04 P.M., with Physician Assistant (PA) #205 was revealed at the time of the mix-up with Resident #36's Clozapine, there was disorganization due to a new DON, Assistant DON (ADON), and psychiatry provider. Concurrent interview with PA #205 revealed he was not aware of the ER's discharge order to titrate Resident #36's Clozapine and she was started on her baseline physician-ordered dose of 100 mg twice a day. Resident #36 was still registered to the previous prescribing provider in the REMS system, so the pharmacy was unable to refill her Clozapine prescriptions that he wrote for. Interview on 02/04/25 at 3:32 P.M., with Regional Director of Clinical Operations (RDCO) #206 verified Resident #36 returned to the facility on [DATE]. RDCO #206 states she spoke to the Nurse Practitioner (NP) with the admitting group on 01/03/25 who stated she did not want to implement the titration orders from the ER for Resident #36's Clozapine. Concurrent interview with RDCO #206 revealed she spoke to PA #205 on 01/04/25 and he stated to resume Resident #36's Clozapine at 100 mg by mouth and twice and did not want to implement the ER recommendations. Interview on 02/04/25 at 3:38 P.M., with PA #205 revealed he spoke to RDCO #206 on 01/04/25 but was not aware of the ER's discharge order to titrate Resident #36's Clozapine. 2. Review of the electronic medical record for Resident #53 revealed an admitted [DATE], with diagnoses including cognitive social or emotional deficit following unspecified cerebrovascular disease, benign prostatic hyperplasia (BPH), vitamin D deficiency, tachycardia, morbid obesity, hypertension (HTN), pulmonary embolism, dysphagia, bipolar disorder, violent behavior, mild intellectual disabilities, other sexual dysfunction, anemia, personal history of diseases of the skin and subcutaneous tissues, paranoid schizophrenia, unspecified psychosis not due to a substance or known physiological condition, anxiety, and insomnia. Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS Score of 10, indicating Resident #53's cognition was moderately impaired. Review of Resident #53's orders revealed physician orders for Clozapine 100 mg by mouth every morning, for psychosis and Clozapine 200 mg by mouth every evening, for psychosis. Review of the eMAR for Resident #53 for November 2024 revealed he did not receive his physician-ordered 100 mg dose of Clozapine on 11/23/24 or 11/26/24. Concurrent review revealed he did not receive his physician-ordered 200 mg dose of Clozapine on 11/08/24, 11/09/24, and 11/10/24. Review of a progress note for Resident #53, dated 11/26/24 at 5:22 A.M., revealed the medication (Clozapine 100 mg) was not available. Review of the eMAR for Resident #53 for December 2024 revealed he did not receive his physician-ordered 100 mg dose of Clozapine on 12/16/14 and 12/30/24. Concurrent review revealed he did not receive his physician-ordered 200 mg dose of Clozapine on 12/28/24, 12/29/24, and 12/30/24. Review of a progress note for Resident #53, dated 12/16/24 at 5:04 A.M., revealed Clozapine 100 mg has not arrived from the pharmacy. The medication was not available, and the facility was awaiting drop ship (expedited delivery) of this medication. Review of a progress note for Resident #53, dated 12/28/24 at 3:31 P.M., revealed Clozapine 200 mg was on order. Review of a progress note for Resident #53, dated 12/29/24 at 3:35 P.M., revealed Clozapine 200 mg was on order. Review of the progress note for Resident #53, dated 12/30/24 at 6:00 A.M., revealed Clozapine 100 mg was on order. Review of the progress note for Resident #53, dated 12/30/24 at 6:55 P.M., revealed Clozapine 100 mg was on order. Review of the eMAR for Resident #53 for January 2025 revealed he did not receive his physician-ordered 100 mg dose of Clozapine on 01/06/25 and 01/07/25. Review of Resident #36's EMR revealed no documentation the facility notified the physician on 11/08/24, 11/09/24, 11/10/24, 11/23/24, 11/26/24, 12/16/24, 12/28/24, 12/29/24, 12/30/24, 01/06/25 and 101/07/25, the doses of Clozapine were not administered as ordered. Interview on 02/04/25 at 10:19 A.M., with RDNC #200 verified Resident #53's physician-ordered Clozapine 100 mg was not administered on 11/23/24, 11/26/24, 12/16/24, 12/30/24, 01/06/24, and 01/07/24. Concurrent interview with RDNC #200 verified Resident #53's physician-ordered Clozapine 200 mg was not administered on 11/08/24, 11/09/24, 11/10/24, 12/28/24, 12/29/24, and 12/30/24. Interview on 02/04/25 at 10:19 A.M., with RDNC #200 verified there was no documentation of physician notification for Resident #53's physician ordered Clozapine 100 mg on 11/23/24, 11/26/24, 12/16/24, 12/20/24, 01/06/25, and 01/07/25; and no documentation of physician notification for Resident #53's physician ordered Clozapine 200 mg on 11/08/24, 11/09/24, 11/10/24, 12/28/24, 12/29/24, and 12/30/24, were not administered. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medications shall be administer in a safe and timely manner, and as prescribed. Review of the policy titled, Adverse Consequences and Medication Errors, revised February 2023, revealed the interdisciplinary team monitors medication usage. An interview on 02/05/25 at 8:29 A.M. with RDNC #200 verified there was no documentation of physician notification for Resident #36's physician-ordered Clozapine 100 mg PO BID not being administered on the evenings of 11/08/24, 11/09/24, 11/10/24, 12/29/24, 12/30/24, 12/31/24, 01/01/25, 01/02/25, 01/03/25, and the mornings of 12/29/24, 12/20/24, 12/31/24, and 01/02/25.

Based on m medical records review, review of pharmacy records, and staff interviews, the facility failed to ensure that physician-ordered medications were available and administered per physcian orders. This affected two residents (#36 and #53) of four residents reviewed for pharmaceutical services. The facility census was 79. Findings include: 1. Review of Resident #36's medical revealed an admitted [DATE], with diagnoses of schizophrenia, obesity, pseudobulbar affect (PBA), vitamin D deficiency, asthma, bipolar disorder, difficulty in walking, hypokalemia, constipation, and weakness. Review of Resident #36's orders revealed Clozapine (an antipsychotic medication) 100 milligrams (mg) was ordered by the physician to be administered two times a day (BID) by mouth (PO) beginning 01/15/19. Review of the Pharmacy Manifest of Delivery, dated 10/21/24, revealed Resident #36 had 60 tablets (30-day supply) of Clozapine 100 mg delivered. Review Resident #36's electronic medication administration record (eMAR) for November 2024 revealed Resident #36 did not receive her physician-ordered dose of Clozapine 100 mg in the evening on 11/08/24, 11/09/24, or 11/10/24. Review of a progress note dated 11/15/24 at 4:24 P.M., which revealed the physician and guardian were aware that Clozapine 100 mg cannot be dispensed until a Patient Services Form (PSF) is completed. (A PSF is a form that is completed in the Clozapine Risk Evaluation and Mitigation (REMS) system to link a patient who is prescribed Clozapine with their prescribing provider to reduce the risk of occurrence or severity of an adverse event. If a resident is linked to a different prescribing provider in the REMS system, the pharmacy will not fill the prescription.) Review of the Pharmacy Manifest of Delivery, dated 11/27/24, revealed Resident #36 had 60 tablets (30-day supply) of Clozapine 100 mg delivered. Review of the eMAR for December 2024 revealed Resident #36 did not receive any of her physician-ordered doses of Clozapine 100 mg on 12/29/24, 12/30/24, and 12/31/24. Review of a progress note for Resident #36, dated 12/29/24 at 11:01 A.M., revealed Resident #36's morning dose of physician-ordered Clozapine 100 mg was not administered due to not having medication and medication will need to be ordered. Review of a progress note for Resident #36, dated 12/29/24 at 7:47 P.M., revealed Resident #36's evening dose of physician-ordered Clozapine 100 mg was not administered due to being on order. Review of a progress note for Resident #36, dated 12/30/24 at 11:08 A.M., revealed Resident #36's morning dose of physician-ordered Clozapine 100 mg was not administer due to waiting on pharmacy to fill the prescription. Review of a progress note for Resident #36, dated 12/30/24 at 8:39 P.M., revealed Resident #36's evening dose of physician ordered Clozapine 100 mg was not administered due to being on back order. Review of a progress note for Resident #36, dated 12/31/24 at 10:01 A.M., revealed Resident #36's morning dose of physician ordered Clozapine 100 mg was not administered as it had been re-ordered from the pharmacy and the facility was awaiting delivery. Review of a progress note for Resident #36, dated 12/31/24 at 7:58 P.M., revealed Resident #36's evening dose of physician ordered Clozapine 100 mg was not administered due to being on back order. Review of the eMAR for January 2025 revealed Resident #36 did not receive her ordered evening doses of Clozapine 100 mg on 01/01/25, 01/02/25, and 01/03/25. Concurrent review of the eMAR revealed Resident #36 did not receive her ordered morning doses of Clozapine 100 mg on 01/02/24 and 01/03/24. Review of the progress note for Resident #36, dated 01/01/25 at 7:36 P.M., revealed Resident #36's evening dose of physician-ordered Clozapine 100 mg was not administered due to being on back order. Review of the progress note for Resident #36, dated 01/02/25 at 1:02 P.M., revealed Resident #36's morning dose of physician-ordered Clozapine was not administered due to her having altered mental status and does not understanding how to take this medication. Review of the progress note for Resident #36, dated 01/03/25 at 9:21 A.M., revealed Resident #36's morning dose of physician-ordered Clozapine 100 mg, was not administered due to not being available. Review of the progress note for Resident #36, dated 01/03/2/5 at 7:17 P.M., revealed Resident #36's evening dose of physician-ordered Clozapine 100 mg, was anticipated to be delivered to the facility on [DATE]. Review of the Pharmacy Manifest of Delivery, dated 01/03/25, revealed Resident #36 had 60 tablets (30-day supply) of Clozapine 100 mg delivered. Interview on 01/30/25 at 10:10 A.M., with Regional Director of Clinical Services (RDNC) #200 verified Resident #36 did not receive the missing doses of Clozapine listed above for the months of November 2024, December 2024, and January 2025. Interview on 01/30/25 at 3:04 P.M., with Physician Assistant (PA) #205 revealed at the time of the mix-up with Resident #36's Clozapine, there was disorganization due to a new DON, Assistant DON (ADON), and psychiatry provider. Interview on 02/05/25 at 1:00 P.M., with RDNC #200 verified a delivery of 60 tablets of Clozapine 100 mg on 11/27/24, which is enough for 30 days for Resident #36. Further interview with RDNC #200 verified Resident #36 did not receive any more deliveries of Clozapine 100 mg until 01/03/25. 2. Review of Resident #53's medical record revealed an admitted [DATE] with diagnoses including: cognitive social or emotional deficit following unspecified cerebrovascular disease, benign prostatic hyperplasia (BPH), vitamin D deficiency, tachycardia, morbid obesity, hypertension (HTN), pulmonary embolism, dysphagia, bipolar disorder, violent behavior, mild intellectual disabilities, other sexual dysfunction, anemia, personal history of diseases of the skin and subcutaneous tissues, personal history of COVID-19, paranoid schizophrenia, unspecified psychosis not due to a substance or known physiological condition, anxiety, and insomnia. Review of Resident #53's monthly physician orders for November, December 2024 and January 2025 revealed physician orders for Clozapine 100 mg by mouth every morning, for psychosis and Clozapine 200 mg by mouth every evening, for psychosis. Review of the Pharmacy Manifest of Delivery, dated 11/02/24 revealed Resident #53 had 30 tablets (30-day supply) of Clozapine 200 mg delivered. Review of the eMAR for Resident #53 for November 2024 revealed he did not receive his physician-ordered 100 mg dose of Clozapine on 11/23/24 or 11/26/24. Concurrent review revealed he did not receive his physician-ordered 200 mg dose of Clozapine on 11/08/24, 11/09/24, and 11/10/24. Review of a progress note for Resident #53, dated 11/26/24 at 5:22 A.M., revealed the medication (Clozapine 100 mg) was not available. Review of the Pharmacy Manifest of Delivery, dated 11/26/24, revealed Resident #53 had 30 tablets (30-day supply) of Clozapine 100 mg delivered. Review of the eMAR for Resident #53 for December 2024 revealed he did not receive is physician-ordered 100 mg dose of Clozapine on 12/16/14 and 12/30/24. Concurrent review revealed he did not receive his physician-ordered 200 mg dose of Clozapine on 12/28/24, 12/29/24, and 12/30/24. Review of a progress note for Resident #53, dated 12/16/24 at 5:04 P.M., revealed Clozapine 100 mg has not arrived from the pharmacy. Review of a progress note for Resident #53, dated 12/28/24 at 3:31 P.M., revealed Clozapine 200 mg was on order. Review of a progress note for Resident #53, dated 12/29/24 at 3:35 P.M., revealed Clozapine 200 mg was on order. Review of the progress note for Resident #53, dated 12/30/24 at 6:00 A.M., revealed Clozapine 100 mg was on order. Review of the progress note for Resident #53, dated 12/30/24 at 6:55 P.M., revealed Clozapine 100 mg was on order. Review of the eMAR for Resident #53 for January 2025 revealed he did not receive his physician-ordered 100 mg dose of Clozapine on 01/06/25 and 01/07/25. Review of the Pharmacy Manifest of Delivery, dated 01/03/25, revealed Resident #54 had 30 tablets (30-day supply) of Clozapine 100 mg delivered and had 30 tablets (30-day supply) of Clozapine 200 mg delivered. Interview on 02/04/25 at 10:19 A.M., with RDNC #200 verified Resident #53's physician-ordered Clozapine 100 mg was not administered on 11/23/24, 11/26/24, 12/16/24, 12/30/24, 01/06/24, and 01/07/24. Concurrent interview with RDNC #200 verified Resident #53's physician-ordered Clozapine 200 mg was not administered on 11/08/24, 11/09/24, 11/10/24, 12/28/24, 12/29/24, and 12/30/24. Interview on 02/05/25 at 1:00 P.M., with RDNC #200 verified a delivery of 30 tablets of Clozapine 200 mg enough for 30 days, for Resident #53 on 11/02/24 and 100 mg 30 day supply delivered on 11/26/24. Further interview with RDNC #200 verified Resident #53 did not receive any further deliveries of this medication until 01/03/25. Review of the policy titled, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00161721.

Based on medical record review, review of a Self-Reported Incident (SRI) investigation, review of a police report, staff interviews, and policy review, the facility failed to provide appropriate supervision to residents who were smoking. This resulted in actual harm when Resident #3 and Resident #8 were unsupervised in the smoking room when an argument took place leading to a physical altercation, causing Resident #3 to sustain a bruised left eye and a broken finger. This affected two (Residents #3 and #8) of three residents reviewed for resident-to-resident altercations. The facility census was 81. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, schizophrenia, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had impaired cognition. The resident was independent with bed mobility, transfers, walking, locomotion on the unit, eating and toileting. Review of a smoking assessment completed 02/04/21 revealed the resident was safe to smoke without supervision. There were no additional smoking assessments included in the medical record. Review of the care plan initiated 10/17/19 revealed the resident required supervision to smoke. Review of a nurse's note dated 09/11/23 at 1:22 P.M. revealed the nurse was notified by housekeeping of two residents fighting in the smoke room. The nurse and the Director of Nursing (DON) walked to the area and noted Resident #3 yelling at Resident #8. Resident #3 said he went to the smoke area and Resident #8 had his feet on Resident #3's chair. Resident #3 sat down and asked Resident #8 to move his feet. Resident #8 said no. Resident #3 stood up and told Resident #8 to give him the chair and Resident #8 started punching Resident #3 in the head. Resident #8 punched Resident #3 ten times and then once right here pointing above his left eye. Resident #3 stated he pushed Resident #8 off himself two times before Resident #8 stopped coming at him, then Resident #3 walked out into the dining room. The nurse checked Resident #3's vitals and completed a skin and pain assessment. The physician was notified and ordered x-rays of the left hand and a computed tomography (CT) of the brain STAT. The resident representative was also notified. Resident #3 and Resident #8 were separated for safety measures. Review of a nurse's note dated 09/11/23 at 7:00 P.M. revealed Resident #3's fifth metacarpal (finger) was fractured. The resident refused to go to the hospital. An orthopedic appointment was scheduled for the following morning. Review of a nurse's note dated 09/12/23 at 11:03 A.M. revealed the resident refused the CT scan. Review of a radiology report dated 09/11/23 revealed Resident #3 had soft tissue swelling and an acute fracture of the fifth metacarpal of the left hand. Review of an orthopedics progress note dated 09/13/23 revealed Resident #3 had mild swelling, ecchymosis, and a fracture to the fifth metacarpal region of the left hand. The resident was placed in an ulnar gutter splint. Review of the medical record for Resident #8 revealed a readmitted [DATE]. Diagnoses included schizoaffective disorder, hypertension, depressive disorder, anxiety, and alcoholic cirrhosis of liver with ascites. Review of the annual MDS assessment completed 06/27/23 revealed the resident had intact cognition. The resident was independent with bed mobility, transfers, walking, locomotion of the unit, eating and toileting. Review of a smoking assessment dated [DATE] revealed the resident was safe to smoke with supervision. No smoking assessment had been completed prior to 09/20/23. Review of a care plan initiated 09/20/23 revealed the resident required supervision to smoke. There was no care plan for smoking prior to 09/20/23. Review of the care plan initiated 05/08/23 revealed Resident #8 had physically aggressive behavior as evidence by initiating aggression toward male peers. Interventions included assessing triggers to behaviors, encouraging coping skills, deep breathing, listening to music and providing diversional activities. Also, to increase the level of observation as needed for safety. Refer to psych services. Review of a nurse's note dated 09/11/23 at 2:42 P.M., Resident #8 reported his feet were on a chair because no one was sitting there. Resident #8 reported Resident #3 walked in the room and pushed Resident #8's feet out of the chair and started yelling. Resident #8 reported Resident #3 grabbed him and he reacted. Resident #8 stated he stood up and swung at Resident #3. Resident #8 reported they naturally stopped fighting. Resident #8 denied pain. Resident #8 had red/purple bruises on the front and back of his left shoulder, right upper inner arm and right side of neck. The physician was notified. No new orders were received. The resident's representative was also notified. Review of a nurse's note dated 09/11/23 at 3:00 P.M., revealed Resident #8 was chuckling and smirking about how he beat up his peer. Review of a police report dated 09/11/23 at 1:00 P.M. revealed the unit responded to the facility for an assault. Resident #3 and Resident #8 stated the argument started over a chair. Resident #3 stated Resident #8 had his feet on a chair and refused to move them. Resident #8 stated Resident #3 pulled the chair away from him completely. This caused an argument in which both Resident #3 and Resident #8 attacked one another in some type of manner, causing bruises on both victims. Victims were advised of follow up procedures. Review of a SRI investigation dated 09/11/23 revealed staff heard two residents arguing in the breakroom. A staff member entered the room and saw Resident #3 and Resident #8 hitting each other. The staff member tried to break up the altercation but was unsuccessful. The staff member got other staff to help separate the two residents and take them to different areas of the unit. The residents were assessed. Resident #8 sustained red marks and possibly bruising to his face. Resident #3 sustained a hand fracture and a black eye. Resident #3 and Resident #8 each said the other started the fight. No other staff was in the room to witness the origin of the altercation. Each resident's physician and representative were notified. Other residents in the area at the time were interviewed and said they were not aware of who started the altercation. Review of a written statement dated 09/11/23 by State tested Nursing Assistant (STNA) #100 revealed while down by the smoke room, residents were smoking. STNA #100 had not seen anything but heard the two residents arguing and going at it with one another. STNA #100 also heard Resident #3 telling Resident #8 that he punched or hit him in the head ten times. Review of statement dated 09/12/23 by the Director of Nursing (DON) revealed speaking with STNA #100 for clarification of statement regarding the altercation between Resident #3 and Resident #8. STNA #100 clarified while she was getting a cigarette for another resident, she heard a commotion. STNA #100 and Housekeeper #120 responded immediately to see what was happening and could not get the residents to separate. Housekeeper #120 went to get assistance. STNA #100 stated she remained in the area in observation. Review of an undated statement by Housekeeper #120 revealed hearing arguing in the smoke room. Upon arrival to the smoking room, Resident #3 and Resident #8 were both throwing punches, and when told to stop, they would not. Housekeeper #120 went to the office and told other staff what was happening, and they came and broke it up. Observation on 09/20/23 at 10:37 A.M. revealed Resident #3 had bruising around his left eye and wore a splint on his left hand. Interview on 09/20/23 at 10:37 A.M. with Resident #3 revealed there was one chair left in the smoking room and Resident #8 had his feet on the chair. Resident #3 reported asking Resident #8 to move his feet off the chair but Resident #8 would not move his feet. Resident #3 stated Resident #8 hit him on the head and head butted him in the left eye. Resident #3 revealed he pushed Resident #8 off himself. Resident #3 stated he had bruising around his left eye and a broken finger. Interview on 09/20/23 at 1:34 P.M. STNA #100 revealed there was no supervision in the smoking room. STNA #100 stated she had a medical condition and was unable to be around cigarette smoke. STNA #100 revealed the facility was provided a physician note for her to not be around cigarette smoke. STNA #100 stated she was sitting across from the smoking room and heard Resident #3 tell Resident #8 he got hit ten times in the head. STNA #100 revealed she yelled for help, and it took less than 30 seconds for Housekeeper #120 to go in the smoking room and tell the residents to stop. STNA #100 stated Housekeeper #120 then went to get additional help. STNA #100 revealed she had not told the residents to stop fighting while Housekeeper #120 went to get help. STNA #100 revealed the fight was over and Resident #3 came out of the smoking room before Housekeeper #120 arrived back to the smoking room with help from the Director of Nursing. Interview on 09/20/23 at 2:11 P.M. with the Director of Nursing (DON) revealed nursing assistants were allowed to trade tasks if they could not do a task. The DON revealed STNA #100 should have approached leadership if she was not able to find someone else to supervise smoking residents. The DON verified STNA #100 provided a physician note for her to not to be around secondhand smoke. The DON revealed the staff assigned to supervise smoking should be standing at the door to see what was going on and should be able to view the residents. Further interview on 09/20/23 at 12:00 P.M., the DON revealed the facility required supervised smoking for all residents. The DON verified Resident #8 had no smoking assessment or smoking care plan completed until 09/20/23. Interview on 09/20/23 at 2:50 P.M. with Housekeeper #120 revealed she heard residents yelling and STNA #100 yelled for help. Housekeeper #120 revealed STNA #100 was sitting outside the smoking room. Housekeeper #120 revealed she told Resident #3 and Resident #8 to stop fighting but they would not, so she went to get help. Housekeeper #120 stated it took less than two minutes to get help and get back to the smoking room, at which time Resident #3 was exiting the smoking room. Interview on 09/20/23 at 5:05 P.M. with Resident #8 revealed Resident #3 pulled a chair out from his feet and they got caught in the chair. Resident #8 stated Resident #3 wanted to sit in the chair. Resident #8 stated a fight happened and it was a big blur. Resident #8 would not say who started the fight. Review of the policy, Smoking Policy-Residents, revised 12/2011, revealed any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. Further review of the policy revealed staff would review the status of a resident's smoking privileges periodically and consult as needed with the Director of Nursing Services and the Attending Physician. This deficiency represents non-compliance investigated under OH00146478.

Based on medical record review, observation, resident interview, staff interview, and review of a Self-Reported Incident (SRI), the facility failed to provide adequate services to de-escalate a verbal altercation between Residents #4 and #83, which resulted in Actual Harm when the altercation progressed to a physical altercation and Resident #4 suffered a right-hand fracture. This affected two residents (#4 and #83) of three residents reviewed for behavioral health services. The facility census was 80. Findings include: Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses including schizophrenia, delusional disorder, and cognitive communication deficit. Review of a plan of care focus area initiated 11/07/19 revealed Resident #4 resided on a secured unit related to refusal of medications with a history of physical aggression towards others at times. Interventions included engaging in activities as needed and as allowed, move to less stimulating area as needed, and redirect as needed. Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired, was independent with bed mobility, eating, toilet use, and personal hygiene and required supervision for dressing, transfers, and ambulation on the unit. Review of the physician orders for April and May 2023 revealed Resident #4 had orders for Ativan solution two milligrams/milliliters (mg/ml) inject one ml intramuscularly every 12 hours as needed for anxiety and/or agitation. Resident #4 required a secured behavior unit related to medication non-adherent and aggressive behaviors due to exacerbation of disease process schizophrenia resulting in impulse control difficulties with poor safety awareness and judgement. Review of the Medication Administration Record (MAR) for 04/30/23 revealed Resident #4 was not administered as needed medications for anxiety or agitation on this date. Review of the nursing progress notes revealed on 04/30/23, Resident #4 was in an altercation with his roommate, Resident #83. An assessment was completed, and the physician and guardian were notified. The resident was placed on one-on-one supervision and the note indicated staff would continue to monitor. Review of a skin assessment dated [DATE] revealed Resident #4 had scratches. No other skin issues noted. Review of a pain assessment dated [DATE] revealed Resident #4 voiced no pain. Further review of the nursing progress notes revealed on 05/01/23, the interdisciplinary team met regarding the altercation last night and the guardian was again made aware of the incident and constant observation continued. Additionally, on 05/01/23, Resident #4 complained of right-hand pain and swelling with bruising noted to the area near the fifth digit. The guardian and physician were notified, and the physician gave an order for right hand x-ray. Mobile x-ray notified and the technician would be out today or tomorrow. On 05/02/23, a message was left for the physician notifying of the x-ray revealing a fifth digit metacarpal fracture to the base, awaiting response. Guardian notified with update of condition. Resident #4 did not complain of pain and refused as needed pain medication and ice pack. The physician returned the call and wanted Resident #4 to be referred to an orthopedic specialist. Lastly, review of a progress note dated 05/03/23 revealed Resident #4 returned from the emergency room (ER) regarding his closed fracture of right hand. The resident was referred to orthopedic surgeon with an appointment scheduled for 05/12/23. Review of a radiology report dated 05/02/23 revealed Resident #4 had an acute avulsion fracture of the fifth metacarpal base. Review of Resident #83's medical record revealed an admitted [DATE], a re-admitted [DATE], and a discharge date of [DATE]. Diagnoses included Parkinson's disease, muscle weakness, major depressive disorder, dementia, delusional disorder, and schizoaffective disorder. Review of a plan of care focus area initiated 12/19/23 revealed Resident #83 had potential to be physically aggressive as evidenced by displayed violence toward female peer and physical threats toward staff. On 04/16/23, the resident struck a male peer and on 04/30/23, the resident struck a male peer. Interventions included adjust voice tone, administer medications as ordered, analyze triggers and what de-escalated the behavior and document, assess and anticipate resident needs, provide physical and verbal cues to alleviate anxiety, engage in activities, and psychiatric consult as indicated. A revision, dated 05/01/23, revealed one-on-one supervision. Review of Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and was independent with activities of daily living (ADLs). Review of a psychiatric progress note dated 04/25/23 revealed Resident #83 continued to be violent toward other residents, unprovoked. The residents' insight and judgment remain severely impaired. It was described and intermittent and worsening. Pertinent findings include agitation, difficulty concentrating, irritability, and oppositional. The symptoms were alleviated by activity and medication. The frequency of episodes was increasing. The resident complained of aggression, agitation/behavior change, depression, disturbance of thinking, and psychosis but denied hallucinations and suicidally. The resident's condition was currently unstable or worsened and to continue current and as needed medications as prescribed. Review of Resident #83's physician orders revealed the following as needed medications: Zyprexa 10 milligrams (mg) ever 24 hours as needed for increased agitation related to schizoaffective disorder, Ativan one mg every eight hours as needed for anxiety/aggression, Ativan injection solution two mg/ml inject 0.5 mg intramuscularly every 12 hours as needed for agitation and increased anxiety, and Haldol solution five mg/ml inject one ml intramuscularly as needed for increased anxiety/agitation. Review of the medication administration record (MAR) revealed on 04/30/23, Resident #83 was not administered any as needed medications for anxiety, aggression, or agitation. Review of a nursing progress note dated 04/30/23 revealed Resident #83 was in an altercation with his roommate. The physician was notified, and Resident #83 was his own guardian. Assessment was completed and the resident was on 15-minute safety checks and one-on-one. The note indicated staff would continue to monitor. Review of the facility SRI investigation, completed 05/04/23, revealed the following timeline on 04/30/23: at approximately 7:15 P.M. Residents #4 and #83 were at the nursing station discussing Resident #83 throwing away his water cup from near the phone. State tested Nurse Aide (STNA) #273 was in the hall, heard Resident #4 asking Resident #83 to wipe drool from the cart and throw away his cup. At approximately 7:30 P.M., both residents were in the dining room/lounge area. Resident #4 stated Resident #83 unplugged the air conditioner (AC) and he told him not to do so. Resident #83 attacked Resident #4. STNA #208 reported being in the shower room and hearing a commotion in the dining room and responded. STNA #273 was down the hall, heard another resident scream, and responded to the area. The residents were separated, assessed for pain and injury, and placed on continuous observation. Further review of the investigation revealed a statement written by STNA #273. STNA #273's statement indicated Resident #83 was using the phone and had drooled on the phone and cart and left a water cup on the cart. Resident #4 asked Resident #83 to wipe up the drool. Resident #83 stated he could not because he had Parkinson's disease. Resident #4 stated please move your cup, I don't know what you have. Resident #83 stated I will hurt you and Resident #4 stated I am not scared of you. Resident #83 went down the hall, Resident #4 used the phone and then went down to the dining room, and STNA #273 went to assist another resident. STNA #273 then heard a commotion, stepped out, and saw the resident's fighting. Observation and interview on 05/24/23 at 9:14 A.M. of Resident #4 revealed the resident ambulating independently throughout the secured unit. Resident #4 stated a few weeks ago, it was really warm in his room, so he opened the window. Resident #83, who was Resident #4's roommate, did not like the window open and began yelling. Resident #4 stated he left his room. Later, in the dining room, Resident #83 unplugged the AC. Resident #4 stated Resident #83 was acting unusual. Resident #4 stated Resident #83 began punching him and he fell to the ground. Resident #83 stomped on his head, chest, and hand. Resident #4 confirmed his right hand was fractured, but he did not want to wear the splint that had been given to him and denied any significant pain. Resident #4 had full range of motion of his right hand and formed a fist. Resident #4 stated he was moved to another room across the hall after the incident. Interview on 05/24/23 at 10:50 A.M. with the Director of Nursing (DON) revealed on 04/30/23, there was an issue between Residents #4 and #83 related to the phone. Resident #83 felt Resident #4 was picking on him. Resident #83 went to the lounge area first, with Resident #4 then going to the area. The STNAs were providing care to other residents at the time. The DON stated Resident #4 was getting on Resident #83 about unplugging the AC. A fight broke out between the two residents and the staff responded to break up the physical altercation. Some scratches were noted on both residents following the altercation. On 05/01/23, bruising and swelling were noted to Resident #4's right hand and an x-ray was ordered. On 05/02/23, the x-ray was completed, and a fracture was identified. The facility physician referred Resident #4 to an orthopedic specialist and the resident sent to theER on [DATE] just to have it splinted until Resident #4 was able to get into the orthopedic specialist. That appointment was scheduled for 05/12/23. The resident refused to go to the appointment and refused to keep his hand splinted. Resident #4 had full range of motion of his right hand. The DON stated Resident #83 signed himself out against medical advise (AMA) on 05/04/23. Additionally, the DON stated Resident #83 had been talking about leaving the facility for some time, but with his behaviors, including aggression and paranoia, there were no options available. Interview on 05/24/23 at 11:09 A.M. with STNA #208 revealed she was working on the secured unit on 04/30/23. STNA #208 stated Resident #83 wanted to leave, he did not want to be at the facility. STNA #208 stated she had been in the shower room with a resident when she heard a lot of commotion, like a loud thump. STNA #208 opened the shower room door to see what was happening and that was when she saw the residents on the floor and Resident #83 had Resident #4 in a choke hold. STNA #208 stated she was able to pry Resident #83's fingers apart so he would let Resident #4 go. At the time of the incident, STNA #208 stated STNA #273 had been in the break room getting something for another resident and the nurse was in the back hall, away from the dining room/lounge area. STNA #208 stated Resident #83 was yelling he wanted to leave and was getting out of here. Following the incident, supervision was increased for both residents. Interview on 05/24/23 at 11:19 A.M. with STNA #273 revealed the altercation between Residents #4 and #83 was all about the AC and window. STNA #273 stated Resident #4 wanted the window open and Resident #83 did not like the air on him. Staff suggested the residents switch beds in their room, which would have placed Resident #4 near the window, but Resident #83 refused to move. STNA #273 stated Resident #83 did not like any suggestions staff made to help make things better. STNA #273 stated Resident #83 was on the phone and Resident #4 was waiting to use it. Resident #83 had drooled on the phone and cart the phone was on. Resident #4 asked Resident #83 to clean up the drool. Resident #83 started yelling at Resident #4 and then went to the dining room. Someone turned the AC on in the dining room and STNA #273 stated she was with another resident when she heard Resident #83 yell I'm going to beat your ass. STNA #273 stated she was with another resident when she saw Resident #83 run toward Resident #4 and hit him. Resident #4 fell , and they were on the floor, on top of each other. STNA #208 came out of the shower room and they were able to get the residents separated. STNA #273 stated Resident #83 did not want to be at the facility and had been aggressive toward other residents and staff. STNA #273 confirmed after Resident #83 walked away from the phone, stating he was going to hurt Resident #4, no increased supervision or activity was provided to decrease Resident #83's anxiety or agitation. Interview on 05/24/23 at 12:12 P.M. with Licensed Practical Nurse (LPN) #234 revealed she did not have much information related to the incident that occurred between the two residents. LPN #234 stated she was passing medication in the back hall and all she knew was Resident #83 had been using the phone, he had a limit on how long he could use the phone and was told he had to get off the phone so others could use it. Resident #83 was drooling on the phone and Resident #4 wanted him to clean up the drool. LPN #234 stated the next thing she knew, they were down the hall fighting. LPN #234 stated both residents had some small scratches as a result of the fight, and it was not until the next day Resident #4 complained of pain in his right hand. LPN #234 stated she did not know how the situation escalated to a physical altercation, but Resident #83 did not want to be at the facility and had been aggressive toward roommates, resulting in room moves, and toward staff. LPN #234 confirmed no as needed medication had been provided to either resident to assist with decreasing anxiety and aggression prior to this incident. Interview on 05/24/23 at 2:34 P.M. with the Administrator and DON revealed Resident #83 had voiced he did not want to be at the facility. However, due to his behavior challenges, they had not been able to secure alternative placement for Resident #83. The DON confirmed Resident #83 had a history of aggression toward staff and residents, including physical altercations with roommates on 03/21/23 and 04/17/23. Resident #4 was Resident #83's third roommate since 03/21/23 due to physical altercations. The Administrator stated the facility did not have any private rooms and it was not possible for Resident #83 to have his own room to prevent conflict between the resident and his roommates. The DON stated psychiatric services had been seeing Resident #83 regularly and had reviewed medications. The DON and Administrator stated the psychiatric services progress notes indicated medication and activity worked best to alleviate Resident #83's aggression and anxiety. The DON confirmed Resident #83 was not administered any as needed medications on 04/30/23, even after the verbal altercation between the residents began, and stated the facility attempted to utilize non-pharmacological interventions to alleviate symptoms prior to administering medications. The DON verified there was no documentation of non-pharmacological interventions implemented in between the verbal and physical altercations between Resident #4 and Resident #83 on 04/30/23. This deficiency represents non-compliance investigated under Complaint Number OH00143028.

Based on closed medical record review, staff interviews, physician interview, review of the facility investigation, review of an emergency medical services (EMS) report, review of the United States National Library of Medicine, National Institute of Health website, and review of facility policy regarding a change in a resident's condition, the facility failed to notify the physician of a significant change in condition for one resident (Resident #140). This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when Resident #140 experienced a low pulse oximetry (pulse-ox) level (a measure of the oxygen saturation of the blood) without physician notification of the change in status and that EMS assessed the resident at the facility and declined transport to the hospital. Resident #140 was found unresponsive with an absence of vital signs five hours after EMS left the facility. The lack of physician notification resulted in Resident #140 not receiving treatment for the low pulse-ox levels and subsequently Resident #140 expired in the facility. This affected one (#140) of five residents (#02, #10, #11, #135, and #140) reviewed for physician notification. The facility census was 81 residents. On [DATE] at 3:01 P.M., Interim Executive Director #700, Interim Executive Director #702, the Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #504 were notified Immediate Jeopardy began on [DATE] at 2:28 P.M. when Registered Nurse (RN) #202 called 911 due to identifying Resident #140 to have a low pulse-ox levels between 75 and 84 percent (normal levels are 95 to 100 percent, levels below 94 percent are considered low, and levels below 92 percent are considered critical) and failed to notify the physician of Resident #140's change in condition with a low pulse-ox level. EMS assessed and treated Resident #140 on-site without transporting the resident to a hospital when leaving the facility at 3:00 P.M. RN #202 failed to notify the physician EMS left the facility without transporting Resident #140 to a hospital. Resident #140 was found unresponsive with no pulse-ox, pulse, or respirations at approximately 8:00 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at approximately 8:00 P.M., RN #202 notified Medical Director #872 of Resident #140's condition, including his death. On [DATE], Corporate Traveling DON #510 obtained witness statements and interviews with staff who provided care for Resident #140. On [DATE], the DON reviewed resident medical records to ensure physician notification occurred with no other incidents noted. On [DATE], the DON began daily audits of resident records for any changes in condition, including physician notification. This will be done daily for three weeks, followed by five times per week indefinitely. On [DATE], the DON obtained a witness statement and clarification on events from RN #202. On [DATE], a root-cause analysis was completed with the interdisciplinary team (IDT) and approved by RDCS #504. The root-cause analysis was discussed with Medical Director #872 during an ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the facility's action plan and to discuss any areas which needed changed or altered. Audits would be submitted to the QAPI committee for further review and recommendations. On [DATE], the DON completed education for all nursing staff regarding notifying the physician when a resident has a change in condition On [DATE] the medical record for three current residents (#02, #10, and #11) and one closed record (#135) were reviewed for physician notification of a change of condition with no concerns identified. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #140's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included COVID-19, unspecified sequelae of unspecified cerebrovascular disease, type II diabetes mellitus without complications, depression, and insomnia. The resident expired in the facility on [DATE]. Review of Resident #140's quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had impaired cognition. The resident did not receive hospice services and did not utilize oxygen at the time of the assessment. Review of Resident #140's nursing progress notes for [DATE], revealed the resident was diagnosed with COVID-19 on [DATE]. The resident's attending physician, Medical Director #872, was notified and new orders were received and implemented. Review of Resident #140's physician orders for [DATE], identified an order dated [DATE] for oxygen via nasal canula at two liters per minute for pulse-ox less than 94 percent, and an order dated [DATE] to check pulse-ox daily for seven days. Review of Resident #140's vital sign record for [DATE] revealed the resident's oxygen level was 94 percent on room air on [DATE] at 5:30 A.M. and was 96 percent on oxygen via nasal canula on [DATE] at 11:31 A.M. No additional pulse-ox levels were documented within the vital sign record on [DATE]. Review of Resident #140's nursing progress notes dated [DATE] and timed 2:48 P.M. revealed Resident #140 was unresponsive to verbal commands and his pulse-ox level was 84 percent on five liters of oxygen. Nine-one-one (911) was contacted, and the nurse obtained the resident's vital signs. There was no documentation the physician was notified of Resident #140's change in condition. Review of the EMS report, dated [DATE], revealed EMS was contacted on [DATE] at 2:28 P.M. regarding a resident with a low pulse-ox level. EMS assessed Resident #140's pulse-ox level to be 84-percent at 2:42 P.M. and 86-percent at 2:46 P.M. The resident was assessed with decreased breath sounds to the left lung. The report revealed the EMS encouraged the facility to continue oxygen therapy and monitor patient. The patient was left in the care of the nursing facility staff and the case was closed at 3:00 P.M. without transporting the resident from the facility. Review of Resident #140's nursing progress notes dated [DATE] and timed 2:53 P.M. revealed the emergency medical technician (EMT) stated Resident #140's symptoms were reflective to those who had COVID-19, they felt taking him to the hospital would not increase chances, and hospital care would not be beneficial. The EMT told staff to keep the resident on oxygen via nasal canula, monitor symptoms, and if (pulse-ox) decreased below 80-percent on rebreather to call 911. There was no documentation the physician was notified of EMS being contacted and not transporting Resident #140. Review of the next nursing progress notes dated [DATE] and timed 8:00 P.M. revealed an unidentified aide checked Resident #140's pulse-ox with no reading observed. Registered Nurse (RN) #280 checked breaths and pulse with none found. Resident #140's body was cold to the touch and cardio-pulmonary resuscitation (CPR) was not started. The physician, Director of Nursing (DON), family, and funeral home were contacted. Review of the facility investigation related to Resident #140's death contained a documented interview statement from RN #202, dated [DATE]. The statement revealed on [DATE] at approximately 3:00 P.M., Resident #140's pulse-ox level was between 75 percent and 80 percent on five liters per minute of oxygen via nasal canula. Nine-one-one (911) was contacted requesting transfer to hospital. The EMT leader stated Resident #140's pulse-ox level was at 90 percent on five liters per minute of oxygen via rebreather mask. RN #202 advocated for Resident #140 to go to the hospital and the EMT leader reported lower oxygen levels were expected with COVID-19 and Resident #140 would not receive better treatment at the hospital. RN #202 ultimately agreed to keep Resident #140 at the facility but would call EMS if he could not keep Resident #140's oxygen level up. At around 8:30 P.M., RN #202 was notified by an unidentified STNA that upon attempting to check Resident #140's pulse-ox there was no reading. RN #202 assessed Resident #140 who was not breathing, and no pulse was found. Resident #140 was cold to touch. RN #202 then contacted Physician #872 who was upset and said RN #202 had messed up and should have sent the resident to the emergency room . Continued review of RN #202's witness statement revealed RN #202 felt guilty that he failed to send Resident #140 to the emergency room . RN #202's statement revealed no documentation or evidence the physician was contacted regarding Resident #140's change in condition, that 911 was called, or that the resident was not sent to the hospital. Review of the documented interview statement from Physician #872, dated [DATE], indicated the nurse called the physician to make aware the patient was not doing well and had a low pulse-ox. The nurse did not call when EMS refused to transport patient. Interviews on [DATE] from 3:42 P.M. to 4:12 P.M. with Interim Administrator #710, and QARN #504 verified RN #202 should have called the physician to notify him when Resident #140 experienced a change in condition and when EMS did not take Resident #140 to the hospital. A telephone interview on [DATE] at 1:35 P.M. with RN #202 revealed 911 was contacted on the afternoon of [DATE] due to Resident #140's oxygen level being low. EMS came to the facility and felt Resident #140's symptoms were consistent with COVID-19 and the hospital wouldn't be able to provide any additional care or services to Resident #140. RN #202 ultimately agreed to keep Resident #140 at the facility, to monitor oxygen levels and to call 911 again if the resident's oxygen level reached below 80 percent while on oxygen. RN #202 stated he should have made EMS take the resident to the hospital and verified he had not contacted the physician regarding Resident #140's status. RN #202 reported on the evening of [DATE], STNA #104 had requested to check Resident #140's pulse-ox. STNA #104 returned stating the resident was not breathing. RN #202 went to Resident #140's room to assess the resident and found the resident was cold to touch. RN #202 verified he did not monitor Resident #140's pulse-ox level or complete an assessment of his condition in between when EMS left the facility at around 3:00 P.M. and when the resident was found unresponsive at around 8:00 P.M., aside from when he went in the resident's room on one occasion at approximately 3:30 P.M. RN #202 also verified he did not contact the physician to notify him of Resident #140's change in condition, that 911 was called, or of EMS not taking Resident #140 to the hospital. RN #202 reported he contacted Physician #872 after Resident #140 expired. RN #202 reported Physician #872 yelled at him, stating he probably deserved it as he should have sent Resident #140 to the hospital. A telephone interview on [DATE] at 2:36 P.M. with Physician #872 verified the physician was not contacted on [DATE] until Resident #140 had already expired. Physician #872 reported he should have been contacted regarding Resident #140's change in condition, as well as when Resident #140 was not sent to the hospital. Physician #872 reported if he had been contacted, he would have made EMS take the resident to the hospital. Physician #872 also reported if a resident was experiencing low or questionable pulse-ox levels, staff would have been instructed/expected to monitor pulse-ox at least every 90 minutes and to call 911 if the pulse-ox level was below 90 percent. Physician #872 reported Resident #140 should have been sent out to the hospital while EMS was at the facility. Interview on [DATE] at 11:43 A.M. with RN #202 revealed facility staff put oxygen up to 5 liters via nasal canula on Resident #140 because he was having trouble. The facility doesn't have any rebreather masks. When the EMS arrived, they placed the rebreather mask on the resident. Review of the facility policy titled Change in a Resident's Condition or Status, revised February 2021, revealed the resident's attending physician would be notified when there has been a significant change in the resident's condition, when there was a need to alter the resident's medical treatment significantly, and when there was a need to transfer the resident to a hospital. Prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact Situation Background Assessment Recommendation (SBAR) Communication Form. Review of the United States National Library of Medicine, National Institute of Health website at www.ncbi.nlm.nih.gov/pub/med/28351240, titled Pulse Oximetry: What the Nurse Needs to Know, an SpO2 less than 94 percent is considered hypoxic. If the SpO2 is less than 90-percent, it is considered a clinical emergency. This deficiency represents non-compliance discovered during the investigation of Complaint Number OH00138813.

Based on closed medical record review, staff interviews, physician interview, review of the facility investigation, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, and review of the American Heart Association Journal, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) or contact emergency medical services (EMS) for one resident (Resident #140) found unresponsive, without a pulse, respirations, or pulse-oximetry (pulse ox) reading, and who was identified as a Full Code status. This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when Resident #140 did not receive CPR after she was discovered with no pulse, respirations, or pulse-ox and EMS was not contacted for assistance. This affected one (#140) of one resident who expired unexpectedly at the facility. The facility census was 81. On [DATE] at 3:01 P.M., Interim Executive Director #700, Interim Executive Director #702, the Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #504. #504 were notified Immediate Jeopardy began on [DATE] at approximately 8:00 P.M. when Resident #140, who was a Full Code resuscitation status, was found unresponsive by State tested Nurse Aide (STNA) #104. STNA #104 notified Registered Nurse (RN) #202 of Resident #140 being unresponsive. RN #202 assessed Resident #140 with no pulse, respirations, or pulse ox, and Resident #140 was cold to the touch. RN #202 chose to not initiate CPR or call EMS. RN #202 contacted Resident #140's physician, the DON, and Resident #140's family to notify them of Resident #140's death. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], at approximately 8:00 P.M., RN #202 notified Medical Director #872 of the incident. On [DATE], Corporate Traveling DON #510 obtained witness statements and interviews with staff who provided care for Resident #140. On [DATE], Business Office Manager (BOM) #600 completed an audit of CPR status and expiration for all nurses. On [DATE], the DON and Executive Director #700 identified there were no other residents who expired in the facility within the past six months. On [DATE], the DON obtained a witness statement and clarification on events from RN #202. On [DATE], Corporate Traveling DON #510 audited all resident charts to identify like-residents with a full code status, for accuracy of the code status. On [DATE], the DON began education to all nurses and STNAs on when to administer CPR per the facility policy. A post-test for validation was completed by staff following the education. On [DATE], the DON completed CPR process education with all nursing staff. On [DATE], a root-cause analysis was completed with the interdisciplinary team (IDT) and approved by RDCS #504. The root-cause analysis was discussed with Medical Director #872 during an ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the facility's action plan and to discuss any areas which needed changed or altered. Beginning on [DATE], a mock code was completed on every shift for one week with evaluation of the mock code and educated after the mock code and results submitted to the QAPI committee. Weekly mocks would then be completed for four weeks with outcomes submitted to the QAPI committee. Interviews on [DATE] with STNA #104 and STNA #218 verified they had been educated in the proper procedure for initiating CPR. On [DATE], the DON began interviewing five staff members, three times per week for five weeks to validate CPR administration understanding. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance 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. Findings include: Review of Resident #140's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included COVID-19, cerebrovascular disease, type II diabetes mellitus, depression, and insomnia. The resident expired in the facility on [DATE]. Review of Resident #140's quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident was cognitively impaired. The resident required extensive assistance of one staff for a majority of the activities of daily living. The resident did not receive hospice services and did not utilize oxygen at the time of the assessment. Review of Resident #140's plan of care, dated [DATE], revealed the resident/responsible party wished for advanced directives and the resident's wishes would be honored. Interventions included full code band worn on wrist. No other interventions were listed. Review of Resident #140's physician orders for [DATE] identified an order for full code status. Review of Resident #140's nursing progress notes, dated [DATE] and timed 8:00 P.M., revealed an unidentified aide checked Resident #140's pulse ox with no reading observed. RN #202 checked respirations and pulse with none found. Resident #140's body was cold to the touch and CPR was not started. The physician, Director of Nursing (DON), and family were contacted. Review of the facility investigation related to Resident #140's death, initiated on [DATE], revealed the DON and Corporate Traveling DON #510 obtained statements from staff working the day Resident #140 expired. Review of the documented interview statement from RN #202, dated [DATE], revealed he was notified by STNA #104 that upon attempting to check Resident #140's pulse ox, there was no reading. RN #202 assessed Resident #140 who was not breathing, and no pulse was found. Resident #140 was cold to touch. RN #202 and the STNA discussed initiating CPR, but since the resident was cold agreed CPR would not be effective. RN #202 called the DON, and the Assistant Director of Nursing (ADON) #508 and left messages. RN #202 then contacted Physician #872. RN #202 then contacted Resident #140's family to inform them of the resident's death. Resident #140's body was picked up by a funeral home representative around 10:00 P.M. Interview on [DATE] at 9:42 A.M. with STNA #104 revealed on [DATE] STNA #104 was not assigned to care for Resident #140 but assisted in attempting to obtain his pulse ox the evening of [DATE]. Resident #140's pulse ox was reading as zero. STNA #104 informed RN #202 who assessed the resident and found the resident wasn't breathing and did not have a pulse. CPR was not performed as the resident had started getting cold. STNA #104 stated she now knew staff should have performed CPR anyway. STNA #104 reported she did not believe 911 was called after Resident #140 was found unresponsive and without a pulse or breathing. STNA #104 reported Resident #140 was pronounced expired by RN #202. A telephone interview on [DATE] at 1:35 P.M. with RN #202 revealed the evening of [DATE], STNA #104 was requested to check Resident #140's pulse ox. STNA #104 returned stating the resident was not breathing. RN #202 went to Resident #140's room to assess the resident and found the resident was cold to touch. RN ##202 verified he did not attempt to perform CPR or call 911 because he believed Resident #140 was already expired. RN #202 reported ultimately no one pronounced Resident #140 as deceased . RN #202 reported he contacted Physician #872, who yelled at him for not sending Resident #140 to the hospital earlier. A telephone interview on [DATE] at 2:36 P.M. with Physician #872 revealed the physician was not contacted until it was obvious Resident #140 had expired. Physician #872 reported if a resident who had a full code status was found unresponsive, CPR should be performed unless there were obvious signs of death such as rigor mortis. Physician #872 reported he could not speculate on whether Resident #140 should have received CPR since he was not there at the facility when the resident was found. Interview on [DATE] at 3:42 P.M. with Interim Executive Director #700 confirmed RN #202 should have initiated CPR on Resident #140, who had a full code status and was found unresponsive on [DATE]. Interview on [DATE] at 9:25 A.M. with the DON verified RN #202 knew Resident #140 was a full code and should have performed CPR. Review of the facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation, revised February 2018, revealed if an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR, Basic Life Support (BLS) shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.970905, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. This deficiency represents non-compliance discovered during the investigation of Complaint Number OH00138813.

Based on closed medical record review, staff interviews, physician interview, review of the facility investigation, review of the emergency medical services (EMS) report, review of the United States National Library of Medicine, National Institute of Health website, and review of facility policy regarding change in a resident's condition, the facility failed to provide assessments and monitoring of a resident with a significant change in condition, send the resident to the hospital when needed, and failed to notify the physician of the change of condition and lack of transport to the hospital for one resident (#140). This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimately resulted in death, when Resident #140 experienced low pulse oximetry (pulse-ox) levels (a measure of the oxygen saturation of the blood), was not transported to the hospital by the EMS staff and was not provided ongoing monitoring of his pulse-ox levels and respiratory status. Resident #140 was found unresponsive with an absence of vital signs five hours after EMS left the facility. This affected one (#140) of five residents (#02, #10, #11, #135, and #140) reviewed for change in condition. The facility census was 81 residents. On [DATE] at 3:01 P.M., Interim Executive Director #700, Interim Executive Director #702, the Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #504 were notified Immediate Jeopardy began on [DATE] at 2:28 P.M. when Registered Nurse (RN) #202 called 911 due to identifying Resident #140 to have low pulse-ox levels between 75 and 84 percent (normal levels are 95 to 100 percent, levels below 94 percent are considered low, and levels below 92 percent are considered critical). EMS assessed and treated Resident #140 on-site without transporting the resident to a hospital when leaving the facility at 3:00 P.M. EMS directed RN #202 to continue oxygen and monitor Resident #140. RN #202 checked Resident #140's pulse-ox level at approximately 3:30 P.M. There was no evidence of any assessment of Resident #140's condition or that any pulse-ox level was checked until Resident #140 was found unresponsive with no pulse-ox, pulse or respiration at approximately 8:00 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at approximately 8:00 P.M., RN #202 notified Medical Director #872 of Resident #140's condition. On [DATE], Corporate Traveling DON #510 obtained witness statements and interviews with staff who provided care for Resident #140. On [DATE], the DON reviewed resident medical records for any changes in condition with no other incidents of not providing assessments and monitoring noted. On [DATE], the DON began daily audits of the resident records for changes in condition. This will be done daily for three weeks, followed by five times per week indefinitely. On [DATE], the DON obtained a witness statement and clarification on events from RN #202. On [DATE], a root-cause analysis was completed with the interdisciplinary team (IDT) and approved by RDCS #504. The root-cause analysis was discussed with Medical Director #872 during an ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the facility's action plan and to discuss any areas which needed changed or altered. Audits would be submitted to the QAPI committee for further review and recommendations. On [DATE], the DON completed education for all nursing staff regarding assessing and monitoring residents with a change of condition. On [DATE], the medical record for three current residents (#02, #10, and #11) and one closed record (#135) were reviewed for change of condition with no concerns identified. Although the Immediate Jeopardy was removed [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #140's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included COVID-19, unspecified sequelae of unspecified cerebrovascular disease, type II diabetes mellitus without complications, depression, and insomnia. The resident expired in the facility on [DATE]. Review of Resident #140's quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had impaired cognition. The resident did not receive hospice services and did not utilize oxygen at the time of the assessment. Review of Resident #140's nursing progress notes for [DATE], revealed the resident was diagnosed with COVID-19 on [DATE]. The resident's attending physician, Medical Director #872, was notified, and new orders were received and implemented. Review of Resident #140's physician orders for [DATE], identified an order dated [DATE] for oxygen via nasal canula at two liters per minute for pulse-ox less than 94 percent, and an order dated [DATE] to check pulse-ox daily for seven days. Review of Resident #140's vital sign record for [DATE] revealed the resident's oxygen level was 94 percent on room air on [DATE] at 5:30 A.M. and was 96 percent on oxygen via nasal canula on [DATE] at 11:31 A.M. No additional pulse-ox levels were documented within the vital sign record on [DATE]. Review of Resident #140's nursing progress notes dated [DATE] and timed 2:48 P.M. revealed Resident #140 was unresponsive to verbal commands and his pulse-ox level was 84 percent on five liters of oxygen. Nine-one-one (911) was contacted, and the nurse obtained the resident's vital signs. Review of the EMS report, dated [DATE], revealed EMS was contacted on [DATE] at 2:28 P.M. regarding a resident with a low pulse-ox level. EMS assessed Resident #140's pulse-ox level to be 84-percent at 2:42 P.M. and 86-percent at 2:46 P.M. The resident was assessed with decreased breath sounds to the left lung. The report revealed the EMS encouraged the facility to continue oxygen therapy and monitor patient. The patient was left in the care of the nursing facility staff and the case was closed at 3:00 P.M. without transporting the resident from the facility. Review of Resident #140's nursing progress notes dated [DATE] and timed 2:53 P.M. revealed the emergency medical technician (EMT) stated Resident #140's symptoms were reflective to those who had COVID-19, they felt taking him to the hospital would not increase chances, and hospital care would not be beneficial. The EMT told staff to keep the resident on oxygen via nasal canula, monitor symptoms, and if (pulse-ox) decreased below 80-percent on rebreather to call 911. There was no documentation the physician was notified of EMS being contacted and not transporting Resident #140. The record contained no additional documentation of any assessment of Resident #140's condition or of Resident #140's pulse-ox level being monitored. Review of the next nursing progress notes dated [DATE] and timed 8:00 P.M. revealed an unidentified State tested Nurse Aide (STNA) checked Resident #140's pulse-ox with no reading observed. Registered Nurse (RN) #280 checked breaths and pulse with none found. Resident #140's body was cold to the touch and cardio-pulmonary resuscitation (CPR) was not started. The physician, Director of Nursing (DON), family, and funeral home were contacted. Review of the facility investigation related to Resident #140's death, initiated on [DATE], revealed the DON and Corporate Traveling DON #510 obtained statements from staff working the day Resident #140 expired. Review of the documented witness statement from RN #205 revealed Resident #140 was in bed during RN #205's shift on [DATE] from 6:30 A.M. to 1:15 P.M. and was sleeping except when he awoke to take scheduled medications. Resident #140 did not eat breakfast or lunch that day. Resident #140's vital signs were within normal limits and the resident was checked on periodically. RN #205 reported Resident #140's condition to the oncoming nurse. Review of the documented interview statement from STNA #115 revealed the STNA checked on Resident #140 at 2:30 P.M. and continued checking on him approximately every 30 minutes until providing incontinence care at approximately 4:00 P.M. Following this interaction, STNA #115 went to the dining area and then to lunch break. Upon returning from lunch break, which began at 7:30 P.M., STNA #115 was informed Resident #140 had expired. Review of the documented interview statement from RN #202, dated [DATE], revealed on [DATE] at approximately 3:00 P.M., Resident #140's pulse-ox level was between 75 percent and 80 percent on five liters per minute of oxygen via nasal canula. Nine-one-one (911) was contacted requesting transfer to hospital. The EMT leader stated Resident #140's pulse-ox level was at 90 percent on five liters per minute of oxygen via rebreather mask. RN #202 advocated for Resident #140 to go to the hospital and the EMT leader reported lower oxygen levels were expected with COVID-19 and Resident #140 would not receive better treatment at the hospital. RN #202 ultimately agreed to keep Resident #140 at the facility but would call EMS if he could not keep Resident #140's oxygen level up. Approximately 30 minutes after EMS left, RN #202 checked on Resident #140, who was not wearing his rebreather mask. Resident #140's pulse-ox level was around 80 percent, the rebreather mask was replaced on the resident, and his oxygen level was rising. At around 8:30 P.M., RN #202 was notified by an unidentified STNA that upon attempting to check Resident #140's pulse-ox there was no reading. RN #202 assessed Resident #140 who was not breathing, and no pulse was found. Resident #140 was cold to touch. RN #202 contacted Physician #872 who was upset and said RN #202 had messed up and should have sent the resident to the emergency room earlier. RN #202's witness statement revealed RN #202 felt guilty that he failed to send Resident #140 to the emergency room . Resident #140's body was picked up by a funeral home representative around 10:00 P.M. Review of the documented interview statement from Physician #872, dated [DATE], indicated the nurse called the physician to make aware the patient was not doing well and had a low pulse-ox. The nurse did not call when EMS refused to transport patient. Interview on [DATE] at 9:42 A.M. with STNA #104 revealed on [DATE] STNA #104 was not assigned to care for Resident #140 but assisted in checking the resident's pulse-ox. Resident #140's pulse-ox was low and 911 was contacted. Later that evening, STNA #104 assisted in attempting to obtain Resident #140's pulse-ox but it was reading as zero. STNA #104 informed RN #202 who assessed the resident and found the resident wasn't breathing and did not have a pulse. STNA #104 reported Resident #140 was pronounced expired by RN #202. A telephone interview on [DATE] at 1:35 P.M. with RN #202 revealed 911 was contacted on the afternoon of [DATE] due to Resident #140's oxygen-level being low. EMS came to the facility and felt Resident #140's symptoms were consistent with COVID-19 and that the hospital wouldn't be able to provide any additional care or services to Resident #140. RN #202 ultimately agreed to keep Resident #140 at the facility, to monitor oxygen, and to call 911 again if the resident's oxygen level reached below 80 percent while on oxygen. RN #202 stated he should have made EMS take the resident to the hospital and verified he had not contacted the physician regarding Resident #140's status. RN #202 reported he went into Resident #140's room on one occasion (possibly around 3:30 P.M.) and Resident #140 had his rebreather off. RN #202 assisted the resident in putting the rebreather back on. On the evening of [DATE], STNA #104 had requested to check Resident #140's pulse-ox. RN #202 agreed. STNA #104 returned stating that the resident was not breathing. RN #202 went to Resident #140's room to assess the resident and found the resident was cold to touch. RN #202 verified he did not monitor Resident #140's pulse-ox level or complete an assessment of his condition in between when EMS left the facility at around 3:00 P.M. and when the resident was found unresponsive at around 8:00 P.M., aside from when he went in the resident's room on one occasion at approximately 3:30 P.M. RN #202 also verified he did not contact the physician to notify him of Resident #140's change in condition, that 911 was called, or of EMS not taking Resident #140 to the hospital. RN #202 reported he contacted Physician #872 after Resident #140 expired. RN #202 reported Physician #872 yelled at him, stating he probably deserved it as he should have sent Resident #140 to the hospital. A telephone interview on [DATE] at 2:36 P.M. with Physician #872 verified the physician was not contacted on [DATE] until Resident #140 had already expired. Physician #872 reported he should have been contacted regarding Resident #140's change in condition, as well as when Resident #140 was not sent to the hospital. Physician #872 reported if he had been contacted, he would have made EMS take the resident to the hospital. Physician #872 also reported if a resident was experiencing low or questionable pulse-ox levels, staff would have been instructed/expected to monitor pulse-ox at least every 90 minutes and to call 911 if the pulse-ox level was below 90 percent. Physician #872 reported Resident #140 should have been sent out to the hospital while EMS was at the facility. Interview on [DATE] at 11:43 A.M. with RN #202 revealed facility staff put oxygen up to 5 liters via nasal canula on Resident #140 because he was having trouble. The facility doesn't have any rebreather masks. When the EMS arrived, they placed the rebreather mask on the resident. Review of the facility policy titled Change in a Resident's Condition or Status, revised February 2021, revealed a significant change of condition is a major decline in the resident's condition. The resident's attending physician would be notified when there has been a significant change in the resident's condition, when there was a need to alter the resident's medical treatment significantly, and when there was a need to transfer the resident to a hospital. Prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact Situation Background Assessment Recommendation (SBAR) Communication Form. Review of United States National Library of Medicine, National Institute of Health website at www.ncbi.nlm.nih.gov/pub/med/28351240, titled Pulse Oximetry: What the Nurse Needs to Know, an SpO2 less than 94 percent is considered hypoxic. If the SpO2 is less than 90 percent, it is considered a clinical emergency. This deficiency represents non-compliance discovered during the investigation of Complaint Number OH00138813.