Every finding on record at Country Lane Gardens Rehab & Nursing CTR

Based on observation, record review, interview with staff and representatives from the local health department (LHD), and review of the facility water management plan, the facility failed to develop and implement an effective water management program to monitor control measures and to prevent the growth of Legionella in the water system. This resulted in Immediate Jeopardy and Actual Harm beginning on 07/27/26 when Resident #9, who demonstrated respiratory complications (i.e. shortness of breath and decreased oxygen saturation) tested positive for Legionella during a hospitalization. Between 07/27/26 and 08/05/26 seven additional residents, (Residents #11, #26, #27, #32, #48, #58, and #78) tested positive for Legionella with six of the seven requiring hospital intervention and treatment including respiratory support and/or intubation for respiratory management. In addition, following the identification of Resident #9 testing positive for legionella, the facility failed to implement immediate and effective interventions to ensure additional residents, staff and visitors were protected from potential exposure to Legionella through the facility's water system. During this time period, water faucets remained operable and without filters for all water sources for use by residents, staff and visitors inside the facility. This affected eight residents (Residents #9, #11, #26, #27, #32, #48, #58 and #78) and had the potential to affect all 74 residents residing in the facility. On 08/05/26 at 3:59 P.M., the Administrator, Director of Nursing (DON), Maintenance Director, [NAME] President of Plant Operations (VPPO) #101, Regional Director of Operations #102, [NAME] President of Operations (VPO)#103, Regional Nurse #108, and [NAME] President of Clinical #109 were notified Immediate Jeopardy began on 07/27/26 when the facility's failure to develop and implement an effective water management plan/program resulted in a legionella outbreak with eight confirmed resident cases and one additional facility employee. The Immediate Jeopardy was removed on 08/07/26 when the facility implemented the following corrective actions: On 07/30/2026 at 12:00 P.M. Ctech Laboratory (a company that tested the water for Legionella) was onsite and obtained water samples from Room A8, F13, E9, the second-floor shower room, maintenance sink and boiler. On 07/30/2026 at 5:10 P.M. point of use water filters were ordered by VPPO #101 with expedited delivery of 08/01/2026 for all areas. On 07/30/2026 at 7:00 P.M. Environmental LCC came to facility and completed hyperchlorination treatment to the facility water system. On 07/31/2026 at 3:00 P.M. letters were sent to residents and families to notify them of a Legionella outbreak. A CDC fact sheet was also provided. On 08/03/2026 at 2:00 P.M. the Administrator, DON/Infection Prevention (IP)Nurse, Maintenance Director #97 and VP of Plant Ops #101 participated in a call with the local health department to review actions taken by the facility related to Legionella. On 08/05/2026 at 9:00 A.M. Ctech returned to the facility to obtain additional water samples (15-20 additional samples were obtained including from the roof AC). On 08/05/2026 at 5:45 P.M. the facility DON/IP nurse and Maintenance Director #97 signed and reviewed water management plan. On 08/06/2026 beginning at 9:00 A.M. to 5:30 P.M. the DON/IP Nurse completed respiratory assessments on all in-house residents. On 08/06/26 Dietary Manager #49 ordered additional water (24 five-gallon jugs) from Magnetic Springs Bottle Water Company with a delivery date scheduled for 08/10/2026. On 08/07/26 the facility had water filters in place to all areas. On 08/07/2026 at 10:00 A.M. the VPO #103, VPPO #101, [NAME] President of Clinical Services (VPCS) #950, DON/IP Nurse, Regional Director of Clinical Services (RDCS) #525, and Unit Manager (UM) #84 met to discuss water sample results which showed positive Legionella growth from the sample taken in the second shower room. (The facility has two shower rooms which are on the same water line). The staff discussed implementation of a plan and staff education. On 08/07/2026 at 11:00 A.M. the DON/IP Nurse and Human Resources (HR) #75 provided education to all staff which included six activities staff, nine dietary staff, nine administrative staff, eight housekeeping staff, one maintenance staff, seven registered nurses (RNs), 20 licensed practical nurses (LPNs) and 31 certified nursing assistants (CNAs) related to shower rooms and a process to audit for filter placement before residents were brought in, audit to be confirmed on shower sheet, correct usage of stall with any issues to be immediately reported. The facility indicated any altering to signage, filters or noncompliance would result in immediate termination. On 08/07/2026 at 12:15 P.M. Nalco Water Management was contracted to begin treatment for Legionella in affected areas. The company would begin remediation on 08/10/26. The treatment plan included two-week monochloride treatment and sample. Repeat treatment and samples. Beginning the week of 08/10/26 the facility planned the following actions and audits to be completed:1. Random water temps and running water in empty rooms weekly which would be audited by regional maintenance via TELS weekly for eight weeks. 2. The DON/designee would review the 24-hour facility report for resident signs and symptoms of illness and standing orders would be followed as applicable five times per week for eight weeks. 3. The Administrator/designee would monitor all rooms without filters for compliance with signage, water turned off and jugged water usage two times per day, five times per week for eight weeks. 4. The facility would communicate and obtain guidance from the local health department, Environmental LLC, Nalco water management and Ctech labs for potential source/ contamination and treatment ongoing. 5. Timely implementation of the health department recommendations would be monitored and audited by RDO #102 and /or RDCS #525. 6. The DON/designee would audit shower sheets for compliance with filter and signage placement five times per week for eight weeks. 7. Maintenance Director #97/designees would audit shower rooms for proper filters and signage twice a day for five days for eight weeks. The facility stated immediate treatment plans would be implemented in accordance with the facility water management policy and guidance from water management consultants and local health department until two negative water results were completed and potential risk was removed as recommended by consultants and local health department. Monitoring of residents would continue for 14 days post remediation. Although the Immediate Jeopardy was removed on 08/07/26, 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: 1. Upon entrance to the facility on [DATE] at 8:48 A.M. a water management policy/plan was requested. As of 08/05/26 at 12:00 P.M. no facility control measure documentation was provided, except water temperature logs. On 08/04/26 at 2:38 P.M. an interview with the Director of Nursing (who was identified as the facility Infection Prevention (IP) Nurse) and Regional Nurse #108 revealed the facility had a Legionella outbreak with eight individuals testing positive for Legionnaire's Disease. The DON stated the facility had been in contact with their local health department regarding the outbreak. During an interview on 08/04/26 at 2:50 P.M., Fairfield County Health Department Staff #104 verified the facility had eight cases (Residents #9, #11, #26, #27, #32, #48, #58, and #78) and one employee (Housekeeper #44) confirmed associated with Legionella as of 08/04/26. LHD Environmental Health Director #105 went out to the facility twice during the prior week and on 08/03/26 had advised the facility to place filters on all water sources and restrict the use of water produced by the facility. A water management policy and plan, undated, was provided on 08/05/26. Review of the plan revealed it included a table which listed the water management team; however, no names were documented as who was on the facility water management team. In the water supply information section under 2b the plan included a [NAME] County municipality as the potable water supplier. However, the city was Westerville, which was an hour and a half away from the facility. In addition, under 2(o) the plan indicated the facility had no holding tanks for potable water; however, there were several holding tanks in the facility. The plan directed for weekly hot water temperature checks to ensure proper heating. A review of the water temperature logs revealed Room A10, A11, A12, B2, B12, C1, C3, C5, C13, D11, D12, F10, F11, and F12 had water temperatures taken on a weekly basis from 04/02/2026 through 07/28/2026. However, no other water temperatures were checked in any other rooms per the logs. The plan revealed this executive summary and risk overview intends to identify areas or devices in your building where risk from Legionella bacteria is greatest. The purpose of this Water Management Program is to minimize growth and transmission of opportunistic waterborne pathogens including Legionella bacteria, the causative agent of Legionnaires' disease. The Program aims to reach this goal by systematically identifying and reducing ways in which building water systems amplify opportunistic waterborne pathogens. Legionella bacteria amplify most rapidly in building water systems which are warm (between 68 degrees F and 120 degrees F), have stagnant conditions including dead legs or storage tanks (encourages bacterial growth and decreases disinfectant levels) Contain biofilm or scale, have long and complex piping, have inadequate disinfection levels, typically when free chlorine values are below 0.5 parts per million (ppm). The Centers for Medicare & Medicaid Services expects Medicare-certified healthcare facilities to have water management policies which reduce the risk of growth and spread of Legionella bacteria and other opportunistic pathogens in building water systems. Part of this process is to conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens can grow and spread in the facility water system. Review of the facility water management plan revealed it did not contain ways to ensure the plan was effective or ways to intervene if control measures were not met. On 08/05/26 at 12:01 P.M., during the review of the facility Water Management Plan (WMP), VPPO #110 stated Maintenance Director (MD) #97 just hits auto-populate in the software system used to document the water temperatures. By using auto-populate, this documented the water temperatures for the same rooms, every time an assessment was completed. VPPO #110 stated he was aware this was being done but he did not instruct MD #97 to record the specific temperatures and the rooms of those being checked. There was no record of the rooms in which water lines were flushed in empty resident rooms to prevent water stagnation and accumulation. VPPO #110 stated during water temperature checks, the hot water was left to run two to three minutes before the hot water temperature was obtained so this was considered flushing the lines in the resident rooms. However, due to the auto-population use, there was no way to identify which room lines were flushed and when. According to the plan, hot water temperatures were measured and recorded from hot water distal outlets daily from resident rooms. There was no evidence this was completed daily. VPPO #110 stated the only place water temperatures were documented was in the software system TELS and he had no additional information to provide to the survey team related to the assessment of the WMP. VPPO #110 verified the WMP provided on 08/05/26 was the plan the facility had access to at the time of the survey entrance but then stated the plan may not have been the most current one available. There was no WMP team identified in the plan he provided and indicated the list must have been lost. Despite information and evidence of the WMP implementation requested several times during day one and day two of the survey, VPPO #110 only provided the water temperature logs as part of the WMP. On 08/07/26 the survey team was provided with additional electronic copies of a Legionella Binder compiled by VPO #103. The binder did not contain evidence of the control measures indicated in the water management program. The contents of the binder were verified with RDO #102 on 08/10/26 at 1:00 P.M. 2. During the onsite investigation, the facility and LHD confirmed eight positive legionella cases for Residents #9, #11, #26, #27, #32, #48, #58, and #78 and one staff, Housekeeper #44. Resident #9 was the first resident identified to test positive for legionella. The eight identified residents resided on either first or second floor and received showers from the facility shower rooms during the month of July 2026. The shower rooms were subsequently confirmed as the source of Legionella in the facility. Housekeeper #44 was also the primary water sample tester for the facility chlorine levels. She was confirmed positive after developing symptoms and required hospitalization for treatment. During an interview on 08/06/26 at 4:41 P.M. VPO #103 stated the facility had not initiated an investigation into the positive Legionella case for Resident #9 , the first Legionella case, since they were unsure if Legionella was in the facility or where the potential source was located. VPO #103 stated she would wait to begin any contact tracing for the affected residents once the source of Legionella was identified and this would also help direct the removal plan for the identified situation of immediate jeopardy. When asked about the lack of WMP information provided to the survey team during the beginning of the survey and how the information provided to the survey team from VPPO #101 was obtained, she stated she didn't know where the information came from as she was not onsite the first few days of the survey. She had a binder to share with the team for review and felt it would show compliance with the facility Legionella WMP and how she believed the facility had done everything they could to prevent a Legionella outbreak in their facility. When asked why the facility staff did not know about the Legionella Binder and the information it contained, the VPO verified she had just compiled the information after she arrived onsite on 08/06/26. When the VPO was asked why the survey team was not provided with the WMP contained in the survey binder, VPO #103 stated she was unsure why the survey team was provided with a different WMP but stated the staff could have contacted her for directions when any concerns, including the WMP, were identified. On 08/07/26 at 3:15 P.M. email communication from VPO #103 revealed the facility showers had tested positive for Legionella and were the source of the facility outbreak. On 08/10/26 at 12:30 P.M. VPO #103 verified seven residents had been hospitalized for Legionella. Two residents did not return to the facility as they transferred to other facilities post hospitalization. One additional resident who had tested positive was treated in the facility. On 08/10/26 at 4:00 P.M. RDO #102 verified the residents who had tested positive for legionella had all used the facility showers during the month of July 2026. 3. Review of Resident #9's medical record revealed an admission date of 06/05/26 with diagnoses including chronic obstructive pulmonary disease, Type 2 Diabetes Mellitus, chronic respiratory failure with hypoxia, muscle weakness and obstructive sleep apnea. Review of Resident #9's shower records revealed the resident received a shower on 07/01/26, 07/04/26, 07/08/26, 07/11/26, 07/15/26, 07/18/26, and 07/22/26. Review of Resident #9's progress note dated 07/25/26 at 1:56 P.M., authored by the DON, revealed the resident was transferred to the hospital for uncontrolled pain after a fall and for a respiratory status evaluation with shortness of breath. No additional respiratory assessment for the resident was documented. Record review revealed positive Legionella urine testing from the hospital dated 07/27/26.Review of Resident #9's hospital record revealed she had tested positive for legionnaire's disease and was having difficulty breathing. On 07/29/26 the pulmonologist wanted to intubate the resident due to her significant shortness of breath, but the resident declined. The pulmonologist ordered C-Pap and high flow oxygen at 60 liters per minute continuously to improve oxygenation. The resident's hospital discharge date could not be determined as the resident was discharged from the hospital to a different nursing facility. During an interview on 08/17/26 at 9:58 A.M., Resident #9's responsible party stated the resident had experienced a fall at the facility which resulted in three broken ribs. The resident was transferred to the hospital due to pain and when she was at the hospital, she was diagnosed with legionella. The doctors and nurses thought the resident was going to die as her oxygen levels were dropping into the 60 percent range (normal 90-100 percent without oxygen) but the resident didn't want to be put on a ventilator so they put her on Bi -Pap while she was hospitalized . The resident really struggled to breathe but she had since improved, and she was doing better now in another nursing facility. 4. Review of Resident #78's medical record revealed an admission date of 03/12/22 with diagnoses including acute and chronic respiratory failure with hypoxia, diabetes, chronic obstructive pulmonary disease, asthma, acute diastolic (congestive) heart failure, and obstructive sleep apnea. Review of Resident #78's shower records revealed the resident received a shower on 07/20/26, and 07/24/26. Review of Resident #78's physicians orders revealed an order dated 07/30/26 for a chest x-ray two views anterior posterior/lateral to rule out pneumonia. Review of Resident #78's nursing progress note dated 08/01/26 at 12:14 P.M., authored by RN #13 revealed the nurse went into the resident's room to administer the resident her medications. Resident #78 seemed more tired than usual and complained of not feeling well and being short of breath. The nurse checked the resident's oxygen saturation, and it was 78 percent. The resident was on bilevel positive airway pressure (BiPAP) at the time. Blood pressure 136/80 millimeters of Mercury (mmHg), pulse 80 beats per minute, and respiratory rate 16 breaths per minute. Resident #78 rated her pain an eight on a one to ten scale, with ten being the worst pain. The nurse called the on-call NP, and he recommended to send the resident to the hospital. The unit manager administrator informed and resident's responsible party were notified. Review of the hospital records for Resident #78 revealed a pulmonology progress note dated 08/02/26 at 11:42 A.M. that documented the resident was currently sedated and intubated, in the intensive care unit (ICU) receiving mechanical ventilation after being diagnosed with legionella. Resident #78 was also diagnosed with severe sepsis, acute respiratory failure, shock, obstructing left ureteral stone with hydronephrosis with urinary tract infection and streptococcal pneumonia. Review of a progress note dated 08/03/26 at 8:12 A.M. documented Resident #78 remained intubated, on the ventilator and receiving a low dose of norepinephrine (used to increase blood pressure). The hospital records indicated the same status on 08/04/26. Review of a progress note dated 08/07/26 at 1:06 P.M. documented Resident #78 had the breathing tube removed on 08/06/26 and was breathing on her own, on oxygen at three liters per minute. Review of the resident's medical record revealed she returned to the facility from the hospital on [DATE]. Interview on 08/13/26 at 12:00 P.M. with Resident #78 revealed she was very sick while in the hospital and on the ventilator for four days due to Legionella/pneumonia. The resident stated she was starting to feel a little better. During the interview, the resident reported being intubated was scary since she couldn't talk to anyone with the breathing tube in place. The resident stated her throat was still sore from the breathing tube but it was starting to get better. 5. Review of Resident #26's medical record revealed the resident had stage IV chronic kidney disease, heart failure, diabetes, and COPD. Review of Resident #9's shower records revealed the resident received a shower on 07/01/26, 07/09/26, 07/15/26, 07/18/26, 07/22/26,07/25/26 and 07/29/26. Review of the nursing progress note dated 07/30/26 at 1:44 A.M. revealed the nurse went to the resident's room and noticed Resident #9 in bed, very weak with excessive sweating. Vital signs were taken with blood pressure 80/50 mmHg, temperature of 102.7 degrees Fahrenheit (F), pulse 103 beats per minute and oxygen saturation at 58 percent on room air. The head of the bed was immediately elevated, and oxygen administered per facility protocol. Resident #9's oxygen saturation improved to 81 percent after the oxygen was applied. The resident was transferred to the emergency room (ER) for further evaluation. Review of the hospital record dated 07/30/26 revealed Resident #26 presented to the emergency room due to increased confusion and was not wearing her usual oxygen at four liters per minute. Emergency Medical Services (EMS) reported her oxygen saturation was in the 50's upon their arrival to the facility. When she arrived at the hospital triage, the resident's saturation was 95 percent on oxygen and she was alert. A chest x-ray was obtained and was concerning for multi-focal pneumonia. Given the resident's sepsis criteria, one liter of intravenous fluids was administered, blood cultures obtained and given antibiotics azithromycin and Rocephin for concerns of pneumonia. Given the resident's condition of kidney injury and acute sepsis, the resident was admitted to the hospital. Resident #26 had a positive Legionella antigen in her urine on 07/30/26 and was diagnosed with Legionella pneumonia. On 08/01/26, the resident was receiving high flow oxygen at nine liters per minute but complained of continued shortness of breath. The resident had significant nausea, vomiting, poor oral intake and now had abdominal distention. A nasogastric tube (an NG tube is inserted through the nose and into the stomach to remove contents and decompress the stomach) trial was initiated with bowel rest for the time being due to refractory symptoms. The resident returned to the facility from the hospital on [DATE]. 6. Review of Resident #32's medical record revealed an admission date of 07/15/25 with diagnoses including schizoaffective disorder depressive type, mild neurocognitive disorder with behavioral disturbance, chronic obstructive pulmonary disease, dementia, and acute respiratory failure with hypoxia. Review of Resident #32's shower records revealed the resident received a shower on 07/03/26, 07/07/26, 07/10/26, 07/11/26, 07/15/26, 07/18/26, and 07/22/26 Review of the progress note dated 07/27/26 documented the nurse practitioner saw Resident #32. She was being seen to complete annual history and physical as well as follow up on cough/chest congestion per the DON's request. She does verbalize having an intermittent cough as well as chest congestion. Review of Resident #32's physicians orders dated 07/27/26 revealed an order for chest x-ray two views, a complete blood count laboratory test and comprehensive metabolic panel laboratory test. The chest x-ray was negative. Review of the nursing progress note dated 07/29/26 at 3:46 P.M. written by Licensed Practical Nurse (LPN) #10 revealed Resident #32's vital signs were abnormal with her oxygen saturation of 86 percent on room air. The resident appeared weak with poor oral intake. The nurse practitioner was notified and new orders received to initiate IV fluids, a urine specimen for urinalysis and culture with sensitivity. Review of the nursing progress note dated 07/30/26 at 8:30 A.M. written by LPN #10 revealed Resident #32 had a condition change that was reported to the medical provider. The resident had mental status change, change in food/fluid intake, worsening function and/or mobility, shortness of breath, The resident's vital signs at the time of the assessment were blood pressure 177/133 mm/Hg, pulse 134 beats per minute and irregular, respirations 31 breaths per minute, temperature 101.2 degrees F and oxygen saturation 85 percent on room air. The on call medical provider was contacted and gave the order to send to the ER. Review of the hospital records revealed a physicians note dated 07/30/26 at 2:32 P.M. that stated Resident #32 was admitted to the progressive care unit (PCU) for concerns of severe sepsis secondary to legionella pneumonia. The resident's oxygen saturation was 94 percent on six liters of oxygen per minute. Review of Resident #32's urine antigen testing dated 07/30/26 revealed the resident was positive for legionella. A hospital physician's note dated 08/02/26 at 1:18 P.M. documented Resident #32's oxygen saturation was 91 to 95 percent on oxygen at 10 liters per minute. The resident returned to the facility from the hospital on [DATE]. 7. Review of Resident #58's medical record revealed an admission date of 03/30/26 with diagnoses including atrial fibrillation, asthma, and acute congestive heart failure. Resident #58 was discharged to the hospital on [DATE] and did not return. Review of Resident #58's shower records revealed the resident received a shower on 07/03/26, 07/07/26, 07/10/26, 07/11/26, 07/15/26, 07/18/26, and 07/22/26. Review of the nursing progress note dated 07/27/26 at 4:35 P.M. by LPN #48 revealed Resident #58 had a temperature of 101.2 degrees F. The NP was notified of the resident's condition and the facility was waiting on any new orders. Review of the nursing progress note dated 07/29/26 at 3:04 P.M. by LPN #54 revealed Resident #58 complained of stomach discomfort and nausea. NP aware. New orders for kidney, ureter and bladder x-ray, Zofran every six hours as needed for nausea and a complete blood count and complete metabolic panel the next day. There was a physician order dated 07/30/26 to obtain a chest x-ray two views anterior posterior/lateral one time only for weakness/fatigue. Review of the progress note written on 07/30/26 at 3:43 P.M. by LPN#10 revealed Resident #58's chest x-ray showed cardiomegaly with prominent interstitial markings in both lungs, concerning pulmonary congestion. Review of the nursing progress note written on 07/31/26 at 8:40 A.M. by LPN #90 revealed upon assessment, Resident #58 had red cheeks and dry lips. Resident #38 stated she was having pain and she pointed to her glasses and then pointed to the base of her chest. Her lung sounds were diminished, and she was unable to take a deep breath. She had abdominal breathing and pursed lips. Her oxygen saturation was 83 percent and oxygen was applied. The on-call provider was notified and sent Resident #38 to the ER. Resident #58 had a urine antigen test on 07/31/26 and was positive for legionella. The resident discharged from the hospital with an unknown date and did not return to the facility. 8. Review of Resident #13's medical record revealed an admission date of 06/20/25 and a recent hospital admission from 08/01/26 to 08/08/26. Diagnoses including chronic obstructive pulmonary disease, asthma and heart failure. Review of Resident #13's shower records revealed the resident received a shower on 07/01/26, 07/03/26, 07/8/26, 07/14/26, 07/17/26, 07/21/26, 07/24/26, and 07/28/26. Review of the nursing progress note dated 07/28/26 at 10:26 A.M., written by LPN #10, stated Resident #13 had a temperature of 100.3 degrees F. Resident #13 was experiencing weakness and had been incontinent with urine and diarrhea all morning. Review the nursing progress note dated 07/28/26 at 1:00 P.M., LPN #10 documented Resident #13's oxygen saturation was 81 percent on room air. A nebulizer breathing treatment was administered and oxygen applied at 2L per nasal cannula. The resident's oxygen saturation improved to 91 percent. The physician arrived and had the oxygen increased to 3L per minute. The physician wrote new orders for labs and a chest x-ray. Review of the nursing progress note dated 08/01/26 at 9:30 A.M. written by LPN #10 that stated at 7:15 A.M., Resident #13 was found vomiting bright yellow bile. The resident had not eaten breakfast. At 9:22 A.M. resident once again vomited bright yellow bile. The resident's abdomen was very distended, and she stated she felt pain upon palpation. The resident has refused multiple times to go to the hospital and is refusing all medications. She has been fully incontinent when usually is fully continent. She's on 4Lpf oxygen via nasal cannula. Vital signs were temperature, 98.2 degrees F., blood pressure 130/70 mm/Hg, respirations 17 breaths per minute and oxygen saturation, 86 percent. The resident had pain, rating a six on a one to ten scale. Review of the nursing progress notes dated 08/01/26 at 10:50 A.M. written by LPN #10 documented that 911 was called and the resident left the facility. Resident #13 had a urine antigen test dated 08/01/26 was positive for legionella. Review of the hospital records for Resident #13 revealed a history and physical dated 08/01/26 that documented the resident was diagnosed with acute respiratory failure with hypoxia, sepsis, legionella pneumonia, and an ileus and was admitted to the progressive care unit (PCU) for continued oxygen support and for bowel monitoring. Resident #13 was receiving oxygen at nine liters per minute and was having rapid shallow breathing and labored to have conversation. Review of a surgical consult dated 08/02/26 documented Resident #13 was diagnosed with acute respiratory failure with hypoxia, sepsis, legionella pneumonia, and ileus. The surgeon recommended nasogastric tube decompression for the ileus and the surgeon further stated the ileus would resolve when the resident's pneumonia was improving and the bowel had been decompressed. Review of a pulmonology consult dated 08/02/26 that documented Resident #13 had acute respiratory failure with hypoxia secondary to legionella pneumonia. Review of the infectious disease consult dated 08/03/26 that documented the resident was being treated with Levofloxacin and was recommended to have 10 to 14 days of antibiotic total therapy for the legionella. Infectious disease also stated that no follow up testing was needed as proof of cure but the mortality rate for a patient who is exposed and infected with Legionella pneumonia and resides in a healthcare facility presumably does have an extremely high mortality rate of one in four. During an interview on 08/11/26 at 1:00 P.M., Resident #13 stated she felt better now with her breathing, she had gone to the hospital because her oxygen dropped and they had to put oxygen on her. She said she was scared because of her breathing trouble while in the hospital. 9. Review of Resident #48's medical record revealed an admission date of 12/19/23 with diagnoses including bipolar disorder, schizoaffective disorder depressive type, chronic kidney disease stage three, hypothyroidism, paranoid schizophrenia, major depressive disorder, and vascular dementia. Review of Resident #48's shower records revealed the resident received a shower on 07/03/26, 07/04/26, 07/06/26, 07/10/26

Based on observations, record review, and staff interviews, the facility failed to maintain heating and cooling systems in operating condition This had the potential to affect all 74 residents. Findings include: A record review of a rental agreement dated 07/01/26 through 07/29/26 showed that the facility needed to rent large Spot Coolers to supplement cooling for the facility.A record review of the inspection reports showed that packaged terminal air conditioner (PTAC) units were cleaned on a quarterly basis. A record review of quarterly inspection reports revealed the last time the packaged terminal air conditioner (PTAC) units were cleaned was 05/15/26.An observation during a tour of the facility on 08/05/26 at approximately 9:25 A.M. with [NAME] President of Plant Operations (VPPO) #101, Maintenance Director (MD) #97, and Contractor #107 revealed a portable residential air conditioning unit in the 1st floor dining area. Further investigation at approximately 10:40 A.M. with the staff revealed the HVAC unit above the 1st floor dining area did not have any visible signs that the unit was working as it should. There was no condensation from PVC piping exiting the unit, vibration from the motor working, or sounds of mechanical operation.An observation during a tour of the facility on 08/06/26 at approximately 3:00 P.M. revealed the air filters in the packaged terminal air conditioner (PTAC) units on the first floor were dirty.An interview with VPPO #101 on 08/05/2026 at approximately 10:40 A.M. stated that the HVAC unit above the dining area has not worked in a while but had an estimate to get it replaced. When asked how long it was not working, he stated he would have to ask MD #97. He stated that they (the facility) maintain all their equipment.An interview with MD #97 on 08/06/26 at approximately 9:05 A.M. stated the HVAC unit hasn't worked since September of 2025. He did not say why it was not working. Further interview with MD #97 stated he cleaned the PTAC units quarterly and didn't know why they were dirty.This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview and review of facility policy the facility failed to dispose of expired medications and ensure medications were dated when opened. This had the potential to affect all residents residing at the facility. The facility census was 82.Findings include:Observation and interview on 03/04/26 at 8:03 A.M. with Licensed Practical Nurse (LPN) #238 during the medication administration, revealed one bottle of Sodium Chloride (mineral) 1 gram (gm) with an expiration date of 11/2025 with an open date of 11/23/25, one bottle of vitamin B12 5000 micrograms (mcg) with an expiration date of 03/27 and no open date, and one bottle of Magnesium Oxide (supplement) 400 milligrams (mg) with an expiration date of 06/27 and no open date. LPN #238 verified the expired medication and the medications that were not dated when they were opened. Observation and interview on 03/04/26 at 9:15 A.M. with Registered Nurse (RN) # 215 of the medication room on the first floor revealed one opened bottle of Tuberculin purified protein derivative, diluted Aplisol with an expiration date of 09/27 and no open date; one unopened bottle of extra strength stool softener Docusate Sodium 250 mg with an expiration date of 02/26; one unopened bottle of Dakins solution (wound cleaner) full strength 16 fluid ounce with an expiration date of 10/25. RN #215 verified the expired medications and the opened bottle of Tuberculin that was opened and not dated. Observation and interview on 03/04/26 at 9:30 A.M. with LPN #168 of medication cart E/F revealed one bottle of vitamin B6 100mg with an open date of 3/03/26 and an expiration date of 01/26. LPN #168 verified the expired medication. Observation and interview on 03/04/26 at 9:40 A.M. with LPN #168 of the treatment cart on the second floor revealed an opened bottle of Dakins solution quarter strength 16 fluid ounce with an expiration date of 05/24, and no open date. LPN #168 verified the expired medication. Review of facility policy titled, Storage of Medications, revised April 2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Review of facility policy titled, Administering Medications, revised December 2012, revealed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on interview, record review, and review of facility policy, the facility failed to develop and implement comprehensive care plans to address identified resident needs and preferences. This affected four residents (#23, #6, #58, and #59) of 33 residents reviewed. The facility census was 82. Findings include:Review of Resident #23's medical record revealed an admission date of 01/31/2026 with diagnoses including primary progressive multiple sclerosis, severe protein-calorie malnutrition, adult failure to thrive, type II diabetes mellitus with complications, bipolar disorder, anxiety disorder, attention-deficit hyperactivity disorder, nicotine dependence, difficulty walking, lack of coordination, and generalized muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had moderately impaired cognition, required substantial to maximal assistance with bathing, toileting hygiene, dressing, and transfers. Resident #23 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident was able to participate in care decisions. Review of Resident #23's Bladder and Bowel assessment dated [DATE] revealed Resident #23 was documented as frequently incontinent of bowel and bladder. Review of the comprehensive care plan for Resident #23 revealed the resident required staff assistance with bathing and personal hygiene; the care plan did not identify resident preferences related to staff providing bathing assistance and did not include interventions addressing resident refusals of bathing care. Review of Resident #23's shower logs, dated 02/09/2026 through 02/19/2026, revealed four total refusals or shower sheets with no supporting documentation if the shower was provided or refused on 02/09/26, 02/12/26, 02/16/2026, and 02/19/2026. Interview with Resident #23 on 03/03/2026 at 9:40 A.M. revealed the resident had concerns regarding bathing and reported he had received only one bath since being admitted in early February. Resident #23 stated he required assistance with bathing and hygiene. Resident #23 further stated he experiences bowel issues and is not always able to make it to the bathroom in time. Resident #23 stated he does not always receive assistance in the mornings when he needs help cleaning up. Interview with Resident #23 on 03/03/2026 at 11:40 AM revealed the resident was asked whether he received a bath on 03/02/2026, as it was his scheduled day for a shower/bath. Resident #23 stated he did not receive a bath on 03/02/2026 and stated no staff member asked if he would like a bath. Resident #23 stated he preferred bathing assistance in the morning. Interview with Certified Nursing Assistant #134 on 03/03/2026 at 11:45 AM revealed nursing assistants follow the facility's shower book to determine when residents are scheduled for showers. CNA #134 stated if a resident is unavailable or declines a shower, staff attempt to offer the shower at least twice and document showers in the record. Interview with CNA #134 and CNA #160 on 03/03/2026 at 3:30 PM confirmed by review of the shower book that Resident #23 did not have a shower sheet completed for 03/02/2026, which was identified as the resident's scheduled shower day CNA #134 and CNA #160 both stated neither worked on 03/02/2026. Interview with CNA #132 on 03/05/2026 at 8:55 AM revealed staff ask residents one to two times if they would like to perform personal hygiene or take a shower. CNA #132 stated if the resident refuses, staff attempt again later and notify the nurse if the resident continues to refuse. Interview with Director of Nursing (DON) #175 on 03/05/2026 at 9:01 AM confirmed the resident's care plan did not include interventions addressing refusals of bathing care or resident preference for staff assisting with bathing. 2.Review of Resident #6's medical record revealed an admission date of 09/08/2022 with diagnoses including cerebral palsy, schizophrenia, schizoaffective disorder bipolar type, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder (PTSD), dysphagia, generalized muscle weakness, and intellectual disability. Review of the psychiatric evaluation completed by Psychiatric Certified Nurse Practitioner (CNP) #248 dated 05/20/2025 revealed Resident #6 had a diagnosis of Post-Traumatic Stress Disorder (PTSD) and reported a history of sexual trauma beginning in childhood. The evaluation documented Resident #6 reported experiencing flashbacks and nightmares every other day and night and identified interactions with male individuals as a trigger that caused increased anxiety, fear, and emotional distress. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #6 dated 02/03/2026 revealed the resident required staff assistance with activities of daily living including transfers, mobility, toileting, bathing, and personal hygiene. Review of Resident #6's comprehensive care plan dated 02/03/2026 revealed a care planned need of Resident #6 requiring staff assistance with activities of daily living including bathing and personal hygiene. The care plan failed to identify the resident's trauma triggers or include individualized interventions for staff to implement to prevent re-traumatization or address PTSD-related symptoms. Interview on 03/02/2026 at 12:45 P.M. with Resident #6 revealed the resident stated she has post-traumatic stress disorder (PTSD) and was unsure if the facility was aware of her triggers. Interview on 03/04/2026 at 1:20 P.M. with Resident #6 revealed the resident reported a history of trauma related to sexual abuse by her father. Resident #6 stated interactions with male individuals can trigger symptoms related to PTSD, and she would prefer to be cared for by female caregivers. Interview on 03/04/2026 at 1:30 PM with CNA #134 regarding Resident #6 revealed CNA #134 stated they were not aware Resident #6 had PTSD or identified triggers related to care. Interview on 03/05/2026 at 9:40 AM with Director of Nursing (DON) #175 regarding documentation of Resident #6's PTSD triggers revealed DON #175 was unable to locate documentation identifying triggers related to PTSD, including interactions with male staff providing care. DON #175 stated they were not aware that interactions with male staff were a trigger for Resident #6. 3. Resident #58 was admitted to the facility on [DATE]. His diagnoses were arthropathy, venous insufficiency, hypokalemia, epilepsy, hyperlipidemia, chronic pulmonary embolism, hypertension, anxiety disorder, major depressive disorder, vitamin D deficiency, vitamin B12 deficiency, dementia, muscle weakness, and insomnia. Review of his minimum data set (MDS) assessment, dated 12/22/25, revealed he was cognitively intact, was dependent on staff for full physical assistance with bathing/showering. Review of Resident #58 shower logs, dated December 2025 to February 2026, revealed nine total refusals or shower sheets with no supporting documentation if the shower was provided or refused on 12/08/25, 12/17/25, 12/29/25, 01/05/26, 01/07/26, 01/21/26, 01/26/26, 02/09/16, and 02/16/26. There was no documentation on the forms to indicate why the shower/bath was refused or why it was not completed on the nine dates. Review of Resident #58's behavior care plan, dated 08/21/25, revealed Resident #58 was identified as someone who can be non-compliant with care and treatment, which included bathing/showering. One of the interventions was for staff to notify the physician of non-compliance with care after more than three refusals. Interview with CNA #132 on 03/05/2026 at 8:55 A.M. revealed they will ask a resident once or twice when it's time perform personal hygiene and/or showers. If the resident refuses, they will try again a short time later. If they continue to refuse, they will let the nurse know. In regard to the care plan intervention, notify physician with three refusals, she understands that as three refusals in the same instance/day for care/shower that they should be notifying the physician. She confirmed there should be documentation of how many times the resident refused and what was done after the last refusal on the forms. Interview with Regional Nurse #217 on 03/05/2026 at 9:01 A.M. revealed the care plan intervention for report for three refusals to physician would be three different instances, like refusing on Monday, Wednesday, and Friday. When told that floor staff stated they took that intervention as three instances on the same day, she confirmed they would have to do some education. She confirmed there was no reasoning why Resident #58 refused his showers. 4. Resident #59 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, morbid obesity, chronic obstructive pulmonary disease, sleep apnea, lymphedema, anxiety disorder, hyperlipidemia, post traumatic stress disorder, bipolar disorder, hypertension, delusional disorder, paranoid personality disorder, insomnia, and irritable bowel syndrome. Review of her minimum data set (MDS) assessment, dated 12/18/25, revealed she was cognitively intact. Review of Resident #59 MDS assessment, section GG, dated 12/22/25, revealed she was dependent on staff for full physical assistance with bathing/showering. Review of Resident #59's's shower logs, dated December 2025 to February 2026, revealed nine total refusals or shower sheets with no supporting documentation if the shower was provided or refused on 12/03/25, 12/17/25, 12/20/25, 12/27/25, 01/14/26, 01/24/26, 01/31/26, 02/07/26, and 02/21/26. There was no documentation on the forms to indicate why the shower/bath was refused or why it was not completed on those dates. Review of Resident #59 's behavior care plan, dated 08/19/25, revealed Resident #59 was identified as someone who can be non-compliant with care. One of the interventions was for staff to notify the physician of non-compliance with care after more than three refusals. Interview with CNA #132 on 03/05/2026 at 8:55 A.M. stated they will ask a resident once or twice when it's time perform personal hygiene and/or showers. If they refuse, they will try again a short time later. If they continue to refuse, they will let the nurse know. In regard to the care plan intervention, notify physician with three refusals, she understands that as three refusals in the same instance/day for care/shower that they should be notifying the physician. She confirmed there should be documentation of how many times the resident refused and what was done after the last refusal on the forms. Interview with Regional Nurse #217 on 03/05/2026 at 9:01 A.M. stated the care plan intervention for report for three refusals to physician would be three different instances, like refusing on Monday, Wednesday, and Friday. When told that floor staff stated they took that intervention as three instances on the same day, she confirmed they would have to do some education. She confirmed there was no reasoning why Resident #59 refused her showers. Review of the facility policy titled Care Plans, Comprehensive Person-Centered revealed the facility policy stated a comprehensive person-centered care plan must be developed and implemented for each resident and include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. The policy stated the interdisciplinary team develops the care plan using information gathered during the comprehensive assessment and the care plan must identify resident needs, preferences, and problem areas and include interventions designed to address those identified needs. The policy also stated the interdisciplinary team must review and update the care plan when resident needs or conditions change or when desired outcomes are not met.

Based on observation, interview, medical record review, review of activities calendars, and review of facility policy, the facility failed to ensure activity preferences were available to aides and failed to complete activities according to preference for Resident #37, #59, #89, and #90. This affected four residents (#37, #59, #89, and #90) of four residents reviewed for activities. The facility census was 82.Findings include: 1.Review of Resident #90's medical record revealed an admission date of 02/27/26 with diagnoses including chronic obstructive pulmonary disease, bipolar disorder, alcohol dependence, and hypertension. Review of Resident #90's admission assessment dated [DATE] revealed the resident was alert to person only. Review of Resident #90's activity assessment dated [DATE] revealed he did not respond to the questions asked. There was no evidence his family was contacted. Review of Resident #90's activity documentation from 02/27/26 to 03/04/26 revealed no evidence Resident #90 had been invited to group activities. The only activity documented was a one on one activity of chatting performed by a nurses aide. Review of Resident #90's care conference dated 03/02/26 revealed activity staff was to offer group activities and review the monthly calendar. Observation on 03/02/26 at 10:30 A.M., 11:40 A.M., 2:12 P.M., and 4:15 P.M. revealed Resident #90 in bed with no entertainment. Observation on 03/03/26 at 9:37 A.M., 10:30 A.M., 11:05 A.M., 1:20 P.M., 2:12 P.M., and 4:15 P.M. revealed Resident #90 in bed with no entertainment. At 1:20 P.M. and 2:12 P.M. activities staff were observed in the common area with craft materials. Interview on 03/03/26 at 1:20 P.M. with Activities #141 verified no residents were participating in the scheduled activity of laundry sorting. Observation on 03/04/26 at 9:35 A.M. revealed Resident #90 in bed. Observation at 10:35 A.M., 1:55 P.M., and 2:29 P.M. revealed the resident in his wheelchair in the hallway with no entertainment. At 10:35 A.M. craft activities were occurring in the common area. Interview on 03/05/26 at 8:37 A.M. Activities #223 revealed she was unable to document any activities for Resident #90 and had no evidence he had participated in or been invited to activities since his admission. 2. Observations on 03/02/26 from 3:15 P.M. to 3:40 P.M., 03/03/26 from 10:00 A.M. to 10:15 A.M., and 03/04/26 from 2:00 P.M. to 2:10 P.M. revealed Resident #59 was lying in bed the entire time. No staff went in her room to ask if she wanted to participate in any activities. Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, morbid obesity, chronic obstructive pulmonary disease, sleep apnea, lymphedema, anxiety disorder, hyperlipidemia, post traumatic stress disorder, bipolar disorder, hypertension, delusional disorder, paranoid personality disorder, insomnia, and irritable bowel syndrome. Review of her minimum data set (MDS) assessment, dated 12/18/25, revealed she was cognitively intact. Review of Resident #59 activity assessments, dated 11/19/25 and 02/19/26, revealed staff will visit her room three times per week. The assessments stated she does not want to participate in activities outside her room, but there was nothing to indicate the question was asked if she wanted to participate in activities in the community. Review of Resident #59's activity logs, dated December 2025 to February 2026, revealed zero activities outside her room, including zero activities in the community. Interview with Resident #59 on 03/02/2026 at 3:21 P.M. confirmed they do not do any activities into the community. She stated she would love to go out to eat at a restaurant or go shopping at a store occasionally, but that is never offered. Interview with Activities Staff #223 on 03/05/26 at 8:38 A.M. confirmed she does not have access to any of the resident's activities assessments. She is not sure what activities each resident would like to complete, unless she gets to know the residents and they tell her. She confirmed they do not have availability or schedule any activities for residents to go out into the community; they will go to the store or pick up food from restaurants and bring them back to the facility. Review of facility activity calendars, dated January 2026 to March 2026, revealed no activities in the community for the residents. 3. Review of Resident #37's medical record revealed an admission date of 11/20/24 with diagnosis including vascular dementia, anxiety disorder, and muscle weakness. Review of an Activities assessment dated [DATE] revealed activities staff will offer independent activities items as needed, staff will offer room visits, she wishes to not participate in group activities, and activity related focuses as per current care plan. Review of most recent Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #37 with moderate cognitive impairment. Review of an Activity plan of care created 07/13/23 and revised 01/23/26 revealed Resident #37 preferred listening to music, doing word searches, going to church services, and staff will provide music and word search books, and crafting supplies for independent activities. Observations made on 03/02/26 at 9:00 A.M., 11:30 A.M. and 3:15 P.M., 03/03/26 at 8:30 A.M., 10:47 A.M., 1:30 P.M. and 3:33 P.M revealed Resident #37 sitting in room and no independent preferred activities provided. Interview on 03/05/26 at 8:38 A.M. with Activities staff #223 revealed 1:1 documentation is completed on paper and kept in a book and the activity coordinator has the book. 1:1 resident individual preferences come from the Activity Director, asking the staff and just by learning what the resident likes. Resident #37 enjoys sitting, talking and going down to the vending machine. Activities staff #223 stated she has not provided any activities for Resident #37 this week. Interview on 03/05/26 at 9:30 A.M. with Activities staff #155 revealed he has not provided any activities this week for Resident #37. 4. Review of Resident #89's record revealed an admission date of 11/12/25 and diagnoses that included but were not limited to major depressive disorder, generalized anxiety disorder, schizoaffective disorder, schizoaffective disorder bipolar type, dementia in other diseases classified elsewhere, and restlessness and agitation. Review of Minimum Data Set (MDS) 3.0 dated 11/12/25 revealed Resident #89 has a Brief Interview of Mental Status score of nine indicating the resident was not cognitively intact. Interview with Resident #89's legal guardian on 03/02/26 at 12:53 P.M. revealed concerns that the resident was not given enough opportunities to engage in activities and believed this was leading to an increase in the residents' behaviors. Resident #89's legal guardian reported the resident would benefit from being able to go outside and did not believe the facility was doing this either. Observations made on 03/03/26 at 10:30 A.M., 11:07 A.M., and 1:30 P.M., and 3:30 P.M. revealed Resident #89 in their room with the door shut and not participating in activities. Residents in the common room were observed to be coloring and/or drawing. Observations made on 03/04/26 from 9:00 A.M to 9:10 A.M., and at 10:40 A.M. revealed Resident #89 in their room with the door shut and not participating in activities. Residents in the common room were observed to be coloring and/or drawing. Review of Resident #89's care plan, initiated 11/12/25, revealed an intervention to encourage resident to attend activities of interest on the unit and to provide activities of interest. Further review revealed an intervention of Resident #89's preferred activities including bingo, dancing, singing, writing and solving math problems, and going outside. The care plan also revealed Resident #89 does not like to color or draw. Review of Resident #89's plan of care (POC) response history for the task of activities on 03/03/26, for the last 30 days, revealed predominately coloring, crafts, 'chit chat', or art being offered to the resident. Further review of the activity task revealed Resident #89's participation was often passive or the resident refused. Review of Resident #89 Documentation Survey Report for one-on-one activities for the last 90 days, on 03/05/26, revealed activities were not consistently offered to Resident #89, and entries entered often labeled the resident as being out of their room or morning news as the activity. Review of the report did not have entries of bingo, music, dancing, or outdoor activities listed for Resident #89. Interview on 03/03/26 at 11:16 A.M. with Activities #223 revealed if a resident does not want to participate in a group activity they will offer a one-on-one activity with the resident. Activities #223 provided examples of sitting in their room and talking and hand massages as activities that would be provided during one-on-ones. Interview with CNA #232 on 03/04/26 at 10:42 A.M. confirmed the residents in the common room were participating in a coloring activity and that craft activities occur often. CNA #232 reported the residents' have an axe throwing game and a balloon game as well that happens a couple times a week. Interview on 03/04/26 at 11:32 A.M. with the Administrator confirmed the facility did not have consistent activity logs to confirm when activities were occurring and which residents were participating in the activity. Additional interview on 03/05/26 at 8:25 A.M. with Activities #223 revealed they keep track of one-on-one activities for some residents on paper due to not having access to it on everyone's chart in their documentation system. Activities #223 revealed activities staff does not have access to residents' activity evaluations to identify what their activity preferences are and will often get the residents' preferences by learning from the residents directly. Activities #223 reported Resident #89 often struggles with group activities due to not being able to sit still for long periods of time, so they will do one-on-ones. Activities #223 identified listening to music and talking as being interests for Resident #89. Activities #223 confirmed the facility was not doing community activities at this time. Review of the facility policy titled Activity Programs, revised August 2006, revealed the activity programs are to be geared to the individual resident's needs. The Activity Programs policy also revealed the individual and group activities are to reflect the schedules, choices, and rights of the residents as well as be reflective of the residents' interests, hobbies and personal preferences. This deficiency represents non-compliance investigated under Complaint Number 2738898.

Based on observation, interviews, and facility policy review, the facility failed to maintain a clean, sanitary environment free from pests. This had the potential to affect all 12 residents residing on the C hall. The facility census was 82.Findings include:Observation on 03/02/26 at 2:48 P.M. and 03/03/26 at 8:00 A.M. revealed live cockroaches iwere observed in Resident #42's room.Interview on 03/03/26 at 8:00 A.M. with Resident #42 revealed he sees them all the time, sometimes he can't sleep because they are crawling in his bed. He also stated he will see them on the walls.Medical record review revealed a progress note dated 10/03/25 authored by Licensed Practical Nurse (LPN) #182 of Resident #42's room being treated by by the exterminator as insects and bugs were observed throughout the room.Interview on 03/03/26 at 8:30 A.M. with LPN #129 verified Resident #42's had live cockroaches currently in his room. Interview on 03/03/26 at 8:35 A.M. with CNA #210 and CNA #132 revealed they had taken Resident #42 his meal tray into his room before and seen cockroaches crawling on his bedside table and in his bed.Interview on 03/03/26 from 9:00 A.M. to 9:30 A.M. revealed two other Residents (#26 and #34) verified they have observed live cockroaches in the C hallway.Review of pest control invoices dated 09/18/25, 10/06/25, 11/14/25, 12/30/25, 01/09/26, 01/30/26, and 02/20/26 revealed no evidence of cockroaches and target pests which included cockroaches.Review of facility policy titled Pest Control last revised May 2008. Revealed our facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to continuously eliminate any insects and rodents. This deficiency represents non-compliance investigated under Master Complaint Number 2738898 and Complaint Number 2730179.

Based on medical record review, interview and review of facility policy, the facility failed to timely review baseline care plans for one (Resident #8) of 33 reviewed. The census was 82.Findings include:Medical record review revealed Resident #8 was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, morbid (severe) obesity, neuromuscular dysfunction of bladder, stage IV pressure ulcer of right buttock, congestive heart failure, atrial fibrillation, paraplegia, and tracheostomy status. Review of the admission Nursing assessment dated [DATE] revealed an unsigned Baseline Care Plan. There was no evidence the resident was provided with the baseline care plan or that it had been reviewed with Resident #8.Interview on 03/03/26 at 2:47 P.M. with Regional Nurse #237 verified Resident #8 had not been provided with a copy or explained the baseline care plan during the required time frame.Review of facility policy title Care Plans, Comprehensive Person-Centered, revised December 2016 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on record review, interview and facility policy review, the facility failed to provide non pressure skin treatments as ordered for Resident #27 and #67. The facility also failed to accurately document the correct location for a skin alteration for Resident #67. This affected two (Resident #27 and #67) of two residents reviewed for non-pressure skin alterations. The facility census was 82.Findings include:1. Review of the medical record for Resident # 67, revealed an admission date of 12/24/24. Diagnoses included but were not limited to type II diabetes mellitus, morbid (severe) obesity due to excess calories, dementia, and rheumatoid arthritis with rheumatoid factor. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident has a severe cognitive impairment. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was assessed to have no skin conditions. Review of the active plan of care for Resident #67 revealed an at risk for red and/or open areas related to present condition, needs assist with bed mobility, toileting, with fluctuating ability with interventions including but not limited to follow facility protocols for treatment of injury and monitor/document location, size and treatment of skin injury. Review of the progress note for Resident #67 dated 02/13/26 revealed two open areas on the right gluteal fold, one the size of an eraser head and the other just smaller than a dime. Physician on call service called. Review of the physician orders and the Treatment Administration Record (TAR) for Resident #67 dated 02/13/26 through 02/16/26 revealed no treatment ordered or treatment being completed for the two open areas on the right gluteal fold. Review of the weekly wound observation tool for Resident #67 dated 02/16/26 revealed an abrasion to the back of the right thigh with measurements, assessment, and a treatment order. Review of the physician order for Resident #67 dated 02/16/26 revealed for the abrasion of the back right thigh to cleanse with normal saline and apply Zinc barrier cream every shift and as needed until healed. Review of the medical record for Resident #67 dated 02/16/26 through 02/24/26 revealed no documentation and treatment order for the two open areas of the right gluteal fold. Review of the weekly wound observation tool for Resident #67 dated 02/24/26 revealed the gluteal fold, (no exact location), other skin alteration (no type provided) acquired on 02/13/26 was healed out. Interview on 03/05/26 at 8:16 A.M. with the Assistant Director of Nursing (ADON) #215 verified Resident #67, had an area discovered on 02/13/26 that was located on the right gluteal fold and no treatment was ordered until 2/16/26. On 2/16/26, the area was incorrectly documented as being located on the resident's back right thigh for the assessment and the treatment order, but was correctly documented for the site but not type of alteration or location of the alteration and was healed out on 02/24/26. That documentation was completed on paper as she was not aware she had to complete a healed out note for skin alteration areas. 2. Review of the medical record for Resident # 27, revealed an admission date of 06/23/21. Diagnoses included but were not limited to type II diabetes mellitus without complications, dementia, and age-related osteoporosis without current pathological fracture. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with transfers and was dependent for toilet hygiene and shower hygiene. Review of the resolved plan of care for Resident #27 revealed the resident had three skin tears to right anterior leg with an intervention including but not limited to treat per facility protocol. Review of the progress notes dated 11/01/25 for Resident #27 revealed three skin tears measured and assessed with a treatment order obtained. Review of the physician order dated 11/01/25 for Resident #27 revealed saline solution (Soft Lens Products) apply to right anterior leg topically every night shift for skin tear cleanse areas to right lower anterior leg with saline, pat dry. Apply then maintain steri strips every day. May apply abdominal pad and secure with kerlix as needed for drainage. Review of the TAR for Resident #27 for the dates of 11/01/25 and 11/02/25 revealed treatment was completed as ordered for the right leg skin tears. Review of the physician order for Resident #27 dated 11/03/25 revealed a treatment for the right lower extremity skin tears to cleanse with normal saline, leave open to air unless drainage noted. Review of the medical record for Resident #27 revealed no clarification and discontinuation of the treatment order dated 11/01/25 for the right leg skin tears. Review of the TAR for Resident #27 dated 11/03/25 revealed two treatment orders completed for the right leg skin tears. Review of the Wound Care Consultation visit dated 11/04/25 by Advanced Practitioner Registered Nurse (APRN) #239 for Resident #27 revealed a new treatment order for the right anterior lower extremity skin tears of daily (and as needed) with no other details of the treatment. Review of the medical record revealed no addendum or clarification with the APRN #239 of a treatment order for the skin tears of the right anterior lower extremities. Review of the TAR for Resident #27 dated 11/04/25 through 11/11/25 revealed the two treatments ordered on 11/01/25 and 11/03/25 for the right leg skin tears were completed. Review of the medical record for Resident #27 dated 11/11/25 through 12/31/25 revealed two treatments on 11/01/25 and 11/03/25 occurred for the right leg skin tear as well as once the area was healed out, ongoing treatment continued to be documented by the staff as completed. Interview on 03/04/26 at 1:31 P.M. with Regional Nurse #217 verified Resident #27 had an order not appropriate for skin tears initiated on 11/01/25 as well as two orders throughout the month of November with ongoing treatment to the skin tear area being continued once the area was healed. Further review of the record revealed and confirmed no clarification of the 11/01/25 order, as well as the incomplete treatment order from APRN #239 on the 11/04/25 visit. Review of the facility policy titled Skin Tears-Abrasions and Minor Breaks, Care of revised September 2013 revealed obtain a physician order as needed. This deficiency represents non-compliance investigated under Complaint Number 2738898.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure resident glasses were obtained in a timely manner. This affected one (Resident #58) of one resident reviewed for vision services. The census was 82.Findings Include:Resident #58 was admitted to the facility on [DATE]. His diagnoses were arthropathy, venous insufficiency, hypokalemia, epilepsy, hyperlipidemia, chronic pulmonary embolism, hypertension, anxiety disorder, major depressive disorder, vitamin D deficiency, vitamin B12 deficiency, dementia, muscle weakness, and insomnia. Review of his minimum data set (MDS) assessment, dated 12/22/25, revealed he was cognitively intact.Review of Resident #58 vision appointment documentation, dated 12/15/25, revealed he had a complete vision exam. Review of the recommendations/plan after this visit included Resident #58 needing new bifocals. Review of resident vision documents, dated 12/15/25 to 03/04/26, revealed no evidence to support the bifocals had been ordered and/or received. Interview with Resident #58 on 03/02/26 at 3:40 P.M. confirmed he has not received his new glasses that they were supposed to order quite a while ago. He confirmed they would help him to see a little better. Interview with Social Service Designee (SSD) #136 on 03/04/2026 at 1:20 P.M. revealed they have not ordered Resident #58 bifocals yet. She stated she contacted the vision doctor's office, and they are waiting for payment. She said the bill for the glasses went to Resident #58, and they didn't get a copy of it; she didn't know they were waiting on that document and/or payment to receive them. She confirmed they did not follow up with Resident #58 or the vision doctor's office to see the progress of the bifocals.

Based on record review, interview and facility policy review the facility failed to document urine output and description each shift for one (Resident #5) of two reviewed for a urinary catheter. The facility census was 82.Findings include:Review of the medical record for Resident #5, revealed an admission date of 12/31/24. Diagnoses included but were not limited to obstructive and reflux uropathy, chronic kidney disease stage III, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12. The resident was assessed to require no assistance with bed mobility, setup or clean-up assistance with shower/bathe self, and supervision or touching assistance with toilet hygiene, and transfers. The resident was coded to have an indwelling catheter. Review of the active plan of care for Resident #5 revealed an at risk for urinary tract infections related to foley in place with interventions including but not limited to empty foley catheter bag every shift and as needed, monitor drainage bag contents for changes in the character of urine and notify nurse of no urine output. Review of the active physician orders dated 02/07/26 through 03/04/26 for Resident #5 revealed no order to empty and document urine description and output every shift. Review of the Medication Administration Record and the Treatment Administration Record dated 02/07/26 through 03/04/26 for Resident #5 revealed no documentation and description of urine output every shift.Review of the progress notes dated 02/07/26 through 03/04/26 for Resident #5 revealed no documentation and description of urine output every shift.Review of the plan of care documentation dated 02/07/26 through 03/04/26 for Resident #5 revealed no documentation and description of urine output every shift.Interview with the Regional Nurse #217 on 03/04/26 at 1:21 P.M. revealed it is not facility policy to document output amounts obtained from foley catheters every shift, the staff are expected to empty the catheter each shift and if there is no output to alert a provider. Regional Nurse #217 verified there was no documentation for Resident #5's urine including a description or place to document no output by either a Nurse or Certified Nurse Assistant for providers and other staff members to be aware. Review of the facility policy titled Catheter Care, Urinary revised September 2014 revealed observe the resident's urine level for noticeable increases and decreased. If the levels stay the same, or increase rapidly, report it to the physician or supervisor.

Based on record review, interview, and facility policy review the facility failed to ensure a speech therapy evaluation was completed for one, (Resident #03) and the facility failed to the facility failed to monitor fluid intake for one (Resident #09) who was on fluid restriction. This affected two residents (#03 and #09) of four reviewed for nutrition. The facility census was 82. Findings include:1. Review of Resident #03's medical record revealed an admission date of 10/18/19 with diagnoses that included but were not limited to other bipolar disorder, schizophrenia, dementia, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 01/02/26 revealed a Brief Interview of Mental Status score of zero, indicating the resident was not cognitively intact. Review of Resident #03's physician orders revealed an order for a mechanical soft diet dated 11/06/25. Review of Resident #03's Nutritional Assessment Review dated 07/01/25 revealed the resident had been on a regular diet, regular texture, and had no swallowing difficulties. Review of Resident #03's quarterly Dietary Review, dated 10/02/25, revealed no swallowing concerns. Review of the resident's assessments revealed no speech therapy evaluation around the time of the altered diet order. Review of Resident #03's progress notes revealed a note dated 10/31/25 at 12:23 P.M. revealed Resident #03 was no longer able to hold handheld foods and that a phone call to the resident's daughter attempted to discuss downgrading the resident's diet to mechanical soft. Review of progress note dated 11/03/25 at 12:30 P.M. revealed a speech evaluation was ordered by the nurse practitioner due to Resident #03's change in ability to hold foods. There were no further progress notes related to the speech therapy evaluation. Interview on 03/04/26 at 1:55 P.M. with Dietitian #180 revealed if there are concerns with the diet a resident is on a referral is made to speech therapy to identify the appropriate diet. Dietitian #180 reported they were not aware of concerns related to Resident #03's ability to swallow or chew their food. Interview on 03/05/26 at 9:38 A.M. with Registered Nurse (RN) #217 confirmed Resident #03's diet was downgraded from regular to mechanical soft without a speech evaluation. RN #217 further confirmed a speech evaluation was ordered but was not completed or followed up with and should have been. 2.Review of Resident #09's medical record revealed an admission date of 07/10/25 with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, major depressive disorder, opioid dependence, anxiety disorder, long term use of antibiotics. Review of Resident #09's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #09's physician order dated 12/03/25 revealed an order for a fluid restriction of 1800 milliliters (ml) per day; 720 ml was to be provided by dietary and 1080 ml from nursing. Review of Resident #09's Medication Administration Record (MAR) from 02/01/26 to 03/01/26 revealed no evidence the amount of liquid that the resident was provided from the nursing during medication pass was tracked. Review of Resident #9's fluid documentation in the tasks portion of the electronic record revealed from 02/03/26 to 03/03/26 Resident #09 exceeded his daily allowance of 1800 ml on 02/10/26, 02/14/26, 02/15/26, 02/18/26, 02/21/26, 02/22/26, 02/23/26, 02/24/26, 02/26/26, 02/28/26, 03/01/26, 03/02/26, and 03/03/26. He exceeded the dietary allowance of 720 ml of fluid on 02/03/25, 02/04/26, 02/05/26, 02/07/27, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/17/26, 02/19/26, 02/20/26, and 02/25/26. Review of Resident #09's plan of care revealed it did not address his fluid restriction or noncompliance with his fluid restriction. Review of Resident #09's progress notes from 02/01/26 to 03/03/26 revealed no mention of Resident #09's noncompliance with his fluid restriction. Additionally, there was no evidence the physician was notified of Resident #9's noncompliance. Interview on 03/04/26 at 1:46 P.M. with Dietitian #180 revealed she did not monitor compliance/noncompliance with Resident #9's fluid restriction, she believed nursing did. Interview on 03/04/26 at 2:25 P.M. with Certified Nursing Assistant (CNA) #115 revealed the aides documented fluid intake under tasks in the electronic record. This included what was provided by the dietary department and what they saw the resident drinking throughout the day. CNA #115 stated the nurses would be documenting fluids they provided separately. CNA #115 reported the resident was noncompliant with his fluid restriction and frequently got beverages from the vending machine. Interview on 03/04/26 at 8:18 A.M. and 9:02 A.M. with the Director of Nursing (DON) and Regional Nurse #237 revealed nurses should be documenting when a resident was noncompliant with their fluid restrictions. It was verified nursing was not documenting the amount of fluids they were providing at medication pass, and the resident was noncompliant with the fluid restriction. It was verified that the medical record did not address Resident #09's noncompliance with the fluid restriction.

Based on interview, record review, and review of facility policy, the facility failed to ensure trauma-informed care was implemented for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). This affected one resident (Resident #6) of eight residents reviewed for behavioral-emotional care. The facility census was 82.Findings include:Review of Resident #6's medical record revealed an admission date of 09/08/2022 with diagnoses including cerebral palsy, schizophrenia, schizoaffective disorder bipolar type, generalized anxiety disorder, major depressive disorder, intellectual disability, and post-traumatic stress disorder (PTSD).Review of the psychiatric evaluation completed by Psychiatric Certified Nurse Practitioner (CNP) #248 dated 05/20/2025 revealed Resident #6 had a diagnosis of Post-Traumatic Stress Disorder (PTSD) and reported a history of sexual trauma beginning in childhood. The evaluation documented Resident #6 reported experiencing flashbacks and nightmares every other day and night and identified interactions with male individuals as a trigger that caused increased anxiety, fear, and emotional distress.Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #6 dated 02/03/2026 revealed the resident required staff assistance with activities of daily living including transfers, mobility, toileting, bathing, and personal hygiene. Review of Resident #6's comprehensive care plan dated 02/03/2026 revealed the resident had care planned needs requiring staff assistance with activities of daily living including bathing and personal hygiene. The comprehensive care plan also revealed interventions addressing psychiatric diagnoses including anxiety, depression, psychosis, and schizoaffective disorder. The care plan did not include interventions addressing PTSD triggers or the resident's preference for female caregivers.Interview on 03/02/2026 at 12:45 P.M. with Resident #6 revealed the resident stated she has post-traumatic stress disorder (PTSD) and was unsure if the facility was aware of her triggers.Interview on 03/04/2026 at 1:20 PM with Resident #6 revealed the resident reported a history of trauma related to sexual abuse by her father. Resident #6 stated interactions with male individuals can trigger symptoms related to PTSD. Resident #6 stated she would prefer to be cared for by female caregivers.Interview on 03/04/2026 at 1:30 PM with CNA #134 regarding Resident #6 revealed CNA #134 stated they were not aware the resident had a diagnosis of PTSD or any identified triggers related to care.Interview on 03/05/2026 at 9:40 AM with Director of Nursing (DON) #175 regarding documentation of Resident #6's PTSD triggers revealed DON #175 was unable to locate documentation identifying triggers related to PTSD, including interactions with male staff providing care. DON #175 stated they were not aware that interactions with male staff were a trigger for Resident #6.Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring revealed behavioral symptoms are to be identified through assessment and evaluated using information obtained from the resident, family, caregivers, and medical record review. The policy stated the interdisciplinary team will identify precipitating factors or triggers related to behavioral symptoms and incorporate findings from the comprehensive assessment into the care plan with targeted and individualized interventions.

Based on interview, medical record review, and policy review, the facility failed to provide medications as ordered for Resident #9. This affected one resident (#9) of five residents reviewed for unnecessary medications. The facility census was 82.Findings include: Review of Resident #9's medical record revealed an admission date of 07/10/25 with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, major depressive disorder, opioid dependence, anxiety disorder, and long term use of antibiotics.Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #9's physician order dated 07/10/25 revealed an order for Amitriptyline (antidepressant) oral tablet 50 milligrams (mg) two tablets by mouth at bedtime for depression.Review of Resident #9's physician order dated 02/21/26 revealed an order for Sevelamer Carbonate (phosphate binder) 800 mg two tablets before meals for hyperphosphatemia.Review of Resident #9's physician order revised 03/02/26 revealed an order for Reglan (antiemetic) five mg by mouth three times a day for nausea.Review of Resident #9's Medication Administration Record (MAR) from 02/04/26 to 03/02/26 revealed Sevelamer Carbonate mid day (lunch) dose was not administered on 02/04/26, 02/07/26, 02/09/26, 02/20/26, and 03/02/26. Reglan was not administered twice on 02/07/26 and Amitriptyline was not administered on 02/28/26 and 03/01/26.Review of Resident #9's progress notes revealed there was no indication why Sevelamer Carbonate was not administered on 02/04/26, 02/07/26, and 03/02/26, on 02/09/26 and 02/20/26 it was indicated he was at dialysis. Reglan was documented as not administered due to being on order. It was indicated Amitriptyline was not available and was reordered. There was no evidence the physician was notified of the missing doses of Sevelamer Carbonate or Amitriptyline, and the physician was not notified of the missing Reglan until 02/09/26.Interview on 03/04/26 at 12:24 P.M. with Regional Nurse #237 verified Reglan and Amitriptyline were not administered due to the facility running out of the medication. The Sevelamer was not administered because it had not been given prior to the resident going to dialysis. However, he was eating lunch at dialysis and they were not providing it, so he did need the medication. She verified there was no evidence the physician was timely notified of missing medications.Review of the policy 'Administering Medications' dated December 2012, revealed medications were to be administered in accordance with orders.This deficiency represents noncompliance investigated under Complaint Number 2738898.

Based on record review, interview and facility policy review, the facility failed to ensure physician oversight for medications prescribed from an outside prescriber for Resident #75 and to failed to ensure parameters were followed for blood pressure medications for Resident # 9 and Resident #29. This affected three Residents (#9, #29 and #75) of 7 reviewed for unnecessary medications. The facility census was 82.Findings include:1. Review of the medical record for Resident #75 , revealed an admission date of 08/12/25. Diagnoses included but were not limited to dementia, muscle weakness generalized, adult failure to thrive and poly osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a the resident had moderate cognitive impairment, required supervision or touching assistance with toilet hygiene, bed mobility, and transfers with total dependence with shower/bathe self. Review of the active plan of care for Resident #75 revealed no interventions for monitoring of multiple medications of the same class. Review of the emergency department patient discharge summary and instructions dated 09/14/25 for Resident #75 revealed two new medications. A Lidocaine (five percent (%)) topical patch (pain) every day for thirty days, to remove the patch after 12 hours and Tizanidine (muscle relaxer) 2 milligrams (mg) give one tablet orally every eight hours as needed for muscle spasms for ten days. Review of the active physician orders dated 11/04/25 for Resident #75 revealed Xanax 2 mg (antianxiety) give one tablet by mouth every eight hours, Baclofen 5 mg (muscle relaxer) give one tablet by mouth every eight hours as needed, Hydroxyzine 25 mg (antianxiety) give one tablet by mouth every eight hours as needed, Tramadol 50 mg (pain) give one tablet by mouth every six hours as needed for pain and Tylenol 325 mg (pain) give two tablets every six hours as needed for pain. Further review of the physician orders dated 09/14/25 for this Resident revealed a verbal order from Certified Nurse Practitioner (CNP) #181 for: Lidocaine (four percent) topical patch (pain) every day for thirty days, to remove the patch after 12 hours and Tizanidine (muscle relaxer) 2 mg give one tablet orally every eight hours as needed or muscle spasms for ten days. These orders were never signed as ordered by CNP #181. Review of the Medication Administration Record (MAR) for Resident #75 dated 09/14/25 through 09/16/25 revealed: Xanax 2 mg given as ordered, and as needed medications administered of: Baclofen 5 mg (muscle relaxer) one tablet , Hydroxyzine 25 mg (antianxiety) one tablet, Lidocaine (4 percent) topical patch (pain) every day for thirty days, to remove the patch after 12 hours and Tizanidine (muscle relaxer) 2 mg give one tablet, Tramadol 50 mg (pain) one tablet and Tylenol 325 mg (pain) give two tablets. Review of the progress note dated 09/17/25 at 1:45 A.M. revealed Resident #75 had fallen in her room and was assessed to be slower to respond. Further review of the progress notes dated 09/17/25 at 2:40 A.M. for this resident revealed the on-call physician was notified of the fall and assessment of slower to respond and slurred speech and was sent out to the emergency department per physician order. Review of the emergency room documentation dated 09/17/25 for Resident #75 revealed a diagnosis of polypharmacy with muscle relaxers held and mental status improvement. Review of the medical record dated 09/14/25 through 09/17/25 for Resident #75 revealed the physician orders entered from the emergency room visit on 09/14/25 were never signed by CNP #181 there additionally was no documented communication to any facility provider this resident was now on new medications. No in-house visits from any provider was also documented. This surveyor was unable to interview CNP #181 as the provider was no longer with the facility. Interview on 03/04/25 at 1:53 P.M. with Regional Nurse # 217 verified for Resident #75, upon return to the facility from the emergency room on [DATE], no documentation could be provided for communication with any provider regarding the new medications and the new medication orders were never signed off by the entered ordering CNP at the facility and should have been as that indicates the provider was aware of the new orders. Therefore, there was no oversight for these medications for this resident as no provider for the facility was aware of the new medications. Interview on 03/05/26 at 9:38 A.M. with Unit Manager Licensed Practical Nurse #225 revealed she had been working at this facility for a while. It is expected when a resident returns from the emergency room for the on-call physician service to be called with new medications to be verified before ordering them especially if a provider is not on site at that time. A progress note needs to be added for return to the facility and notification of the provider of return and verification of new orders. The Unit Managers then do review of the new and or changed orders upon return. 2. Review of the medical record for Resident # 29, revealed an admission date of 08/03/18. Diagnoses included but were not limited to dementia, hypotension, other specified anxiety disorder, unspecified mood disorder, major depressive disorder and paraphilia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident has a severe cognitive impairment. The resident was assessed to require supervision or touching assistance with bed mobility, substantial/maximal assistance with transfers and total dependence with toilet hygiene, and shower/bathe self. Review of the active plan of care for Resident # 29 revealed altered cardiovascular status related to hypotension with an intervention including but not limited to medication as ordered by the physician. Review of the physician order for Resident #29 dated 11/18/25 revealed Midodrine Hydrochloride (for low blood pressure) 15 mg give orally three times a day, hold if systolic (blood pressure) is greater than 110 millimeters of mercury (mm/hg). Review of the MAR dated 11/19/25 through 02/28/26 for Resident #29 revealed Midodrine Hydrochloride 15 mg being administered when systolic was greater than 110 mm/hg Review of the November 2025 MAR revealed Midodrine Hydrochloride 15 mg being administered w [NAME] systolic was greater than 110 at the 9:00A.M. dose on 11/19/25, 11/20/25, 11/24/25. 11/25/25, 11/26/25, 11/27/25 and 11/18/25. At the 2:00 P.M. dose on 11/19/25, 11/20/25, 11/21/25, 11/24/25, 11/25/25, 11/26/25, 11/27/25, 11/28/26, 11/29/25, and 11/30/25. And at the 9:00 P.M. dose on 11/24/25, and 11/27/25. Review of the December 2025 MAR revealed Midodrine Hydrochloride 15 mg being administered when systolic was greater than 110 at the 9:00A.M. dose on 12/03/25,12/06/25,12/08/25,12/09/25,12/1225, 12/13/25, 12/17/25, 12/19/25, 12/20/25, 12/24/25, 12/25/, and 12/27/25. At the 2:00P.M. dose on 12/02/25/, 12/08/25, 12/09/25, 12/12/25, 12/13/25, 12/14/25, 12/20/25, 12/25/25, 12/27/25, and 12/28/25. And on the 9:00P.M. dose on 12/06/25, 12/07/25, 12/09/25, 12/11/25, 12/17/25, 12/18/25, 12/20/25, 12/24/25, and 12/25/25. Review of the January 2026 MAR revealed Midodrine Hydrochloride 15 mg being administered when systolic was greater than 110 at the 9:00A.M. dose on01/08/26, 01/15/26, 01/16/26, 01/19/26, 01/22/26, 01/23/2601/28/26, 01/29/26, and 01/31/26, On the 2:00P.M. dose on 01/01/26, 01/08/26, 01/09/26, 01/15/26, 01/16/26, 01/19/26, 01/21/26, 01/22/26, 01/23/26, 01/27/26, 01/28/26, 01/29,26 and 01/31/26. And on the 9:00P.M. dose on 01/02/26, 01/22/26, and 01/23/26. Review of the MAR for February 2026 revealed Midodrine Hydrochloride 15 mg being administered when systolic was greater than 110 at 9:00 A.M. 02/01/25, 02/02/26, 02/05/26, 02/08/26, 02/11/26, 02/12/26, 02/14/26, 02/15/26, 02/16/25, 02/17/26, and 02/18/26. And on 2:00 P.M. on 02/02/26, 02/03/26, 02/04/26, 02/06/26, 02/08/26, 02/09/26, 02/10/26, 02/11/26, 02/12/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, 02/18/26, 02/19/26, 02/22/26. And at 9:00 P.M. on 02/02/26, 02/04/26, 02/08/26, 02/14/26, 02/15/26, and 02/18/26. Interview on 03/05/26 at 1:10 P.M. with Regional Nurse #217 verified Resident #29 had systolic blood pressure numbers greater than 110mm/hg throughout 11/19/25 to 02/28/26 and the Midodrine Hydrochloride was not held per physician orders. Review of the facility policy titled Administering Medications revised December 2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. 3. Review of Resident #9's medical record revealed an admission date of 07/10/25 with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, major depressive disorder, opioid dependence, anxiety disorder, and long term use of antibiotics. Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #9's plan of care dated 07/22/25 revealed he had hypertension. Interventions included providing antihypertensive medication as ordered and monitor for side effects, monitor blood pressure as clinically indicated, and monitoring and reporting signs of malignant hypertension. Review of Resident #9's physician order dated 11/20/25 revealed an order for Clonidine (a medication that lowers blood pressure) 0.1 milligrams (mg) three tablet by mouth twice a day. The medication was to be held for a systolic blood pressure (SBP) above 110 mmHg and a pulse above 60 beats per minute (bpm). Review of Resident #9's Medication Administration Record (MAR) from 02/01/26 to 03/02/26 revealed Clonidine was to be administered at 10:00 A.M. and at 10:00 P.M. There was no evidence his blood pressure was checked for the evening dose and no evidence his heart rate was obtained during the reviewed period. Review of Resident #9's vitals from 02/01/26 to 03/02/26 revealed no evidence his blood pressure was checked for the evening dose and no evidence his heart rate was obtained during the reviewed period. Interview on 03/04/26 at 3:23 P.M. and 4:23 P.M. with Regional Nurse #237 verified the parameters for Clonidine were incorrect in the order, the medication should be held for SBP below 110 mmHg and a pulse below 60 bpm. Review of the policy 'Administering Medications' dated December 2012, revealed medications were to be administered in accordance with orders. This deficiency represents non-compliance investigated under Complaint Number 2738898.

Based on record review, review of pharmacy recommendations, interview, and policy review, the facility failed to ensure laboratory tests were completed as ordered and the physician was notified of incomplete laboratory tests. This affected one resident (Resident #89) of five reviewed for unnecessary medications. The facility census was 82. Findings include:Review of Resident #89's record revealed an admission date of 11/12/25 and diagnoses that included but were not limited to major depressive disorder, generalized anxiety disorder, schizoaffective disorder, schizoaffective disorder bipolar type, dementia in other diseases classified elsewhere, restlessness and agitation. Review of Minimum Data Set (MDS) 3.0 dated 11/12/25 revealed Resident #89 had a Brief Interview of Mental Status score of nine indicating the resident was not cognitively intact. Review of pharmacy recommendations for Resident #89 revealed a Medication Regimen Review (MRR) dated on 01/19/26 for Atorvastatin (used to lower cholesterol) 80 milligrams (mg) one tab by mouth daily with a request to order a lipid panel laboratory test with the next scheduled laboratory draw. This recommendation was agreed to by the physician and signed with a date of 01/20/26. Review of the laboratory report for Resident #89 dated 01/22/26 revealed the resident refused, two more attempts would be made and then the order would be discontinued. The report also requested for the physician to be informed of the resident's refusal. Review of Resident #89's physician orders on 03/03/26 revealed no further orders for laboratory test. Review of Resident #89's progress notes revealed no notification to the physician after the 01/22/26 refusal and no further attempts to schedule the laboratory test. Interview on 03/04/26 at 1:40 P.M. with Regional Registered Nurse (RN) #237 confirmed there was no documentation of the notification to the physician of Resident #89 refusing to have laboratory test completed. Additional interview on 03/05/26 at 10:00 A.M. with Regional RN #237 confirmed the facility did follow up with the laboratory company for another attempt to obtain the laboratory test. Review of the facility's protocol titled Lab and Diagnostic Test Results, revised September 2012, revealed staff will process test requisitions and arrange for tests. Further review of the protocol revealed facility staff, for physician notification, should document information about when, how, and to whom information was provided and the response, and that this should be done in the progress notes of the medical record.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure routine dental appointments occurred for all residents. This affected one (Resident #59) of one resident reviewed for dental services. The census was 82.Findings Include:Resident #59 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, morbid obesity, chronic obstructive pulmonary disease, sleep apnea, lymphedema, anxiety disorder, hyperlipidemia, post traumatic stress disorder, bipolar disorder, hypertension, delusional disorder, paranoid personality disorder, insomnia, and irritable bowel syndrome. Review of her minimum data set (MDS) assessment, dated 12/18/25, revealed she was cognitively intact.Review of Resident #59's dental appointment records revealed she had an initial appointment completed on 12/04/24. She was scheduled for another appointment on 12/10/25, but the appointment was cancelled due to Resident #59's refusal on that day. There were no other appointments documented as being completed and/or scheduled for Resident #59. Interview with Resident #59 on 03/02/26 at 3:21 P.M. confirmed she has not had a dental appointment scheduled for a while. She stated she does want to have one. Interview with Social Service Designee (SSD) #136 on 03/04/2026 at 10:07 A.M. confirmed Resident #59 refused her dental appointment. She confirmed Resident #59 was sick on 12/10/25, so she refused her dental appointment. She confirmed they have not rescheduled the appointment yet, but will do so this day. She confirmed each resident will be scheduled and see (barring refusals) at least once a year.

Based on interview and record review the facility failed to implement antibiotic stewardship regarding antibiotic use. This affected one (Resident #8) of one resident reviewed for antibiotics. The facility census was 82.Findings include:Review of the medical record for Resident #8 revealed an admission date of 12/16/25 with diagnoses including acute respiratory failure with hypoxia, morbid (severe) obesity, neuromuscular dysfunction of bladder, stage IV pressure ulcer of right buttock, congestive heart failure, atrial fibrillation, paraplegia, and tracheostomy status. Review of the most recent minimum data set (MDS) completed 12/23/25 revealed the resident had intact cognition and had an indwelling foley catheter.Review of the physician's orders revealed Resident #8 had an order for Ciprofoxacin (antibiotic) 500 milligrams (mg) twice daily for 14 days dated 02/17/26 through 03/03/26.Review of the medical record revealed hospital paperwork dated 02/17/26 with urinalysis results with no urine culture. Interview on 03/04/2026 at 2:12 P.M. with regional nurse #237 revealed the facility used McGeer's Criteria for the antibiotic stewardship program and verified Resident #8 did not meet criteria for antibiotic usage for a urinary tract infection. Review of facility policy titled Antibiotic Stewardship revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program.

Based on review of medical records, interviews with staff and the contracted psychiatric mental health nurse practitioner, review of facility self-reported incidents (SRIs), review of facility investigation documents, and review of facility policies and clinical protocols, the facility failed to ensure residents with a diagnosis of dementia and history of sexually inappropriate behaviors received adequate and effective behavioral health services to address their need for individualized interventions, monitoring, and supervision. This resulted in Immediate Jeopardy and the risk for serious life-threatening harm or negative health outcomes beginning on 12/12/25 when Resident #10, who was assessed with severely impaired cognition and had a history of sexual inappropriate behaviors, was moved to the secured unit where a resident (#05) with moderately impaired cognition and history of sexual acts with other residents resided, without either resident being adequately assessed/reassessed or revisions made to their behavioral health care plans related to monitoring and supervision to prevent potentially unsafe and inappropriate (sexual) behaviors. Due to the lack of individualized and effective behavioral health care, on 12/18/25 at 11:00 A.M., facility staff discovered Resident #10 in Resident #05's bedroom, with Resident #05 wearing no pants straddling Resident #10 who was also wearing no pants. The residents were observed engaged in sexual intercourse. This affected two residents (#05 and #10) of four sampled residents reviewed with a diagnosis of dementia who were vulnerable to targeted behaviors of other residents. The facility identified five residents (#60, #61, #63, #64, and #65) residents with impaired cognition and who exhibited sexually inappropriate behaviors. The facility census was 81.On 01/21/26 at 5:14 P.M., the Administrator, Regional Director of Operations (RDO) #490, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 12/12/25 when Resident #10, with a diagnosis of dementia, a history of sexually inappropriate behaviors, and after having recently been identified to have exhibited an increase in sexual behaviors, was moved to the secured unit on the second floor where Resident #05 resided. Resident #05 also had a diagnosis of dementia and a history of sexually inappropriate behaviors. Once Resident #10 and Resident #05 resided on the same unit, the facility failed to perform re-assessments of the residents or implement any increased supervision or monitoring related to their sexually inappropriate behaviors to prevent further sexual incidents. This continued until 12/18/25 at 11:00 A.M. when Resident #10 was discovered in Resident #05's bedroom both wearing no pants and engaged in sexual intercourse and required intervention by multiple staff members to separate the two residents. The Immediate Jeopardy was removed on 01/21/26 when the facility implemented the following corrective actions:- On 12/18/25 at 11:00 A.M., the DON, Certified Nurse Practitioner (CNP) #900, and Resident #05's guardian were all notified of the sexual incident with Resident #10. Full body skin assessments were completed for Resident #05 and Resident #10. - On 12/18/25 at 1:07 P.M., Resident #10's guardian was notified by the facility of the sexual incident with Resident #05. The facility requested permission to transfer Resident #10 out of the facility later that day.- On 12/18/25 at 1:24 P.M., the facility submitted an initial SRI with an allegation of sexual abuse to the State Survey Agency regarding the incident between Resident #05 and Resident #10.- On 12/18/25 at 1:30 P.M., Resident #05 and Resident #10 were visited and evaluated by Psychiatric Mental Health Nurse Practitioner (PMHNP) #905. - On 12/18/25 at 4:41 P.M., Resident #05 was sent to the hospital for further medical evaluation and sexually transmitted disease and hepatitis screenings.- On 12/18/25 at 5:55 P.M., Resident #10 was discharged to another facility.- On 12/23/25, Resident #05 was discharged to another facility.- On 01/21/26, Minimum Data Set (MDS) Nurse #273, Assistant Director of Nursing (ADON) #339, and Wound Nurse #354 interviewed all residents with a Brief Interview for Mental Status score of 13 and above (indicating intact cognition) and asked if they had ever experienced an inappropriate sexual encounter while in the facility, if they knew who to report those types of encounters to, and if they felt safe in the facility. All other residents with a BIMS score of 12 and below (indicating cognitive impairment) had a skin assessment completed to identify any possible changes. - On 01/21/26, MDS Nurse #273, ADON #339, and Wound Nurse #354 completed behavior assessments for all residents in the facility.- On 01/21/26, RDO #490 and Corporate Quality Assurance Nurse (CQAN) #467 completed education to all staff on the facility dementia clinical protocol, resident routine checks, behavioral assessment, intervention, and monitoring, and the facility system change for sexually inappropriate residents. The new process included, before residents were admitted to the facility, the interdisciplinary team (IDT) would review the referrals to see if the residents had sexual inappropriate behaviors. All residents with diagnosis of dementia with sexual inappropriate behaviors, as well as cognitive intact residents with sexual inappropriate behaviors, would be care planned for sexual inappropriate behaviors. All of the identified residents would be followed by the psychiatric team. If a resident was sexually inappropriate with staff and/or another resident, the nursing management team and psychiatric team would be notified immediately. The resident would immediately be placed on every 15-minute checks and/or up to being placed on one-to-one observation until the resident was deemed safe by the psychiatric team or physician.- On 01/21/26, ADON #339 and Regional Nurse #255 reviewed the last 72 hours of resident charting to identify any documentation of sexual behaviors. During the review, five (#60, #61, #63, #64, and #65) residents were placed on every 15-minute checks for inappropriate comments to staff. All orders were in place for monitoring and notifications were made on 01/21/26. All direct care staff, including nurses and nurse aides, would be completing the resident observations and if a change was needed, a member of the management team would conduct the resident checks. The IDT team, collaborating with the psychiatric team and physician, would determine when the resident checks would be discontinued. All residents at risk would be reviewed weekly, and any change would warrant a conversation and meeting with the team to determine a plan of action.- On 01/21/26, MDS Nurse #273 reviewed and confirmed all residents with sexual behaviors had care plans in place with appropriate interventions.- On 01/21/26 at 7:30 P.M., an ad hoc (as needed) Quality Assurance and Performance Improvement (QAPI) meeting was held to review the system change for sexually inappropriate residents and education provided to staff. Staff who were at the meeting included Medical Director #1 (via telephone), Activities Director #440, Human Resources Director (HRD) #201, Social Services Assistant #430, Regional Nurse #255, MDS Nurse #273, Receptionist #221, Wound Nurse #354, and CQAN #467.- On 01/21/26, the facility created an audit tool to be reviewed weekly at the standard of care meetings with the IDT to ensure residents were identified and interventions were in place. The residents would be audited with a diagnosis of sexual behavior or any sexual behavior identified. The IDT would be completing the audits weekly. The system change was on-going and would continue to ensure all residents at risk would be identified and interventions would be put into place.- The DON or designee would audit behavior documentation five times a week for four weeks to ensure interventions were in place.- On 01/22/26, the medical records for Resident #60, Resident #61, Resident #63, Resident #64, and Resident #65 were reviewed and verified care plans were in place with acceptable interventions for inappropriate sexual behaviors and confirmed each resident was under the care of PMHNP #905.- On 01/22/26 between 3:20 P.M. and 3:55 P.M., direct staff members were noted to be providing adequate surveillance for Resident #60, Resident #61, Resident #63, Resident #64, and Resident #65 with no issues noted.- Interviews on 01/22/26 between 3:20 P.M. and 3:52 P.M. with Registered Nurse (RN) #191, Licensed Practical Nurse (LPN) #504, and Certified Nurse Aide (CNA) #141 verified all staff members were educated on 01/21/26 regarding dementia clinical protocol, resident routine checks, and behavioral assessment, intervention, and monitoring, and were knowledgeable of the education content and were able to identify residents requiring increased surveillance and procedure for the resident checks.Although the Immediate Jeopardy was removed on 01/21/26, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance.Findings include:Review of Resident #05's medical record revealed an admission date of 02/17/25 with diagnoses including anoxic brain damage, dementia, bipolar disorder, post-traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD). Resident #05 had an appointed legal guardian.Review of Resident #5's admission progress note dated 02/17/25 revealed the resident arrived at the facility and was alert and oriented to self. Resident #05 exhibited repetitive speech, inappropriate laughter, was pacing the hallways, and had flight of ideas with unrelated conversation. Further review revealed Resident #05 made unusual statements regarding miscarriages, birth control, and her prior facility. Resident #05 frequently asked questions, did not like to be alone, and required encouragement to remain appropriately dressed.Review of a care plan dated 02/18/25 revealed Resident #05 could be sexually inappropriate with others per her guardian. The care plan indicated the resident's guardian was agreeable to Resident #05 having one partner. Interventions on 02/18/25 included but were not limited to providing behavioral health services as indicated, monitoring the resident for wandering into other residents' rooms, if sexually inappropriate behaviors occurred, remove the resident from the situation and place on a one-on-one observation immediately until the Administrator is notified for further instruction, and administer medication as ordered.Review of Resident #05's comprehensive care plan revealed a focus area initiated on 04/01/25 to place Resident #05 on every 15-minute checks for sexually inappropriate behaviors as the resident stated she gave another resident oral sex and her mouth hurt. The care plan focus area was marked as resolved on 04/04/25. On 09/19/25 a plan of care was initiated for Resident #05 to have one-to-one observation with a staff member to be with the resident at all times (this care plan was resolved on 09/23/25) and the resident was placed on every 15-minute checks. This care plan was resolved on 09/25/25. Resident #05's care plan was updated again on 09/25/25 to include a focus area for the resident to be on one-to-one observation with a staff member at all times (care plan resolved on 10/17/25). On 11/20/25, Resident #05 was care-planned for every 15-minute checks with a resolution date of 12/02/25.Review of Resident #05's nursing progress note dated 04/01/25 revealed the resident had oral sex with another resident. Resident's guardian was informed of the resident's sexual behaviors the same date and the guardian requested male residents be kept out of Resident #05's room.Review of the provider visit notes by PMHNP #905 dated 04/01/25 revealed Resident #05 was restless and stated she wanted to slit her wrists but promised she would not harm herself. Resident #05 again reported she had engaged in oral sex with a male resident. PMHNP #905 educated Resident #05 on safe sexual practices and condoms were provided. Resident #05 agreed to not have males in her room while she was unclothed.Review of a nursing progress note dated 04/06/25 revealed Resident #05 was observed rolling up her pant legs and encouraging a male resident to rub her legs. Per nursing staff, Resident #05 remained non-compliant with redirection despite repeated attempts. Her guardian was notified and stated she was agreeable to the resident having a boyfriend but requested Resident #05 and the boyfriend not be left alone together.Review of a nursing progress note dated 04/10/25 revealed Resident #05 was observed by facility staff kissing a male resident in her room. Review of a nursing progress note dated 04/18/25 revealed Resident #05 was observed by other residents with a male resident's hands in her pants while the two residents were sitting together. Facility staff separated the residents and placed Resident #05 temporarily on every 15-minute checks.Review of a nursing progress note dated 05/05/25 revealed Resident #05 was observed entering multiple male residents' rooms. The note indicated staff redirected the resident with short-term success.Review of a nursing progress note dated 05/11/25 revealed Resident #05 was repeatedly observed in a male resident's room. The note indicated staff redirected the resident with short-term success.Review of nursing progress note dated 07/18/25 at 12:43 P.M. revealed the facility suggested, and Resident #05 and her guardian agreed to a room change from the second-floor secured unit to the first floor. The move was in effort to curb ongoing sexual behaviors by Resident #05. The guardian stated if the inappropriate sexual behaviors persisted, she would request placement of Resident #05 in an all-female facility in the interest of her safety.Review of the nursing progress note dated 08/25/25 revealed Resident #05 repeatedly entered the lobby without wearing pants or an incontinence brief. Further review revealed when staff redirected Resident #05, she mocked staff. The note also indicated Resident #05 was found sitting on a male resident's bed the same day.Review of the nursing progress note dated 09/14/25 revealed Resident #05 was speaking in explicit sexual detail to her roommate. Facility staff encouraged her to stop; however, the resident refused and stated she liked discussing the topic.Review of an incident note dated 09/19/25 at 1:00 P.M. revealed Resident #05 was found in Resident #61's room and appeared to touch Resident #61's penis. Resident #05 was removed from the room and placed on one-to-one observation for safety. A head-to-toe assessment was completed on both residents with no injuries identified, and Resident #05's physician and guardian were notified. Review of the provider visit notes by PMHNP #905 dated 09/19/25 at 1:00 P.M. revealed Resident #05 denied sexual encounters and reported she was assisting the male resident (#61) with dressing. Resident #05 was educated to avoid male residents' rooms.Review of the nursing progress note for Resident #05 revealed she was placed on one-to-one observation from 09/19/25 to 09/23/25. On 09/23/25, during an interdisciplinary team (IDT) meeting, PMHNP #905 decreased Resident #05's surveillance activity to every 15-minute checks. The intervention of every 15-minute checks was subsequently discontinued after 10/11/25, but there was no documentation in the medical record of the reason for it being discontinued. Review of social services documentation dated 09/30/25 revealed Resident #05's guardian officially requested the resident be transferred to an all-female facility due to ongoing inappropriate sexual behavioral concerns.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 was assessed with moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12 and required (staff) assistance with activities of daily living (ADLs).Review of a nursing progress note dated 12/18/25 at 11:00 A.M. revealed Resident #05 was found in a room with another resident (#10). The note indicated the residents were separated immediately. The guardian and the DON were notified. The note included Resident #05 was assessed with no pain or injuries reported.Review of Resident #05's psychosocial visit note dated 12/18/25 at 4:16 P.M. revealed the resident admitted she initiated the sexual encounter with Resident #10 and believed she did nothing wrong.Review of Resident #05's Discharge summary dated [DATE] revealed the resident was discharged to another long-term care facility with an all-female unit per the guardian's request.Review of Resident #10's medical record revealed an admission date of 09/11/25 with diagnoses including ischemic cardiomyopathy, diabetes mellitus, gastroesophageal reflux disease, dementia, and major depressive disorder.Review of an admission note dated 09/11/25 at 4:25 P.M. revealed at the time of admission, Resident #10 was alert and oriented, pleasant, and cooperative. Review of a progress note dated 09/16/25 revealed Resident #10 and his sister requested and agreed to a room transfer with no concerns reported.Review of the comprehensive MDS assessment dated [DATE] revealed Resident #10 had severely impaired cognition evidenced by a BIMS score of four (04) and required self-care assistance from staff.Review of Resident #10's care plan dated 10/07/25 revealed the resident exhibited sexually inappropriate behaviors related to an encounter with another resident. Interventions included but were not limited to administering medications as ordered, behavioral health services as indicated, and if sexually inappropriate behavior occurred, remove the resident from the situation and place on one-on-one observation until the Administrator was notified for further instruction, monitor for wandering in other residents' rooms. One of the goals for the care plan was Resident #10 would be monitored every 15 minutes for 72 hours for adjustments with being moved to the locked unit and no sexual behaviors which was initiated on 12/12/25.Review of the provider visit notes by PMHNP #905 dated 10/07/25 revealed Resident #10 was prescribed cimetidine (Tagamet), a medication used to reduce the amount of acid in the stomach, but an off-label use to reduce sexual desires, to target sexually inappropriate behaviors related to his dementia.Review of the nursing progress notes dated 11/28/25 revealed Resident #10 was observed in the dining hall touching himself inappropriately. The note indicated Resident #10 was redirected to his room and educated on boundaries and privacy. The note included the resident verbalized understanding.Review of the nursing progress note dated 11/30/25 revealed Resident #10 was observed fondling his genitals in the dining room. The note indicated the resident was redirected to his room, educated on privacy, and complied.Review of nursing progress notes dated 12/01/25 revealed Resident #10 was observed touching himself inappropriately on multiple occasions in common areas. The documentation indicated staff redirected the resident to his room each time.Review of the social services progress notes dated 12/10/25 at 2:54 P.M. revealed Resident #10's sister reported sexually inappropriate behaviors occurring at the resident's day program.Review of the nursing progress notes dated 12/11/25 revealed Resident #10's sister expressed concerns regarding medication (Tagamet) effectiveness for sexually inappropriate behaviors and discussed possible medication adjustments with nursing staff. Review of the provider notes by PMHNP #905 dated 12/12/25 revealed she adjusted Resident #10's medication (Tagamet) at the request of Resident #10's guardian and due to his recently observed inappropriate sexual behaviors.Review of the nursing progress notes dated 12/12/25 revealed Resident #10's room was changed from the first floor to the second-floor secured unit after staff witnessed the resident engaging in inappropriate touching of a female resident (#70).Review of nursing progress notes dated between 12/12/25 and 12/18/25 revealed no documented evidence Resident #10 was monitored at any increased intervals or new interventions were initiated.Review of the nursing progress notes dated 12/15/25 revealed Resident #10 made inappropriate sexual comments and attempted to touch a nurse during a blood sugar check. Resident #10 was educated on boundaries and redirected. Review of the nursing progress notes dated 12/16/25 revealed Resident #10 touched a nurse inappropriately following a shower. The resident was educated and redirected.Review of a nursing progress note dated 12/18/25 at 11:00 A.M. revealed Resident #10 was found in another resident's (#05) bed. The note indicated both residents were separated immediately and a head-to-toe assessment was completed with no injuries identified. The DON and the resident's family member were notified.Review of Resident #10's Discharge summary dated [DATE] revealed Resident #10 was discharged to another long-term care facility with all belongings and medications. The note indicated the resident's mood was stable at discharge and the receiving facility was aware of the resident's attendance at a day program.Review of a facility self-reported incident (SRI) dated 12/18/25 revealed the facility submitted the SRI related to an incident of sexual abuse. The facility initiated an investigation into Resident #05 and Resident #10's sexual encounter. CNA #141 reported to a nurse Resident #05 was in bed with Resident #10 in an alleged sexual encounter. The residents were separated and both were assessed with no negative findings. The Administrator, both residents' responsible parties, and the physician were notified. Resident #05 was sent to the emergency room for evaluation with no new orders given at the hospital. Resident #10 was placed on one-to-one observation with no events noted until discharged to another facility on 12/18/25 at 8:00 P.M. Resident #05 was placed on every 15-minute checks until 12/19/25 with no negative outcomes. Review of CNA #141's written statement regarding the incident on 12/18/25 revealed she got Resident #05's roommate up for a shower and Resident #05 was noted to be half-asleep. After finishing Resident #05's roommate's shower, CNA #141 walked the resident down the hallway back to her room and noticed the bedroom door was closed. When CNA #141 opened the door, she witnessed Resident #05 on top of Resident #10 with no pants on and only wearing a shirt. Resident #10 was underneath Resident #05 with his pants down to his ankles and was penetrating Resident #05.Review of CNA #300's written statement regarding the incident on 12/18/25 revealed she noticed the door to Resident #05's room was closed, and when she opened the door, she saw Resident #05 on top of Resident #10. Resident #05 was wearing a big t-shirt and was wearing no pants, and Resident #10 was underneath Resident #05 with his pants down to his ankles and was penetrating Resident #05. The nurses were notified and after getting Resident #05 off of Resident #10, Resident #10 continued to masturbate. Interview on 01/15/26 at 10:45 A.M with CNA #141 confirmed she found Resident #05 and Resident #10 in bed together on 12/18/25 and verified the two residents were engaged in sexual intercourse. CNA #141 stated when she opened Resident #05's closed bedroom door, she observed Resident #05, without a covering on her perineal and sacral area, straddling Resident #10. CNA #141 stated underneath Resident #05, she saw Resident #10's exposed bare testicles exposed. CNA #141 stated she alerted other staff members to help separate the two residents. CNA #141 stated Resident #10 had been recently moved to the secured unit due to his sexually inappropriate behaviors and had concerns about him being moved there. CNA #141 stated residents on the secured unit were, generally, less cognitively aware and more vulnerable to another resident's behaviors. CNA #141 stated she reported her concerns to management on 12/12/25 on the date Resident #10 was moved to the second-floor secured unit. CNA #141 stated neither Resident #05 or Resident #10 were on any increased monitoring and she was not aware of any changes to their behavioral interventions after Resident #10 was moved to the secured unit on 12/12/25. Interview on 01/15/26 at 11:20 A.M. with CNA #161 stated she was working on the first floor of the facility on 12/18/25 but had concerns about Resident #10 being moved to the secured unit on the second floor due to his sexual inappropriateness. CNA #161 stated she did not relay her concerns to any of the management team.Interview with Resident #05's guardian on 01/15/26 at 11:50 A.M. confirmed Resident #05 had a history of inappropriate sexual behaviors at the facility and at her previous facility. She thought the behaviors would continue because the facility did not have the resources to provide the supervision Resident #05 needed to prevent these sexual encounters with other residents. Resident #05's guardian stated that was the reason she previously requested the resident be transferred to a facility with an all-female unit.Interview on 01/15/25 at 2:25 P.M. with HRD #201 revealed Resident #10 was moved from the first floor to the second floor because he had become romantically involved with Resident #70, who was cognitively impaired, and the staff thought they were being proactive to deter Resident #10 from engaging in inappropriate sexual activity. HRD #201 denied knowledge of any direct care staff member advising against Resident #10 being moved to the secured unit.Interview with the DON on 01/20/26 at 3:47 P.M. revealed she was alerted of the incident with Resident #05 and Resident #10 on 12/18/25 by Registered Nurse (RN) #199 soon after it occurred. The DON stated the staff did not expect anything of that nature to occur when Resident #10's room was moved to the second-floor secured unit. The DON stated she believed she was preventing further sexual incidents between Resident #10 and Resident #70. The DON did not provide a response when asked if additional supervision of Resident #10 and Resident #05 was ever explored due to their history of inappropriate sexual behaviors.Interview with Resident #10's guardian on 01/21/25 at 3:10 P.M. confirmed she reported to the facility that Resident #10 was displaying inappropriate sexual behaviors at his offsite day program, and she expressed dissatisfaction with his current treatment plan for these behaviors, including the prescribed Tagamet. She stated she felt the facility was not providing enough surveillance for Resident #10 for the incident on 12/18/25 to occur during the day with facility staff present. Resident #10's guardian stated no staff member ever discussed concerns with her about Resident #10 being moved to the second floor.Interview with PMHNP #905 on 01/21/26 at 9:29 A.M. stated both Resident #05 and Resident #10 suffered traumatic brain injuries earlier in their lives and believed their inappropriate sexual behaviors were partially attributed to those injuries which made the behaviors more difficult to manage and treat. PMHNP #905 revealed her expectation was the facility staff would report to her anytime a resident was having sexually inappropriate behavior so she could recommend an intervention. She verified she was not advised by facility staff that Resident #10 was continuing to have inappropriate sexual behaviors following his room change on 12/12/25. She confirmed she would have adjusted his medication and/or implemented more frequent supervision for him if she had known. She also stated she did not authorize the facility staff to stop the 15-minute checks of Resident #05 in October 2025. Review of a facility policy titled, Dementia-Clinical Protocol, revised 03/15, revealed for the resident with confirmed dementia, the IDT would identify a resident-centered care plan to maximize remaining function and quality of life. The IDT would identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Progressive or persistent worsening of symptoms and increased need for staff support will be reported to the physician. The IDT would adjust interventions and the overall plan depending on the individual's response to the interventions, progression of dementia, development of new acute medical conditions or complications, and changes in the resident or family's wishes.Review of a facility policy titled, Behavior Assessment, Intervention, and Monitoring, revised 12/16, revealed during the initial and comprehensive assessments, nursing staff and the attending physician were required to identify residents with a history of cognitive impairment or behavioral health conditions and evaluate baseline cognition and behavioral patterns. The IDT would evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Interventions would be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. If the resident was being treated for altered behavior or mood, the IDT would seek and document any improvements or worsening in the individual's behavior, mood, and function. The IDT would monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms would be documented and reported. Interventions would be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment.This deficiency represents an incidental finding discovered during the investigation for Complaint Number 2705791.

Based on observation, medical record review, and staff, and resident interview, the facility failed to maintain a homelike environment for residents by ensuring the facility supplied sufficient hot water for resident bathing and laundry needs. This deficiency had the potential to affect all 81 residents residing in the facility. The census was 81. Findings include:Observation and interview on 01/14/26 from 10:15 A.M. through 10:25 A.M. revealed the water temperature from Resident #60's bathroom faucet was tepid to touch. Interview with Resident #60 at the time of the observation confirmed the water in the resident's room was sometimes too cold. Interview on 01/14/26 at 10:28 A.M with Certified Nurse Aide (CNA) #141 confirmed the facility had issues with the boiler at least once every week, since at least March 2025. CNA #141 stated nursing management had previously advised staff that if the hot water was not working, to reschedule the assigned residents' baths and showers for the residents' comfort. She confirmed several residents have complained about the lack of hot water because their scheduled baths and showers for the impacted day have to be postponed.Observation and interview on 01/14/26 at 10:46 A.M., during a walking tour with Maintenance Director (MD) #750 and Regional Maintenance Director (RMD) #800, it was discovered the water temperature in the resident rooms on the first floor B area was 95.4 degrees Fahrenheit (F). The temperature reading was obtained on RMD #800's temperature gauge. MD #750 and RMD #800 acknowledged the temperature was below acceptable hot water temperatures. Interview with RMD #800 on 01/14/26 at 10:57 A.M. stated the facility had been in the process of purchasing and installing a new boiler. He said the process began in February 2025, but due to issues with their preferred supplier hindering the completion of the purchase, the new boiler had just been delivered to the facility within the past thirty days. The facility was currently obtaining bids for the boiler installation, which he expected to be completed soon. In the interim, MD #750 hired a consultant to immediately fix the existing boiler to produce water at the appropriate temperature.Interview with Housekeeping Director #799 on 01/20/26 at 11:53 A.M. confirmed the hot water in the facility intermittently did not get very hot. She acknowledged sometimes the water temperature delayed the residents from receiving their laundry in a timely manner because she has to wait to complete the laundry until the issue was fixed. She said it was usually less than a day that the issue persists.Review of medical record of Resident #70, who was cognitively impaired, revealed on 12/17/25 she declined to take her scheduled shower that evening because the water in the facility was too cold.Interview on 01/21/26 between 1:03 P.M. and 1:29 P.M. with Resident #20, Resident #08, and Resident #15 all confirmed the hot water temperatures in the facility do not always get hot enough and it had an impact of their bathing schedule. Interview on 01/20/26 at 11:21 A.M. with the Administrator and Regional Director of Operations (RDO) #490 revealed neither were aware of the water temperature concerns by residents and direct care staff within the facility.This deficiency represents non-compliance investigated under Master Complaint Number 2711777.

Based on record reviews, interview, and facility policies review, the facility failed to ensure residents were not physically restrained. This affected one (#10) of three residents reviewed for abuse. The facility census was 84. Findings Include:Review of the medical record for the Resident # 10 revealed an admission date of 11/18/25. Diagnoses included Type II Diabetes, morbid obesity, bipolar disorder and depression. Review of his admission Minimum Data Set (MDS) assessment dated [DATE] and discharged MDS dated [DATE] revealed Resident #10's brief interview of mental status (BIMS) was not recorded. Review of hospital documentation dated 11/22/25 revealed Resident #10 was alert and oriented three times (person, place and time). He used a walker and wheelchair to transport himself throughout the facility and required one person supervision for activities of daily living. Review of nursing facility progress notes dated 11/22/25 from 11:10 A.M. through 11:30 A.M. revealed Resident #10 was in the hall yelling he was going to punch everyone. Staff immediately went to talk to the resident and assist with his needs and calm the resident down. Resident #10 started swinging his fist at all the staff attempting to go to other resident rooms. Staff continued to attempt to talk with Resident #10 unsuccessfully. Resident #10 continued to yell and swing his fist in the hallway. The physician was made aware. At 11:05 A.M. Resident #10 was documented to become more aggressive and staff was not successful in assisting the resident. 911 was called. At 1:30 P.M. the Sheriff arrived to assist with the resident and the resident stated he would listen to the Sheriff when asked if he would calm down. The resident was agreeable to go to the hospital, and the ambulance transported Resident #10 out of the facility. Review of progress note dated 11/22/25 at 7:02 P.M. revealed Resident #10 was returned to the facility from the hospital at 4:30 P.M. and upon return the resident was yelling at the ambulance crew using profanity and the ambulance crew was attempting to calm the resident, who did transfer to his wheelchair so the ambulance crew could leave the facility. Nursing staff offered to get the resident food or something to drink and attempted to see if he had other needs, but the Resident said no he was fine. Resident #10 was then documented to start yelling at staff about where his dog went, started swinging at staff making contact with his fist and multiple staff members. The physician was called immediately, and the facility retained an order to pink slip the resident. Resident #10 continued to get aggressive, and staff stayed with the resident to assist in keeping him safe and other staff and residents safe. At 5:20 P.M. the Sheriff deputy arrived at the facility and the resident started to calm down when he saw them stating he would be good with them at the facility. The sheriff went to the resident room and at approximately 6:00 P.M. the paperwork for the pink slip was obtained. At 7:00 P.M. the county ambulance was at the facility to transport Resident #10 out of the facility. Review of Resident #10's physician orders revealed no orders for a restraint. Interview on 12/08/25 at 2:37 P.M. with Regional Administrator (RA) revealed it was reported to her on Monday, 11/24/25 that Resident #10 was restrained to a chair over the weekend due to behavior. RA stated because of the information, she started an internal investigation which determined Resident #10 was not restrained. RA did confirm Resident #10's behavior was out of control and LPN #118 used a bath sheet held in front of Resident #10 to prevent Resident #10 from hurting other residents and staff until the police and emergency medical services (EMS) arrived at the facility. Review of staff statements for the internal investigation revealed CNA #205, and LPN # 126 had statements related to the incident with Resident #10 on 11/22/25 but neither documented LPN #118 using a bath blanket to prevent Resident #10 from hurting staff or residents. The statements obtained explained the behaviors Resident #10 was displaying.Review of the internal investigation documents compiled by the Regional Administrator confirmed LPN #118 on 11/22/25 had an incident with Resident #10 where Resident #10 was being held in his wheelchair with a bath sheet across his torso. The sheet was being held behind Resident #10 by LPN #118. Further review of the progress notes revealed the there was no documentation of Resident #10 having a sheet put around him and held by LPN #118. Interview on 12/08/25 from 3:20 P.M. to 3:45 P.M. with Certified Nursing Assistant (CNA) #124 confirmed she was working in the unit when Resident #10 was having behaviors, his behaviors were bad, he was trying to go through the unit doors to get to other residents. Several attempts were made to calm him, but they were unsuccessful. CNA #124 stated Resident #10 was a large man and punched her in the stomach causing bruises. She confirmed a bed sheet was used to prevent Resident #10 from hitting other residents or staff. The bed sheet was placed across his torso and one across his chest and held behind him by Licensed Practical Nurse (LPN)#118. CNA #124 stated the sheet was not tied in a knot but was just being held by LPN #118 hands. Interview on 12/09/25 at 12:00 P.M. with LPN # 126 confirmed he was working as the nurse on 11/22/25 when Resident #10 was sent to the hospital two times for his behaviors. He confirmed staff tried every possible intervention to calm Residents #10 with no success. He confirmed that a sheet was used across Resident #10's torso and chest which was held behind the resident's back by LPN #118 to keep Resident #10 from striking or hurting other residents and staff. Telephone interview on 12/12/10/25 at 10:01 A.M. with LPN #118 confirmed she was the nurse who on 11/22/25 at approximately 5:15 P.M. did place the sheets across Resident #10's body to prevent him from hurting himself, staff and residents. LPN #118 stated she was instructed by corporate to do whatever was needed to keep everyone safe. She stated she held the sheets for approximately five minutes until Police and EMS arrived at the facility and Resident #10 was taken to a local hospital.Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property 10/27/2017 , revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain , or mental anguish.Review of facility policy titled, Use of Restraints the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given that resident's physical condition and restricts his typical ability to change position or place, that device is considered a restraint.

Based on observation, record review, review of a facility timeline of events, review of hospital records and a physician after visit summary, facility policy review and interview, the facility failed to prevent an incident of neglect involving Resident #32. This resulted in Immediate Jeopardy and Actual Harm beginning on 09/19/25 at 10:30 A.M. when Resident #32, who was identified to have confusion and poor decision making, was left outside the facility in the sun with the air temperature between 82 and 85 degrees Fahrenheit unattended. On 09/19/25 at approximately 1:45 P.M. Resident #32 was found outside the facility unresponsive with a body temperature of 107 degrees (F) and an oxygen saturation level of 88 percent with resulting second degree burns/blisters on her arms and legs. The physician was not notified for approximately 12 hours, and the resident was not transferred to the hospital for evaluation/treatment until approximately 24 hours after the incident. This affected one resident (#32) of 17 sampled residents. The facility census was 94. On 09/25/25 at 10:00 A.M., the Administrator, Acting Director of Nursing #303, Regional Director of Operations #350, [NAME] President of Operations #203, and [NAME] President of Clinical Services #300 were notified Immediate Jeopardy began on 09/19/25 at approximately 10:30 A.M. when Resident #32 was left outside the facility in the sun with air temperatures of 82-85 degrees F until approximately 1:45 P.M. when she was found unresponsive with a body temperature of 107 degrees (F) and an oxygen saturation level of 88 percent with resulting second degree burns/blisters on her arms and legs. The physician was not notified for approximately 12 hours, and the resident was not transferred to the hospital for approximately 24 hours after the incident. The Immediate Jeopardy was removed on 09/29/25 when the facility implemented the following corrective actions: On 09/20/25- Resident #32 was sent to the ER for evaluation and treatment. Resident #32 returned to facility with an order to follow up with the outpatient burn center for 10/03/25. Resident #32 has wound care orders in place to affected areas. Resident #32 was also reeducated on risks factors of prolonged heat and sun exposure. On 09/20/25- The [NAME] President of Clinical Services reviewed the following policies and procedures to ensure they were comprehensive and accurate: Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, Heat Related Illness, and Abuse Policy. These policies and procedures were deemed to be comprehensive and accurate, and no changes were made. On 09/20/25 at 5:00 P.M.- The Regional Director of Clinical Services, Regional Director of Operations and the Administrator initiated education for all licensed staff on the following: Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, Heat Related Illness, and Abuse Policy. The education was completed on 9/20/25 for 22 Licensed Practical Nurses (LPNs), three (3) Registered Nurses (RN), 35 Certified Nurse Aides (CNAs), four (4) Activity Personnel, seven (7) Dietary Staff, eight (8) Housekeeping/Laundry Staff, one (1) Maintenance Staff, 12 Administrative Staff. All staff did receive the education by 9/20/25. Education was completed via phone and in person. On 09/20/25 at 5:00 P.M.- , the Administrator posted at the Second Floor Courtyard door, First Floor Courtyard door and Smoking Area door, the 7-day forecast of weather conditions with high and low temperatures. At this time, staff were educated by the Administrator to reference the high temperature to the heat-related illness guidance and to educate all residents on risks of outside temperatures that day if they request to go outside. For temperatures of 80 degrees (Fahrenheit) or higher, staff will increase resident safety checks to every 30 minutes. If residents choose to remain outside, they offer additional safety interventions from the facility Excessive Heat policy, which include additional education, ice water, move to shaded areas, etc. On 09/20/25 at 5:03 P.M.- The MDS Nurse reviewed Resident 32's care plan and the care plan was updated to reflect the current resident's condition and needs. On 09/20/25 at 6:00 P.M.-, the Administrator initiated a post-education test on Heat Illness Education for 22 LPNs, three (3) RNs, 35 CNAs, four (4) Activity Personnel, seven (7) Dietary Staff, eight (8) Housekeeping/Laundry Staff, one (1) Maintenance Staff, 12 Administrative Staff. All staff successfully completed the post test. On 09/20/25 at 6:00 P.M.-., the Regional Director of Clinical Services (RDCS) and the ADON initiated head-to-toe assessments on all residents to ensure there were no negative outcomes from heat-related illnesses. The RDCS and the ADON completed these assessments, and no adverse outcomes were noted. On 09/20/25- , the facility Quality Assessment and Performance Improvement (QAPI) Committee, including the Administrator, Regional Director of Clinical Service, SSD, Minimum Data Set (MDS) Nurse, Human Resources (HR), Director of Nursing (DON), activities, Assistant DON (ADON)/LPN , and Medical Director reviewed the deficiencies, the plan of action, the policies and procedures related to Heat Related Illness, Change in Condition and Notification and a root cause analysis was completed. The root cause analysis identified the facility failed to monitor the outside temperatures and failed to ensure timely and appropriate intervention was provided. On 09/20/25-Outside thermometers were hung by the Administrator with the 7-day forecast posting so staff can see the actual temperature compared to the forecasted highs and lows. On 09/20/25-Administrator/Designee educated staff that if resident(s) will not come inside, they will immediately contact the Director of Nursing, Administrator and or the Director of Social Services to assist bringing in the resident(s) to ensure their safety. On 09/20/25- facility began reviewing change of condition will be via 24hr and 72hr report 5x per week ongoing by DON/Designee. Audit will include notification, interventions, assessments. On 09/20/25- facility began posting outside temperature listing which will be audited 5x weekly x4 weeks, then weekly x4 weeks by Administrator/ Designee. On 09/20/25- facility began resident interviews regarding neglect for residents with BIMS of 13 or higher. Five (5) random residents will be interviewed 5x per week, then 5 random residents weekly x4 weeks by Administrator/Designee. On 09/20/25- facility began random resident assessments on residents with BIMS of 12 or lower for signs of neglect. Three (3) random residents 5x per week x4 weeks, then three (3) random residents weekly x5 weeks by DON/Designee. On 09/20/25- facility began random staff interviews on heat illness via posttest and what current outside temperature is that day 5x per week by Administrator/Designee. Effective 09/20/25- all findings will be reviewed in weekly QAPI. The Administrator and the DON will be responsible for the oversight of the monitoring/audits. Effective 09/20/25- Before residents are taken outside, by activities or other staff, they will check with charge nurse to determine which residents are able to go outside. On 09/29/25- the External Courtyard Keypad was repaired by the facility maintenance director and determined to be in working order. The Keypad will be audited for functionality 5x per week x4 weeks, then weekly x4 weeks by Administrator/Designee. Effective 09/29/25- all residents that go outside will be supervised by facility staff. Prior to taking residents outside, for activity or other reasons, staff will verify with charge nurses that residents are safe to go outside supervised based upon resident's current medical condition. Although the Immediate Jeopardy was removed on 09/29/25- the facility remains out of compliance at severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified related to the facility's failure to appropriately protect a resident from sexual abuse. This affected one resident (#50) of two residents (#14, #50) reviewed for sexual abuse. Findings include: 1.Review of the medical record for Resident #32 revealed an admission date of 07/10/23 with diagnoses including cerebral infarction, glaucoma, vascular dementia, and anxiety disorder. Review of the plan of care for Resident #32 dated 07/10/23 revealed the resident was noted to have impaired cognitive function/dementia or impaired thought process. On 08/05/24 the plan of care revealed the resident was noted with behaviors of biting staff during transfers and pulling the fire alarm/combativeness. Interventions included to anticipate and meet needs. On 07/07/25 the plan of care noted the resident often refused care, had vision problems, was non ambulatory, and required maximum assistance for transfers. On 09/17/25 a plan of care was initiated indicating the resident had been undressing herself and sitting in public areas including lobby and outside. The goal was for the resident to return to her room or be compliant with getting dressed when in public areas. Interventions included assisting in putting clothes back on, attempt to cover with a blanket when not wanting to get re-dressed and encourage not to undress in public areas. Review of the Minimum Data Set assessment completed 07/07/25 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 14 (out of 15) reflecting the resident had intact cognition. The MDS included the resident required the use of a wheelchair and was dependent upon staff for toileting. It further indicated she required substantial/maximal assistance from staff with dressing, hygiene, sitting to standing, and transfers from chair to bed. Review of a nursing progress note dated 09/19/25 at 7:45 P.M. revealed Licensed Practical Nurse (LPN) #248 documented Resident #32 was approved to go outside to the courtyard by social service assistant. Resident #32 was noted by staff to be slumped in her wheelchair. Staff applied sternal rub with no response noted. Resident was brought into the building and taken to her room. The resident's temperature was 107.5 degree F temporal. Ice packs were applied to the resident's underarms, groin area. Moved placement of bed to air-conditioned area. The resident's pulse ox was 88 percent on room air. Oxygen was applied via nasal cannula at two liters. The note included after about 125 minutes, the resident began to moan and slightly open eyes. Management was present in room. The note also documented the resident's code status was Do Not Resuscitate. Review of Resident #32's nursing progress note on 09/19/25 at 7:30 P.M. by LPN #248 stated it was a clarification for the previous note. Resident was not nonresponsive for 125 minutes. It was approximately five to 10 minutes before the resident's eyes opened and sounds being heard. Resident #32 was up in her wheelchair in the hallway within 30 minutes after incident. A message was left for Med One (on call physician service) but no call was received before this nurse left shift. Review of the resident's medical record did not reveal any evidence the physician was notified or that the resident was transported to the hospital immediately after the incident. There was also no evidence of any other vital signs after the incident to re-check the resident's temperature or pulse oxygen level until 09/21/25 at 9:30 P.M. (two days later). The vital signs at that time included temperature 97.8, pulse 77, respirations 16, blood pressure 128/66, and oxygen saturation level of 97 percent. The next nursing progress note regarding the incident on 09/20/25 at 1:57 A.M. authored by LPN #169 revealed the nursing assistant informed the nurse the resident had multiple blistered areas on her arms and legs. Upon assessment, the resident had multiple blisters to bilateral forearms and bilateral lower extremities. The areas were measured and assessed. Blisters appeared to be intact without any drainage. Resident stated, they tell me I fell out of my wheelchair, but I don't remember doing that. Cleansed areas with normal saline and patted dry. Covered with dressings and wrapped with Kerlix. Med One was contacted. This nurse spoke with the certified nurse practitioner (CNP) (this was approximately 12 hours after the incident). New order was obtained to cleanse areas with normal saline and pat dry. Cover with dressing and wrap with Kerlix every shift. Review of a nursing progress note dated 09/20/25 at 1:52 P.M. revealed an order was received per Certified Nurse Practitioner (CNP) #202 to send Resident #32 to the emergency room for evaluation. (This was approximately 24 hours after the incident). A nursing progress note on 09/21/25 at 2:01 A.M. indicated the resident returned to the facility. A nursing progress note on 09/21/25 at 3:10 A.M. revealed the resident was to follow up with a hospital burn unit on 09/24/25. Review of hospital records revealed Resident #32 arrived (to the hospital) on 09/20/25 at 3:46 P.M. The note stated she arrived via emergency medical services (EMS) for burns on arms and legs due to being out in the sun for an extended period of time at the nursing home she resided. The note included the resident was unable to provide history secondary to her underlying dementia. Per EMS, facility staff called EMS due to concerns for blistering on the resident's arms and legs. Per EMS, the resident was out in the sun for extended period of time yesterday. Multiple blisters noted to bilateral upper and lower extremities. Notably, a dime size blister on dorsum of left hand. One blister had ruptured with mild serous drainage. The records indicated to see pictures. The differential diagnosis included superficial burn, partial thickness burn, cellulitis. Given multiple blisters, it was discussed with hospital burn team. They recommended local wound care/dressing and outpatient follow up with their burn clinic on 09/24/25. Review of a progress note dated 09/22/25 at 3:37 P.M. by CNP #202 revealed Resident #32 had second degree burns to all extremities after prolonged sun exposure on 09/19/25. Blisters developed overnight 09/19/25. Resident evaluated in emergency department 09/20/25 for burns. They recommended local wound care/dressing and outpatient follow up with their burn unit on 09/24/25. The resident was found slumped over in her wheelchair after prolonged sun exposure on 09/19/25 with decreased level of consciousness. The resident's temperature, when brought in from sun exposure, was 107.5 (F) per record. History limited/unobtainable due to (resident's) confusion with dementia. She repeated she wanted to go to hospital right now. Staff report resident was out in the sun for approximately 4-5 hours on 09/19/25. Noted with fluid filled blisters to all extremities- worse to lower extremities, pink abraded area to left lateral foot/toes. Alert and oriented times two (person/place). Confused with poor insight and decision making. Review of outside air temperatures according to the website Underground Weather revealed the temperature on 09/18/25 between 12:00 P.M. and 4:00 P.M. ranged from 79 degrees to 85 degrees. The temperature on 09/19/25 at 12:00 P.M. was 82 degrees, at 1:00 P.M. was 85 degrees, and at 2:00 P.M. was 85 degrees. A nursing progress note on 09/24/25 at 11:18 A.M. revealed the resident was taken for the appointment at the burn clinic. Provider was unavailable so new appointment was made for 09/26/25. Review of the after-visit summary from the burn clinic on 09/26/25 revealed orders were given to provide dressing changes daily to arms/hands and bilateral lower legs. The resident was to return in one week. Review of a facility timeline of events provided on 09/25/25 at approximately 1:30 P.M. for Resident #32 revealed on 09/19/25 the resident expressed she wanted to go outside (banging on door). At 8:05 A.M. LPN #222 said the resident could not go out at this time. At 8:07 A.M. Social Service Assistant (SSA) #150 said the resident needed to be let out (BIMS score of 14 as noted on 07/07/25 and (resident was her own person). On 8:08 A.M. SSA #150 told LPN #248 that her resident was outside. At 8:30 A.M. LPN #222 witnessed the resident was naked and asked SSA #150 for help. SSA #150 went outside and covered the resident with a gown. At 11:00 A.M. Nursing Assistant #176 told the resident (still outside) to come in for lunch. The resident refused to come in. The resident was naked, and staff covered her. At 1:45 P.M. Nursing Assistant #176 stated to the nurse the resident was still outside and was not responding to stimuli. At 1:47 P.M. Nursing Assistant #176 and nurse manager (not specified) brought non-responsive resident back inside and took to room. At 1:47 P.M. LPN #222 performed sternal rub and placed resident on the floor. At 1:50 P.M. LPN/Unit Manager #175 and LPN #248 came in and stated the resident was Do Not Resuscitate. At 1:51 P.M. staff got the resident off the floor; they used cool towels and ice to cool the resident down. At 1:52 P.M. the Director of Nursing came to the room and was told what happened. Noted the resident's temperature was 105 (F). Bed was moved in front of A/C to help cool temperature. The resident's temperature was taken again and it was 107 degrees (F). At 1:53 P.M. LPN/Unit Manager #241 came to the room to assist with the resident; resident responded to Unit Manager and eyes fluttered. At 1:55 P.M., the Director of Nursing notified Regional Director of Clinical Services of the situation. At 5:00 P.M., the Director of Nursing noticed the resident was up in the wheelchair and seemed normal (baseline). At 09/20/25 at 12:12 A.M. LPN/Unit Manager #175 notified the Administrator. At 1:45 A.M. the facility left a voice mail with Med One about the situation. At 12:10 P.M. the Certified Nurse Practitioner spoke with LPN/Unit Manager #175 who stated they did not send the resident out (for evaluation), then pictures were sent. At 12:46 P.M. the Certified Nurse Practitioner said to send the resident out.Interview with Regional Director #350 on 09/29/25 at 8:45 A.M. revealed the times on the facility timeline provided to surveyors were not correct. He stated the resident (#32) did not go outside at 8:08 A.M. per the timeline. He stated they had put that time (on the timeline) because the nurse had initially said the resident went out after breakfast. He said staff interviews clarified the resident went out at a later time. Interview with LPN #248 on 09/24/25 at 9:15 A.M. revealed she was Resident #32's nurse on 09/19/25. She stated she did not know the resident went outside and did not know who let her out. She stated it was hot outside that day. She stated LPN #222 told her SSA #150 approved the resident to go outside. However, she stated she did not know the resident was outside until LPN #222 was bringing the resident inside in her wheelchair and she was unresponsive. She stated they took the resident to her room. She stated LPN #222 checked her oxygen saturation level and it was 88 percent. LPN/Unit Manager #175 brought oxygen and put on her. Her temperature was 107 degrees (F). She stated she did not know if any other vital signs were taken. She stated they got ice packs and put under arms and groin area and moved the bed closer to the air conditioner in the room. She stated she then left the room because she was needed for another resident. She stated the resident (#32) was unresponsive for approximately 8-10 minutes. She stated the next time she went in the room; the resident was responsive and knew who she was. She stated she did not know if any follow up vital signs were obtained or not. She stated she thought it was around 2:30 P.M. when the resident was brought in from outside. She stated the resident had a habit of taking her clothes off. She said sunscreen was not applied prior as she did not know the resident was outside. She confirmed she did not document the incident in the nursing progress notes until 7:45 P.M. that day and confirmed the timeline of the incident was not included in the notes. She stated she left a message for the on-call physician service around 7:30 P.M. but they did not call back. She confirmed the physician was not notified at the time of the incident and the resident was not sent to the hospital at the time of the incident. She stated this was because the resident had a Do Not Resuscitate order. Interview with LPN #222 on 09/25/25 at 9:50 A.M. revealed Resident #32 had also been outside in the courtyard on the day before the incident (on 09/18/25). She stated the resident had not wanted to come back inside on 09/18/25 and the Administrator assisted in bringing her back in. She stated the Administrator had stated not to let the resident go back outside after she did not want to come in on 09/18/25 (this incident was not documented in resident's nursing progress notes). LPN #222 stated she did not feel it was a good idea for Resident #32 to be outside alone due to her mental status and the fact she can't make good decisions. She stated she was working on 09/19/25 but was not Resident #32's nurse. She stated Resident #32 had been pounding on the door to go outside and she tried to find a manager since the Administrator had told staff the day prior not to let the resident out again. She stated SSA #150 then told her to let the resident go outside because of her BIMS score. She stated she thought it was around 10:15-10:45 A.M. when the resident went outside on 09/19/25. She stated after about 30 minutes, staff checked on her and she was naked. Staff got a blanket to cover her. She stated the resident was sitting in the sun and stated she would not let staff move her out of the sun. She stated another staff member got a gown for the resident. During the interview, the LPN revealed the resident would not have been able to get back inside the facility on her own as the door from the courtyard was locked and the keypad outside the door did not work. She stated staff went to check on her around 1:30 P.M.-1:45 P.M. She stated it was a really hot day. She stated the resident then had a thready pulse, her head was hyper-extended back in the wheelchair, she was unresponsive, and her skin was black on her knees and legs. She stated they took the resident to her room and put her in bed. She stated no one knew what to do. She stated they then soaked her down with tepid water. She stated her temperature was 107 degrees (F) and her oxygen saturation level was 86-87 percent. She stated another staff got oxygen and put on her and they got a fan and lowered the air conditioning in the room. She stated the resident was unresponsive for approximately 30 minutes. She stated both LPN/Unit Managers #175 and #241 were in the room. She stated she thought that someone was calling 911 and calling the physician. She stated no one did. She stated the resident woke up at some point, she does not know when. She stated she saw a blister on her left foot at the time of the incident. She stated she was not aware of any other vital signs being taken. Interview with Social Service Assistant #150 on 09/24/25 at 10:05 A.M. revealed on 09/19/25 LPN #222 had asked if Resident #32 was allowed to go outside. She stated that, because the resident was her own person and had a high BIMS score, she was allowed to go outside so a nursing assistant took her out where she remained by herself. She stated she was aware that the resident removed her clothing, and she had told staff if she did this to call her and she would come down. She stated staff called her at about 12:00 P.M. and stated the resident was outside and was taking her clothes off. She stated a nursing assistant took a gown outside and the resident put the gown on. She stated about 30 minutes later, staff were running around, and LPN #248 said the resident's body temperature was 107 degrees (F). She said the resident was outside for a maximum of two hours. She confirmed the temperature outside was in the 80's that day. She stated she did not know if the resident had sunscreen applied.Interview with Nursing Assistant #176 on 09/24/25 at 10:35 A.M. revealed she did not know when Resident #32 initially went outside on 09/19/25. She stated around 11:30 A.M. she went outside and the resident was naked so she got a gown for the resident. She stated she tried to get the resident to come inside and she said no. She stated LPN #222 went outside around 1:45 P.M. to check on her and she held the exit door for the nurse. She stated the nurse said the resident was not responding. She stated she pushed the resident's wheelchair and the nurse held up her legs and they took her to her room. She stated they put the resident on the floor. She said LPN #248 said the resident had a Do Not Resuscitate order. She said they then put the resident in bed. A nurse put oxygen on her and they used cold towels and ice packs, moved her bed close to the air conditioner, and put a fan on her. She stated the resident was unresponsive for about 45 minutes-1 hour. She stated the resident was not sent to the hospital and no paramedics came. She stated that when the resident was in bed, she noticed the skin on top of her left foot had torn. She stated the resident had taken her socks off outside. She stated the resident did not have any sunscreen applied that she was aware of. She stated someone tried to take her blood pressure but it would not take. She stated she was not sure if any further vital signs were obtained. Interview with LPN/Unit Manager #175 on 09/24/25 at 11:05 A.M. revealed on 09/19/25 she was at the nurse's desk and heard someone banging on the door. She went to open it. Resident #32 was in a wheelchair and the nurse, and another staff pulled her into the building and took her to her room. She texted the other unit manager to help and checked the resident's code status. She went to the resident's room. She heard staff say her oxygen saturation was 88% so she ran to get oxygen. She took the oxygen to the room then went to get another part for the oxygen. When she came back, the resident was talking to staff. She did not see any blisters on the resident. She then left the room. The next time she was involved was when the night nurse notified her of the blisters on the resident's legs. She told the nurse to call the on-call physician service. She checked the charting and realized that no one followed up with the physician and no follow up vital signs were done. She thought LPN #248 called the physician. She stated the physician should have been notified right away or 911 called. She stated it was a pretty hot day but she was not aware the resident was outside prior to her being brought into the facility. Interview with Certified Nurse Practitioner (CNP) #202 on 09/24/25 at 11:29 A.M. revealed neither she nor the attending physician were notified on 09/19/25 of the incident with Resident #32. She stated she was on the computer on 09/20/25 and saw in the notes what was documented. She stated she called the facility and gave an order for them to send the resident to the hospital. She stated 911 should have been called when the resident was noted to be unresponsive, even if the resident was a Do Not Resuscitate. She stated either her or the primary care physician should have been notified at the time of the incident. She stated that the Regional Director of Operations had told her the resident was outside from 8:30 A.M. to 1:30 P.M. She stated the resident's vital signs should have been monitored after the incident. She confirmed the resident had second degree burns on her extremities. She stated the resident should not be out in the sun for long periods. On 09/23/25 at 9:30 A.M. Resident #32 was observed to be sitting in her wheelchair near the front door of the facility. Both legs and arms were wrapped with gauze. A blister, approximately the size of a fifty-cent piece was noted on the left shin above the gauze. Interview with the resident at the time of the observation revealed the resident stated the blisters were caused from being out in the sun. The resident stated she did not know how long she was outside. The resident then stated she was waiting to go to the hospital because she needed to have her leg amputated. On 09/23/25 at 9:55 A.M. observation revealed Resident #32 had an 11.5 centimeter (cm) by 5.5 cm fluid filled blister above her right ankle, a one cm by 0.6 cm fluid filled blister below the right knee, a 3.5 by 2.5 cm fluid filled blister on the right thigh (above the knee), a seven cm by four cm open blister with red tissue exposed in the center on the top of the left foot, a 16 cm by 10 cm area on the left shin that included an intact blister below the knee and an open blister above the ankle with exposed pink tissue, a six cm by four cm fluid filled blister on the right forearm, a 3.7 cm by 1.5 cm fluid filled blister on the right wrist, a 13.5 cm by three cm fluid filled blister on the left forearm, a 4.5 cm by 3.5 cm fluid filled blister on the left forearm above the wrist, and a 1.5 cm by two cm fluid filled blister on the back of the left hand. Interview with the Acting Director of Nursing #303 on 09/24/25 at 2:00 P.M. confirmed there was no specific documentation in Resident #32's medical record of the timeline of events that happened on 09/19/25 when the resident became unresponsive outside. She stated there should have been. She confirmed there were no additional vital sign assessment/monitoring documented besides temperature and oxygen saturation at the time of the incident and no further follow up vital signs documented which should have been. She confirmed there was no evidence the physician was notified or that the resident was transferred to the hospital at the time of the incident. She confirmed the resident was not transferred to the hospital until the next day (approximately 24 hours later). Interview with the Administrator on 09/29/25 at 8:45 A.M. revealed she was aware Resident #32 was outside on 09/18/25. She stated staff were having trouble getting her back inside, so she went and talked to the resident and brought her back in. She stated the resident was only outside for a short time. She stated she told staff it was the resident's right to go outside. She stated she also told staff if she refused to come in, to get someone with good rapport with the resident. She stated there were days the resident was more irritable. The Administrator stated she was not at the facility on 09/19/25 when the incident happened. She stated that is why she felt SSA #150 was involved in the decision to allow the resident to go outside. Observations and interview with Nursing Assistant #217 on 09/29/25 at 9:13 A.M. revealed the keypad outside the exit door from the lounge by the Unit A, B, and C nurse's station does not work and will not allow anyone to come back inside the facility through that door once they are outside, unless someone inside opens the door for them. She stated it had been broken for months. She stated the maintenance man had tried to fix it but stated he needed to get ahold of the company. Interview with Acting Director of Nursing #303 on 09/29/25 at 9:13 A.M. confirmed the keypad on the outside of the exit door did not work, even when the correct code was put in. She confirmed neither staff or residents (the residents were not provided the code) would be able to get back in if they went outside and the door closed. Interview with Maintenance Director #181 on 09/29/25 at 9:15 A.M. revealed the keypad outside of the exit door off the lounge by the Unit A, B, and C nurse's station had been broken for about two months. However, he stated he did not feel it was a priority at the moment. He stated staff could go in another door to get back into the facility. The nearest door in the courtyard was approximately 120 feet from the door with the broken keypad and required staff to go upstairs. (They would be unable to take a resident inside who was in a wheelchair or having a medical emergency). Review of the facility policy last revised [TRUNCATED]

Based on closed medical record review, hospital record review, death certificate review, facility policy and procedure review, facility assessment review, and interview, the facility failed to timely identify and provide comprehensive, resident centered interventions following an acute change in condition for Resident #95. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on 06/27/25 when Resident #95, who had severe cognitive impairment and required staff assistance with activities of daily living (ADL) was noted by staff to have an acute change in medical condition which included dusky colored hands and feet, limited food and fluid intake, lethargy, and the need for supplemental oxygen. There was no additional assessment of the resident's condition at that time or intervention provided. On 06/29/25 at 8:30 P.M. (two days later) Licensed Practical Nurse (LPN) #194 notified Resident #95's physician of this change in condition (lethargy, lying in bed in the fetal position, dusky skin color with poor skin turgor) and the resident was transferred by emergency medical transport to the emergency room where she was admitted to the hospital with a diagnosis of severe dehydration (with thin, frail skin, muscle/fat wasting, and poor skin turgor) and acute kidney injury. Hospital records identified the resident was estimated to have a 3.8-to-4-liter free water deficit. The resident was subsequently admitted to a hospice facility on 06/30/25 and passed away on 07/02/25. This affected one resident (#95) of three residents reviewed for change in condition. The facility census was 94. On 09/26/25 at 10:00 A.M. the Administrator, Regional Director of Operations #350, [NAME] President of Clinical Operations #203 and Acting Director of Nursing (DON) #303 were notified Immediate Jeopardy began on 06/27/25 when Certified Nursing Assistant (CNA) #204 identified a change in condition for Resident #95 and verbally notified Licensed Practical Nurse (LPN) #198, without evidence the LPN or other licensed staff completed a timely assessment of the resident's condition and/or implemented/obtained necessary intervention/medical treatment. Resident #95 remained in the facility until 06/29/25 at approximately 8:30 P.M. when LPN #194 notified the resident's medical provider, called 911, and the resident was transferred to the emergency room and subsequently admitted to the hospital with diagnoses including severe dehydration and acute kidney injury. Resident #95's status did not improve, and the resident was transferred from the hospital to a hospice facility on 06/30/25 and expired on 07/02/25. The Immediate Jeopardy was removed on 09/20/25 when the facility implemented the following actions: On 06/29/25 Resident #95 was transferred to the hospital and did not return to the facility. The resident expired on 07/02/25. On 09/20/25, an audit was completed by DON/ Designee on all 44 residents who went out to the hospital between 06/29/25 and 9/20/25 to determine if any changes in resident conditions went unreported. On 09/20/25 the [NAME] President of Clinical Operations #203 reviewed the following policies and procedures to ensure they were comprehensive and accurate: Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, and Abuse. On 09/20/25 at 5:00 P.M. the Regional Director of Clinical Services #201, Regional Director of Operations (RDO) #350 and Administrator initiated education for all licensed staff on Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, and Abuse Policy. Education was completed on 09/20/25 for 22 Licensed Practical Nurses (LPNs), three (3) Registered Nurses (RN), 35 Certified Nurse Aides (CNAs), four (4) Activity Personnel, seven (7) Dietary Staff, eight (8) Housekeeping/Laundry Staff, one (1) Maintenance Staff, 12 Administrative Staff. All staff were educated on 9/20/25. On 09/20/25, the DON/Designee provided education for nursing staff on the POC alert function in Point Click Care (PCC) charting to identify potential condition changes and how alerts generate on the alert panel on PCC dashboard. Education was completed on 09/20/25 for 22 Licensed Practical Nurses (LPNs), 3 Registered Nurses (RNs) and 35 Certified Nurse Aides (CNAs). This was provided in person and via phone before staff were allowed to work. Education included how alerts appear on the dashboard and are reviewed daily in morning clinical meetings. If reported changes were not addressed by the nurse, they were to report it to the DON. Education also included ongoing changes in conditions would be reported to the DON. On 09/20/25, the DON/Designee educated in person and via phone 22 Licensed Practical Nurses (LPNs) and 3 Registered Nurses (RNs) on the Change in Condition policy, which included when a change of condition was reported, new orders were obtained, entered in PCC/implemented, which would include appropriate monitoring, including oxygen therapy needs. Ongoing compliance would include new nurses in orientation upon hire. On 09/20/25 the Quality Assessment and Performance Improvement (QAPI) Committee, including the Administrator, Regional Director of Clinical Services #201, Social Services, Minimum Data Set (MDS) Nurse #218, Human Resources (HR) #152, Director of Nursing (DON), Activities Director #165, Assistant DON (ADON)/LPN , and Medical Director #301 reviewed the facility plan of action, the policies and procedures related to Change in Condition and Notification and a root cause analysis was completed. The root cause analysis identified that the facility failed to comprehensively assess and address a change in condition in a timely manner. On 09/20/25 a whole house audit was conducted on all 93 current facility residents by the DON/Designee by reviewing 72-hour report for any change of condition and need for interventions and notifications and head to toe assessments by DON/Designee. On 9/20/2025, the facility began audits on resident change in condition by reviewing the 24 hour and 72-hour reports which would be reviewed five times per week ongoing by DON/Designee. Audits would include Change in Condition and Notification. If adverse findings were noted, an immediate head to toe assessment would be completed and notification to physician. Effective 9/20/2025, all findings would be reviewed weekly in QAPI. The Administrator and the DON would be responsible for the oversight of the monitoring/audits. On 09/22/25-Director of Nursing/Designee conducted an audit on all orders placed, including medications, treatments, monitoring, therapy, etc. in the past 24 hours for all residents. This audit concluded that all orders were appropriate, contained no errors, and provided necessary monitoring where needed. Although the Immediate Jeopardy was removed on 09/20/25 the deficiency remained at a Severity Level II (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 #95's closed medical record revealed an admission date of 05/30/25 with diagnoses including Alzheimer's disease, osteoarthritis, osteoporosis, cannabis use, nicotine dependence, and dementia (severe with agitation). Resident #95 was admitted to the facility after a hospital stay for treatment of agitation and combativeness.Review of Resident #95's medical record revealed on 05/30/25 the resident weighed 98 pounds on admission to the facility.Further review of the medical record revealed an order dated 06/02/25 which indicated the resident was a full code (advance directive status) (the resident wished to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). The resident also had an order for a regular diet with thin liquids. Review of Resident #95's progress note dated 06/02/25 at 10:50 A.M. revealed an admission note written by Certified Nurse Practitioner (CNP) #202 that indicated Resident #95 was in no acute distress. Further review revealed CNP #202 confirmed Resident #95's advance directives with her family on 06/02/25. Review of the resident's weights revealed on 06/03/25, the resident weighed 92.6 pounds with a Body mass Index of 18.6 (placing the resident at nutritional risk due to the low BMI).Review of Resident #95's medical record revealed a nutrition assessment dated [DATE] at 10:06 A.M. indicating the resident had lost 5.4 pounds in a week, a significant weight loss of 5.8%, related to poor appetite. Registered Dietician #302 recommended the addition of 240 milliliters of the house supplement three times daily. The resident was also assessed to have estimated nutritional needs of 1,263-1,473 calories per day and an estimated fluid need of one milliliter (ml) of fluid per calorie a day (1,263-1,473 ml of fluid per day). However, please note, the resident's meal intake records only included fluid consumed but did not specify how much actual fluid was consumed during meals. Review of Resident #95's physician orders revealed an order dated 06/04/25 for house supplement 240 ml three times daily.Review of the resident's meal tickets revealed the house supplement (nutritional shake for weight loss) was to be provided by dietary staff on the resident's meal trays. Review of Resident #95's care plan revealed a nutrition care plan initiated on 06/03/25 for a nutritional problem or potential nutritional problem related to a borderline low body mass index (BMI), dementia, osteoporosis, cannabis use, poor appetite, weight loss in the facility and the need for an oral nutritional supplement. The goal was for Resident #95 to maintain adequate nutritional status as evidenced by her maintaining her weight without significant weight changes, having no signs or symptoms of malnutrition and consuming at least 50% of her meals daily through the next review date. Interventions for Resident #95 were to administer medications as ordered and monitor for and document side effects and effectiveness of the medications, provide and serve the resident's diet as ordered, monitor the resident's food and fluid intake and record the intake for every meal and the registered dietician was to evaluate the resident and make diet change recommendations as needed. Record review revealed there were no additional interventions added to the nutrition care plan after the care plan was created. Further review of the resident's care plan revealed the facility had not developed a plan of care related to hydration or a risk for dehydration or related to the resident's physical ability to consume food/liquids. There was no plan of care in place to reflect the resident's needed/required staff assistance for eating/fluid consumption as it pertained to her cognitive status, identified poor appetite and weight loss.Review of Resident #95's admission Minimum Data Set (MDS) assessment, dated 06/06/25, revealed a Brief Interview for Mental Status (BIMS) score of 03 (out of a possible score of 15) indicating the resident had impaired cognition. The assessment revealed the resident required setup/cleanup assistance with eating, supervision with bed mobility, transfers and walking and substantial/maximal assistance with toileting hygiene. The MDS indicated Resident #95 was frequently incontinent of bladder and always incontinent of bowel. No weight loss or skin alterations were identified during the assessment, and the resident was not receiving therapy.Review of Resident #95's medical record revealed a weight on 06/09/25 of 92 pounds an additional weight loss of 0.6 pounds since 06/02/25. Review of Resident #95's progress note dated 06/11/25 at 12:00 A.M. revealed a progress note written by CNP #202 to follow up on the resident's mood disorder, dementia and insomnia. CNP #202 noted the staff had no new concerns with Resident #95. The progress note did not include mention of the resident's weight loss identified since admission to the facility. (A significant weight loss since admission to the facility from 98 pounds to 92 pounds).Review of Resident #95's medical record revealed no documentation of a weight for Resident #95 the week of 06/14/25.Review of Resident #95's medical record revealed a weight on 06/25/25 of 91 pounds (an additional weight loss of one pound from 06/09/25). Record review revealed no evidence the cause of the weight loss was identified, the resident's nutritional intake was reviewed and/or evidence new interventions were implemented at this time to address the resident's nutrition/hydration status. Review of progress notes dated 05/20/25 to 06/24/25 revealed, during this time period, the resident was ambulatory and able to engage with staff verbally, she exhibited some behaviors including being combative with staff at times. Review of Resident #95's progress note dated 06/25/25 at 12:00 A.M. and authored by CNP #202 indicated she saw the resident as follow up for ecchymosis related to a recent fall, dementia and mood disorder. The CNP noted the resident was at her neurological baseline and included the resident's mucus membranes were moist. However, there was no mention of the resident's weight or nutritional status. Review of the resident's medical record revealed an alert progress note dated 06/25/25 at 8:23 A.M. which indicated the resident had not had a bowel movement in three days. There was no mention of any assessment of the resident or additional documentation of the resident's status on the remainder of 06/25/26.In addition, review of the resident's medical record revealed no progress note documentation or assessment/monitoring of the resident was completed on 06/26/25, 06/27/29 or 06/28/29. Review of the resident's meal intake records (which included fluid intakes during the meal but was not isolated from food consumed and calculated in with the meal percentage) revealed the following:On 06/24/25 the resident had no intake (food or fluid) for breakfast, lunch or dinner with one staff member assisting with each meal.On 06/25/25 the resident had no intake for breakfast with one staff member assisting, up to 25% of the lunch meal with one staff member assisting and 75-100% of the dinner meal with only set up help from one staff.On 06/26/25 the resident had no intake for breakfast or lunch with set up help from staff and there was no documentation for the dinner meal.On 06/27/25 the resident refused breakfast and lunch and had no intake for dinner with set up help for the meal.On 06/28/25 the resident had no intake for breakfast and lunch with the assistance of one staff member and up to 25% of the dinner meal was consumed with staff assistance.On 06/29/25 the resident had no intake for breakfast, lunch or dinner with assistance of one staff.Review of Resident #95's medical record revealed the next progress note was dated 06/29/25 at 8:25 P.M., written by LPN #194 which revealed Resident #95 was lying in bed in the fetal position with oxygen on via mask. Resident #95 did not want to open her eyes, was restless and less verbal than her normal. Resident #95's color was pale, her skin was cool to touch, her skin turgor was poor (refers to the elasticity of the skin and represents a person's hydration status) and her lips and mouth were very dry. The resident's vital signs included blood pressure 102/53 millimeters of Mercury (mmHg) (normal 120/60 mmHg), temperature 97.3 (degrees Fahrenheit) (average body temperature 98.6 degrees F), pulse 54 (normal range 60-90 beats per minute) and respirations 14 (normal 12-20 breaths per minute). LPN #194 was unable to obtain Resident #95's peripheral oxygenation saturation (a pulse oximeter is placed on a person's finger and will provide a reading of the resident's oxygen level in the bloodstream but the oximeter will have difficulty identifying oxygen levels with cool hands and/or movement) reading due to the resident moving her hands. LPN #194 notified the on-call physician and received an order to send the resident to the emergency room for evaluation and treatment and activated 911 to transport the resident. LPN #194 notified the resident's spouse of the resident being sent to the hospital. Review of Resident #95's hospital records revealed an admission history and physical dated 06/30/25 at 2:03 A.M. that indicated the resident was admitted to the service of the hospitalist for severe dehydration. Resident #95's weight when admitted to the hospital was documented to be 77 pounds (the facility's most recent weight on 06/25/25 was documented to be 91 pounds). The resident was described as extremely debilitated, malnourished, as well as very dehydrated with parched lips and parched oral mucosa. The hospitalist estimated the resident had an approximate 3.8-to-4-liter free water deficit. A hospice consultation was initiated after discussion with the resident's family, and the resident was changed from a full code status to a do not resuscitate comfort care status (in the event of a cardiac or respiratory arrest no life-saving measures would be initiated and the resident would be kept as comfortable as possible).Further review of the resident's hospital records revealed a consultation note dated 06/30/25 at 11:33 A.M. that revealed the resident was brought to the emergency room on [DATE] from the facility with decreased food/fluid intake for several days according to staff. Labs were notable including a hemoglobin of 17, hematocrit of 42.6 and a (critical) sodium level of 173 (all indicative lab studies for dehydration). The resident's admission weight was documented to be 77.66 pounds with a body mass index of 13. The consultation note included the patient was examined at bedside. She was lethargic, unable to answer questions and unable to follow simple commands. The resident appeared thin, frail and cachectic with muscle/fat wasting noted to temples, orbits, cheeks, clavicles, arms and legs. Mucus membranes appeared dry and skin turgor was poor. The resident's skin was warm, dry and dusky. Spouse agreeable to hospice consult with patient hopefully being transported to (named) house (hospice house). Primary hospice diagnosis could either be advanced dementia (no specified type but based on clinical picture and review of medical records, likely Alzheimer's dementia with possibility of vascular component) or severe malnutrition as patient was eligible with either diagnosis. Review of Resident #95's death certificate dated 07/02/25 revealed the resident's cause of death was vascular dementia secondary to cerebrovascular disease. Malnutrition was also listed as another significant condition contributing to the resident's death.Interview on 09/17/25 at 6:25 A.M. with LPN #194 revealed she came into work on Sunday, 06/29/25 (after being off for a few days), and when she went into Resident #95's room to administer her evening medication, she found the resident in bed with oxygen on and not really responding. The LPN stated she could not find anything about a change in the resident's condition in the nurse's progress notes (prior to her observation) or an order for oxygen use in the medical record so she contacted the on-call medical provider and then transferred the resident to the emergency room due to this significant change in the resident's condition since the last time she had worked with the resident (the night of 06/24/25).Interview on 09/18/25 at 4:00 P.M. with Certified Nursing Assistant (CNA) #226 revealed Resident #95 normally spent a lot of time during the day either lying or sitting on her bed. CNA #226 stated she cared for Resident #95 during the day on 06/29/25, the day the resident was sent to the hospital. CNA #226 stated the resident had slept all day, was hard to wake up, and did not eat or drink on day shift. CNA #226 stated she verbally reported this to her nurse, Registered Nurse (RN) #237, who responded that she would look into getting hospice for the resident.Interview on 09/19/25 at 6:49 P.M. with CNA #204 revealed Resident #95 would typically be up in the evening and had a habit of wandering (was ambulatory) into other residents' rooms. CNA #204 revealed on the evening of 06/27/25, Resident #95 was lying in bed and her hands and feet were blue/purple in color (this was a change for the resident). She said she reported this to her nurse, LPN #198, but the nurse was not concerned. Another nurse, LPN #240, was working with her (CNA #204) as a nurse aide and LPN #240 assessed the resident, took her vital signs and placed oxygen on her (this information was not documented in the resident's medical record). During a follow-up interview on 09/22/25 at 11:10 A.M. with CNA #204, the CNA confirmed oxygen was applied to Resident #95 on Friday 06/27/25. CNA #204 stated about a week prior to this, the facility staff were looking for her (Resident #95), and CNA #204 found her in another resident's room, sitting at a piano keyboard, with her head lying on the keyboard. CNA #204 stated she reported this to her nurse that night but could not recall who the nurse was. CNA #204 also shared it seemed like Resident #95 was less verbal, seemed to sleep more, and her food and fluid intake became more limited (the documentation in the resident's medical record reflects poor intake of food and/or fluid during meals leading up to the resident's hospital transfer). Prior to this, the resident had been up and wandering around and rummaging in other residents' rooms.Interview on 09/23/25 at 1:40 P.M. with Registered Dietician (RD) #302 revealed the resident did not get weighed the week of 06/14/25 and was not weighed the following week until after the weekly dietician visit (the visit was on 06/24/25 and the resident was not weighed until 06/25/25 when she weighed 91 pounds) so she was not aware Resident #95's weight was continuing to decline and no new interventions were implemented. Interview on 09/22/25 at 11:55 A.M. with CNP #202 revealed she was not notified of Resident #95's changes in condition (not eating or drinking, wearing oxygen, previous weight loss or changes in her usual activity). CNP #202 further stated that when she saw Resident #95 on 06/25/25 she felt the resident was at her neurological baseline and she was unaware of issues or concerns with the resident's status. The CNP verified the on-call service had not added a system note for Resident #95 between her visit on 06/25/25 until 06/29/25, when the order was given to transfer the resident to the emergency room. CNP #202 stated her expectation would be for her or the on-call provider to be notified when Resident #95's condition changed, including the need for oxygen for a resident who doesn't normally require oxygen use.Interview on 09/22/25 at 1:37 P.M. with Registered Nurse (RN) #237 revealed she did not normally work the hall Resident #95 resided on and did not know the resident well. RN #237 stated she did recall the resident being very sleepy that weekend (06/27-06/28/25), the CNAs assisted the resident with eating, and she did not eat much. RN #237 stated Resident #95 had been a wanderer prior to that weekend and had to be frequently redirected from other residents' rooms, but that wasn't her activity over the weekend when she worked. She could not recall if the resident had oxygen on that weekend (and there was no documentation of the resident's changes from her usual presentation and activity noted in the medical record for the RN to review from 06/28/25 or 06/29/25 when the RN was responsible for the resident's overall care).Interview on 09/22/25 at 3:18 P.M. with CNA #163 revealed she had just recently started working at the facility in June 2025 and did not know much about Resident #95 other than she was difficult to redirect and she did not eat or drink well. The CNA stated she attempted to assist the resident with her lunch meal on 06/27/25 but Resident #95 would not open her mouth. She stated she did report this to a nurse working on this date but could not recall the nurse she reported this to. CNA #163 revealed she did not recall Resident #95 wearing oxygen when she worked with her on dayshift on 06/27/25. A follow up interview on 09/23/25 at 8:03 A.M. with LPN #194 revealed when she entered Resident #95's room on 06/29/25 to give the resident her evening medication, the resident was lying in bed in the fetal position with oxygen on via mask. She stated the resident's lips were very dry and crusted and the CNA reported the resident had been in bed all weekend with the oxygen on. The LPN verified she was unaware of any changes in the resident's condition and reviewed the medical record for documentation in the progress notes to include physician notification and an order for the use of oxygen but there was no documentation found.Interview on 09/23/25 at 8:30 A.M with LPN #240 revealed on the evening of 06/27/25 she was working as a nurse aide, and the CNA (#204) asked her to look at Resident #95. She stated the resident's hands and feet were dusky in color and she notified the nurse assigned to care for the resident and then went to get an oxygen concentrator and placed it in the resident's room in case it was needed. She stated she did not know if the oxygen was used and she did not notify the resident's medical provider because the nurse, LPN #198, was in the room taking care of the resident and she assumed that the nurse would notify the medical provider since LPN #198 was the nurse assigned to the resident's care.Interview on 09/23/25 at 8:48 A.M. with CNA #249 revealed she worked day shift on Saturday and Sunday (06/28/25 and 06/29/25) before Resident #95 was sent to the hospital on [DATE]. CNA #249 stated Resident #95 slept a lot and did not eat or drink well those two days. CNA #249 stated Resident #95 had oxygen per mask and the resident kept taking the oxygen off, so she replaced it several times. The resident's hands and feet were discolored/dusky all weekend but more so on Sunday (06?29?25). CNA #249 stated she told the nurse, RN #237, caring for Resident #95 that her hands and feet were discolored.Three attempts were made to contact RN #237 after the interview with CNA #249 with voicemail messages left with each attempt. No return calls were provided. Interview on 09/23/25 at 4:20 P.M. with LPN #198 revealed she did not recall Resident #95 having dusky colored hands or feet on the evening of 06/27/25 when she was caring for the resident nor did she recall any other staff reporting this to her on this date. LPN #198 stated she only worked every other weekend (please note, there was no documentation in the resident's medical record of the resident's status for the LPN to review for 06/27/25, 06/28/25 or 06/29/25 prior to the resident's transfer to the hospital).Interview on 09/23/25 at 4:25 P.M. with Medical Director #301 revealed the resident's overall condition would have been documented in his progress notes if he was notified of the resident's condition change. Further interview revealed it would be his expectation nursing would evaluate a resident experiencing a condition change and then notify him, the CNP or the on-call medical provider to obtain orders.Interview on 09/24/25 at 1:30 P.M. with Acting Director of Nursing #303 revealed Resident #95 should have been assessed, the medical provider contacted, and the resident transferred to the hospital or discussed hospice and end-of-life care when the change of condition was reported. The Acting DON verified a root cause analysis completed by the facility following the concern with Resident #95's care identified the cause was the facility's failure to assess the resident when the CNAs reported to different nurses she was exhibiting changes in condition with discolored hands and feet, wearing oxygen and not acting per her usual. The Acting DON verified the delay in assessment and notification of the resident's condition change resulted in the resident being transported to the hospital at which time the resident's condition was determined to be terminal and she was transferred to a hospice facility and then passed away. The Acting DON confirmed the facility did not identify the delay in treatment until the concern was identified by the State Survey Agency so an investigation into the incident involving Resident #95 was not previously initiated. The Acting DON verified her expectations of the nursing staff would have been to assess the resident when the changes were reported and notify the medical practitioner of the resident's needs, including the use of oxygen so additional treatment orders or interventions could have been implemented. Review of the policy titled Change in a Resident's Condition or Status revealed the facility is to promptly notify the resident, the resident's attending medical provider, and the resident's representative of changes in the resident's medical/mental condition. Further review revealed nurse is to record information related to the resident's change in condition in the resident's medical record.Review of the facility assessment dated [DATE] revealed that under the area of services and care offered the facility would manage medical conditions by assessment, early identification of problems or deterioration. Further review indicated that all newly hired personnel receive training during their orientation on identification of resident changes in condition including how to identify medical issues appropriately and how to determine if symptoms represent problems in need of intervention.This deficiency represents non-compliance investigated under Complaint Number 2615387.

Based on record review, clinic note review, hospital record review and interview the facility failed to ensure Resident #79 was provided adequate and necessary comprehensive, resident centered care following a vascular procedure for arterial stenosis to prevent complications. Actual Harm occurred on 09/02/25 when Resident #79 was diagnosed with osteomyelitis (infection of the bone) of the left foot after the facility failed to administer physician ordered medication following a vascular procedure (on 05/23/25) to maintain patency of the stent placed and failed to arrange transportation to follow up appointments with the vascular surgeon from 07/02/25 to 09/02/25, resulting in the resident developing infected arterial wounds that required emergent transport to the hospital for evaluation and treatment of osteomyelitis with intravenous antibiotics administered through a peripherally inserted central catheter. This affected one (#79) resident of 17 residents reviewed for care. Findings include:Review of the medical record for Resident #79 revealed an admission date of 06/15/24 with diagnoses including diabetes, peripheral vascular disease, dementia, chronic kidney disease, hypertension, and atrial fibrillation. Review of the plan of care initiated on 05/01/25 revealed the resident had an arterial/ischemic ulcer to the left lateral foot with interventions including monitoring the wound and circulation of the foot. Review of a vascular office clinic note by the vascular surgeon on 05/02/25 revealed he had called the resident's daughter to discuss the results of a bilateral lower extremity arterial duplex and ankle-brachial index (ABI) testing which showed moderate disease. (ABI testing assesses the blood flow in the legs and detects artery disease, a condition where arteries in the legs become narrowed and blocked). The resident had stenosis of the left anterior tibial artery and nonvisualization of the tibials on the right. A right lower extremity angiogram with possible intervention was offered and the power of attorney was in agreement to proceed. The surgeon also contacted the facility and spoke with the wound nurse who reported the resident's right heel wound was not healing but the wounds on the right toes were. The resident would continue taking his Aspirin (81 milligrams (mg) daily). Review of a nursing progress note dated 05/23/25 at 7:40 A.M. revealed the resident was picked up by transport for the angiogram procedure. Further review of the nursing progress note dated 05/23/25 at 6:43 P.M. revealed the resident returned from the hospital, transferred from cot back into bed. There was no mention of the resident's discharge/post-procedure orders. Review of the Patient Discharge Summary and Instructions dated 05/23/25 revealed the resident was to receive medications including Plavix 75 mg every day and Aspirin 81mg. The discharge instructions also directed the resident to keep all follow-up appointments. This is important. Review of the medical record revealed the resident had not received Aspirin since 11/14/24 and the Plavix was never administered after ordered on 05/23/25. Review of additional care plan documentation revealed arterial/ischemic ulcer to the right heel, right lateral foot initiated 06/25/25, an arterial/ischemic ulcer to the right third and forth toes initiated 09/04/25 with interventions including to inspect the feet daily, keep the feet clean and dry, monitor/document the wound, monitor/document signs/symptoms of infection. There was no care plan related to the resident's angiogram, post operative care, follow-up appointments or transportation needs required for appointments. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 (out of 15), indicating the resident had moderately impaired cognition. The assessment also revealed the resident required assistance of one to two staff with activities of daily living. Review of a consultant wound care note dated 09/02/25 revealed Resident #79 was being followed for multiple arterial wounds to his bilateral feet that appeared to decline quickly. The wound locations were identified as Wound #1 located on the right foot, third digit measuring 0.7 centimeters (cm) by (x) 0.7 cm with the wound bed 50% slough (stringy tissue) and 50% exposed bone with a moderate amount of thick, white, purulent drainage (this wound was slightly larger in size than the week prior). Wound #2 was the right lateral foot measuring 2.0 cm x 2.2 cm with the wound base 10% granulation tissue (new tissue) and 90% necrotic tissue (black, dead tissue) with a moderate amount of serosanguinous (bloody) drainage (this wound was concerning to the wound team and represented an infected wound); Wound #3 right foot 4th digit measuring 0.5 cm x 0.5 cm with 100% slough and a moderate amount of thick, white, purulent drainage; Wound #4 left foot, third toe, dorsal measuring 0.9 x 1.0 cm covered completely by a scab and no drainage. This wound was unchanged; Wound #5 was located at the left lateral foot and measured 2.1 cm x 1.7 cm with the wound bed covered with 80% granulation and 20% slough with a moderate amount of serosanguinous (thin, watery blood) (this wound was identified to be improving) drainage. The assessment also noted erythema (skin redness), warmth, reported tenderness, and purulent exudate (pus) present to the wounds located on the right foot. The note included concerned about risk of osteomyelitis (infection of the bone) and possible amputation. Recommend resident to be sent to hospital for further evaluation and management. Review of a nursing progress note dated 09/02/25 at 12:40 P.M. revealed resident was seen by the wound care provider during rounds this shift as a follow up visit for multiple arterial wounds to bilateral feet. Wounds have deteriorated this week. Provider did suggest the resident be sent out to the hospital for evaluation. On 09/02/25 at 2:34 P.M. call to 911 per unit manager/wound nurse who was having resident transported for wound evaluation and due to missed follow up with the vascular surgeon. Appointments missed due to no cot service at facility (for transportation). On 09/02/25 at 2:49 P.M. the resident was transported to the hospital. Review of hospital records dated 09/02/25 revealed the resident was diagnosed with osteomyelitis of the left foot. The resident was ordered Bactrim DS (antibiotic) orally twice a day for 14 days. The instructions directed to continue medications, including Aspirin 81 mg and Plavix 75 mg with no changes. Review of a nursing progress note dated 09/09/25 at 10:09 P.M. revealed the facility received a call from the hospital. Wound culture results (of the feet) had been received and the resident needed intravenous (IV) antibiotics to treat the bacteria/infection identified. Review of a Certified Nurse Practitioner (CNP) progress note dated 09/10/25 revealed Resident #79 was seen for osteomyelitis and was diagnosed with left foot osteomyelitis. Bilateral foot x-rays were completed with destructive changes to the left 5th metatarsal, possible osteo (osteomyelitis), soft tissue swelling of bilateral feet. No elevated white blood cells. Started on Bactrim through 09/17/25 and wound culture obtained. The wound culture from the hospital was reviewed with the organism proteus providencia and meropenem for seven days was ordered (IV). Physician orders were obtained on 09/10/25 for the placement of a peripherally inserted central catheter (PICC) line and to administer antibiotics through the line every eight hours for seven days for osteomyelitis/wound infection. Interview with Unit Manager/Licensed Practical Nurse (LPN) #175 on 09/18/25 at 1:40 P.M. confirmed Resident #79 had missed follow-up appointments with the vascular surgeon. She stated it was because the facility did not have a contract with a non-emergent ambulance service. Interview with Administrator #188 on 09/18/25 at 1:55 P.M. revealed around the beginning of July 2025 the facility no longer had a contract with a non-emergent ambulance transportation service. She stated the facility currently did not have a contract with a non-emergent ambulance transportation service. She stated a contract had been arranged but she had not yet signed the contract to put it into effect. She stated she did not know who or how many residents were not transported to appointments during that time. Interview with Transportation Manager #221 on 09/22/25 at 7:38 A.M. confirmed the facility did not have a contract for non-emergent transportation since 07/01/25. She confirmed Resident #79 had missed appointments with the vascular surgeon on 07/02/25 (his first scheduled appointment after his vascular procedure), 09/08/25, and 09/10/25 (please note, the facility did not reschedule the cancelled 07/02/25 appointment until September with testing on 09/08/25 and a vascular surgeon appointment on 09/10/25; however, both September appointments were cancelled due to no transportation and the resident had not been seen by the vascular surgeon since his procedure was done on 05/23/25). Interview with CNP #202 on 09/22/25 at 11:39 A.M. revealed she was aware of the facility not being able to transport residents to appointments who required going by cot. However, she was not aware that Resident #79 had missed follow up appointments with the vascular surgeon. Interview with Physician/Medical Director #301 on 09/22/25 at 1:45 P.M. revealed he was aware Resident #79 had the angiogram with an intervention to open and dilate the right leg artery on 05/23/25. He stated that going to a follow-up appointment would have checked to see if things were still ok. Interview with Nurse Supervisor #700 at the vascular surgeon's office on 09/22/25 at 3:40 P.M. (to discuss the procedure discharge instructions for 05/23/25) revealed Resident #79 had the angiogram done on 05/23/25 with physician orders upon discharge to begin Plavix 75 mg daily and continue Aspirin 81 mg daily. (Plavix is used with Aspirin following angioplasty with stenting to prevent the stent from closing). Nurse Supervisor #700 stated the Aspirin 81 mg had been ordered by the vascular surgeon on 03/25/25. Further interview revealed their office began calling the facility on 05/30/25 to schedule a follow-up visit with the vascular surgeon but they had difficulty reaching the facility and had to call the facility five times to get someone to answer the phone. Finally, on 06/03/25 they were able to talk to someone and a follow-up visit was scheduled with the vascular surgeon for 07/02/25. However, the facility called on 07/02/25 and cancelled the appointment due to a lack of transportation. The nurse supervisor shared the facility did not call back to reschedule the appointment until September 2025. She stated testing was scheduled for 09/08/25 and a follow up visit on 09/10/25. However, those appointments were also cancelled on 09/05/25 due to the facility having no transportation. She confirmed the resident had not been seen by the vascular surgeon since 05/23/25. During the interview, the nurse supervisor revealed not receiving the Plavix medication could impair the stent that was put in and cause occlusion of blood flow. She stated impaired blood flow in the legs could cause worsening of the wounds and osteomyelitis. Lastly, the nurse supervisor indicated the purpose of follow-up appointments was to verify how the patient was progressing after their procedure, and the patient (Resident #79) should have been transported to the appointments to be evaluated by the physician and monitor healing. Interview with RN/Vice President of Clinical Operations #300 on 09/23/25 at 11:45 A.M. confirmed Resident #79 had not received Aspirin as ordered. She believed it had been discontinued on 11/14/24. She also confirmed the resident had not received the Plavix that was ordered on 05/23/25. This deficiency represents noncompliance investigated under Complaint Number 2623671, 2623597, 2619174.

Based on closed record review, hospital record review, interview and policy review the facility failed to provide a comprehensive, resident centered plan of care to prevent, timely identify, and treat weight loss and dehydration.This resulted in actual harm on 06/29/25 when Resident #95, who was identified at nutritional risk, was cognitively impaired and required staff assistance with activities of daily living (ADLs), was assessed by hospital staff to exhibit possible severe malnutrition and severe dehydration with a weight of 77 pounds. The most recent facility weight, documented on 06/25/25 was recorded to be 91 pounds. The facility failed to ensure effective, appropriate and sustainable interventions were in place to prevent the significant weight loss and severe dehydration resulting in hospitalization. This affected one resident (#95) of three residents reviewed for change in condition. An additional example that did not rise to the level of actual harm resulted when the facility failed to ensure dietician follow up after a significant weight loss for a resident. This affected one (#65) of three residents reviewed. The facility census was 94. Findings include: 1.Review of Resident #95's closed medical record revealed an admission date of 05/30/25 with diagnoses including Alzheimer's disease, osteoarthritis, osteoporosis, cannabis use, nicotine dependence, and dementia severe with agitation. Resident #95 was admitted to the facility after a hospital stay for treatment of agitation and combativeness. Review of Resident #95's physician's orders revealed an order dated 05/30/25 for weekly weights for four weeks and then monthly. A physician's order dated 06/02/25 revealed the resident received a regular diet with thin liquids and requested a full code status (the resident wished to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). Review of Resident #95's medical record revealed on 05/30/25 the resident weighed 98 pounds on admission to the facility and on 06/02/25 the resident weighed 92.6 pounds. Review of Certified Nurse Practitioner (CNP) #202 progress note on 06/02/25 at 10:50 A.M. revealed the resident was in no acute distress, the CNP confirmed the resident's advanced directive with the family on 06/02/25. There was no mention of the resident's weight loss since admission. Review of the History and Physician dated 06/03/25 at 12:00 A.M. and written by Medical Director #301 did not indicate the resident had experienced a significant weight loss since admission. Review of Resident #95's medical record revealed a nutrition assessment dated [DATE] at 10:06 A.M. indicating the resident had lost 5.4 pounds in a week, a significant weight loss of 5.8%, related to poor appetite. Registered Dietician #302 recommended the addition of 240 milliliters of the house supplement three times daily. The resident was also assessed to have estimated nutritional need of 1263-1473 calories per day and an estimated fluid need of one milliliter (ml) of fluid per calorie a day (1263-1473 ml of fluid per day). However, please note, the resident's meal intake records only included fluids consumed but did not specify how much actual fluid was consumed during meals. Review of Resident #95's physicians orders revealed an order dated 06/04/25 for house supplement 240 milliliters three times daily. Please note, there was no evidence of the resident receiving the nutritional supplement, consumption or acceptance of the ordered nutritional supplement contained within the medical record. Review of the resident's meal tickets revealed the house supplement (nutritional shake for weight loss) was to be provided by dietary staff on the resident's meal trays. Review of Resident #95's care plan revealed a nutrition care plan initiated on 06/03/25 for a nutritional problem or potential nutritional problem related to a borderline low body mass index (BMI), dementia, osteoporosis, cannabis use, poor appetite, weight loss in the facility and the need for an oral nutritional supplement. The goal was for Resident #95 to maintain adequate nutritional status as evidenced by her maintaining her weight without significant weight changes, having no signs or symptoms of malnutrition and consuming at least 50% of her meals daily through the next review date. Interventions for Resident #95 were to administer medications as ordered and monitor for and document side effects and effectiveness of the medications, provide and serve the resident's diet as ordered, monitor the resident's food and fluid intake and record the intake for every meal and the registered dietician was to evaluate the resident and make diet change recommendations as needed. Record review revealed there were no additional interventions added to the nutrition care plan after the care plan was created. Further review of the resident's care plan revealed the facility had not developed a plan of care related to hydration or a risk for dehydration or related to the resident's physical ability to consume food/liquids. There was no plan of care in place to reflect the resident needed/required staff assistance for eating/fluid consumption as it pertained to her cognitive status, identified poor appetite and weight loss. Review of Resident #95's admission Minimum Data Set (MDS) assessment, dated 06/06/25, revealed a Brief Interview for Mental Status (BIMS) score of 03 (out of a possible score of 15) indicating the resident had impaired cognition. The assessment revealed the resident required setup/cleanup assistance with eating, supervision with bed mobility, transfers and walking and substantial/maximal assistance with toileting hygiene. The MDS indicated Resident #95 was frequently incontinent of bladder and always incontinent of bowel. No weight loss or skin alterations were identified during the assessment. Review of the resident's meal percentages for breakfast, lunch and dinner from 06/06/26 through 06/23/25 revealed the resident's meal (food and fluid) intake varied from day to day and meal to meal. There was no documentation to support the resident was offered different foods or selections when she did not eat what was offered and no documentation the resident received the ordered nutritional supplement or accepted any amount of the supplement. Review of Resident #95's medical record revealed a weight on 06/09/25 of 92 pounds, an additional weight loss of 0.6 pounds since 06/02/25. Review of Resident #95's progress note dated 06/10/25 at 11:22 A.M. revealed a nutrition note written by Registered Dietician (RD) #302 revealed the resident had not had any significant changes in weight since the dietician's previous assessment and her weight had been stable for one week. Further review of the progress note revealed RD #302 stated Resident #95 was on appropriate nutrition and the RD had no new recommendations at the time of the note and would monitor the resident as needed. Review of Resident #95's progress note written by CNP #202 dated 06/11/25 at 12:00 A.M. revealed a follow up on the resident's mood disorder, dementia and insomnia. CNP #202 noted the staff had no new concerns with Resident #95. The progress note did not include mention of the resident's weight loss identified since admission to the facility. (A significant weight loss since admission to the facility from 98 pounds to 92 pounds). Review of Resident #95's medical record revealed no documentation of a weight for Resident #95 the week of 06/14/25 and no documentation of a weight the week of 06/21/25. Review of Resident #95's medical record revealed a weight on 06/25/25 of 91 pounds (an additional weight loss of one pound from 06/09/25). Record review revealed no evidence the cause of the weight loss was identified, the resident's nutritional intake was reviewed and/or evidence new interventions were implemented at this time to address the resident's nutrition/hydration status. There was no documentation the RD was notified the resident had experienced additional weight loss. Review of the resident's meal intake records (which included fluid intakes during the meal but was not isolated from food consumed and calculated in with the meal percentage) from 06/24/25 through 06/29/25 revealed the following: On 06/24/25 the resident had no intake (food or fluid) for breakfast, lunch or dinner with one staff member assisting with each meal. On 06/25/25 the resident had no intake for breakfast with one staff member assisting, up to 25% of the lunch meal with one staff member assisting and 75-100% of the dinner meal with only set up help from one staff. On 06/26/25 the resident had no intake for breakfast or lunch with set up help from staff and there was no documentation for the dinner meal. On 06/27/25 the resident refused breakfast and lunch and had no intake for dinner with set up help for the meal. On 06/28/25 the resident had no intake for breakfast and lunch with the assistance of one staff member and up to 25% of the dinner meal was consumed with staff assistance. On 06/29/25 the resident had no intake for breakfast, lunch or dinner with assistance of one staff. Review of the medical record revealed no notification of the resident's decreased food or fluid intake from 06/24/25 through 06/29/25 to the medical provider or RD. There was also no documentation as to why the resident was not eating or drinking or alternate options attempted or provided. Review of Resident #95's medical record revealed the next progress note was dated 06/29/25 at 8:25 P.M., written by LPN #194 which revealed Resident #95 was lying in bed in the fetal position with oxygen on via mask. Resident #95 did not want to open her eyes, was restless and less verbal than her normal. Resident #95's color was pale, her skin was cool to touch, her skin turgor was poor (refers to the elasticity of the skin and represents a person's hydration status) and her lips and mouth were very dry. The resident's vital signs included blood pressure 102/53 millimeters of Mercury (mmHg) (normal 120/60 mmHg), temperature 97.3 (degrees Fahrenheit) (average body temperature 98.6 degrees F), pulse 54 (normal range 60-90 beats per minute) and respirations 14 (normal 12-20 breaths per minute). LPN #194 was unable to obtain Resident #95's peripheral oxygenation saturation (a pulse oximeter is placed on a person's finger and will provide a reading of the resident's oxygen level in the bloodstream but the oximeter will have difficulty identifying oxygen levels with cool hands and movement) reading due to the resident moving her hands. LPN #194 notified the on-call physician and received an order to send the resident to the emergency room for evaluation and treatment and activated 911 to transport the resident. LPN #194 notified the resident's spouse of the resident being sent to the hospital. Review of Resident #95's hospital records revealed an admission history and physical dated 06/30/25 at 2:03 A.M. that indicated the resident was admitted to the service of the hospitalist for severe dehydration. Resident #95's weight when admitted to the hospital was documented to be 77 pounds (the facility's most recent weight on 06/25/25 was documented to be 91 pounds). The resident was described as extremely debilitated, malnourished, as well as very dehydrated with parched lips and parched oral mucosa. The hospitalist estimated the resident had an approximate 3.8-to-4-liter free water deficit. A hospice consultation was initiated after discussion with the resident's family. Further review of the resident's hospital records revealed a consultation note dated 06/30/25 at 11:33 A.M. that revealed the resident was brought to the emergency room on [DATE] from the facility with decreased food/fluid intake for several days according to staff. Labs were notable including a hemoglobin of 17, hematocrit of 42.6 and a (critical) sodium level of 173 (all indicative lab studies for dehydration). The resident's admission weight was documented to be 77.66 pounds with a body mass index of 13. The consultation note included the patient was examined at bedside. She was lethargic, unable to answer questions and unable to follow simple commands. The resident appeared thin, frail and cachectic with muscle/fat wasting noted to temples, orbits, cheeks, clavicles, arms and legs. Mucus membranes appeared dry and skin turgor was poor. The resident's skin was warm, dry and dusky. Spouse agreeable to hospice consult with patient hopefully being transported to (named) house (hospice house). Primary hospice diagnosis could either be advanced dementia (no specified type but based on clinical picture and review of medical records, likely Alzheimer's dementia with possibility of vascular component) or severe malnutrition as patient was eligible with either diagnosis. Interview on 09/17/25 at 6:25 A.M. with LPN #194 revealed she came into work on Sunday, 06/29/25 (after being off for a few days), and when she went into Resident #95's room to administer her evening medication, she found the resident in bed with oxygen on and not really responding. The LPN stated she could not find anything about a change in the resident's condition in the nurse's progress notes (prior to her observation) or an order for oxygen use in the medical record so she contacted the on-call medical provider and then transferred the resident to the emergency room due to this significant change in the resident's condition since the last time she had worked with the resident (the night of 06/24/25). Interview on 09/18/25 at 4:00 P.M. with Certified Nursing Assistant (CNA) #226 revealed Resident #95 normally spent a lot of time during the day either lying or sitting on her bed. CNA #226 stated she cared for Resident #95 during the day on 06/29/25, the day the resident was sent to the hospital. CNA #226 stated the resident had slept all day, was hard to wake up, and did not eat or drink on day shift. CNA #226 stated she verbally reported this to her nurse, Registered Nurse (RN) #237, who responded that she would look into getting hospice for the resident. Interview on 09/22/25 at 11:10 A.M. with CNA #204, stated Resident #95 seemed to sleep more, and her food and fluid intake became more limited (the documentation in the resident's medical record reflects poor intake of food and/or fluid during meals leading up to the resident's hospital transfer). Prior to this, the resident had been up and wandering around and rummaging in other residents' rooms. Interview on 09/22/25 at 11:55 A.M. with CNP #202 revealed she was not notified of Resident #95's changes in condition (not eating or drinking, wearing oxygen, previous weight loss or changes in her usual activity). CNP #202 further stated that when she saw Resident #95 on 06/25/25 she felt the resident was at her neurological baseline and she was unaware of issues or concerns with the resident's status. The CNP verified the on-call service had not added a system note for Resident #95 between her visit on 06/25/25 until 06/29/25, when the order was given to transfer the resident to the emergency room. Interview on 09/22/25 at 10:30 A.M. with Regional Registered Nurse #200 verified no weight was obtained for Resident #95 the week of 06/14/25. Regional Registered Nurse #200 also verified that there was no specific documentation of the percentage or amount of the house supplement that the resident consumed and stated this should be documented. Interview on 09//22/25 at 11:55 A.M. with CNP #202 revealed she was not notified of Resident #95's weight loss or changes in the resident's condition (not eating or drinking, wearing oxygen, not her usual behaviors). CNP #202 further stated that when she saw Resident #95 on 06/25/25 she felt the resident was at her neurological baseline. The CNP verified the on-call service had not added a system note for Resident #95 between her visit on 06/25/25 until 06/29/25 when the order was given to transfer the resident to the emergency room. CNP #202 stated she or the on-call provider should have been notified when Resident #95's condition changed enough that oxygen was placed on her. CNP #202 also expected to be made aware of weight changes and any other changes with residents that she was caring for. Interview on 09/22/25 at 1:37 P.M. with Registered Nurse (RN) #237 revealed she did not normally work the hall Resident #95 resided on and did not know the resident well. RN #237 stated she did recall the resident being very sleepy that weekend (June 27-28), the CNAs assisted the resident with eating, and she did not eat much. Interview on 09/22/25 at 3:18 P.M. with CNA #163 revealed she had just recently started working at the facility in June 2025 and did not know much about Resident #95 other than she was difficult to redirect and she did not eat or drink well. The CNA stated she attempted to assist the resident with her lunch meal on 06/27/25 but Resident #95 would not open her mouth. She stated she did report this to a nurse working on this date but could not recall the nurse she reported this to. Interview on 09/23/25 at 8:48 A.M. with CNA #249 revealed she worked day shift on Saturday and Sunday (06/28/25 and 06/29/25) before Resident #95 was sent to the hospital on [DATE]. CNA #249 stated Resident #95 slept a lot and did not eat or drink well those two days. Interview on 09/23/25 at 1:40 P.M. with RD #302 revealed she believed the house supplement was given by nursing and the amount the resident received was recorded on the medication administration record, but she stated that she could be wrong about that. RD #302 stated that new admissions were to be weighed weekly for four weeks and any resident that weighed less than 100 pounds should also be on weekly weights. RD #302 indicated that she was at the facility on Tuesdays and reviewed any weights taken since the previous Tuesday while at the facility and made any recommendations at that time. RD #302 stated Resident #95 was stable at 92 pounds on 06/10/25 when she reviewed her weight but Resident #95 did not get weighed the week of 06/14/25 and was not weighed the following week until after the weekly dietician visit (06/24/25) so she was not aware Resident #95's weight was continuing to decline and was not notified of the continued weight loss. Review of the policy titled Weight Assessment and Intervention updated 01/10/23 revealed that the assessment information would be analyzed by the multidisciplinary team and the physician to identify conditions and medications that may be causing anorexia, weight loss or increasing the risk for weight loss. 2. Review of the medical record for Resident #65 revealed an admission date of 10/10/12 with diagnoses that included encephalopathy, ataxia, cerebral aneurysm non-ruptured, nontraumatic subdural hemorrhage, chronic obstructive pulmonary disease, psychotic disorder, bipolar disorder, convulsions, vitamin B deficiency, sexual disorders, anxiety disorders, hypokalemia, combined forms of age-related cataract, fracture of shaft of left fibula, panic disorder, vitamin B12 deficiency, mood disorder, hypo-osmolality and hyponatremia, dementia, constipation, personal history of COVID-19, presence of cerebrospinal fluid drainage device, alcohol use, and hypertension. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating impaired cognition. Review of the weights for Resident #65 revealed a decrease from 181.7 pounds on 08/05/24 to 168.9 pounds on 09/10/24, reflecting a weight loss of 12.8 pounds (7.6%), followed by an increase to 188.8 pounds on 10/14/24. More recently, weights decreased from 188 pounds on 08/19/25 to 178.4 pounds on 09/13/25, reflecting a loss of 9.6 pounds (5.1%), with a reweight on 09/19/25 confirming no change at 178.4 pounds. Review of the progress notes for Resident #65 revealed a dietician note dated 09/10/24 at 11:18 A.M. documenting a significant weight loss of 12.8 pounds (7.6%) over 30 days with a current weight of 168.9 pounds. The resident was on a regular diet with regular texture and thin liquids, with oral intakes ranging from 50–100%. Medications were reviewed, and skin was noted to be intact per the 09/04/24 weekly skin assessment. The registered dietitian (RD) requested a reweight to verify the weight loss. No follow-up weight or note occurred after this dietician note. Review of the progress notes for Resident #65 revealed a dietician note dated 09/16/25 at 10:27 A.M. documenting a triggering weight loss of 9.6 pounds (5.4%) over 30 days with a current weight of 178.4 pounds and body mass index of 29.7, indicating overweight. The resident was on a regular diet with regular texture and thin liquids, with oral intakes ranging from 75–100%. Medications were reviewed, and skin assessment revealed no pressure areas or edema. Estimated nutritional needs were calculated based on an adjusted body weight of 147 pounds at 1,670–2,005 kcal/day, 67 grams protein/day. The RD requested a reweight to verify weight loss and noted that the resident remained on appropriate nutrition orders with monitoring as needed. Review of the progress notes for Resident #65 revealed a dietician follow-up note dated 09/23/25 at 9:24 A.M. indicating that the resident's weight had remained stable for one week. The RD noted the goal to promote weight stability and slow the rate of further weight loss. A plan was made to add an oral nutrition supplement (ONS) and monitor weight trends, with a recommendation to add a 120 ml house supplement once daily. The RD stated the resident would be monitored as needed. Interview on 09/25/25 at 1:16 P.M. with the Registered Dietitian (RD) confirmed that for the period of August 2024 through September 2024, she suspected the documented weight was inaccurate and requested a reweight; however, the reweight was never completed. She explained that this oversight slipped through the cracks. The RD further stated that when a resident refuses a meal or supplement, staff should attempt multiple times to encourage intake, but in this case, no such attempts were documented. The RD also reported that a reweight was missed following the weight obtained on 09/13/25. She stated that when nutrition orders were recommended, she expected the orders to be implemented within 24 hours so that supplements could be started and monitoring initiated promptly. The RD explained that staff were expected to record in the Medication Administration Record (MAR) the percentage of the supplement consumed, and if intake was low, staff should offer an alternative supplement to determine if the resident preferred it. The RD confirmed that the recommended 120 ml house supplement for Resident #65 had not yet been initiated as of the interview date, despite being recommended in the progress notes. She emphasized that timely implementation and monitoring of nutrition interventions were critical to addressing weight loss and preventing further nutritional decline. Review of the facility policy titled, Weight Assessment and Intervention dated 01/13/23 revealed that a 5% or greater weight change since the last assessment triggered a re-measurement the next day, with the nurse notifying the Dietitian in writing for confirmation within 24 hours, who then responded within 24 hours to recommend trends over time. Significant weight loss was defined as 5% in one month (severe if >5%), 7.5% in three months (severe if >7.5%), or 10% in six months (severe if >10%), with desirable changes documented without care plan adjustments. The multidisciplinary team analyzed assessment data, considering target weight ranges, medical conditions, and potential causes such as anorexia or cognitive decline, and developed individualized care plans with goals, benchmarks, and monitoring timelines, ensuring resident preferences and rights were respected, including documentation if a resident declined intervention. This deficiency represents non-compliance investigated under Complaint Number 2615387.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, resident and staff interviews, review of the facility's Self-Reported Incident (SRI) and investigation, review of the police report, policy review, and review of the Sexual Assault Nurse Examiner (SANE) exam, the facility failed to ensure a resident was free from sexual abuse. Actual Harm occurred to Resident #71 when Resident #88 sexually assaulted Resident #71, leaving Resident #71 with internal injuries after the sexual assault and psychosocial harm when Resident #71 had significant decline in her mental condition with increased anger, depression, and scared, disclosed a history of sexual trauma, and reported flashbacks, nightmares, and increased anxiety triggered by a male resident (Resident #88). The facility census was 85. Findings include: Review of the medical record for Resident #71 revealed an admission date of 09/08/22 with diagnoses including cerebral palsy, intellectual disabilities, schizoaffective disorder bipolar type, psychosis not due to a substance or known physiological condition, major depressive disorder recurrent moderate, generalized anxiety disorder, and post-traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had intact cognition. Resident #71 had moderate symptoms of depression, and verbal behavioral symptoms were noted one to three days during the look-back period. Resident #71 required extensive to total assistance from staff with most activities of daily living, including hygiene, dressing, toileting, and transfers. Review of the care plan for Resident #71 revealed she has a past traumatic event of exposure to sexual assault (rape/attempted rape/made to perform any type of sexual act through for or threat of harm/other unwanted or uncomfortable sexual experiences). Interventions included monitoring for residual emotional effects Review of the progress notes revealed on 05/08/25 at 12:41 P.M., Resident #71 reported to Certified Nursing Assistant (CNA) #115 that a male resident (Resident #88) had sexually assaulted her. The nurse immediately assessed Resident #71, who confirmed the allegation, stating the male resident had touched her inappropriately and against her will. A CNA remained with Resident #71 while the nurse reported the incident to facility management. The social services note dated 05/08/25 at 1:00 P.M. revealed Resident #71 stated she felt safe in the facility, especially knowing the male resident (#88) was placed on one-on-one supervision. She expressed fear about being transferred to another facility, as she had lived there for over 20 years. She was resting comfortably, watching television, and was aware that emergency medical services (EMS) would arrive soon to transport her to the hospital per her request. The progress note dated 05/08/25 at 3:20 P.M. revealed Resident #71 was transferred to the hospital for a sexual assault kit and further evaluation. The progress note dated 05/08/25 at 9:55 P.M. revealed Resident #71 returned from the hospital and was transferred to bed with staff assistance. The resident was crying, requested as needed anxiety medication, and expressed fear about the male resident (#88) still being in the facility. She stated she never wanted to see him again. Review of the facilities SRI control number 260173 dated 05/08/25 revealed Resident #71 alleged a male resident (#88) touched her inappropriately and wanted it reported to the police. Resident #71 reported Resident #88 had attempted to put his hand under her shirt and had touched her genital area. Resident #88 denied the incident occurred. Review of the police report for Resident #71 dated 05/08/25 revealed the related offense was gross sexual imposition of substantial impairment. Resident #88 (alleged assailant) denied anything happened then stated he went into Resident #71's room to just talk. Resident #88 stated that he would never do anything like that, knowing Resident #71's condition (unable to move from her waste down). Resident #88 stated that this was his second time he has been accused of this. Resident #71 stated Resident #88 came into her room asking for a relationship with her and Resident #71 did not know what that meant. Resident #88 stuck his fingers in her vagina and then groped her breast. Resident #71 told Resident #88 no but Resident #88 continued to do it anyway. Resident #71 began to cry and stated she shouldn't have to feel scared living in her home because of this incident. Review of the SANE exam conducted on 05/08/25 for Resident #71 (State Survey Agency received on 06/06/25) revealed there was vaginal penetration by assailant's fingers completed by direct visualization from the examiner. There were mild abrasions showed with Toluidine blue dye application (a diagnostic tool used to highlight microscopic tears or abrasions on the genital or anal areas that may not be visible to the naked eye). Resident #71 reported in the examination that she was lying in her bed in her room between 7:00 A.M. and 8:00 A.M. Resident #71 stated she was eating a bagel with cream cheese and Resident #88 entered her room and they were talking. Resident #88 stated 'I would like to do some stuff with you' and wanted Resident #71 to date Resident #88. Resident #71 responded maybe we will just watch television or something. Resident #71's roommate was in the room sleeping and Resident #71 didn't want to interrupt her roommate's sleep. Resident #71 told Resident #88 that they cannot do anything as her was roommate was sleeping and Resident #71 did not feel well and was not going to get out of bed that day. Resident #88 stated to Resident #71 that she did not have to get up and Resident #88 will return to her room later. Resident #71 felt better after she ate and Resident #88 returned to her room. Resident #71's roommate was not in the room and staff were also not in her room. Resident #88 asked Resident #71 if she was feeling better and Resident #88 replied that she was feeling better. Resident #88 stated Resident #71's roommate was not in the room so they can be alone now. Resident #88 proceeded to put his hands down Resident #71's adult brief and put his fingers in Resident #77's vagina. Resident #71 said Ouch, that hurts, stop that. I don't like that.Resident #88 stopped after that. A CNA (#115) walked into Resident #71's room and saw Resident #88's chair and said get out of the room. The CNA asked Resident #71 how long Resident #88 was in her room. Resident #71 was unable to see her clock and couldn not state how long Resident #88 was in her room. The CNA said it was 45 minutes when she was last in Resident #88's room. The CNA said Resident #88 has been doing this to all the women, and told Resident #71 she needed to press charges. The police came to the facility and Resident #71 talked to the police to press charges and then the police brought Resident #71 to the hospital for a sexual assault kit. The social services note dated 05/09/25 revealed Resident #71 agreed to resume counseling services. Review of psychiatric progress notes revealed on 05/06/25, Resident #71 reported a good mood with no signs of depression, anxiety, psychosis, or suicidal ideation. However, following a SRI incident, the 05/20/25 the progress note documented a significant decline in her condition-she described feeling angry, depressed, and scared, disclosed a history of sexual trauma, and reported flashbacks, nightmares, and increased anxiety triggered by a male resident. A treatment plan was developed, and she agreed to initiate low-dose Ativan (treats anxiety) and Prazosin (treats PTSD-associated nightmares). By 06/03/25, her symptoms had improved; she described her mood as good, denied depression, anxiety, or hallucinations, and noted that scheduled Ativan had reduced her anxiety. Staff also observed an improved mood, reduced anxiety, and continued medication compliance with no signs of psychosis or worsening symptoms. Prior interview on 05/19/25 at 2:52 P.M. with Resident #71 reported Resident #88 came into her room just to talk initially then began to touch her breast and told Resident #88 to stop and didn't want to be touched. Resident #88 continued to sexually abuse her and put his hands down her adult brief and Resident #71 yelled stop. A CNA (#115) came into her room and Resident #88 then stopped. Interview on 06/10/25 at 7:45 A.M. with Assistant Director of Nursing (ADON) #183 stated Resident #88 no longer resided in the facility and was transferred out on 06/02/25. Interview on 06/10/25 at 9:48 A.M. with Director of Nursing (DON) revealed Resident #88 was on one-on-one supervision after the incident until he was transferred to another facility. Interview on 06/10/25 at 10:37 A.M. with CNA #115 revealed she had been walking down the hall when she observed a wheelchair outside of Resident #71's room. CNA #115 entered the room and saw Resident #88's hand near Resident #71's waist. Resident #71 stated they were not doing anything. CNA #115 asked Resident #88 to leave Resident #71's room. Then Resident #71 reported that Resident #88 had been playing with her breast and sticking his hands down her pants. Interview on 06/10/25 at 11:08 A.M. with Resident #75 revealed she and other female residents were on edge with Resident #88 being in the building and were happy when they put him on a 24-hour watch and eventually transferred to another facility. Review of the facilities Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy dated 11/01/19 revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. As a result of the incident, the facility took the following action to correct the deficient practice by 06/02/25: • On 05/08/25, Resident #88 was placed on 1:1 supervision to prevent him from entering any rooms, • On 05/08/25, a SANE exam was completed. • On 05/08/25 a Police report was filed and investigation was ongoing as of 06/16/25. • Counseling services started with Resident #71 on 05/20/25. • Resident #88 was transferred to another facility as of 06/02/25. • All staff abuse education and resident rights training was completed on 05/29/25 and 06/02/25. This deficiency represents non-compliance investigated under Complaint Number OH00165920.

Based on observation, medical record review, facility policy and procedure reviews and interviews, the facility failed to ensure Resident #9, who was identified as nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring of nutritional status, physician notification of diet changes and discharge from hospice services, and implementation of nutritional interventions to prevent weight loss and honor the resident's right for food preferences. This resulted in Immediate Jeopardy and serious life-threatening harm beginning on 08/01/23 related to malnutrition/weight loss for Resident #9, who experienced a 9.47 percent weight loss in three months from 07/25/23 (92.9 pounds) to 10/31/23 (84.1 pounds), and a 12.91 percent weight loss in five months from 01/16/24 (85.2 pounds) to 06/02/24 (74.2 pounds) with a total weight loss of 22.38 percent of her body weight (a 19.8 pound weight loss) and a severely low body-mass index of 13.6 due to the facility's failure to address the resident's refusal to consume pureed foods, obtain hospice services/offer in-house palliative care or order comfort foods, negatively impacting the resident's psychosocial well-being due to not being able to participate in food related activities and evidence of continued weight loss. The resident was identified and/or observed during the survey to request money to obtain food from the facility vending machine and obtain food of regular consistency on her own to consume indicating she was hungry. This affected one resident (#9) of three residents reviewed for weight loss. The facility census was 77. On 06/27/24 at 5:18 P.M., the Administrator, Regional Director of Operations (RDO) and Regional Nurse were notified Immediate Jeopardy began on 08/01/23 when Resident #9's orders were changed from a regular diet with regular textures to regular diet with pureed textures which the resident refused to accept. Prior to and following this change in diet order the resident sustained a 9.47 percent (%) /8.8-pound weight loss in three months and continued to progressively lose weight, with another significant weight loss of 12.91% over five months resulting in admission to Hospice services on 03/22/24 with an admitting diagnosis of severe protein calorie malnutrition. On 03/24/24, hospice services and comfort foods were discontinued related to a clerical error which the facility failed to notify Registered Dietician (RD) #352, Certified Nurse Practitioner (CNP) #502, physician, or Resident #9's legal guardian of. The facility failed to follow-up with hospice and the resident's guardian or offer in-house palliative care and comfort foods until hospice services could be re-established. Additionally, the RD was not familiar with the facility policy related to comfort foods. The Immediate Jeopardy was removed on 06/27/24 when the facility implemented the following corrective actions: On 06/27/24 at 5:45 P.M., the RDO and Regional Director of Clinical Services (RDCS) educated the facility Administrator on the Weight Assessment Interdisciplinary Interventions policy and Resident Dietary Preferences. On 06/27/24 at 6:00 P.M., an emergency Quality Assurance Performance Improvement (QAPI) meeting was held with department heads including Dietary Manager #150, Unit Managers #440 and #330, Human Resource Director #200, Social Service Assistant #123, MDS Coordinator #101, Business Office Manager #108, Director of nursing (DON) and Medical Director (MD) #115 via telephone to discuss notification of Immediate Jeopardy and initiation of abatement plan for corrective action. On 06/27/24 at 6:00 P.M., Transitions Hospice' Regional Care Coordinator #500 had communications with Resident #9 and her guardian to sign new consents to enter hospice care. On 06/27/24 at 6:23 P.M., the facility Administrator contacted Resident #9's guardian to discuss Resident #9's wishes for comfort/pleasure foods due to Resident #9 disliking pureed food. A dietary waiver was emailed to Resident #9's guardian after a telephone conversation to obtain a signed dietary waiver. On 06/27/24 at 6:31 P.M., the facility Administrator received a signed dietary waiver via email to change Resident #9's recommended diet to comfort foods. On 06/27/24 at 7:24 P.M., Unit Manager #330 notified facility CNP #502 of new signed waiver for Resident #9 and a new order was received for comfort foods on 06/27/24. On 06/27/24 at 7:28 P.M., the Administrator provided education to RD #352 regarding updates to the Weight Assessment Interdisciplinary Interventions Policy and Resident Dietary Preferences. On 06/27/24 at 7:29 P.M., notification was made to Resident #9's guardian by Administrator of Resident #9's new orders. On 06/27/24 at 8:34 P.M., Resident #9 and her guardian were notified of diet changes. On 06/27/24 at 8:40 P.M., Unit Manager #440 notified the dietary department of the resident's diet change, and a diet slip was completed for Resident #9 to receive comfort food items. On 06/27/24 at 8:45 P.M., Administrator developed an action plan for residents who voiced concerns regarding their diet type. The plan included for the interdisciplinary team (IDT) to meet with the resident(s) and guardian(s) to discuss diet concerns and changes per preference the resident may desire. The IDT would notify Speech and Occupational therapies for a need to screen resident to identify any physical conditions that may be causing the resident's refusal of diet. On 06/27/24 at 9 P.M., Resident #9's care plan was updated by Unit Manager #330 to reflect changes to Resident #9's diet to regular/comfort food. On 06/27/24 at 9:10 P.M., the facility policy for Weight Assessment and Interdisciplinary Intervention was updated by RDCS. On 06/27/24 at 10 P.M., education was completed by the Administrator to the facility department heads via phone message per group chat. Employees responded back they received and read education which was documented by the Administrator with the date and time on an employee roster. A total of 103 staff members were notified of the education. Education included the updated policy for Weight Assessment and Interdisciplinary Interventions as well as resident preferences for diet. On 06/27/24 at 10:30 P.M., the Administrator completed education to the facility staff on updated policy for Weight Assessments and Interdisciplinary Interventions as well as resident preferences for diet. 21 Licensed Practical Nurses (LPN) and six Registered Nurses (RN) were educated at this time. On 06/27/24 at 10:40 P.M. Administrator, UM #440 and UM #330 assessed 76 residents for weight loss and identified nine additional residents with weight loss (Residents #51, #34, #65, #81, #28, #1, #57, #56 and #40) to ensure their weight loss was not due to psychosocial issues from dislike of their current diets. Interviews with identified residents provided no concerns with their current diets. If a resident was not interviewable, a legal representative was called. Care conference sheets were completed for the identified residents (#1, #9, #28, #34, #40, #51, #56, #57, #65 and #81) and conferences were completed in person or via phone. On 06/27/24 at 10:50 P.M., care conferences were completed with residents or guardians to review weights, diets and preferences to ensure residents' psychosocial status is maintained. Care conferences were completed by Unit Managers #330 and #440, RDO, and Director of Business Development. On 06/27/24 at 10:55 P.M., the Administrator implemented a plan to complete weekly audits for all residents for weight loss. This audit would be completed three times per week for two weeks, two times a week for two weeks, then weekly for four weeks. Any new residents with weight loss identified by the RD would be added to the audit list. Residents would be reviewed in QAPI for further need of monitoring or enhancement. Although the Immediate Jeopardy was removed on 06/27/24, 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 still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, alcoholic liver disease, unspecified psychosis not due to a substance or known physiological condition, hypertension, anemia, hyperlipidemia, schizoaffective disorder, major depression, adult failure to thrive, insomnia, and diverticulosis of large intestine without perforation or abscess without bleeding. An additional diagnosis of unspecified severe protein-calorie malnutrition was added on 09/13/21. Review of a Dietary Review completed on 06/08/23 by the RD revealed Resident #9 did not have a therapeutic diet order, received house shakes twice daily, had no swallowing concerns, no weight loss, a Body Mass Index (BMI) of less than 19, intakes met 26-75% of estimated needs, and the resident was independent for eating after set-up. Review of a progress note dated 07/02/23 at 5:39 P.M. by Registered Nurse (RN) #223 revealed Resident #9 was going to other resident's rooms using feet to knock at doors trying to get snacks and money from residents and was redirected. Review of Resident #9's weight records revealed the resident's weight on 07/25/23 was 92.9 pounds. Review of a nursing note dated 07/26/23 at 11:42 A.M. by Licensed Practical Nurse (LPN) #227 revealed Resident #9 received a new diet order for mechanical soft foods and thin liquids. Review of a progress note dated 07/26/23 at 11:52 A.M. by Speech Therapist (ST) #321 revealed Resident #9's guardian was informed of Resident #9's new onset of choking and coughing with meals. Updated regarding new diet order with potential to downgrade to pureed if coughing continued. Record review revealed on 08/01/23 the resident's weight was 92.1 lbs. Review of a modified barium swallow study completed on 08/01/23 revealed Resident #9 exhibited intermittent pre-spill into the pharynx during the oral phase and displayed up to a two second swallow delay, intermittent flash penetration with thin liquids, and decreased epiglottic inversion with moderate vallecular residue with reflexive swallows able to clear in the pharyngeal phase. Recommendations included pureed diet, crushed medications or liquids medications, and noted the resident would benefit from speech therapy. Review of Speech Therapy information revealed the following: Review of a Speech Therapy (ST) Evaluation and Treatment plan revealed Resident #9 received services from 07/26/23 through 09/26/23. Review of a ST note dated 08/02/23 by ST #321 revealed Resident #9 stated she will not eat pureed food and declined to participate in therapy on this date. Review of a ST note dated 08/29/23 by ST #321 revealed staff requested allowance of cheese puffs to pureed diet due to very poor intake and weight loss. Review of the ST note dated 09/07/23 by ST #321 revealed staff reported concerns over poor intake of pureed food and risk for weight loss with request for soft food items such as beefaroni. Resident #9 did not like pureed diet. There was no documented evidence facility staff requests for Resident #9 to receive cheese puffs or soft food items such as beefaroni were addressed and these food additions implemented. Review of the physician's orders revealed Resident #9 had a diet order dated 08/01/23 for a regular diet with pureed textures, thin liquids, ice cream with lunch and dinner, and super cereal for breakfast. Review of a dietary note dated 08/08/23 at 12:34 P.M. by RD #352 revealed Resident #9's diet was downgraded to pureed on 08/01/23 and as a result, her by mouth intake had decreased. RD #352 stated Resident #9 received house shake twice daily with good intakes. Recommendations included offer milkshakes once or twice daily. Record review revealed on 08/15/23 the resident's weight was 90.2 lbs. On 09/10/23 the resident's weight was 92 lbs. On 09/19/23 the resident weighed 89.9 lbs. and on 09/26/23 she weighed 88.2 pounds. Review of a dietary note dated 09/26/23 at 9:48 A.M. by RD #352 revealed Resident #9 had an insignificant weight loss of 3.8 pounds, continued with poor appetite with 38% of meals consumed on average. Further weight loss was expected with poor appetite and refusal of supplements. Record review revealed no new interventions or changes made at this time. On 10/02/23 the resident weighed 88.6 lbs. which was noted to be a 4.3 pound weight loss from the weight of 92.9 lbs. on 07/25/23. Review of a quarterly Minimum Data Set (MDS) completed on 10/04/23 revealed Resident #9 had moderate cognitive impairment, no behaviors, required supervision for eating, had no signs of a swallowing disorder, had no significant weight loss, and received a mechanically altered diet. On 10/31/23 the resident weighed 84.1 lbs. On 11/01/23 the resident weighed 84.3 lbs. and on 11/06/23 she weighed 84.5 lbs., indicating a weight loss of 4.63% from 10/02/23 through 11/06/23. Review of a dietary note dated 11/07/23 at 11:16 A.M. by RD #352 revealed Resident #9 had a significant weight loss of 7.5 pounds in 60 days, 7.6 pounds in 90 days, and 8.5 pounds in 120 days, appetite remains poor, and Resident #9 was being noncompliant with diet order. Recommendations included adding ice cream with lunch. Review of a progress note dated 11/08/23 at 1:13 P.M. by LPN #227 revealed Resident #9 received a new order for speech therapy (ST) to evaluate and treat up to three times a week for three weeks for dysphagia management. Resident #9 and guardian aware of new order. Review of ST information revealed the following: Review of ST Evaluation and Treatment revealed Resident #9 received ST from 11/08/23 through 11/29/23. Review of a ST note dated 11/13/23 by ST #321 revealed extensive education was provided to Resident #9 regarding rationale for pureed diet. Review of a ST note dated 11/20/23 by ST #321 revealed Resident #9 was highly agitated and wanted a sandwich. There was no evidence the resident's right to consume foods other than pureed was considered or further pursued at this time. On 11/14/23 the resident weighed 85 lbs., on 11/20/23 she weighed 83 lbs., on 11/27/23 she weighed 84.2 lbs. and on 12/01/23 she weighed 82.4 lbs., indicating a weight loss of 3.06% from 11/08/23 through 12/01/23. Review of a progress note dated 12/06/23 at 1:34 P.M. by LPN #227 revealed Resident #9 had a new order for a dietary consult for low protein. Resident #9 and guardian were aware of new order. Record review revealed on 12/11/23 the resident weighed 84.4 lbs. Review of a nutrition note dated 12/12/23 at 10:19 A.M. by RD #352 revealed Resident #9's BMI was 15.4 and considered to be severely underweight. Resident #9 continued to receive a regular diet with pureed texture, fortified foods, and appetite was varying from 0-100% meals consumed on average. Resident #9 frequently refuses ONS (oral nutritional supplement) to aid in meeting nutritional needs and is a picky eater, does not like pureed diet, occasionally is noncompliant with diet texture. No new recommendations and the note indicated will monitor as needed. Review of a care plan dated 12/12/23 revealed Resident #9 had potential for behavior problems related to dementia, mood disorder, depression, psychosis, calls staff derogatory names, can be both physically and verbally aggressive towards staff, raises her voice at times, will refuse ADL care such as bathing, changing clothes and oral care; taking peers personal belongings for herself; going into rooms of others uninvited; confabulating stories about staff/residents; will attempt to assist other residents with ADLs; 07/31/23 asking other residents for money; 08/15/23 asking other residents for food/etc. since downgrade of her diet; 08/28/23 attempting to get ice herself from ice bucket; and 12/12/23 will often refuse medications. Interventions included redirecting Resident #9 when she asks others for money/snacks and reminding her she cannot ask others for food that is not on her diet. On 12/18/23 the resident weighed 81.8 lbs. which reflected an 11.1 pound weight loss since the weight on 07/25/23 of 92.9 lbs. Review of a nutrition note dated 12/19/23 at 11:09 A.M. by RD #352 revealed Resident #9 triggered for a significant weight loss of 2.6 pounds times one week, appetite was varying and overall poor with 0-50% of meals consumed on average. Record review revealed no new interventions or changes made at that time. On 12/28/23 the resident weighed 82.6 lbs., and on 01/01/24 the resident weighed 81.4 lbs. Review of a nutrition note dated 01/02/24 at 10:34 A.M. by RD #352 revealed Resident #9 triggered for a 7.2 lb. weight loss in 90 days and 11.6 lb. weight loss in 180 days. Resident #9 had a poor appetite with 0-75% of meals consumed on average with two meals consumed a day. No new interventions or recommendations were made at this time. Review of a quarterly MDS completed on 01/03/24 revealed Resident #9 had moderately impaired cognition, no behaviors, required supervision for eating, no signs of a swallowing disorder, had a weight loss of either five percent in the last month or loss of ten percent or more in the last six months and was not on a prescribed weight-loss regimen, and had a mechanically altered diet. Review of a Dietary Review completed on 01/04/24 revealed Resident #9 received a mechanically altered diet, house supplement twice daily, had no swallowing concerns, had a weight loss of five percent or more in the last month or loss of ten percent or more in the last six months without a prescribed weight-loss regimen, had a BMI of less than 19, intakes met 26-75% of needs, and was independent for eating after setup. Record review revealed no new interventions or recommendations were made at this time. Review of a care conference sheet dated 01/04/24 revealed Resident #9, her guardian via phone, Activities Director, Social Services Director, Dietary Manager, and another staff member were present. The sheet revealed Resident #9 was still on a pureed diet and the facility was having trouble getting her to eat, discussed her degenerative tongue issue, reviewed her weight, and the resident's guardian wanted to know if or when hospice should step in and discussed potential of comfort foods. However, no further information was documented in the chart as a follow-up to this care conference. On 01/15/24 the resident weighed 81.3 lbs., and on 01/16/24 the resident weighed 85.2 pounds. Review of a nutrition note dated 01/16/24 at 11:52 A.M. by RD #352 revealed Resident #9 triggered for a significant weight loss of 11.6 pounds in 180 days. The note indicated to continue nutrition plan of care and will follow up as needed. No new interventions or recommendations were implemented at this time. On 02/08/24 the resident weighed 71 lbs., indicating a weight loss of 16.67% from previous weight of 85.2 lbs. on 01/16/24. Review of a nutrition note dated 02/12/24 at 10:14 A.M. by RD #352 revealed Resident #9 triggered for a significant weight loss of 10.4 pounds in 30 days, 13.3 pounds in 90 days, and 21.1 pounds in 180 days. No changes in diet or appetite documented, and RD #352 requested a re-weight to verify weight loss. Record review revealed no new interventions or recommendations were implemented at this time. On 02/20/24 the resident weighed 76.2 lbs. Review of a nutrition note dated 02/27/24 at 10:22 A.M. by RD #352 revealed Resident #9 triggered for a weight gain of 5.2 pounds in 12 days, a weight loss of 9 pounds in 30 days, loss of 8 pounds in 90 days and 15.9 pounds in 180 days, with a question of the accuracy of weight taken on 02/08/24. No new interventions were noted at this time. On 03/04/24 the resident weighed 74.2 lbs., and on 03/11/24 the resident weighed 74.6 lbs. Review of a nutrition note dated 03/12/24 at 10:33 A.M. revealed Resident #9 triggered for a significant weight loss of 1.8 pounds in seven days with a recommendation to increase ice cream to twice daily (with lunch and dinner) and add pudding as a snack. Review of a social services note dated 03/14/24 at 2:05 P.M. by Social Services Assistant (SSA) #123 revealed Resident #9's guardian gave permission to get a hospice consult due to weight loss with no preference for hospice provider. A referral was sent and an additional note at 2:09 P.M. revealed SSA #123 was awaiting a response regarding hospice consult from the hospice provider. Review of a progress note dated 03/15/24 at 11:38 A.M. by previous DON #160 revealed a referral was sent to a different hospice provider and the social worker was to come to facility at noon for intake paperwork. An additional note at 2:39 P.M. revealed hospice representative was present and received paperwork. Review of a progress note dated 03/15/24 at 2:47 P.M. by previous DON #160 revealed Resident #9's weights were reviewed for one, three and six months with a 10% weight loss noted in six months. Review of the progress note revealed no additional information related to the root cause of the weight loss and/or any new interventions to prevent additional weight loss/promote weight gain. Review of a progress note dated 03/18/24 at 3:47 P.M. by previous DON #160 revealed the facility was awaiting paperwork from the hospice provider. Review of a progress note dated 03/22/24 at 7:16 P.M. by RN #389 revealed Resident #9 was admitted to Hospice for severe protein calorie malnutrition, routine level of care, continue DNRCC (do not resuscitate-comfort care), and continue all current medications. The resident's diet plan was for comfort foods and a liberalized diet at this time. Review of written orders dated 03/22/24 revealed Resident #9 admitted to Hospice for severe protein calorie malnutrition/routine level of care. There was no documented evidence Resident #9 ever received a liberalized diet or comfort foods. Review of Resident #9's medical record revealed no documented evidence of a physician order to discontinue hospice services. However, medical record review revealed staff progress notes that identified Hospice services were discontinued on 03/24/24 for Resident #9 with no evidence of notification to the physician, resident or guardian at that time. In addition, there was no evidence of follow-up to resolve why services were discontinued at this time. On 03/25/24 the resident weighed 74.6 lbs. Review of a nutrition note dated 03/26/24 at 2:05 P.M. by RD #352 revealed Resident #9 recently admitted to hospice care, overall goal was for comfort and quality of life with hospice. The note did not include any additional information related to comfort foods/liberalized diet at this time. The note also failed to identify that although hospice services had recently been initiated, they were not being provided as of this time. Review of a Nutritional Assessment Review completed by the RD on 03/26/24 revealed Resident #9's BMI was 13.6 and her goal weight was 110 lbs., she did not have swallowing issues, and her overall goal was for comfort and quality of life with hospice, expect decline in weight, skin integrity, and intakes as disease state progress. Recommendations included discontinuing weekly weights order due to hospice, consider discontinuing monthly weights due to hospice and monitor as needed. Review of a significant change MDS completed on 04/03/24 revealed Resident #9 had moderately impaired cognition, had no behaviors, required set-up help for eating, had no signs of a swallowing condition, had a weight loss of five percent or more in the last month or loss of ten percent or more in the last six months and was not on a prescribed weight-loss regimen, received a mechanically altered diet, and received hospice care. Review of a Dietary Review completed on 04/05/24 revealed Resident #9 received a mechanically altered diet, house supplement twice daily, had no swallowing issues, had a weight loss of five percent or more in the last month or loss of ten percent or more in last six months without a prescribed weight loss regimen, had a BMI of less than 19, intakes met 26-75% of estimated needs, and was independent for eating after set-up. Record review revealed no evidence of the resident receiving any type of comfort foods/liberalized diet at this time. Review of a social services note dated 04/09/24 at 2 P.M. by SSA #123 revealed a quarterly care conference was held with Resident #9, her guardian did not answer, and she would follow up as soon as guardian called back. Review of the care conference sheet revealed no additional information. There was no indication the resident's nutritional status, weight loss, diet order or hospice were discussed. On 04/16/24 the resident weighed 76 lbs. Review of a dietary note dated 04/16/24 at 10:40 A.M. by RD #352 revealed Resident #9 had a significant weight loss of 12.6 pounds in 180 days, she remained with varying appetite. At the time of this note, the RD documented the resident's overall rate of weight loss had slowed with a goal of comfort and quality of life with hospice. Review of a care plan dated 04/18/24 revealed Resident #9 was at risk for fluctuations in activity of daily living (ADL) ability related to current condition, diagnosis of psychosis, dementia, schizophrenia, on noted the resident was on hospice services at this time. The care plan also reflected the resident had communication problems and may need tasks explained. On 05/07/24 the resident weighed 74.8 lbs. Review of a dietary note dated 05/14/24 at 10:24 A.M. by RD #352 revealed no new recommendations regarding weight loss. Review of a dietary care plan dated 06/04/24 revealed Resident #9 was at risk for impaired nutritional status due to diagnoses including chronic obstructive pulmonary disease, anemia, hyperlipidemia, depression, ETOH abuse, hypertension, cataract, malnutrition. Underweight BMI and history of refusal of supplements, refuses to be weighed at times, need for mood-altering medications that may alter weight/appetite, and consistent weight loss in facility. On 03/25/24 the resident had been identified to have a significant weight loss in six months. Interventions included monitor intakes, monitor labs, monitor skin integrity, provide supplements as ordered, provide diet as ordered, provide medications as ordered, if meal was refused offer an alternative from the always available menu. On 06/02/24 the resident weighed 74.2 lbs. Review of a nutrition note on 06/11/24 at 11:38 A.M. by RD #352 revealed Resident #9 had a goal to clarify fortified foods. Fortified foods order discontinued and new order for super potatoes or super cereal once a day. Interview on 06/24/24 at 4:07 P.M. with Resident #9 revealed she refused to eat the facility food because they puree it. During the interview, Resident #9 was observed to have a bag of cool ranch Doritos and was observed to smash the chips into smaller pieces before eating them. No coughing was noted. Observation on 06/25/24 at 2:27 P.M. revealed Resident #9 had a pudding cup for a snack, and as she finished the pudding, she was scraping the sides clean trying to get as much of the pudding as she could from the cup to consume it. Interview on 06/25/24 at 2:31 P.M. with RN #223 revealed Resident #9 received mighty shakes as a supplement. RN #223 stated in January 2024, Resident #9's guardian had begun requesting hospice services, but services were stopped due to a clerical issue with the paperwork. RN #223 could not recall when hospice stopped but stated it had been weeks (since hospice stopped) and she was told Resident #9's guardian had not contacted hospice to resume services. RN #223 stated Resident #9 would eat but because she received pureed food she refuses to eat. RN #223 stated a paper was signed by Resident #9's guardian so that she could eat comfort foods (liberalized diet) and when she was on hospice services, she could eat whatever she wanted. RN #223 stated staff were told residents could only have comfort food if they received hospice services. RN #223 stated Resident #9 did have trouble swallowing, sometimes she was fine and sometimes she would cough. RN #223 stated Resident #9 had not been receiving any type of palliative care in house while awaiting readmission to hospice services. RN #223 stated Resident #9 has always been small but has had a weight loss. RN #223 stated Resident #9 mostly just eats mighty shakes, pudding, Jell-O and some pureed fruits. Interview on 06/26/24 at 4:11 P.M. with Resident #9's guardian revealed she was not aware Resident #9 was not receiving hospice services. The guardian stated there had been challenges with weight loss but stated Resident #9 was supposed to have been taken off the pureed diet and given whatever she wanted to eat. During the interview, Resident #9's guardian revealed she was aware Resident #9 buys food from the vending machine with her monthly allowance. Interview on 06/26/24 at 4:44 P.M. with Hospice Receptionist (HR) #111 revealed Resident #9 admitted to hospice on 03/22/24 and was discharged on [DATE]. An additional hospice evaluation was completed on 04/01/24 but she was not readmitted at that time. No additional information was provided. Interview on 06/26/24 at 4:54 P.M. with the Hospice Administrator revealed Resident #9's paperwork had a different last name listed than her medical card, so she was discharged from services. Interview on 06/26/24 at 4:58 P.M. with the Administrator, the RDO, and the ROCS revealed Resident #9 was to receive a house shake twice daily but confirmed even with this supplement she had not regained any of the weight she lost. The ROCS stated she believed Resident #9's weight was stable, and revealed the facility does not have paperwork for a comfort food diet being in place for Resident #9. The ROCS revealed hospice was offered in house but not palliative care because she was not sure Resident #9's primary care provider would offer palliative care. The Administrator revealed the hospice company had attempted to contact Resident #9's guardian about the paperwork and confirmed apart from one attempt at a care conference on 04/09/24, no one from the facility had reached out the Resident #9's guardian regarding comfort care, palliative care, or hospice care as it pertained to the resident's ability to consume foods other than pureed foods which the resident was refusing. Interview on 06/26/24 at 6:33 P.M. with the Administrator confirmed Resident #9's care conference notes, nursing progress notes, dietary notes, care plan listed hospice, and a hospice order entered by RN #389 as noted above. Observation on 06/27/24 at 10:35 A.M. revealed Resident #9 was following the surveyor demanding money to purchase food from the vending machine. Observation on 06/27/24 at 11:40 A.M., revealed Resident #9 was following surveyor and calling her name demanding money to purchase food out of the vending machine. Observation on 06/27/24 at 12:10 P.M., revealed Resident #9 was sitting in the office asking staff and surveyor for money to purchase food items from the vending machine. Interview on 06/27/24 at 1:02 P.M. with Medical Director (MD), who was also Resident #9's primary care physician, revealed he was not familiar with Resident #9, and he would not be able to answer questions regarding Resident #9 until he had access to a computer. No additional information was provided from the medical director during the survey. Interview on 06/27/24 at 1:09 P.M. with Resident #9 revealed for dinner she had pureed chicken, but she did not want it and put it back because she does not eat that pureed s**t. Resident #9 was observed to have two packs of [NAME] Link's jerky which she [TRUNCATED]

Based on observation, record review, interview with staff, interview with guardian and review of the facility Wandering, Unsafe Resident policy and procedure, the facility failed to provide adequate supervision and safety interventions to prevent Resident #61 from eloping from the facility secure care unit. This resulted in Immediate Jeopardy and the potential for serious harm, injury, death on [DATE] between approximately 4:30 P.M. and 5:40 P.M. when Resident #61, who had a legal guardian, had a known history of eloping from skilled nursing facilities (SNFs) and who made verbal threats to elope from the facility exited the facility without staff knowledge and remained missing overnight. On [DATE] at 7:00 A.M. Resident #61 contacted his legal (court-appointed) guardian and notified her of his location which was noted to be approximately 50 miles away from the facility across major highways with speeds reaching up to 70 miles per hour (mph). The resident was noted to be admitted to a behavioral health crisis care center due to suicidal ideations at the time his whereabouts were identified. This affected one resident (#61) of three residents reviewed for elopement. The facility census was 86. On [DATE] at 1:55 P.M., the Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] between approximately 4:30 P.M. and 5:40 P.M., when Resident #61 exited the facility without staff knowledge. The resident remained missing overnight and was not located until [DATE] when he contacted his legal guardian to report his location. The resident's legal guardian contacted the facility and reported the resident was currently at a behavioral health crisis care center in Columbus. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 5:45 P.M., State tested Nursing Assistant (STNA) #171 activated the facility's code [NAME] (missing resident). On [DATE] at 5:58 P.M., Registered Nurse (RN) #172 notified the Administrator in Training (AIT), the resident's legal guardian and the Medical Director (MD). On [DATE] at 6:02 P.M., the facility notified the local law enforcement Resident #61 was missing from the facility's secure care unit. Staff began to search the facility grounds working out to the county roads, corn fields and woods. On [DATE] at 6:30 P.M., local law enforcement arrived at the facility and obtained a description of the resident. On [DATE] at 8:00 P.M., Regional Administrator (RA) #191, DON, Unit Managers (UM) #180 and #176 undated elopement assessments for all residents based on their elopement review and Brief Interview for Mental Status (BIMS). On [DATE] at 12:00 A.M., Regional Director of Clinical Services (RDCS) #195, AIT and DON completed education to all staff regarding the facility elopement policy and procedure. On [DATE] at 7:45 A.M., UM #180 received an email from Resident #61's guardian alerting the facility Resident #61 was found and was safe at a behavioral health crisis care center. On [DATE] at 12:00 P.M., Regional Maintenance Director (RMD) #194 changed the door security system codes to all doors. RA #191, AIT, educated all department heads, Dietary Manager (DM) #145, Human Resources (HR) #190, Admissions Coordinator (AC) #107, UM #176 and #180, Minimum Data Set Coordinator (MDSC) #119, Activities Director (AD)/Business Office Manager (BOM) #119, Social Services Designee (SSD) #169 and Marketing Director #189 regarding door code changes and assuring the code is covered when entering the code into the door security system when exiting the facility. All department managers would then educate their respective departments. On [DATE] at 12:30 P.M., the AIT and DON spoke with Resident #61's guardian who revealed the resident was currently at a behavioral health crisis center and planned to be transferred to a different behavioral health setting housed in the same building due to Resident #61 exhibiting suicidal ideations. The guardian would follow up with facility when more information was available. On [DATE] at 12:45 P.M., RA #191 called the behavioral health crisis center to obtain an update on Resident #61; however, the center would not release any information to the facility due to court appointed guardian in place. On [DATE], RMD #194 installed cameras above all exit doors on the secure care unit. On [DATE] at 3:00 P.M., a Quality Assurance Performance Improvement (QAPI) meeting was held with RA #191, Regional Director of Clinical Services (RDCS) #197, DON, UM #176, #180, AIT and Medical Director (MD) to discuss Resident #61's eloping from the facility, changing security system codes to the doors, BIMS and elopement review on all residents, how Resident #61 was able to elope from the facility, education to complete with staff, audits for facility and root cause analysis. On [DATE] at 3:15 P.M., AIT/designee began to audit for safe entry and exit of doors. The audits would continue five times per week for four weeks. On [DATE] at 3:00 P.M., RA #191, RDCS, #197, educated the following department heads Dietary Manager (DM) #145, Human Resources (HR) #190, Admissions Coordinator (AC) #107, UM #176 and #180, Minimum Data Set Coordinator (MDSC) #119, Activities Director (AD)/Business Office Manager (BOM) #119, Social Services Designee (SSD) #169 and Marketing Director #189 regarding what to do if they hear a resident state they want to leave the facility. The staff would notify the nurse on duty so that the nurse may review resident cognition status (BIMS score) to identify if resident had a BIMS score of 12 or below and/or if the resident had a legal guardian. If the BIMS was noted to be 12 or below and/or the resident had a guardian, the resident would have increased safety measures implemented such as 15-minute checks, 30-minute checks, 1 on 1 supervision, psych eval, etc. The DON/Admin, Guardian and MD would be notified of resident statements and of plan to increase resident safety. On [DATE] at 3:55 P.M., one resident (#58) was identified and placed on every 15-minute checks. The Medication Administration Record (MAR) and care plan was updated. The facility implemented a plan beginning [DATE] for the DON/designee to begin audits for residents who have stated that they want to leave to ensure that interventions had been put into place to increase resident safety. This would be completed five days per week for four weeks then weekly for eight weeks. The results of the audits would be reviewed in QAPI for further need of monitoring or enhancement. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #61 revealed an initial admitted [DATE] with admitting diagnoses including traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, nontraumatic subdural hemorrhage, chronic obstructive pulmonary disease (COPD), diabetes mellitus, bipolar disorder, cerebral infarction, gastro-esophageal reflux disease (GERD), major depressive disorder, post-traumatic stress disorder, hypertension, seizures, anxiety disorder, atrial fibrillation, anterior displaced fracture of sternal end of clavicle, conversion disorder with motor symptom of deficit, mood disorder, fracture of second thoracic vertebra, multiple fractures of ribs, right side, psychoactive substance abuse, cocaine dependence in remission, nicotine dependence in remission, history of traumatic brain injury (TBI) and alcohol dependence. Record review revealed Resident #61 had a legal (court-appointed) guardian effective [DATE] due to incompetency. Review of Resident #61's acute care hospital discharge summary dated [DATE] revealed the resident was admitted to the hospital on [DATE] following a motor vehicle accident versus pedestrian after the resident had walked away from another skilled nursing facility (SNF) and was living homeless in downtown Columbus. The resident was admitted with diagnoses of subdural hematoma over right frontal and right temporal convexities, right temporal intraparenchymal hemorrhage, right thoracic one transverse process fracture and non-displaced right sphenoid fracture. Review of the physician's orders revealed an order dated [DATE] to admit to secure unit. Review of the resident's elopement assessment dated [DATE] (admission) revealed a score of 16 indicating the resident was at high risk for elopement. Review of the resident's physician medication orders revealed the resident had orders dated [DATE] Lipitor 40 milligrams (mg) by mouth daily at bedtime, Flector external patch 1.3% with special instructions to apply one patch to the left shoulder topically twice daily for pain, Depakote 500 mg by mouth daily for bipolar disorder, Dulera inhalation ,d+[DATE] micrograms (mcg) with the special instructions to inhale two puffs orally twice daily for COPD, Folic Acid 1 mg by mouth daily, Lidocaine external patch 4% with the special instructions to apply to skin topically daily and remove in 12 hours, Miralax 17 grams one scoop by mouth twice daily for constipation, Protonix 40 mg by mouth daily for GERD, Oxycodone 5 mg by mouth every six hours as needed for pain, Senna S 8XXX,d+[DATE] mg by mouth twice daily for constipation, Seroquel 50 mg by mouth daily at bedtime for bipolar disorder, Zoloft 150 mg by mouth daily for major depressive disorder, Sodium Chloride 1000 mg by mouth three times a day, Thiamine 100 mg by mouth daily and Metoprolol 50 mg by mouth daily for hypertension. Review of a plan of care dated [DATE] revealed Resident #61 resided on a secured unit related to history of elopement at other facilities. Interventions included encourage to attend activities of interest on the unit as needed, monitor for changes that may reduce the need for secure unit, monitor for exit seeking behavior and document when exit seeking occurs, promote consistent routine and caregivers, provide activities of interest, provide education to family and/or guardian about risks/benefits of secured unit as needed, secure unit orders per physician and supervision is required for attendance to off unit activities. Review of a plan of care dated [DATE] revealed Resident #61 was an elopement risk/wanderer related to history of attempts to leave other facilities unattended and impaired safety. Interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, identify pattern of wandering, divert as needed and intervene as appropriate, monitor for fatigue and weight loss, provide activities of interest to deter wandering, and take the resident for a walk inside the building. Review of a Social Service (SS) progress note dated [DATE] at 5:06 P.M. revealed a care conference was held with the resident and guardian. The Interdisciplinary Team (IDT) discussed the resident refusing medications. The entry also documented the resident did not want to be at the facility and saying he was going back to Columbus wherever he wants. The guardian verified the resident was admitted for long term care placement at the facility. Review of the electronic Medication Administration Record (eMAR) dated [DATE] at 1:41 P.M. revealed Resident #61 had refused all morning medications and breakfast. The resident also stated, I want out of this place, I would rather be on the streets. The nurse educated the resident on the importance of taking medication as ordered. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior section of the MDS assessment revealed the resident rejected care. The assessment indicated the resident required supervision with transfers and ambulation and received scheduled and as needed pain medication. The resident denied pain at the time of the interview for the assessment. Review of the progress note dated [DATE] at 5:36 P.M. revealed the resident had constantly called his guardian after returning from an appointment. The resident stated he was leaving tomorrow regardless of what his guardian said. The resident's guardian was informed of the resident's behavior. However, record review revealed no new safety or individualized interventions were implemented at this time to address the resident's desire to leave the facility. Review of a progress note dated [DATE] at 6:00 P.M. and authored by the DON revealed she was notified at 6:00 P.M. Resident #61 was not in the facility. A facility wide and facility grounds search was conducted without finding the resident. The Administrator in Training (AIT), DON, guardian and local law enforcement were notified the resident was missing. There were no additional nursing progress notes completed for Resident #61 to document when or where the resident was located, the circumstances of the resident being missing from the facility and/or the resident's condition/status when found. Record review revealed the incident of elopement involving Resident #61 was not reported to the State agency as a facility self-reported incident (SRI) as a potential incident of neglect. On [DATE] at 8:15 A.M., interview with the Administrator in Training (AIT) and DON revealed on [DATE] Resident #61 eloped from the facility secure care unit between the hours of 4:30 P.M. and 5:40 P.M. The DON revealed she felt the resident knew the secure system code on the door to the courtyard and he put it in and left the facility. The AIT said she felt when Resident #61 went out to smoke, he saw a staff member punch the code into the secure system on the door and was able to remember the code (which allowed him to leave without staff knowledge). During the interview, the AIT verified not permitting the residents residing on the secure care unit to visualize the code was a component of keeping the residents safe. The AIT stated, right' when asked if it was neglectful to not keep the code covered when staff punched the code into the secure system on the door. The AIT revealed she was told a self-reported incident (SRI) was not required because the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 (out of 15). However, the AIT indicated the facility had initiated corrective actions following the incident of elopement involving Resident #61. On [DATE] at 9:44 A.M., an interview with Unit Manger (UM) #180 revealed Resident #61's guardian was made aware of he was threatening to leave on [DATE]. UM #180 revealed she received a phone call on [DATE] alerting her Resident #61 was missing from the facility. UM #180 revealed she instructed the staff to call the AIT, DON and the police to file a missing persons report. UM #180 revealed she felt Resident #61 obtained the code to the door secure system watching a staff member enter the code on the keypad. UM #180 revealed the E hallway was the only hallway on the second floor with an exit door to the outside of the facility. UM #180 revealed the door opened into a fenced in courtyard however, the gate used the same code for the secure system keypad and after entering the code, the resident likely was able to walk down the sidewalk. On [DATE] at 11:17 A.M., an interview with the Administrator revealed he was notified of Resident #61's elopement on [DATE] between 6:03 P.M. to 6:08 P.M. The Administrator said the AIT called him and said the resident eloped from the secure care unit at the facility. The Administrator revealed he assumed based on the resident's cognition he observed a staff member enter the code on the secure system when taking the residents out to smoke. The Administrator revealed the resident's court appointed guardian felt the resident was not safe to reside off the secure care unit. The Administrator revealed the guardian alerted the facility on [DATE] the resident called her and reported he was at a psychiatric facility that he had hitchhiked to the Columbus area. On [DATE] at 8:52 A.M., during an interview with Registered Nurse (RN) #172, the RN indicated the facility elevator doors were not working properly and were opening randomly allowing residents to potentially enter the elevators and leave the secure care unit. RN #172 revealed staff were supposed to be doing every 15-minute checks on all residents on the secure care unit (due to the elevators not working). RN #172 revealed State tested Nursing Assistant (STNA) #171 delivered Resident #61's dinner meal at approximately 4:30 P.M. however, STNA #171 failed to visually ensure Resident #61 was in his room and/or bathroom when the meal tray was delivered. RN #172 revealed when STNA #171 returned to remove the meal tray, the resident was not observed in his room and the meal remained untouched. RN #172 revealed STNA #171 searched Resident #61's room and was unable to locate him. STNA #171 then notified RN #172 Resident #61 was missing. RN #172 revealed a facility wide and ground search was conducted; however, Resident #61 was not found. RN #172 revealed she notified the AIT and the DON of Resident #61's elopement. RN #172 revealed she was instructed to call 911 and report Resident #61 as a missing person. RN #172 revealed Resident #61 vocalized he was leaving the facility daily. On [DATE] at 9:05 A.M., an interview with Licensed Practical Nurse (LPN) #100 revealed she reported to duty on the secure care unit the morning of [DATE] and the elevators were barricaded with the medication carts. LPN #100 revealed for approximately two months the elevator doors were randomly opening so the staff were supposed to be doing every 15-minute checks and keep a staff member in the lounge to watch the elevator doors. LPN #100 revealed on [DATE] Resident #61 had removed the window frame in his room trying to escape the secured care unit. LPN #100 revealed Resident #61 was moved from the F hallway to the D hallway (as a result of this incident). LPN #100 revealed she had last seen Resident #61 at 4:00 P.M. when she tried to administer his scheduled medication to him. She revealed at 5:40 P.M. she was made aware by RN #172 Resident #61 was missing. LPN #100 revealed she assisted with the facility search and gave the local law enforcement a statement. LPN #100 revealed she felt Resident #61 obtained the code to the secure system on the exit door and walked away from the facility. LPN #100 revealed Resident #61 threatened to leave the facility daily. On [DATE] at 9:27 A.M., an interview with STNA #171 verified she delivered Resident #61 his meal tray on [DATE] at approximately 4:30 P.M. STNA #171 revealed she did not see the resident at that time and verified she had not visually ensured Resident #61 was in his room when she delivered his dinner meal. STNA #171 revealed she went to Resident #61's room to pick his meal tray up, the meal was untouched, and Resident #61 was not in his room. STNA #171 revealed she search his room, closet, bathroom and under his bed. STNA #171 revealed she asked STNA #118 if she had seen Resident #61; however, the STNA stated she had not. STNA #171 revealed she reported to RN #172 she was unable to locate Resident #61 and thought he was missing. STNA #171 revealed she then assisted with the facility wide and grounds search for Resident #61 but was unable to locate him. STNA #171 revealed she did give a written statement to local law enforcement. STNA #171 revealed Resident #61 previously was on the F hallway but Resident #61 removed his entire window trying to leave the facility on [DATE]. STNA #171 revealed he was then moved to the D hallway. On [DATE] at 9:38 A.M., interview with STNA #118 revealed Resident #61 was discovered missing on [DATE] at dinner time between 4:30 P.M. and 5:30 P.M. STNA #118 revealed she assisted with the facility wide search and grounds search but was unable to locate Resident #61. STNA #118 revealed she had not visually observed Resident #61 since 3:30 P.M. when she assisted with smoke break (Resident #61 did participate in the smoke break). STNA #118 revealed Resident #61 attended smoke breaks in the courtyard of the secure care unit. STNA #118 revealed Resident #61 voiced he was leaving the facility on a daily basis. On [DATE] at 9:47 A.M., an interview with Resident #61's legal guardian revealed she was notified on [DATE] at 6:00 P.M. the resident was missing from the secured care unit of the facility. The guardian revealed the resident stated he walked out the back door and hitchhiked to Columbus. The guardian revealed Resident #61 called her the morning of [DATE] and informed her he was at a behavioral health crisis center in Columbus. She revealed Resident #61 had severe alcohol damage and a history of a traumatic brain injury (TBI) which affected the resident by him being impulsive and not making good decisions. The guardian revealed Resident #61 walked away from the last SNF he resided at (in [DATE]) and was homeless in downtown Columbus where he was stuck (as a pedestrian) by a motor vehicle requiring hospitalization . The resident was admitted to this facility following the hospitalization for treatment of the injuries he sustained after being struck by a motor vehicle. Based on the time period the resident was noted to be missing from the facility, the resident did not receive any scheduled medications after he left the faciity on [DATE] at 3:30 P.M. Attempts to reach the resident's primary care physician during the investigation were unsuccessful. An attempt to obtain the police report associated with this incident was also requested during the investigation, but not provided. Review of the facility Root Cause Analysis, not dated revealed the resident expressed want to leave the facility several times and the facility failed to put proper interventions in place to stop the resident from leaving the facility. The resident exited the facility without the staff's knowledge of the event due to staff not properly hiding the code to the secure system when exiting the door. Review of the facility policy, Wandering, Unsafe Resident, last revised [DATE] revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for elopement or other risk due to judgement or cognition. The staff would identify residents who were at risk for harm because of unsafe wandering, including elopement. This deficiency represents non-compliance investigated under Complaint Number OH00152379.

Based on observation, record review, review of a facility self-reported incident investigation, review of hospital records and interview the facility failed to ensure Resident #86 received adequate assistance during a transfer to prevent an injury and failed to ensure fall safety interventions were in place for Resident #25. This affected two residents (#25 and #86) of three residents reviewed for falls. Actual harm occurred on 11/26/20 when Resident #86, who required two staff to assist with transfers was being transferred to bed with only one staff member (State tested nursing assistant) #123 when the resident sustained [REDACTED]. The injury resulted in increased pain to the resident and hospitalization . Findings Include: 1. Review of Resident #86's closed medical record revealed the resident was hospitalized from [DATE] to 12/03/20. The resident passed away in the facility on 12/05/20. The resident had [DIAGNOSES REDACTED]. Review of Resident #86's care plan, dated 10/12/20 revealed the resident had a self-care performance deficit and required two staff to assist for transfers. The resident was unable to walk. The resident was at risk for falls due to deconditioning, [MEDICAL TREATMENT] treatments, use of narcotic medications, [MEDICAL CONDITION], diabetes and use of diuretic therapy. Review of Resident #86's Medicare 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition with an eight out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The assessment revealed the resident required extensive assistance from two staff for transfers. Review of the progress notes for Resident #86 revealed on 11/26/20 at 10:30 P.M., the resident was assisted to bed by an STNA and while she was assisted with a stand pivot transfer from the resident's manual wheelchair to her bed, the aide stated, I heard her knee make a popping sound. The resident was assisted to bed and started to moan out loudly but once she was repositioned she had no additional complaint of pain. The resident was assessed from head to toe and when asked to straighten out her left leg, the resident was able to straighten it but had difficulty moving her toes. No swelling or bruising was noted at that time. The note revealed the resident was noted to require maximum assistance with all activities of daily living (ADLs). The resident was in a low bed with a mattress to the floor at bedside per the resident's request. On 11/27/20 at 12:50 A.M., a progress note revealed this nurse went into resident's room to evaluate resident and found resident to be in pain moaning out stating, my leg, my leg. The nurse found the resident to be attempting to hold her left leg. The nurse found resident's left knee cap and lower leg to be swollen with a bruise noted to the resident's left inner, upper thigh. The nurse asked the resident to straighten her left leg and move her toes and the resident was not able to do so. The nurse assessed the resident's vital signs and her blood pressure was 144/62. The nurse notified the physician and an order was given to transport the resident to the hospital via ambulance for evaluation of her left leg. The nurse notified all the appropriate parties and then called the ambulance to have the resident transported. On 11/27/20 at 5:29 A.M., a progress note revealed the nurse called the hospital for an update on the resident and was informed the resident was being admitted for a [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE]. Review of the facility self-reported incident, tracking number 4 investigation conducted by the Director Of Nursing (DON), dated 12/01/20, revealed an incident of physical abuse involving Resident #86 was investigated by the facility. The investigation included a written statement from STNA #123. The statement indicated STNA #123 assisted the resident to bed on 11/26/20. The aide requested the resident help as much as possible and the resident agreed. The resident stood up on her own with a little assistance from the aide under the resident's armpit. The resident pivoted to get her legs against the back of the bed. The aide placed her feet in front of the resident's to prevent any sliding. As the aide guided the resident down, both the resident and the aide heard a pop. The resident stated her knee just broke per the aide's statement. The aide checked the resident's feet and they were not twisted or stuck under anything, they were parallel and flat on the floor. After the resident calmed down, the aide then lifted her legs into bed and the resident continued to scream that her leg hurt. The aide reported this to the nurse and monitored the resident. The aide noticed swelling and the nurse was advised. The resident was sent to the hospital. A written statement by Physical Therapy Assistant (PTA) #184 revealed he demonstrated how he was able to transfer Resident #86 by himself during therapy sessions to two staff members, Licensed Practical Nurse (LPN) #164 and STNA #156. The PTA indicated the demonstration was not an endorsement to change Resident #86's current transfer guidelines of two assist. After the demonstration, the staff stated they could not do a transfer that way and PTA #184 did not recommend that staff attempt that kind of transfer. An interview with STNA #123 was conducted on 12/02/20. The interview revealed STNA #123 did not attempt to raise the resident's bed prior to transferring the resident because she thought the bed was broken and she did not place her leg between the resident's knees. The aide stated Resident #86's legs started to give out as they got lower to the bed and that was when the pop was heard from the resident's knee. STNA #123 stated she received report that Resident #86 was a one assist for transfers unless she had behaviors. STNA #123 was educated by the DON that Resident #86 was always a two person assist for transfers. The aide also indicated she did not know where to find transfer information on residents and just asked the previous aide or nurse. On 12/04/20, a written statement from LPN #147 was obtained and revealed the nurse instructed STNA #123 that Resident #86 required two people to assist for transfers but the aide insisted the resident was a one person assist for transfers. LPN #147 instructed STNA #123 to wait for help but the aide continued to Resident #86's room. LPN #147 stated the other aide on the floor, STNA #108, yelled to STNA #123 that she was coming to help STNA #123 but STNA #123 continued to Resident #86's room and transferred the resident by herself. On 12/03/20, STNA #123 was terminated. On 12/14/20 at 7:21 A.M. interview with LPN #147 revealed Resident #86 was a two person assist for transfers. The nurse did not witness the transfer that resulted in the fracture to the resident's left leg. The nurse stated there were two aides assigned to assist the residents on A, B, and C halls, STNA #123 and STNA #108. The nurse stated she informed STNA #123 that Resident #86 required two people to transfer her but STNA #123 ignored the instruction and transferred the resident by herself. LPN #147 stated Resident #86 preferred to sit and lay on a mattress on the floor. LPN #147 stated within three minutes of STNA #123 entering Resident #86's room, the resident was heard screaming out in pain. LPN #147 completed the initial assessment of the resident and the resident was on the mattress on the floor. No injuries were observed at the time of the initial assessment. However, STNA #108 continued to monitor the resident and later observed Resident #86's leg to be bruised and swollen and the resident was not able to move her toes. Review of the hospital records for Resident #86's hospitalized from [DATE] to 12/03/20 revealed an x-ray was completed on the resident's lower left leg and was identified to have a tibial spiral fracture. The resident was admitted to be evaluated by orthopedics as well as evaluated for potential elder abuse and pain control. The assessment and plan for Resident #86 revealed the nature of the fractures gave way to concern for elder abuse as the resident had a spiral (twisting type) fracture. The resident received a consult with orthopedics but was found not to be a good candidate for surgery due to her complex medical history. The resident's left tibia fracture would be treated with immobilization and non weight bearing status. An attempted interview on 12/14/20 at 7:00 A.M. via telephone with STNA #123 was unsuccessful. An attempted interview on 12/14/20 at 7:05 A.M. via telephone with STNA #108. was unsuccessful. On 12/14/20 at 11:02 A.M. interview with the DON confirmed Resident #86 should have had two people assist with transfers and STNA #123 transferred the resident by herself on 11/26/20 resulting in a spiral fracture to the resident's leg requiring hospitalization . 2. Review of the medical record for Resident #25 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment, dated 10/05/20 revealed Resident #25 had intact cognition and was independent for locomotion. Review of the progress notes and fall investigations for Resident #25 revealed the resident had a fall on 11/08/20. Resident #25 was found lying on the floor after falling out of her chair. The new intervention ordered was Dycem (a non-skid device) to her chair. Review of the plan of care for Resident #25 revealed the resident was at risk for falls. Interventions included Dycem to chair, visual cues, anticipating and meeting the resident's needs and appropriate footwear. Observation on 12/14/20 at 1:45 P.M. revealed no Dycem in Resident #25's chair. On 12/14/20 at 1:45 P.M. interview with STNA #125 confirmed there was no Dycem in Resident #25's chair. On 12/14/20 at 2:00 P.M. interview with the DON confirmed a Dycem should be in Resident #25's chair as a fall intervention. The DON was unsure how long the Dycem had been out of the chair or who had removed it. The deficiency is an incidental finding to Complaint Number OH 431.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC) , observations, record reviews, review of the undated facility COVID-19 plan, Screening of Residents for Signs and Symptoms of COVID-19 policy and procedure, review of facility timeline documentation, and interviews with staff and the local health department, the facility failed to implement effective and recommended infection control practices including proper isolation of residents and the appropriate use of personal protective equipment (PPE) to prevent the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on [DATE] when Resident #12 was moved off the unit for residents with presumptive symptoms (C hall at the time) after only being there for two days. The resident had been placed on the presumptive unit due to experiencing symptoms of COVID and a temperature of 100.4. Resident #12 was moved to a COVID negative unit (A unit), on [DATE]. Resident #12 tested positive for COVID-19 on [DATE] and was moved from the COVID negative hall (A hall) to the COVID positive hall (C hall). This exposed the residents and staff on the COVID negative unit (A hall) to COVID-19. The lack of current effective infection control practices and implementation of effective infection control policies and procedures placed all residents at risk for harm, complications and/or death related to the facilities failure to control the spread of COVID-19 throughout the facility. The facility census was 74. From [DATE] to [DATE], there were 31 residents identified to test positive for COVID-19, with the most current resident (Resident #13) testing positive on [DATE] and three residents who expired. In addition, seven staff members tested positive for COVID-19. An investigation, including the use of a facility timeline revealed infection control concerns involving Resident #73, #50, #63, #74, #59, #77, #18, #60, #67, #2, #30, #31, #35, #25, #42, #53, #54 and #75. During this time period, the facility failed to implement an effective infection control program to include recommended infection control practices, including proper quarantine/isolation for residents, dedicated staff to provide care for COVID positive and/or COVID symptomatic residents, and proper use of personal protective equipment by staff. Through interviews it was determined the facility failed to coordinate with the local health department to prevent and contain the spread of COVID-19 within the facility. The Director of Nursing (DON #109), who was also the facility ' s infection control nurse was no longer employed with the facility after [DATE]. Acting Director of Nursing #10 started on [DATE]. At the time of the survey, the facility Administrator was on maternity leave with her last date worked on [DATE]. The Acting Administrator's first day was [DATE]. On [DATE] at 4:00 P.M., Acting Director of Nursing #100 and Corporate Registered Nurse #101 were notified Immediate Jeopardy began on [DATE] when Resident #12, who was experiencing presumptive symptoms of COVID-19 was moved from the presumptive unit after two days and placed on a unit where no residents were positive/symptomatic. This exposed the residents and staff on A hall (COVID negative hall). Resident #12 tested positive for COVID-19 on [DATE]. The facility failed to operationalize the undated COVID-19 plan when residents with signs and symptoms of COVID-19 were not cohorted on the same unit with the same staff, when the same PPE (including gowns and masks) were worn by staff for the entire 12 hour shift without evidence of a PPE shortage, and when they failed to maintain a close communication and collaboration with local health authorities. In addition, the facility failed to notify the physician, take appropriate action, and monitor Resident #75 when he exhibited a temperature of 101 and a lower oxygen saturation level. Resident #75 expired at the facility on [DATE]. On [DATE] onsite observations and interviews revealed ongoing infection control concerns including but not limited to the following: Units B and C contained residents who were positive for COVID-19 and Unit A was identified as the presumptive unit. Observations and staff interviews revealed staff were provided with one set of PPE (gown, mask, face shield, and shoe covers) at the beginning of their 12 hour shift. Staff wore the same PPE set for the whole shift. No PPE was observed near each resident's room for use when entering the resident's room. Resident #25, #42, #53, and #54, who were roommates of residents who tested positive, remained upstairs on the secured dementia unit at the time of the onsite survey. Staff interviews also revealed staff were working on the COVID positive units on one day, then later, on another day, worked on the units where non-COVID positive residents resided with no evidence this was due to a staffing shortage. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · On [DATE] the facility identified due to the high number of positive COVID test results and the uncertainty of additional exposure, all facility staff were instructed to utilize PPE in all resident care areas to minimize risk of spread throughout the facility per the CDC guidelines for optimizing PPE supplies. The instruction included non-shared staff, proper donning and doffing, proper frequent hand hygiene and glove changing with procedures and between resident contact. The PPE was being counted and monitored daily by DON/designee to ensure supplies are available. · On [DATE] Acting DON #100 updated the local health department of the resident COVID testing results since [DATE]. · On [DATE] Acting DON #100/Designee reached out to the local health department/EMA and sister facilities for assistance with PPE shortage. 230 face shields, 240 N95 masks, 300 surgical masks were delivered to the building. However, no gowns were delivered to the building. · On [DATE] the Regional Clinical Nurse completed an audit to ensure staff were using plastic probe covers over oral thermometers and being cleaned between each use. Infrared thermometers were ordered. The Regional Clinical Nurse also cleaned the medication cart on the A hall that had been found in a doffing room on the unit. · On [DATE] at 12:05 P.M. the Acting DON #100, VP of Clinical Services and Interim Administrator spoke with the Infectious Disease Coordinator for the Fairfield Health Department regarding the facility PPE shortages. Information for how to reach out to the EMA for assistance was provided. The Health Department also provided information for the Tele-ICAR program and the local health department offered to set this up for the facility. · On [DATE] a plan for Acting DON #100/designee to audit units to ensure the medication carts were in an appropriate location five times a week for two weeks, then three times a week for six weeks and randomly thereafter. Audit results will be submitted to quality assessment/performance improvement (QAPI) for review and further recommendations. · On [DATE] at 3:30 P.M. the VP of Clinical Services called and left a message with EMA regarding PPE shortages for some assistance of gowns available to the facility. At 4:30 P.M. Acting DON #100 called three local sister facilities to request PPE assistance that could be provided (specifically to gowns). At this time, no one had any extra gowns available, but would assist if any shipments were received. · On [DATE] the facility received all resident and staff Covid testing back. Any resident who newly tested positive, was placed in droplet precautions as well as physician and family notification. A plan for all room changes to go through the facility interdisciplinary (IDT) team for appropriate room moves. Any resident who tested positive for COVID who was a smoker would be offered a nicotine patch and remain in droplet isolation for the duration of their infectious period. Residents who intermittently refuse testing will remain in quarantine isolation and will be offered to smoke three times a day separate from other smokers. The two residents that have consistently refused testing are nonsmokers. · On [DATE] all residents who gave consent on the second floor were re-tested for COVID-19 by MDS, RN, SS and LPN staff. Resident physicians and their families were notified of the retesting schedule. On this date, all nurses had been educated by Acting DON #100/designee on change in condition, the facility COVID policy and monitoring for COVID symptoms. · On [DATE] from 4:00 P.M. to 5:30 P.M. the Interim Administrator, VP of Clinical Services, Acting DON #100, MDS, RN, SS and LPN participated in a Tele-ICAR to assist the facility with the COVID outbreak. · On [DATE] the VP of Clinical Services reviewed/updated the facility COVID policy, which was approved by the Medical Director to reflect the current CDC and ODH guidelines. All staff were educated on the updated policy. All staff, including contracted and agency staff were re-educated either in person or by phone by Acting DON #100/designee on the COVID care policy. · On [DATE] a plan for Acting DON #100/designee to audit for change in condition for all residents for appropriate care and notification of physician was implemented. The audits will be conducted five times per week for two weeks and then three times per week for six weeks and randomly thereafter to ensure ongoing compliance. Audit results will be submitted to the quality assessment/performance improvement (QAPI) committee for review and further recommendations. · On [DATE] at 10:00 A.M. the facility received PPE supplies from EMA for one week to cover the needs of increased PPE burn using gowns for residents. A plan was reviewed for EMA to provide additional relief next week and the procurement director placed orders for 400 reusable gowns to augment the supply. This is expected to be delivered [DATE]. No additional shortages were identified at this time. Infrared thermometers and additional pulse oximeters were received and placed in use on this date. · As of [DATE] at 7:30 P.M. Acting DON #100/designee provided staff education for all employees related to PPE and COVID. PRN employees who are scheduled to work will receive education by Acting DON #100/designee before they work a shift until all employees are educated. Agency staff who are new to the facility will be educated prior to the start of the shift. No staff will work without receiving education. All new staff will receive the education contained herein as part of new employee orientation to ensure compliance is maintained. said she would review the survey and see if they could assist. · Beginning [DATE] a plan for Acting DON #100/Designee to audit the appropriate usage of PPE for three staff members three times a week for eight weeks and then randomly thereafter to ensure ongoing availability. · On [DATE] a plan for all staff to be retested for COVID by MDS, RN, SS and LPN staff. A plan for the B and C hall to follow symptom-based guidelines and physician guidance per the CDC guidelines regarding COVID status and testing. · On [DATE] a plan was implemented to observe all staff to ensure PPE was being properly donned and doffed and to ensure equipment was being safely utilized by all staff. These audits will be completed by Acting DON #100/designee who will observe three staff per week for eight weeks to ensure ongoing compliance. Audit results will be submitted to QAPI for review and further recommendations. · On [DATE] a plan for Acting DON #100/designee to audit units to ensure appropriate thermometers are being used five times a week for two weeks, then three times a week for six weeks,and randomly thereafter. Audit results will be submitted to QAPI for review and further recommendations. 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 still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1. Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America ' s health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. This document may be requested by surveyors, if an onsite investigation takes place. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). On [DATE] at 3:45 P.M. Acting Director of Nursing #100 stated she did not know if the voluntary self-assessment had been completed by the facility. As of [DATE] at 7:00 A.M., no CMS recommended voluntary assessment was provided for review. 2. Review of the Centers for Disease Control and Prevention (CDC) website updated [DATE] revealed: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated [DATE] revealed As a measure to limit health care personnel (HCP) exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift. Limit transport and movement of the patient outside of the room to medically essential purposes. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. In regards to PPE, healthcare personnel who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher level respirator, gown, gloves and eye protection. Personal protective equipment training, on understanding and demonstrate when to use PPE, what PPE was necessary, how to properly apply (don), use and remove (doff) PPE in a manner to prevent self-contamination, how to properly dispose or disinfect and maintain PPE and the limitations of PPE. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. Put on an N95 respirator or equivalent or higher-levels respirator before entry into the patient room or care area. Disposable respirators and facemask should be removed and discarded after exiting the patient room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or face masks. Eye protection: put on eye protection (i.e. goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. Protective eyewear (e.g. safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays. Gowns, put on a clean isolation gown upon entry into the patient room or area, change the gown if it becomes soiled, remove and discard the gown in a dedicated container for waist or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. Information obtained as part of the COVID-19 Focused Infection Control Survey and complaint survey, between [DATE] and [DATE] from the Director of Nursing and then Acting Director of Nursing #100 revealed the first resident (Resident #76) tested positive on [DATE] while at the hospital. Before the resident returned to the facility, Resident #73 tested positive on [DATE] (was tested at the hospital on [DATE]) and Residents #50, #63, and #74 tested positive on [DATE] after mass testing of residents was completed on [DATE]. The following concerns were identified as part of the survey: a. Review of the medical record for Resident #12 revealed on [DATE] the resident was moved off the unit for residents with presumptive symptoms (C hall at the time) after only being there for two days. Nurse ' s notes revealed the resident was placed on the presumptive unit due to experiencing symptoms of COVID and a temperature of 100.4. Resident #12 was moved to a room on the COVID negative unit (A hall) on [DATE]. Resident #12 tested positive for COVID-19 on [DATE] and was then moved from the COVID negative unit (A hall) to the COVID positive hall (C hall). This exposed the residents and staff on A hall (COVID negative unit) to a resident positive for COVID-19. Interview with Acting Director of Nursing #100 on [DATE] at 12:15 P.M. confirmed Resident #12 was moved from the presumptive unit after only two days to the COVID negative hall (A hall). Review of the facility undated policy and procedure, titled COVID 19 revealed the facility would cohort residents with similar respiratory symptoms on the same unit with the same staff. Droplet precautions would be implemented for residents with symptoms or confirmed coronavirus for 14 days after illness onset. b. Review of the facility timeline and test results revealed three additional residents tested positive for COVID-19 on [DATE]. This included two residents (Residents #59 and #77) who resided in a room on the COVID negative unit (A hall) next to the room where Resident #12 resided. Resident #18 also tested positive on [DATE] and had also resided on the COVID negative unit (A hall). The facility timeline and their medical records confirmed their room numbers. Review of the medical record for Resident #77 revealed, after being diagnosed on [DATE] with COVID-19, the resident died on [DATE]. c. Review of mass resident testing results on [DATE] and the medical record for Resident #60 revealed no evidence the resident was tested on [DATE]. On [DATE] nurse's notes at 6:48 P.M. revealed Resident #60 refused a COVID test. Nurse's notes on [DATE] at 5:31 P.M. revealed the resident was transferred to the hospital due to behaviors including throwing a trash can and dumping over the housekeeper's mop bucket. Resident #60 returned to the facility [DATE] with a positive [DIAGNOSES REDACTED]. Review of the census tab in the electronic medical record revealed on [DATE] Resident #60 was moved to a room on the F hall, the secured dementia unit upstairs. Prior to [DATE], there had been no positive cases of COVID-19 on the dementia unit upstairs. The census tab in the electronic medical record revealed Resident #60 was moved back to the COVID positive unit (C hall) on [DATE]. Interview with Acting Director of Nursing (DON) #100 on [DATE] at 12:15 P.M. confirmed the room change for Resident #60 noted in the census section of the electronic medical record. The Acting DON confirmed there was no documentation to explain the resident being moved from the COVID positive unit to the secured dementia unit upstairs (no positive cases prior) and then back to the COVID positive unit. d. Review of resident testing results revealed one resident who resided upstairs on the secured dementia unit tested positive for COVID-19 on [DATE] (Resident #67) and four residents on [DATE] (Residents #2, #30, #31, and #35). Those residents were moved to the COVID positive units (which was identified to be B hall and C hall at this time) and the A hall was being used for residents who were presumptive COVID-19. However, these residents roommates on the secured dementia unit, Residents #25, #42, #53, and #54) were not moved, even though exposed, and remained upstairs on the secured dementia unit with residents who had not tested positive or had symptoms. A total of 30 residents were residing on the upstairs secured dementia unit as of this time. Interview with Acting Director of Nursing #100 on [DATE] at 12:15 P.M. verified the roommates (Residents #25, #42, #53, and #54) who were exposed to Residents #2, #30, #31, and #35 were not moved because all of the residents in the building have now potentially been exposed. e. Review of the medical record for Resident #75 revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the census tab in the electronic medical record, the resident was moved to a room on the COVID negative hall (A hall) on [DATE] due to negative COVID-19 test results on [DATE]. The resident also had a negative test result on [DATE]. However, record review revealed the resident was moved to a room on the COVID positive hall (C hall) on [DATE] with no reason documented for the room change. Review of nurse's notes, dated [DATE] at 4:47 P.M. revealed Resident #75 was moved from the COVID positive hall (C hall) to the presumptive hall (B hall). This resulted in Resident #75 residing on the COVID positive hall (C hall) for two days without being positive for COVID. There was no written information available to explain these room changes for the resident. Resident #75 had a physician's orders [REDACTED]. It stated that if symptoms were present to document in progress notes. The facility assessment every four hours included temperature and oxygen saturation levels. A nurse's note on [DATE] 7:38 A.M. written by Licensed Practical Nurse (LPN) #105 revealed she was alerted Resident #75's oxygen saturation level was 85 percent. The note revealed the LPN had the resident do purse lip breathing to bring his oxygen level up to 95 percent. There was no evidence the physician or Director of Nursing were notified of this change in condition. On [DATE] at 8:00 P.M. Resident #75 had an elevated temperature of 101 degrees and oxygen saturation level of 92 on the medication administration record (MAR) documented by Registered Nurse (RN) #102. The MAR documented Tylenol was given at 10:45 P.M. by RN #102. At 12:00 A.M. on [DATE] the temperature was documented on the MAR as 100.1. and an oxygen saturation level of 91. The resident had not had a temperature above 100 degrees since [DATE] (10 days prior). There was no evidence the physician was notified. There was no evidence the Director of Nursing/Unit Manager was notified. There was no evidence the temperature check or oxygen saturation level were completed at 4:00 A.M. on [DATE]. There was no documentation in the nurse ' s notes between 11:45 P.M. (documentation regarding Tylenol given for temperature above 100) and [DATE] at 5:26 A.M. Resident #75 was found on [DATE] at 5:26 A.M. with no pulse or respirations. CPR was initiated and 911 called. However, Resident #75 was pronounced deceased at the facility on [DATE] at 6:19 A.M. Resident #75 had been tested for COVID-19 on [DATE]. The test results received on [DATE] were positive for COVID-19. Interview with State tested Nursing Assistant (STNA) #103 on [DATE] at 5:50 A.M. revealed she worked the night shift on Sunday night ([DATE]). She stated she was not working on Resident #75's unit but Resident #75 looked bad. She stated he was breathing funny, was slurring his words, and was very confused. She stated she kept going to the nurse (Licensed Practical Nurse #104) but she kept shrugging her shoulders. Interview with LPN #104 on [DATE] between 5:10 A.M. and 5:30 A.M. revealed she worked Sunday night ([DATE]). She stated the STNA staff said Resident #75 was acting funny and was confused. She stated she assessed the resident and he was rubbing snuff and asked for a pain pill. She stated his vital signs were stable. She stated she saw no need to notify the physician. (There were no nurses notes by LPN #104 on [DATE]). Interview with STNA #106 on [DATE] at 6:35 A.M. revealed she worked on Resident #75 ' s unit on Sunday night ([DATE]) and Monday night ([DATE]). She stated on Sunday night the resident was a little confused. STNA #106 stated she told LPN #104, who stated she was already aware. On Monday night ([DATE]) he was a little more confused. STNA #106 stated he thought his phone was a bottle of soap. The STNA stated he was panicky and was having trouble breathing. STNA #106 stated she got the nurse (RN #102) at the beginning of the shift (6 P.M. to 6 A.M. shift), because the resident stated he wanted to go to the hospital. The STNA stated RN #102 went into his room. STNA #106 stated she heard the resident ask the nurse if she thought he should go to the hospital. The STNA stated she did not hear the nurse's reply. STNA #106 stated she knew the resident had a temperature and the nurse had given him Tylenol. The STNA stated she was in his room around midnight and again at 4:00 A.M. and at at 4:00 A.M. he was snoring. STNA #106 said around 5:30 A.M. she heard RN #102 yelling trying to arouse the resident. STNA #106 stated she then went to get the crash cart for the nurse. The STNA said another nurse came and the two nurses were doing CPR. Interview with RN #102 on [DATE] at 7:15 A.M. revealed she was the nurse for Resident #75 on Monday night ([DATE]) from 7:00 P.M. to 7:00 A.M. RN #102 stated the STNA staff had reported Resident #75 had fever but did not report any breathing difficulties. RN #102 stated Resident #75 had a fever of 101 degrees around ,[DATE]:00 P.M. (documented at 8:00 P.M.) and she gave him Tylenol. The RN stated she rechecked his temperature but did not remember what time. (Documented at midnight). RN #102 stated she was not in the resident ' s room again until 5:30 A.M. when she found him unresponsive with no pulse or respirations. RN #102 confirmed the physician ordered vital signs at 4:00 A.M. were not done. RN #102 confirmed she did not notify the physician or Director of Nursing of the increased temperature or decreased pulse oximetry level from that night. RN #102 stated staff were to notify the physician of a temperature above 99.5 but she did not because he had been having elevated temperatures, although none were documented above 100 degrees in the previous 10 days. Interview with Assistant Director of Nursing #107 on [DATE] at 3:00 P.M. revealed Resident #75 initially resided on the C hall (this hall was used as a presumptive hall until the first COVID positive resident was moved there on [DATE], then it became COVID positive) after admission so he could be in isolation for 14 days. She revealed he was moved to a COVID negative hall (A hall) on [DATE] after a negative COVID test. The Assistant Director of Nursing confirmed Resident #75 was moved to the COVID positive hall (C hall) again on [DATE]. She stated staff had been told by corporate to move presumptive residents to the COVID positive hall, then they found out they should not cohabitate presumptive residents with positive residents. Resident #75 was then moved to the B hall (the new presumptive unit). The Assistant Director of Nursing stated if a resident had a temperature over 100 degrees staff should administer Tylenol and recheck the temperature. She stated if the temperature remained above 100 degrees, staff should call the physician. The Assistant Director of Nursing confirmed the vital signs at 4:00 A.M. on [DATE] were not completed and confirmed the physician should have been notified of his elevated temperature. Review of the facility undated policy titled Screening of Residents for Signs and Symptoms of COVID-19 revealed: In order to provide for the early detection of COVID-19, residents would be screened for signs and symptoms of this infection at least once every shift. Residents should be screened for symptoms of COVID-19 by taking the resident ' s temperature and pulse oximetry at least once a shift. Contact the Director of Nursing or Unit Manager if any of the following are detected: new onset fever, shortness of breath, cough, sore throat, or a decrease in pulse oximetry from resident baseline or any pulse oximetry reading less than 92. 3. Interview with a staff person from the local County Health Department (HD Staff #108) on [DATE] at 1:42 P.M. revealed she was concerned because of the minimal contact she had had from the facility regarding their COVID cases. HD Staff #108 stated DON #109 had left a message on [DATE] and they then had a lengthier conversation on [DATE]. HD Staff #108 stated her last conversation with the facility was with DON #109 on [DATE] and had not received an update since then. HD Staff #108 stated she had faxed forms to the facility on [DATE] to be filled out for each resident who was positive but had not received any response. She stated she had recommended the facility utilize the Tele-ICAR resource available to them, however they declined. Tele-ICAR is a Tele-Infection Control Assessment and Response (Tele-ICAR) tool. Through this tool, the facility would work with the local health department to complete a detailed infection control assessment of elements of infection control practices and specifically related to COVID-19. The findings of the assessment could then be used to target specific infection prevention and control practices. https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/assessment-tool-nursing-homes.pdf Interview with Acting Director of Nursing #100 on [DATE] at 3:45 P.M. revealed the facility had called the local health department that day and were now interested in the Tele-ICAR resource. However, she stated they told the health department they would not be available for this resource this week as they were too busy. Review of the facility undated policy titled COVID policy revealed the facility was to maintain close communication and collaboration with the local health authorities. 4. Interview with DON #109 on [DATE] at 11:15 A.M. revealed the facility had an adequate supply of PPE for staff. Interview with LPN #104 on [DATE] and observations between 5:10 A.M. and 5:30 A.M. revealed she was working on A hall. She stated this was now the presumptive hall as B and C halls were now all COVID positive residents. She stated the facility recently changed their PPE procedure and now staff get one set of PPE (gown, mask, face shield, shoe covers) when they come on duty and they wear this (TRUNCATED)

Based on closed medical record review, staff interview, and review of the facility policy related to change in condition and screening residents for signs and symptoms of COVID-19, the facility failed to provide adequate and timely monitoring and treatment for [REDACTED].M. until [DATE] at 5:26 A.M. when the resident was found without vital signs. Actual harm occurred on [DATE] at 6:19 A.M. when the resident was pronouced deceased in the facility. This affected one resident (#75) of twelve sampled residents. Findings include: Review of the closed medical record for Resident #75 revealed the resident was admitted to the facility [DATE] and had [DIAGNOSES REDACTED]. A Minimum Data Set Assessment completed [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired decision making skills. According to the census tab in the electronic medical record, the resident was moved to a room on the A hall on [DATE] (the unit for residents negative for COVID-19 or no symptoms) due to negative COVID-19 test results on [DATE]. The resident also had a negative COVID-19 test result on [DATE]. However, record review revealed the resident was moved to a room on the C hall (the unit with COVID positive residents) on [DATE]. review of the resident's medical record revealed [REDACTED]. Continued review of nurse's notes on [DATE] at 4:47 P.M. revealed the resident was moved from C hall to B hall ( the unit for COVID presumptive residents). Record review revealed no documentation related to why this room change occurred. As a result of the room changes, Resident #75 resided for two days on the unit where COVID positive residents were residing when he was not positive for COVID 19. Review of the physician's orders for [DATE] revealed the resident had an order for [REDACTED].M. for diabetes and [MEDICATION NAME]three times a day at 7:01 A.M. , 11:30 A.M., and 4:30 P.M. per sliding scale (amount of insulin given was based on the resident's blood sugar level at that time). The resident would receive four units for a blood sugar of ,[DATE], six units for ,[DATE], eight units for ,[DATE] and ten units for a blood sugar ,[DATE]. The physician was to be notified if the blood sugar was above 400. The resident also had a physician's order to assess for signs and symptoms of COVID-19 every four hours. The order indicated if symptoms were present to document in progress notes. The facility assessment every four hours included temperature and oxygen saturation levels. Review of the medication administration record (MAR) for Resident #75 revealed on [DATE] at 7:01 A.M. Licensed Practical Nurse (LPN) #105 documented the resident refused his blood sugar check. Therefore, there was no evidence any insulin was given. Blood sugars on the previous two days had ranged from ,[DATE]. A nurse's note on [DATE] at 7:38 A.M. by LPN #105 revealed she was alerted Resident #75's oxygen saturation level was 85 percent. The note indicated the nurse had the resident do purse lip breathing to bring his oxygen level up to 95 percent. There was no evidence the physician or Director of Nursing/unit manager were notified. Review of the MAR revealed LPN #105 documented Resident #75 refused his blood sugar checks on [DATE] at 11:30 A.M. and 4:30 P.M. and his regularly scheduled insulin at 5:00 P.M. There was no reason for the refusals documented in the record. Record review revealed the resident had not refused his insulin any other day in [DATE] and had required sliding scale insulin 52 times in [DATE]. The residents oxygen saturation level at 12:00 P.M. and 4:00 P.M. on [DATE] was 91 percent. There was no evidence any treatment was provided and no evidence the physician or director of nursing/unit manager were notified. On [DATE] at 8:00 P.M. the resident had an elevated temperature of 101 degrees and oxygen saturation level of 92 documented on the medication administration record (MAR) by Registered Nurse (RN) #102. The MAR documented Tylenol was given at 10:45 P.M. by RN #102. At 12:00 A.M. on [DATE] the temperature was documented on the MAR as 100.1 degrees and an oxygen saturation level of 91. The resident had not had a temperature above 100 degrees since [DATE] (10 days prior). There was no evidence the physician was notified. There was no evidence the Director of Nursing/Unit Manager were notified. There was no evidence a temperature check or oxygen saturation level were obtained at 4:00 A.M. on [DATE]. There was no documentation in the nurse's notes between 11:45 P.M. (documentation regarding Tylenol given for temperature above 100) and [DATE] at 5:26 A.M. Record review revealed Resident #75 was found on [DATE] at 5:26 A.M. with no pulse or respirations. CPR was initiated and 911 called. However, Resident #75 was pronounced deceased at the facility on [DATE] at 6:19 A.M. Resident #75 had been tested for COVID-19 on [DATE]. The test results received on [DATE] were positive for COVID-19. Interview with State tested Nurse Aide (STNA) #103 on [DATE] at 5:50 A.M. revealed she worked the night shift on Sunday night ([DATE]). She stated she was not working on Resident #75's unit but Resident #75 looked bad. She stated he was breathing funny, was slurring his words, and was very confused. She stated she kept going to the nurse (Licensed Practical Nurse #104) but she kept shrugging her shoulders. Interview with Licensed Practical Nurse (LPN) #104 on [DATE] between 5:10 A.M. and 5:30 A.M. revealed she worked Sunday night ([DATE]). She stated the STNA staff reported Resident #75 was acting funny and was confused. She stated she assessed him and he was rubbing snuff and asked for a pain pill. She stated his vital signs were stable. She stated she saw no need to notify the physician. (There were no nurse's notes completed for Resident #75 by LPN #104 on [DATE]). Interview with STNA #106 on [DATE] at 6:35 A.M. revealed she worked on Resident #75's unit on Sunday night ([DATE]) and Monday night ([DATE]). She stated on Sunday night the resident was a little confused. She stated she told LPN #104, who stated she was already aware. On Monday night ([DATE]) the resident was a little more confused. She stated he thought his phone was a bottle of soap. She stated he was panicky and was having trouble breathing. She stated she got the nurse (RN #102) at the beginning of the shift (6 P.M. to 6 A.M. shift), because the resident stated he wanted to go to the hospital. She stated RN #102 went into his room. She stated she heard the resident ask the nurse if she thought he should go to the hospital. She stated she did not hear the nurses' reply. She stated she knew the resident had a temperature and the nurse had given him Tylenol. She stated she was in his room around midnight and again at 4:00 A.M. She stated at 4:00 A.M. he was snoring. She said then around 5:30 A.M. she heard RN #102 yelling trying to arouse the resident. She stated she then went to get the crash cart for the nurse. She stated another nurse came and the two nurses were doing CPR. Interview with RN #102 on [DATE] at 7:15 A.M. revealed she was the nurse for Resident #75 on Monday night ([DATE]) from 7:00 P.M. to 7:00 A.M. She stated the STNA staff had reported the resident had a fever but did not report any breathing difficulties. She stated the resident had a fever of 101 degrees around ,[DATE]:00 P.M. (documented at 8:00 P.M.) and she gave him Tylenol. She stated she rechecked his temperature but did not remember what time. (Documented at midnight). She stated she was not in his room again until 5:30 A.M. when she found him unresponsive with no pulse or respirations. She confirmed the physician ordered vital signs at 4:00 A.M. were not done prior to him being found unresponsive at 5:30 A.M. She confirmed she did not notify the physician or Director of Nursing of the increased temperature or decreased oxygen saturation level that night. RN #102 revealed the expectation was to notify the physician of a temperature above 99.5 but she did not because the resident had been having elevated temperatures. However, record review revealed no temperatures documented above 100 in the past 10 days. Interview with Assistant Director of Nursing #107 on [DATE] at 3:00 P.M. revealed Resident #75 initially resided on the C hall (the unit for COVID positive residents)after admission so he could be in isolation for 14 days. She confirmed he was moved to A hall (hall with no positive or presumptive at the time) on [DATE] after a negative COVID test. She confirmed he was moved to C hall again on [DATE] (unit for positive residents). She stated staff had been told by corporate to move presumptive residents to the COVID positive hall, then they found out they should not cohabitate presumptive residents with positive residents. The resident was then moved to B hall (the new presumptive unit). She stated if a resident had a temperature over 100, the nurse should give Tylenol and recheck the temperature. She stated if the temperature stays above 100, staff should call the physician. She confirmed the vital signs at 4:00 A.M. on [DATE] were not completed and confirmed the physician should have been notified of the resident's elevated temperature. She also confirmed it was documented the resident refused his blood sugar checks and insulin on [DATE] with no explanation why. The Assistant Director of Nursing revealed the physician should have been notified of this also. Review of the facility undated policy titled Screening of Residents for Signs and Symptoms of COVID-19 revealed: In order to provide for the early detection of COVID-19, residents would be screened for signs and symptoms of this infection at least once every shift. Residents should be screened for symptoms of COVID-19 by taking the resident's temperature and pulse oximetry at least once a shift. Contact the Director of Nursing or Unit Manager if any of the following were detected: new onset fever, shortness of breath, cough, sore throat, or a decrease in pulse oximetry from resident baseline or any pulse oximetry reading less than 92. Review of the facility policy dated 2001 and revised ,[DATE] titled, Change in a Resident's Condition or Status revealed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a: a. Significant change in resident's physical/emotional/mental condition. b. Need to alter resident's medical treatment c. Refusal of treatment or medication two or more consecutive times. The policy further stated a significant change of condition was a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff. b. Impacts more than one area of the resident's health. c. Requires interdisciplinary team review and/or revision of the care plan. d. Ultimately is based on the judgement of the clinical staff. The nurse would record in the resident's medical record information relative to change in the resident's medical/mental condition or status. This deficiency substantiates Complaint Number OH 392.

Based on observations, review of the medical record, Sheriff's Office Dispatch Detail report, the facility investigation, staff witness statements, facility policy and staff, resident, and resident guardian interviews, the facility failed to provide adequate supervision to prevent the elopement of one cognitively impaired resident (Resident #1) who had exhibited exit seeking behaviors. This resulted in Immediate Jeopardy when Resident #1 eloped from the facility on 09/01/18. The likelihood of serious harm or injury occurred when the resident was found approximately three and half miles from the facility the evening of 09/01/18 having traveled winding country roads in the rain and darkness and was returned to the facility by the local sheriff department. This affected one of one resident reviewed for elopement. The facility identified five residents at risk for elopement. On 09/11/18 at 3:29 P.M., the Administrator and Director of Nursing (DON), were notified Immediate Jeopardy began on 09/01/18 at approximately 7:15 P.M., when Resident #1, who had previously exhibited exit seeking behaviors, was last seen and subsequently exited the facility without staff knowledge. Staff failed to investigate the sounding of door alarms and failed to search the grounds for the cause of the alarms sounding. The Immediate Jeopardy was removed on 09/12/18 when the facility implemented the following corrective actions: · On 09/01/18 at 9:30 P.M. Resident #1 was returned to the facility by the local sheriff department and was placed on 1:1 supervision. Resident #1 was re-assessed for risk of wandering and elopement and determined to be at high risk for elopement. The resident's physician was notified and ordered the resident be transferred to the hospital emergency room for evaluation and treatment. · On 09/04/18 at 4:25 P.M. Resident #1 returned to the facility, was re-assessed for wandering and risk of elopement and was placed on the facility's secured unit. · On 09/11/18 at 4:50 P.M. and 5:30 P.M. The Regional Director of Clinical Services provided education to the Administrator and Director of Nursing on the Missing Resident and Elopement Policies and Elopement Risk Prevention including investigation of elopements. · On 09/11/18, beginning at 2:30 P.M. and ending at midnight, the Administrator and the DON completed education to all staff including 15 licensed nursing staff, 28 state tested nurse aides (STNAs), seven (7) kitchen staff, five (5) housekeeping/laundry staff, one (1) Activity Staff, 11 Department Managers, two (2) office staff, and five (5) therapy department staff on the facility Elopement and Missing Resident policies, and Elopement Risk Prevention. Three (3) staff are currently on medical leave of absence and will receive education by either the DON or Administrator prior to being placed back on the schedule to return to work. · On 09/11/18 Elopement Drills were completed on the 6AM-6PM shift (completed at 5:00 P.M.) and the 6PM-6AM shift (completed at 7:35 P.M.). The Elopement Policy was reinforced after both drills. · On 09/11/18, no time identified, the Administrator and the DON re-interviewed all staff working on 09/01/18 at the time of the incident and established a timeline of events. · On 09/11/18 a laminated copy of the Missing Resident Policy was posted at each alarm panel for ease of access to employees. · On 09/11/18 a copy of the Missing Resident Policy and procedure was added to the communication and exit seeking binder located at each nurse's station for ease of access by employees. · On 09/12/18 Registered Nurse (RN) #29 completed a whole facility audit for each resident to ensure a wandering assessment had been completed and was included in the medical record. In addition, RN #29 completed wandering risk assessments for a total of 12 residents (5 newly admitted residents, 3 reassessments of residents who had been assessed previously as being at risk for elopement, and 4 residents who had quarterly assessments due). There were no changes to the resident's risk for wandering based on the completed assessments. · On 09/12/18 between 9:27 A.M. and 9:43 A.M. interview with STNA #27 and LPN #28 revealed they acknowledged being in-serviced and educated regarding the facility's Missing Resident and Elopement Policies. · On 09/12/18 between 11:30 A.M. and 12:00 P.M. observations verified a laminated copy of the Missing Resident Policy was posted at each alarm panel and a copy of the Missing Resident Policy was added to the communication and exit seeking binder located at each nurse's station. · On 09/12/18 the facility indicated audits will be conducted weekly for four (4) weeks utilizing an elopement drill to ensure staff responds appropriately to the alarms. Results of the audits will be reviewed by the IDT and QAPI for any continued training needs. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan including conducting education for as needed staff and monitoring to ensure on-going compliance. Findings include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment. The assessment indicated Resident #1 required supervision for ambulation. Review of the admission wandering risk assessment dated [DATE] revealed Resident #1 was at low risk for wandering. An elopement assessment was not completed on admission. A progress note dated 07/22/18 at 11:15 P.M., authored by Licensed Practical Nurse (LPN) #23, revealed a door alarm was sounding in the dining room and Resident #1 was observed outside the door standing in the grass. The resident was redirected, 15-minute checks were started and the charge nurse was notified. The plan of care was not updated to reflect the resident was at risk for elopement. Review of the medical record revealed no documented evidence an elopement assessment or updated wandering assessment was completed. A physician order [REDACTED].M. revealed a wander guard (a resident tracking bracelet device that alerts staff of unaccompanied exit) was ordered for Resident #1. The placement and function of the wander guard was to be checked every shift. The 15-minute checks were discontinued. A plan of care initiated on 08/03/18, indicated Resident #1 was at risk for elopement due to a history of attempting to leave the facility unattended. Interventions included to redirect from exit doors as able and a wander alert bracelet to the resident's ankle. A progress note dated 09/01/18 at 8:25 P.M., authored by RN #22 revealed Resident #1 returned to the facility. The progress note indicated the physician was made aware, the resident was showered, and report was called to the hospital. The note contained no other information. A wandering risk assessment dated [DATE] revealed Resident #1 was at high risk for wandering. An elopement review dated 09/01/18 revealed Resident #1 had intermittent confusion, purposeful exit seeking and eloped on 09/01/18. Resident #1 was identified as a high risk for elopement. Review of the elopement investigation completed by the facility revealed a statement by STNA #25, a written time line by RN #22, and an Elopement form that was not part of the medical record. The written statement by STNA #25 dated 09/01/18 (no time) revealed around 7:45 P.M. he told STNA #20 about Resident #1 being outside during the smoke break at 7:00 P.M. STNA #20 stated the courtyard gate alarm was going off earlier in the shift as well. Since it was an alarm that rarely sounded, STNA #25, told STNA #20 she may want to check to see if Resident #1 was in his room. Resident #1 was not in his room and was not located in or around the building. The nurse supervisor (R.N. #200) began the procedure for a resident elopement. A written statement by RN #22 (no date) revealed at approximately 7:20 P.M. STNA #25 reported Resident #1 was outside in the courtyard. At approximately 7:45 P.M., STNA #20 told STNA #25 the outside gate alarm was going off and there was no one outside. The staff started searching for Resident #1. R.N. #200 was notified around 8:10 P.M., the family was notified around 8:15 P.M., and 911 was called around 8:20 P.M. Resident #1 returned to the facility around 9:30 P.M. and was sent to the hospital around 10:10 P.M. The Elopement form dated 09/01/18 revealed Resident #1 had eloped on 09/01/18. The staff reported to the DON on 09/01/18 at 8:08 P.M. Resident #1 was not in the courtyard. The grounds and inside the facility were immediately searched and Resident #1 was not located. The physician was notified on 09/01/18 at 8:20 P.M., the resident's guardian was notified at 8:23 P.M., and the Sheriff's Office was notified at 8:27 P.M. The Sheriff's Office discovered Resident #1 at a gas station and returned the resident to the facility. A head to toe assessment was completed and no apparent injuries were noted. Resident #1 was sent to the emergency department for evaluation. Review of the Sheriff's Office Dispatched Event Details dated 09/01/18 revealed the 911 call was received at 8:22 P.M. The Event Details revealed RN #22 reported a resident was missing and had last been seen at 7:15 P.M. An officer advised at 9:17 P.M. he was with the resident in the middle of a neighboring town. The resident was transported to the facility at 9:30 P.M. According to Global Positioning System (GPS), Resident #1's location was approximately 3.7 miles from the facility when he was found by the local sheriff. According to historical weather (www.wunderground.com) for the area where Resident #1 was found on 09/01/18 a thunderstorm occurred at 6:34 P.M. and rain was in the area at 6:54 P.M. and 7:54 P.M. The temperature was 75 degrees Fahrenheit. A Progress Note dated 09/04/18 at 4:09 P.M., authored by LPN #24, revealed Resident #1 was readmitted to the facility. ON 09/04/18 at 9:59 P.M, LPN #24 documented Resident #1 was wandering about the unit and had set the door alarms off three times. Observation on 09/11/18 at 10:09 A.M. revealed the door to a fenced in courtyard was alarmed. A code had to be entered to open the door. The door would alarm if a code was not entered and someone attempted to exit. After 15 seconds of continuous pushing, the door would open and the alarm would continue to sound. The courtyard was a large area with a smokers building for staff and two covered patios for residents to sit. The alarming gate to the outside of the courtyard was not able to be seen from the resident patios or the lobby where the door was alarming. The staff smokers building obstructed the view from the lobby to the gate. The gate had a keypad and would alarm if the code was not entered. The gate could be opened after 15 seconds of continuous pushing; however, the alarm continued to sound until it was shut off at the keypad located inside the facility. Interview on 09/11/18 at 8:37 A.M. with Resident #1 revealed he went for a walk from Somerset to Junction City. Resident #1 stated he got a ride from a friend he had just met. He was unable to provide any additional information related to his elopement from the facility on 09/01/18. Interview on 09/11/18 at 9:34 A.M. with the guardian of Resident #1 revealed he was told by the facility staff Resident #1 was found at a gas station where two busy highways intersect. The guardian stated RN #29 told him it was protocol to send the resident to the hospital for a physical and psychological evaluation after an elopement. The guardian stated he was told by facility staff the resident went under the fence and did not set off any alarms. The guardian stated he was concerned the resident had been missing because it was getting dark and a watershed (an area that channels rainfall to creeks, streams, and rivers) was in the area of the facility. The guardian stated he was told the last time anyone saw Resident #1 was around 7:15 P.M. and the facility did not contact him until 8:14 P.M. The guardian stated he did not understand why the facility did not contact the sheriff department first. The guardian stated when Resident #1 was readmitted to the facility he was placed on a secure unit. Interview on 09/11/18 at 9:58 A.M. with the DON revealed Resident #1 had gone out on the front porch in July, (YEAR) (no specific date was provided) and a wander guard was put in place at that time. The DON stated on 09/01/18 staff took Resident #1 into the courtyard. The DON stated the resident stated he went under the gate. The DON stated her understanding was an alarm was not sounding. The DON verified there was nothing in the medical record about Resident #1 eloping from the facility on 09/01/18, a thorough investigation was not completed, and no in-service or staff education had been completed at that time. The DON stated a staff meeting was planned for 09/18/18 to discuss the elopement policy and elopement risk prevention. A telephone interview on 09/11/18 at 12:50 P.M. with STNA #20 (employed by a nursing agency) revealed on 09/01/18 (during the time Resident #1 eloped from the facility) she was in a room feeding another resident. When she went into the hallway, she heard the door alarm sounding. STNA #20 stated there were multiple people at the nurse's station but no one was doing anything about the alarms. STNA #20 stated the alarms to the door to the courtyard and to the gate used to exit the courtyard were both sounding. STNA #20 stated she then turned off the alarms as she did not see any residents in the courtyard. She did not leave the building or go out in the courtyard to see if there were any residents outside (the keypad to shut off the alarm was located inside the facility at the door leading to the outside courtyard; it was not necessary to go outside to the courtyard to shut off the alarm). At the end of the shift during shift change report, STNA #20 stated the dayshift nurse said she had let Resident #1 go out into the courtyard and the evening nurse stated she had seen Resident #1 out in the courtyard. STNA #20 was not sure of the timeline but stated it was probably after 7:00 P.M. when it was discovered Resident #1 was missing. STNA #20 asked other staff if she needed to write a statement about what happened but was ignored by the staff. STNA #20 stated she was aware Resident #1 was an elopement risk because he had tried to leave before and other STNAs had told her to watch Resident #1. During an interview on 09/11/18 at 1:12 P.M. with the DON, she provided a copy of a Teachable Moment dated 09/01/18. The DON stated she did not know who did the Teachable Moment and was not aware of it prior to 09/11/18. The DON stated she had found the paperwork in the scheduling book. The Teachable Moment dated 09/01/18 revealed ALL STAFF were to be educated about door alarms and wander guard alarms. The education included door alarms and wander guard alarms were to be immediately investigated and residents on 1:1 supervision were not to be in the courtyard without staff supervision. The Teachable Moment was signed by six nursing staff members: two RNs, two LPNs, and two STNAs. Interview on 09/11/18 at 2:02 P.M. with LPN #21 revealed she was working on 09/01/18 but did not know anything about Resident #1 leaving the facility. LPN #21 stated she was not asked to write a statement. LPN #21 further stated on 09/01/18, during the time Resident #1 eloped, the doors alarmed but there was plenty of other staff to investigate why the alarms were sounding. LPN #21 stated Resident #1 was not her assigned resident and she was working on another hall, so it did not concern her. Interview on 09/12/18 at 11:03 A.M. with RN #29 revealed she started the Teachable Moment on 09/11/18. RN #29 stated she had written the incorrect date of 09/01/18 on the form. RN #29 verified there was no documentation in the medical record about Resident #1 having behaviors or detailed information about the elopement. RN #29 stated she did not know why the documentation was not in the record. RN #29 stated she told all the staff working on 09/01/18 to write a statement and put it in her mailbox. RN #29 did not know why only two staff members wrote statements. Review of the Elopement Risk Prevention Policy, dated (YEAR), revealed residents that elope and were not located for a period of time were at high risk of serious illness or death. An incident report should be completed, and key information should be documented in the medical record. The documentation should include the date and time the resident was last seen and when they were noticed missing, the residents condition prior to elopement and the status when found. A thorough investigation should be completed to determine whether the elopement was a result of neglect. Review of the Elopement policy, dated 2007, revealed when a resident returned to the facility a report of incident/accident would be completed and the event would be recorded in the resident's medical record. Review of the Missing Resident policy, revised (MONTH) (YEAR), revealed missing resident drills were to be conducted at least annually in facilities with secure units. The steps to be completed following a missing resident included the incident to be documented in the nursing notes. All documentation must be concise and reflect the actual facts as they relate to the incident including: dates, times, persons contacted, condition of resident upon return to the facility, physician notification, physician orders, treatment indicated, and any other pertinent information. This deficiency substantiates Complaint Number OH 853. This deficiency is evidence of continued non compliance from the annual survey completed on 08/09/18.

Based on observation, record review and interview the facility failed to ensure fall safety interventions were in place as planned for Resident #37 and Resident #74, failed to ensure a safety belt restraining device was properly and safely applied to Resident #44 and failed to ensure chemical hazards were securely and safely stored to prevent access to Resident #30, #44 and #63 who were assessed to exhibit cognitive impairment. Actual harm occurred when Resident #37, who was at risk for falls sustained a fall requiring hospitalization . The fall resulted in the resident requiring sutures to the head, a possible hip fracture and acute intracranial injury. There was no evidence fall/safety interventions were in place at the time of the fall to prevent the fall from occurring. This affected two residents (Resident #37 and #74) of three residents reviewed for accidents, one resident (Resident #44) of two residents reviewed for physical restraints and three residents (Resident #30, #44 and #63) of 35 residents whose rooms were observed. Findings include: 1. Closed medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was severely impaired. The assessment revealed the resident required extensive assistance with two-person physical assistance for bed mobility and transferring. Record review revealed the resident was admitted to Hospice services on 05/19/17. Review of the resident's fall plan of care, dated 05/10/17 revealed the resident was at a high risk for falls related to gait/balance problems, incontinence and an unawareness of safety needs. The care plan also reflected the resident had fallen prior to admission while living in the community. The goal was for the resident to be free of falls. The resident had three fall interventions, to anticipate and meet the resident's needs, ensure the resident was wearing appropriate footwear when ambulating, transferring or mobilizing in wheelchair and for physical therapy to evaluate and treat as ordered or as needed. Review of Resident #37's progress notes revealed on 05/19/17 at 8:25 P.M. the resident was sitting in his wheelchair in front of the nurse's station, waiting to get a shower. A nurse was passing medication on another unit and heard a loud thump and saw the resident laying on the floor and screaming for help. The resident had a new skin tear on top of his head and on his left and right elbow. A visitor who witnessed the fall called 911. The emergency medical team arrived at the facility and spoke with the resident's power of attorney and requested the resident be sent to the hospital to be examined. A resident, who had witnessed the resident fall revealed he tried to stand up and fell hitting his head and shoulder on the wheelchair then on the ground. Review of the emergency room (ER) visit, dated 05/19/17 revealed Resident #37's level of consciousness had decreased since the fall. The ER physician noted the resident had a possible hip fracture and possible acute intracranial injury. The documented clinical impression included: Fall, Head Injury and Left Hip Injury. The resident received sutures to his head. Family and Hospice staff discussion with the ER physician revealed no additional imaging studies/testing at that time and family requested the resident be transferred to an inpatient Hospice facility. Review of the facility's fall investigation revealed no evidence of the planned fall interventions being in place prior to or at the time of the fall. The fall investigation included documentation of the resident's injuries, a sentence from the nurse that assisted the resident and a resident witness statement from the resident who witnessed the resident fall. The investigation also noted the resident was confused, ambulatory without assistance and an active exit seeker. Interview with the Director of Nursing (DON) on 6/20/17 at 3:05 P.M. verified Resident #37 sustained a fall with injury on 05/19/17. The DON also verified the facility fall investigation did not including any evidence that fall/safety interventions were in place prior to or at the time of the fall. 2. Medical record review revealed the Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive assistance with two persons assistance with bed mobility and transferring. The assessment also noted the resident had severe cognitive impairment and no falls since the last assessment. Review of the resident's fall plan of care dated 06/30/16 revealed the resident was at risk for falls due to dementia. The goal was to minimize for falls. Interventions included for the resident to have an anti-roll back to wheelchair, assist as needed for toileting at routine times such as upon arising in the morning, before and after meals, activities and bed time, bed in low position, body pillow when in bed, have commonly used articles within reach and Dycem to wheelchair under cushion. Review of the resident's progress note, dated 01/09/17 at 12:15 A.M., revealed the nurse was notified by a State tested nursing assistant (STNA) the resident was on floor. Resident #74 was sitting on the floor next to her bed, with her back resting against the bed and both legs stretched out in front of her. No injuries were noted. Review of the facility's fall investigation revealed there was no indication the resident's bed was in low position and/or if the resident was toileted prior to her being assisted to bed. Review of the the resident's progress notes dated 06/14/17 at 6:31 A.M. revealed an STNA called the nurse into the resident's room and noted the resident was on the floor at the side of bed. Her legs were outstretched behind her with her arms bent at the elbows at her side. The resident was noted to be assisted to the side of her low bed with a gait belt. Skin assessment revealed a small purplish area developing on the right front shoulder blade. Review of the facility's fall investigation revealed there was no indication a perimeter mattress was in place, if the resident toileted prior to her being assisted to bed, if the resident's call light was within reach and/or if it was on. Interview with the Director of Nursing on 06/22/17 at 10:04 A.M. confirmed the resident's fall investigations did not include if fall interventions were in place prior to and at the time of the above falls. Review of the facility's undated policy and procedure on falls and falls managing revealed the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 3. Medical record review revealed Resident #44 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan titled At Risk for Falls, revised 02/27/17 revealed the resident had an alarming seat belt that was to be assessed when the resident was in his wheelchair. Review of the quarterly Restraint-Physical (RP) Evaluation dated 04/13/17 and the annual RP Evaluation dated 06/21/17 revealed Resident #44 had irreversible cognitive deficits associated with advanced dementia, declining mobility capabilities and minimal safety understanding. Resident #44 had an alarming seat belt that was assessed to be a restraint. Between 06/19/17 and 06/22/17, Resident #44 was observed to have a lap seat belt secured around his waist when he was in the wheelchair. Further observation revealed the following: On 06/19/17 at 10:58 A.M., the lap seat belt was loosely applied and observed drooping between the resident's legs. On 06/19/17 at 1:35 P.M., the lap seat belt was loosely applied allowing the straps to rest on the resident's knees. On 06/19/17 at 2:19 P.M., interview with Registered Nurse (RN) #13 and STNA #40 verified Resident #44's lap seat belt was loose and not applied properly. At the time of the interview, Resident #44 was unable to release the seatbelt; therefore, RN #13 correctly applied the lap seat belt for the resident. On 06/20/17 at 9:04 A.M., the lap seat belt was observed loosely applied and lying across the resident's upper thighs. Registered Nurse #58 verified the lap seat belt was not snug. Review of the manufacturer guidelines: E-Z Release Belt Alarm revised 10/15/12 revealed the belt was to placed around the resident's waist and adjusted so that the belt was snug. 4. Record review revealed Resident #44 was admitted on [DATE] with a [DIAGNOSES REDACTED].#44 had severe cognitive impairment. Record review revealed Resident #30 was admitted on [DATE] with a [DIAGNOSES REDACTED].#30 had severe cognitive impairment. Record review revealed Resident #63 was admitted on [DATE] with a [DIAGNOSES REDACTED].#63 had severe cognitive impairment. On 06/19/17 during an initial facility tour revealed skin repair cream dispensers were observed on the wall above Resident #44, Resident #30, and Resident #63's bed. The beds were observed against the wall and the dispensers were located directly above the bed approximately where the resident's thigh would be when the resident was lying in bed making the dispensers easily accessible to residents when they were lying or sitting up in bed. Medline Remedy skin repair cream was noted in all three dispensers. On 06/22/17 at 11:01 A.M. an interview with Administrator #37 revealed the skin repair cream dispensers had been in place since he was the administrator. On 06/22/17 at 11:03 A.M. an interview with Director of Nursing (DON) #79 revealed the previous company had skin repair cream dispensers put in the rooms but the lotion dispensers were not filled especially in the rooms of residents with dementia. On 06/22/17 at 11:17 A.M. STNA #65 verified the skin repair cream dispensers had cream in them. STNA #65 stated the refills were kept in central supply and were filled by maintenance or nursing staff. STNA #65 stated the skin repair cream was mainly used by the staff for dry hands and was not used on the residents. On 06/22/17 an interview with DON #79 revealed the label only indicated the product was for external use and there was no Material Safety Data Sheet (MSDS) available and most of the ingredients appeared to be natural. Review of the label on the skin repair cream revealed it was for external use only and to avoid getting the cream in a persons eyes. The MSDS sheet on www.medexsupply.com revealed if there was contact with the skin repair cream and the eyes, the persons eyes should be flushed with water and medical attention should be taken if eyes continued to be irritated. The MSDS also revealed medical attention was needed if large quantities were ingested.

Based on observation, record review and interview the facility failed to ensure Resident #53's nutritional needs were met to avoid severe weight loss. Actual harm occurred when Resident #53, who received nutrition and hydration both orally and via a gastrostomy tube exhibited decreased oral intake which resulted in a 4.8 percent weight loss in one month and a severe weight loss of 7.6% in three months with no timely and effective nutritional interventions being initiated. This affected one resident (Resident #53) of four residents reviewed for nutrition. The facility failed to identify any residents who had sustained an unplanned significant weight loss/gain. Findings include: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was severely impaired, the resident required supervision with set up assistance with meals, had no significant weight changes, had a feeding tube and received less than 25% of nutritional needs through the feeding tube, received 501 milliliters or more of water flushes through the feeding tube and was on a mechanically altered diet. Review of the resident's nutrition plan of care, dated 09/26/12 and last revised on 06/19/17 revealed the resident was at nutrition risk due to presence of chewing and swallowing difficulty, history of significant weight loss, meals intakes less than 50% at most meals and refuses often, impaired cognition which may alter intake and appetite and low [MEDICATION NAME]. Review of Resident #53's weights and vital summary form revealed the following resident weights: On 03/23/17 at 184 pounds (#), on 04/06/17 at 185.4#, on 05/21/17 at 180.8# and on 06/19/17 at 172.2#. This revealed the resident lost 8.6# in one month from 05/21/17 to 06/19/17 which reflected a 4.8 percent (%) weight loss and lost 14.2# in three months which indicated a severe weight loss in three months of 7.6%. Review of the resident's nutrition/weight progress notes revealed on 04/07/17 the resident's weight was documented as being stable and Registered Dietitian #95 stated she would discontinue weekly weights. The plan at that time was to monitor every month and continue without tube feeding at that time. The resident's estimated nutritional needs were 1655 calories, 66 grams of protein and 2522 milliliters (ml.) of water per day. On 05/19/17 a nutrition/weight progress note revealed the resident was having decreased intakes, which could be related to the resident being on antibiotic (review of physician orders [REDACTED]. It was discussed with nursing and the plan was to increase the water flushes through the resident's feeding tube and continue to monitor for the need of enteral feeding to be restarted if the resident's oral intake did not increase. On 05/24/17 a quarterly review was completed which noted the resident's May 2017 weight was pending, intakes were zero to 75% with some meals being 50% and 100%. The diet order was for mechanical soft texture with a divided plate. The resident received a house shake at breakfast and the acceptance was varied. The resident was fed per staff. There were no new recommendations at that time. A note dated 05/31/17 revealed nursing called Registered Dietitian (RD) #95 on 05/30/17 in regards to the resident's decreased oral intake and wanted to decrease the water flushes back to 150 ml. twice daily. Intakes varied from 0% to 100% with many refusals noted too. The note stated to continue to follow weights to see if the restart of bolus enteral feedings were indicated. Review of the resident's care conference form dated 06/02/17 revealed the resident's June 2017 weight was pending, the resident was eating poorly, had gradual weight loss, was at risk for significant weight loss and had a decline in visceral protein stores. The form revealed a Promod supplement was increased and the resident had poor intakes and refusals. RD #95 stated the goal body weight was to be no lower than 180#. On 06/06/17, the resident's laboratory value which tested the visceral protein stores, [MEDICATION NAME] was low at 3.0 (normal 3.5 to 5.0) and it was noted a decline from the previous lab (3.3 level in month of 02/2017). The RD increased a protein supplement, Promod to 30 ml. twice daily to provide 20 grams of protein through the feeding tube and noted the bolus tube feedings may need to be restarted. There was not another nutrition/weight note until 06/19/17 which stated the resident's current body weight was 172.2# which was a 7.6% significant weight loss in 90 days and 13% significant weight loss in six months. RD #95 noted she would discuss with the interdisciplinary team about restarting bolus feeding through the resident's gastrostomy tube. Intakes were zero to 50%. The resident had a house shake daily in place at breakfast and acceptance of this was good and the RD would add another house shake at lunch as well. On 06/20/17, the resident was added to weekly weights due to weight loss to further evaluate. After surveyor intervention on 06/22/17, the physician was notified of the resident's weight loss and decreased oral intake and responded with regards to restarting the resident's tube feed and agreed with the RD's recommendation. RD #95 recommended restarting a tube feed product, [MEDICATION NAME] 1.5 to run at 50 ml. continuously, until 500 ml. had infused from 8:00 P.M. to 6:00 A.M. This would provide 750 calories, 32 grams of protein and 380 ml. of free water. RD #95 noted that this would provide approximately 70% of the resident's estimated calorie and protein needs. Review of the residents meal intakes revealed the following: From 05/01/17 to 05/31/17 the resident had zero, 25% and 50% recorded meals for 60 times out of the 87 meals that were recorded and offered to the resident in that time period. This was equivalent to 69% of the residents meal intakes were 50% or less and 46% of the meals were 25% or less in the month of May 2017. The resident refused her nutritional house shake at breakfast 42% of the time in the month of 05/2017. From 06/01/17 to 06/21/17 the resident had zero, 25% and 50% recorded meals for 41 times out of the 57 meals that were recorded and offered to the resident in that time period. This was equivalent to 72% of the residents meal intakes were 50% or less and 49% of the meals were 25% or less in the time period from 06/01/17 to 06/21/17. Observation of Resident #53 on 06/20/17 at 11:54 A.M. revealed she was sitting in the resident lounge area and a State tested nursing assistant (STNA) brought the resident's meal tray and placed it on a bedside table. The resident received spaghetti, mixed vegetables, a dinner roll on a divided plated and also received a bowl of cheesecake, a nutritional health shake and a carton of 2% milk. Observation of STNA #47 on 06/20/17 at 12:28 P.M. revealed she asked the resident if she was full and the resident responded yes and then the STNA removed the tray from the resident. Interview with STNA #47 on 12:28 P.M. revealed she felt the resident ate 25% of her meal and 100% of her nutritional health shake. The STNA confirmed she did not offer the resident any substitutes. Interview with RD #95 on 06/22/17 at 9:46 A.M. revealed the resident always had a variable intake and the family wanted the resident off the tube feeding. The RD confirmed the physician and family were not notified of the resident's weight loss that occurred on 06/19/17 and were not notified of the residents decline in meal intakes that were noted by nursing in 05/2017 per the nutrition/weight progress notes. The RD stated she was waiting for a monthly weight to be obtained to add any further calories to the resident's diet either by oral or feeding tube. The RD stated she thought the resident was on weekly weights and that nursing was not obtaining them. After surveyor intervention, the RD confirmed the RD recommended monthly weights in 04/2017. The RD was unaware of the facility's weight policy under new management company which occurred 01/2017 and stated she knew it was taking a long time to obtain a June weight. Interview with Unit Nurse Manager (UM) #51 on 06/22/17 at 9:59 A.M. revealed monthly weights were to be done the first week. The UM was unable to answer why Resident #53 was not weighed the first week in June and stated monthly weights were generated in the facility's electronic medical record so nursing knew who to weigh. The UM stated RD #95 told nursing what weights in general were missing for residents, including Resident #53. The UM stated the facility does not have weight meeting but the RD would notify nursing of significant weight changes. Review of the facility's undated policy and procedure on enteral nutrition revealed adequate nutritional support through enteral feeding would be provided to residents as ordered. The decision to continue or discontinue the use of the feeding tube would be made through collaboration between the interdisciplinary team, the physician and the resident. Residents receiving enteral nutrition would be periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments would be documented and any changes would be made to the care plan. Input from the resident or legal representative will be included in the assessment.

Based on clinical record review, review of a facility's investigation report, staff interview and review of the facility's Pain Process Flowchart, the facility failed to maintain the highest practicable level of well being related to assessing and managing pain. This affected one of three residents reviewed for pain (Resident #101). The census was 59. Harm occurred after Resident #101 fell on [DATE] and wasn't medicated for pain even after staff assessed and confirmed the resident was in pain. Findings include: Clinical record review for Resident #101 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had both short and long term memory loss and moderately impaired cognitive skills for daily decision making. Review of a nursing note, written by Licensed Practical Nurse (LPN) #22 on 09/26/11 at 9:20 A.M. revealed at 5:10 A.M. Resident #101's PSA (pressure sensitive alarm) sounded and the resident was heard to call out. The resident was found lying on her right side and was log rolled onto her back and range of motion was completed without complaint of pain. LPN #22 documented the resident was raised to her feet per a two person assist, was not weight bearing on her left lower extremity and called out in pain. A neurological assessment was completed and vital signs were obtained. LPN #22 further documented Resident #101's left leg was externally rotated. The physician was notified at 5:50 A.M. with new orders received for an x-ray of her left hip. LPN #22 documented a mobile x-ray service was notified. Further review of the nursing note revealed Resident #101 was again assessed at 7:15 A.M. per herself and the day shift LPN and the resident "yells out in pain". The narrative note then revealed a new order was received to transfer the resident to the hospital for an x-ray and evaluation. The nursing note stated the transport company was called and arrived at the facility at 7:55 A.M. There was no evidence in the nursing note or on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M.) up to the time the transport ambulance arrived at the facility (7:55 A.M.) Review of the facility's Investigation Report of Resident #101's fall on 09/26/11 revealed she was found on the floor with her PSA sounding, the bed was in the low position and the resident was complaining of left hip pain. She was sent to the emergency room and had a [MEDICAL CONDITION]. The summary of critical information obtained during the investigation revealed LPN #22 did not call for a Registered Nurse (RN) assessment and moved the resident back to bed after her fall (following her assessment of no apparent injuries). The summary verified the resident did not go to the hospital until 8:35 A.M. The summary verified the resident reported pain to the LPN, however, no pain medication was administered. Review of an additional Narrative Summary of Incident, dated 09/30/11, revealed LPN #22 indicated Resident #101 did not complain of pain on 09/26/11 "except on movement" LPN #22 did acknowledge she was aware of the resident complaining of pain. The summary further revealed during the change of nursing shift at 7:00 A.M. the oncoming nurse visualized the resident and saw the external rotation of her leg. The on-coming nurse also acknowledged the resident was in pain. On 10/31/11 at 3:20 P.M., interview was conducted with the Director of Nursing (DON) and the Administrator. The DON stated she observed the resident on 09/26/11 at 7:15 A.M. and she was quiet in her bed until the DON attempted to elevate the head of her bed. She stated with about two cranks of the bed the resident began to yell out in pain. Review of the facility's Pain Process Flowchart (undated) revealed a resident was to be assessed for pain, a plan of care was to be in place, the plan was to be implemented upon evaluation of pain and evaluated for the outcome. The Administrator verified no pain medication was administered to Resident #101 and the facility substantiated neglect and educated and disciplined LPN #22 Interview with facility's Clinical Services Consultant Registered Nurse #5 on 11/01/11 at 8:45 A.M. verified facility LPN #22 failed to follow the Pain Process Flowchart on 09/26/11 and provide adequate assessment and implementation of the plan of care when she failed to administer pain medication to Resident #101 after her fall. Further interview revealed all nurses were inserviced to include unplanned discharge, emergency management, post fall evaluations and critical components to evaluate pain on 09/30/11. RN #5 verified the facility substantiated neglect related to the lack of evaluation and administration of pain medication to Resident #110 on 09/26/11 and the investigation was submitted as a Self Reported Incident to the State. This citation substantiates Complaint Control Number OH 853.

Based on staff interview, medical record review, personnel files review, in-service review, Self-Reported Incident (SRI) review, and observation, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents. This affected one of six sampled residents (Resident #67). Actual harm occurred to Resident #67 when a State-tested nurse aide (STNA) failed to use a gait belt during transfer and ambulation of this resident. Resident #67 fell and sustained a subdural hematoma and a fractured shoulder. Findings include: Resident #67's closed medical record review revealed this resident was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired short-term memory, moderately impaired decision-making, required extensive assistance from one staff member for transfers and limited assistance of one staff member to walk in his room or corridor. The resident had no falls in past 0 to 180 days. Review of the Resident Assessment Protocol dated 12/10/09 revealed the resident was at risk for falls. Review of the plan of care dated 02/25/10 revealed the resident was at risk for falls due to psychotropic medication use, impaired balance/poor coordination, unsteady gait, and recent falls. The listed interventions included but were not limited to: ambulate with a walker and use a gait belt for transfer. Review of the Resident Information Sheet (RIS) (updated 09/10/10) revealed Resident #67 required one person assistance for ambulation and transfer. Review of Resident #67's nurses' notes dated 09/12/10 at 3:15 P.M. revealed this resident was in the main bathroom on Arcadia Unit when the resident fell on his right side from a standing position. This note revealed the resident was guarding his right shoulder, and he would not extend it in any direction. Also noted were the following wounds: 1 centimeter (cm) by 0.25 cm by 1 cm laceration to his forehead above the right eye that was bleeding, and a 3 cm by 1 cm by 0.25 cm laceration to his left elbow. The resident was sent to the local emergency room for treatment. The nurse's note revealed at 5:40 P.M. the resident was sent to a large metropolitan hospital emergency room due to a fractured right shoulder and subdural hematoma. This resident returned to the facility on [DATE]. Review of the SRI for Resident #67 (dated 09/13/10) revealed on 09/12/10 at 3:00 P.M., Resident #67 was assisted to the restroom, lost his balance, and fell . The resident sustained [REDACTED]. Interview of the STNA #10 on 09/22/10 at 12:50 P.M. revealed she was the STNA who had assisted Resident #67 on 09/12/10. STNA #10 stated she got the resident up and did not use a gait belt for him and instructed him to go to the bathroom. STNA #10 stated Resident #67 was walking behind her as she was pushing another resident in a wheel chair down the hall. STNA #10 revealed once she and Resident #67 were in the bathroom, she was at the sink and the resident got his feet tangled and she was unable to reach this resident before he fell . Further interview of STNA #10 revealed she had not used the gait belt on Resident #67 because the use of a personal alarm for him was discontinued. STNA #10 further stated she thought once the alarms were discontinued she did not think she needed to use the gait belt. STNA #10 also stated she did not have the RIS with her. Review of STNA #10's personnel file revealed she had attended a facility sponsored in-service on 09/08/10 regarding Body Mechanics Awareness. This in-service addressed the use of a gait belt for every transfer. Interview of Physical Therapist #11 on 09/23/10 at 12:00 P.M. revealed she was the primary instructor for Body Mechanics Awareness in-service. This staff member stated she instructed the STNAs if they needed to be present for a transfer they needed to use a gait belt. This staff further revealed if a resident was a one person assist for transfer and ambulation then staff were to use a gait belt for that resident. This certification deficiency substantiates Complaint Number OH 462.