Every finding on record at Crawford Manor Healthcare Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, self-reported incident (SRI) review, review of a witness statement, and staff interview, the facility failed to ensure a resident was provided adequate assistance with activities of daily living (ADLs) to prevent an avoidable fall with injury. Actual harm occurred to Resident #28 on 03/19/26 when a nurse aide assisted the resident with bed mobility without another staff member present and Resident #28 fell to the floor. Resident #28 had care plan interventions and therapy recommendations in place at the time of the fall indicating two staff members were to assist the resident with ADLs and bed mobility. Resident #28 subsequently sustained an abrasion on the right shin and a laceration on the left foot requiring hospitalization and six sutures to close. This affected one (Resident #28) of three residents reviewed for accidents. The census was 35. Findings Include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, dementia, muscle weakness, impaired mobility, and a history of falls. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was severely cognitively impaired and required extensive assistance with ADLs and mobility.Review of the comprehensive care plan dated 06/19/24 revealed Resident #28 required two-person assistance for bed mobility, transfers, toileting, and bathing, and required the use of a mechanical lift for transfers. Further review of the care plan revealed staff were instructed to assist the resident with all ADLs due to impaired mobility, hemiplegia, and cognitive impairment.Review of a nursing progress note dated 03/20/26 at 1:47 A.M., regarding a fall on 03/19/26, revealed the nurse was called to Resident #28's room by a nurse aide and found the resident laying on the floor between the bed and the wall. Resident #28 was assessed to be alert, oriented, and denied pain. The nurse and nurse aide assisted Resident #28 to bed using a mechanical (Hoyer) lift and an abrasion was noted to the resident's right shin. Review of a subsequent nursing progress note dated 03/20/26 at 8:03 A.M. revealed Resident #28 was assessed with two wounds including an abrasion to the right shin and a laceration to the left foot.Review of a therapy note dated 03/20/26 at 2:41 P.M. revealed Resident #28 was screened by therapy as a result of a fall on 03/19/26. The resident was noted with increased left foot pain following the fall and nursing was aware. Per the electronic medical record (EMR) and Resident #28's report, the resident was receiving care with a single nurse aide when a fall out of bed occurred. Therapy recommendation and the resident's current plan of care in place at the time of the fall indicated Resident #28 needed two-person assistance for all ADLs and all bed mobility tasks. Therapy deferred the fall to nursing and the physician with no new recommendations at that time. Review of a nursing progress note dated 03/20/26 at 5:23 P.M. revealed, upon nursing assessment, the laceration to Resident #28's left foot appeared to require more treatment than what could be provided at the facility, so the resident was transferred to the hospital for evaluation and treatment.Review of a nursing progress note dated 03/21/26 at 8:56 A.M. revealed Resident #28 returned to the facility at 8:35 A.M. following a fall with injury. Resident #28 received six sutures to the wound on his left foot to be removed in seven to 10 days and Neosporin to be applied to the wound.Review of a SRI dated 03/20/26 at 1:36 P.M. revealed, on 03/20/26 during morning meeting, the Administrator was made aware of a situation of possible neglect with a nurse aide and Resident #28 during the night of 03/19/26. Further review revealed Certified Nurse Aide (CNA) #454 repositioned Resident #28 in bed with no other staff assistance, and the resident was rolled from bed onto the floor where he sustained injuries to his right shin and left foot. CNA #454 had just completed facility orientation the day prior, and upon arrival at the facility on 03/19/26, discovered her electronic credentials were missing and was inexperienced in using the facility electronic medical record. This resulted in CNA #454 not having access to resident-specific care needs from the medical record prior to providing care. Review of CNA #454's witness statement dated 03/20/26 revealed, on 03/19/26, she was getting Resident #28 ready for bed and completing his ADLs. CNA #454 documented she undressed the resident to clean him up and noticed Resident #28 needed new bed sheets, so she went to get clean sheets. Upon returning to the room, CNA #454 documented she moved the resident's bed close to the wall, locked the bed wheels, and got the bed sheets and washcloths to clean the resident. CNA #454 documented she rolled Resident #28 over to begin cleaning him and in the process the resident rolled over the side of the bed. CNA #454 checked on the resident and then went to get a nurse. CNA #454 and the nurse assisted Resident #28 from the floor to his bed with a Hoyer lift. After the resident was in bed, the nurse informed CNA #454 that any resident who required a Hoyer lift should always be assisted with two staff members for everything. Interview with the Administrator on 04/21/26 at 2:30 P.M. verified CNA #454 performed bed mobility for Resident #28 without assistance from another staff member on 03/19/26 which resulted in the resident falling from bed necessitating the resident to be sent to the hospital for injuries sustained from the fall which required sutures. The Administrator confirmed CNA #454 did not follow Resident #28's care plan intervention and therapy recommendation in place at the time of the fall for two staff members to perform all ADLs and bed mobility for the resident. The deficiency was corrected on 03/20/26 after the facility implemented the following corrective actions: - On 03/19/26 at 9:50 P.M., the on-call medical doctor was notified of the incident involving Resident #28. A head-to-toe assessment was completed, and injuries were noted to the resident's right shin and left foot. - On 03/19/26 at 9:45 P.M., a message was left for Resident's #28's guardian for notification of the incident.- On 03/20/26 at approximately 9:30 A.M., the facility interdisciplinary team (IDT) reviewed the incident and identified Resident #28's plan of care and profile indicated he required two staff member assistance for bathing, toileting hygiene, and bed mobility at the time of the incident.- On 03/20/26, a statement was obtained from the CNA #454 who was performing care at the time of Resident #28's fall and was removed from the schedule pending the outcome of the investigation. CNA #454 reported she left her facility electronic medical records credentials at home and was unable to log into the system to see Resident #28's profile, so she was unaware Resident #28 required two staff assistance with bed mobility.- On 03/20/26 a SRI was filed for an alleged incident of neglect for staff not utilizing care planned level of assistance for Resident #28's bed mobility during care. CNA #454 was removed from the schedule pending the investigation.- On 03/20/26 at 2:30 P.M, an occupational therapy screen was completed, and no changes were recommended to Resident #28's plan of care.- On 03/20/26 at 3:00 P.M., the Administrator and the Director of Nursing (DON) updated Resident #28's guardian on the incident and the pending investigation.- On 03/20/26 at 4:00 P.M., the IDT reviewed Resident #28's plan of care and profile. An intervention was implemented for a bariatric bed and mattress.- On 03/20/26, the DON/Designee reviewed all residents that required two staff member assistance for bathing, toileting hygiene, and/or bed mobility care needs to ensure the assistance was reflected accurately on the residents' care plans and profiles. No concerns were noted.- On 03/20/26, the Administrator/Designee questioned all interviewable residents to ensure they had not felt they were neglected in any way, and they felt their care needs were being provided per their care plans. No concerns were identified. - On 03/20/26 the DON/Designee completed a head-to-toe assessment of all non-interviewable residents to assess for any indication of care not being performed per the resident's care plan. No concerns were noted with no identification of any new skin impairments or deviations from the residents' psychosocial baseline. - On 03/20/26, information technology (IT) support contact information was immediately posted at each nurse's station and by the time clock with instructions on how to obtain access, including the after-hours telephone number.- On 03/20/26, the DON/Designee educated all nursing staff related to the expectation of accessing the resident profile prior to providing care to each resident, how to access the profile, and how to identify the number of staff assistance required for ADL care and mobility needs on the profile. - On 03/20/26, the Administrator/Designee educated all staff on the abuse policy and procedure, with emphasis on what constitutes neglect with regards to staff providing care needs per residents' care plans.- On 03/20/26, a Quality Assurance and Performance Improvement (QAPI) meeting was held to address the incident with Resident #28.- Beginning on 03/20/26, the DON and/or Designee will complete an observation audit for three residents two times weekly for four weeks then monthly for two months to ensure residents who required two staff member assistance were being cared for appropriately per the plan of care and profile.- Beginning on 03/20/26, the DON and/or Designee will interview three clinical staff two times weekly for four weeks then monthly for two months to ensure that clinical staff have the credentials to be able to access the resident profile and can identify where to find the level of care needs on the resident profile.- Beginning on 03/20/26, the Administrator and/or Designee will interview three interviewable residents two times weekly for four weeks then monthly for two months for receipt of care needs and any unreported abuse allegations.- Beginning on 03/20/26, the DON and/or Designee will complete head-to-toe assessments on three non-interviewable weekly for four weeks then monthly for two months to ensure that there have been no new skin impairments or deviations from the residents' psychosocial baseline indicative of care not being performed per the care plan.This deficiency represents an incidental finding discovered during investigation of Complaint Number 2986375.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a self-reported incident (SRI), review of a witness statement, staff interview, and policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse. This affected one (Resident #21) of three residents reviewed for abuse. The facility census was 35.Findings Include:Review of the medical record for Resident #16 revealed the resident was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, hypertension, history of cerebral infarction, altered mental status, muscle weakness, history of falls, and adjustment disorder with mixed anxiety and depressed mood.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact and able to make needs known. Additional documentation revealed the resident had a history of inappropriate behaviors and the need for behavioral monitoring, supervision, and intervention to ensure the safety of others.Review of Resident #16's hospital paperwork dated 10/30/25 noted the resident was previously incarcerated multiple times and was recently, in July 2025, convicted of gross sexual imposition.Review of the medical record for Resident #21 revealed the resident was admitted on [DATE] with diagnoses including severe intellectual disabilities; muscle weakness; and localization-related (focal) (partial) symptomatic epilepsy syndromes with complex partial seizure, intractable, without status epilepticus.Review of the most recent MDS assessment dated [DATE] revealed Resident #21 revealed the resident was rarely or never understood and had severely impaired cognitive skills for daily decision making.Review of Resident #16's nursing progress note dated 04/11/26 at 1:29 P.M. revealed the resident was observed inappropriately touching a female resident (#21). It was reported Resident #16 was pulling on Resident #21's brief and touched her private area. Both residents were immediately separated. A nurse spoke to Resident #16 to inform him of what was considered inappropriate touching and if the resident understood the situation. Resident #16 verbalized he was aware he was touching someone's private area and began saying sexually inappropriate and explicit things to the nurse. All appropriate parties were notified.Review of Resident #21's nursing progress note dated 04/11/26 with late entry at 3:57 P.M. revealed a nurse was notified by a nurse aide that a male resident (#16) was observed in the hallway engaged in sexually inappropriate behavior, including inappropriate touching, toward Resident #21. The residents were immediately separated and Resident #21 was assessed with no bruising, redness, bleeding, or signs of trauma. Resident #21 voiced no complaints of pain or discomfort and all appropriate parties were notified.Review of a self-reported incident dated 04/11/26 at 3:14 P.M. revealed Resident #16 was observed to be wheeling past Resident #21 who was seated in a wheelchair in the hallway. Resident #16 was observed to pull at the elastic waistband of Resident #21's pants and brief with one hand and placed his other hand near Resident #21's groin area. Staff immediately intervened and removed Resident #16 from the situation and placed the resident on one-on-one observation. Resident #16 was assessed and determined to have no signs or symptoms of injury and the resident remained at her psychosocial baseline. Through investigation the facility verified the allegation of sexual abuse between Resident #16 and Resident #21.Review of a written statement by Certified Nurse Aide (CNA) #201 dated 04/11/26 revealed when he was exiting the elevator he observed in the hallway Resident #16 pulling Resident #21's pants and brief out toward him and placed his hand inside Resident #16's brief and touched her private area. CNA #201 approached the two residents and Resident #16 removed his hands from Resident #21's pants. Resident #16 was removed from the floor and the nurse was notified of what happened.Interview with the Administrator and the Director of Nursing (DON) on 04/21/26 at 11:00 A.M. verified Resident #16 was observed pulling at Resident #21's pants and brief then inappropriately touching her private area. The Administrator and the DON confirmed staff immediately intervened to separate the two residents and Resident #16 was placed on a one-on-one observation. The Administrator and the DON stated an investigation was completed into the situation and the facility confirmed an allegation of resident-to-resident sexual abuse involving Resident #16 and Resident #21.Review of the facility abuse prevention policy, dated 08/25/25, revealed the facility defined sexual abuse as non-consensual sexual contact of any type and required staff to immediately report, investigate, and implement interventions to protect residents from abuse. The policy further required the facility to assess residents with behaviors that may lead to abuse, implement appropriate supervision and interventions, and take immediate action to prevent recurrence.The deficiency was corrected on 04/15/26 when the facility implemented the following corrective actions:- On 04/11/26, at approximately 12:00 P.M., staff immediately identified an inappropriate interaction and separated Resident #16 and Resident #21, stopping the behavior.- On 04/11/26, Resident #16 was removed from the area, returned to his assigned unit, and one-on-one observation was initiated immediately to ensure safety of others.- On 04/11/26, staff notified nursing immediately and appropriate supervisory staff were alerted to the incident.- On 04/11/26, two licensed nurses completed an immediate head-to-toe assessment of Resident #21 with no skin alterations, injuries, or signs of trauma identified. Resident #21 demonstrated no psychosocial changes, including no distress, grimacing, resistance to care, or change from baseline mental status.- On 04/11/26, Resident #21 was unable to provide a reliable account of the incident due to baseline cognitive impairment.- On 04/11/26, Resident #16 was interviewed and acknowledged awareness of inappropriate touching, and was educated by nursing staff on appropriate boundaries and unacceptable behavior.- On 04/11/26, responsible parties and physicians were notified of the incident and assessment findings for Resident #16 and Resident #21. No immediate new medical orders were received at that time.- On 04/11/26, the incident was reported to the State Survey Agency.- On 04/11/26, local law enforcement was notified and responded to the facility, conducted staff interviews, and determined no evidence collection was necessary at that time. Linens were bagged per facility policy; however, law enforcement declined to take possession of materials.- On 04/11/26, a witness (Resident #18) reported observing Resident #16 pulling down the brief of Resident #21 and touching the resident's private area in the hallway.- On 04/11/26, staff interview corroborated that upon approach, Resident #16 had his hand inside Resident #21's brief in the groin area and removed his hand when confronted.- On 04/11/26, findings from resident and staff interviews were consistent and supported the occurrence of inappropriate contact.- On 04/11/26, the facility implemented systemic corrective actions, including enhanced supervision, staff education, behavioral management interventions, and ongoing monitoring to prevent recurrence.- On 04/11/26 at approximately 4:30 P.M., Resident #16 was transferred via emergency medical services (EMS) for emergency psychiatric evaluation due to sexually inappropriate behaviors.- On 04/11/26 at approximately 8:30 P.M., findings from law enforcement interviews were reviewed with the responsible party of Resident #21, resulting in the request for hospital evaluation.- On 04/11/26 at approximately 9:00 P.M., Resident #21 was transferred via EMS to the hospital per responsible party request for further evaluation.- On 04/11/26 at approximately 9:30 P.M., Resident #16 returned to the facility with no new orders and one-on-one observation was re-initiated.- On 04/11/26, all interviewable residents were interviewed to determine if additional inappropriate contact or safety concerns existed. No concerns were identified.- On 04/11/26, all non-interviewable residents received head-to-toe assessments to identify any signs of abuse or injury. No concerns were identified.- On 04/11/26, the facility conducted a review of residents with similar behaviors to ensure appropriate interventions and supervision were in place. No concerns were identified.- On 04/11/26, all staff received abuse prevention education, including recognition of inappropriate sexual contact, reporting requirements, and intervention expectations.- On 04/11/26, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was completed with the interdisciplinary team (IDT), the Medical Director, and leadership to review the incident and interventions.- Beginning 04/11/26, weekly monitoring was initiated including interviews with five residents weekly for four (4) weeks and then monthly for two (2) months. Head-to-toe assessments of non-interviewable residents will occur weekly for 4 weeks and then monthly for 2 months with results monitored and reviewed through QAPI and revised as indicated. As of 04/23/26, no concerns were identified.- On 04/12/26 at approximately 2:00 A.M., Resident #21 returned to the facility with no new orders and continued to be monitored.- On 04/12/26, medication adjustments were initiated for Resident #16, including behavioral and psychotropic medications.- On 04/13/26, pharmacy medication review was completed for Resident #16 with no additional recommendations.- On 04/13/26, Resident #16 was evaluated via Telehealth by psychiatric services, and a new diagnosis of inappropriate sexual behavior was added with additional treatment planning.- On 04/13/26, Resident #21 was interviewed and reported feeling safe within the facility.- On 04/14/26, Resident #16 was re-evaluated via Telehealth psychiatric services and reported awareness of inappropriate behavior but inability to control impulses.- On 04/14/26, Resident #16 was again transferred via EMS for emergency psychiatric evaluation due to continued inappropriate behaviors.- On 04/14/26 at approximately 11:30 P.M., Resident #16 returned to the facility with no new relevant orders, and one-on-one observation was re-initiated and remained on-going. No concerns further incidents were identified.- On 04/15/26, Depo-Provera (drug used to control sexual behaviors) was received and administered to Resident #16 as part of behavior management.This deficiency represents non-compliance investigated under Complaint Number 2986375.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed medical record review, resident, family, and staff interviews, review of the National Weather Service forecast, and review of the facility Elopement Policy and Procedure, the facility failed to provide adequate supervision and intervention to prevent Resident #33, who had a history of wandering, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury, or death when Resident #33 was seen (by camera footage) on 12/04/24 at 6:47 P.M. leaving the facility on foot with his rollator walker. The resident was missing from the facility for approximately one hour and 45 minutes without staff knowledge. The resident's whereabouts remained unknown until 12/05/24 at 12:07 A.M. when Resident #33's nephew found the resident approximately five miles from the facility in the garage of the home in the community where he had previously resided. On 12/04/24 temperatures were between 21 degrees and 37 degrees Fahrenheit with a severe winter weather warning in effect. Upon being found by his nephew, the resident was taken to the hospital for examination, admitted (to the hospital) and did not return to the facility. This affected one resident (#33) of six residents reviewed for elopement. The facility identified seven residents (#1, #9, #12, #20, #24, #27, and #32) who were at risk for elopement. The facility census was 34. On 12/18/24 at 4:37 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 12/04/24 at 6:47 P.M. when the facility failed to provide adequate supervision and intervention to prevent Resident #33 from eloping from the facility. Resident #33 exited the facility through the front door. At the time of the incident, a staff member reported hearing the door alarm sound but turned it off without investigation as the staff member assumed the alarm was activated by a person who had just delivered a food order. The Immediate Jeopardy was removed on 12/05/24 and deficiency corrected on 12/09/24 when the facility implemented the following corrective actions: On 12/04/24 at 8:24 P.M. Resident #33 was noted to be missing by Licensed Practical Nurse (LPN) #237. A facility wide search of both the internal and external facility property and surrounding areas was initiated. The resident was located on 12/05/24 at 12:07 A.M. and did not return to the facility following the incident. On 12/04/24 at 8:24 P.M. LPN #237 notified the Director of Nursing (DON) that Resident #33 was missing. The LPN then notified the police. The DON notified the Administrator and Resident #33's family. On 12/04/24 at 8:30 P.M. the facility staff completed a head count and identified no other residents were missing. All other residents were accounted for in the facility. On 12/04/24 at 9:45 P.M. alarms on all doors were validated by the Regional Director of Clinical Services (RDCS) #245 for proper function and sound including annunciation to the second- floor nursing unit. No annunciator panel was found on the third-floor nursing unit. On 12/05/24 at 1:00 A.M. an Elopement Drill was conducted by the Administrator, the DON, and Assistant Director of Nursing (ADON) #240 and then conducted each shift for 72 hours by one of the following Leadership team members: the Administrator, the DON, LPN/ Minimum Data Set (MDS) #218, LPN/ Charge Nurse (CN) #237, or ADON #240 On 12/05/24 at 9:30 A.M. an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review plan / progress with the Medical Director. The meeting was attended by the Medical Director via phone, the Administrator, DON, ADON #240, Dietary Director #229, Activity Director #226, RDCS #245, and Scheduler/Medical Records #205. On 12/05/24 at 12:45 P.M. the Administrator conducted facility window checks to ensure all were secured with stop brackets to limit less than six-inch opening. No issues were identified. On 12/05/24 at 1:00 P.M. RDCS in conjunction with the Administrator validated the function of the outside exits, front door, back door (employee entrance) extending inspection beyond what the security camera observations that were completed, to include the third floor East stairwell door, third floor [NAME] stairwell door, second floor East stairwell door, second floor [NAME] stairwell door, first floor [NAME] exit door, therapy exit Door (end of hallway across from employee entrance). Each door was checked for local alarm sound when activated and the sound of the alarm was readily audible via the annunciator panel on the second floor. All functioned appropriately. The first-floor East exit door in the stairwell does alarm locally but was not alarming nor was it listed on the annunciator panel on the second floor. The first-floor [NAME] exit door in the stairwell does alarm locally but was not alarming on the annunciator panel on the second floor, where it is listed. A contracted company was contacted to obtain quote for connecting these exit doors with the annunciator panel on the second floor or other intervention. A door monitor was initiated. On 12/05/24 at 2:48 P.M. ADON #240 completed updated elopement observations for current residents, reviewed plan of care and updated as indicated for risk and interventions. On 12/05/24 at 3:00 P.M. the Administrator and ADON #240 completed the audit and update of the Elopement binders to reflect residents that are currently identified as risk for elopement (#1, #12, #20, #24, #27, #32, #34). On 12/05/24 the DON completed review of current residents Leave of Absence (LOA) orders, updated as indicated, reviewed plan of care and updated as indicated. On 12/05/24 DON and ADON #240 completed updated smoking observations for the current residents who smoked (#2, #7, #8, #10, #17, #18, #27, #32, #35, and #36), reviewed each resident's plan of care and updated as indicated. In addition, the facility posted lists on nursing units identifying supervised or independent smokers. On 12/05/24 at 4:40 P.M. the Administrator and DON completed staff education related to resident safety including elopement risk and interventions, and importance of alarm response and investigation. Staff who were not present at the facility were educated via phone. Newly hired staff would receive education as part of the orientation process. On 12/05/24 the Administrator completed the education of the Admissions Director related to the review of hospital paperwork prior to admission to identify special needs/safety concerns and communicate special needs with facility team. On 12/05/24 the Administrator and DON completed education of staff on what to do if a resident was stating they want to go home or leave the facility, or if they observe exit seeking behaviors. On 12/05/24 The Administrator and DON completed educating staff on how to identify resident smoking status if they had a resident state they were going outside to smoke. On 12/05/24 at 5:00 P.M. residents with a Brief Interview for Mental Status (BlMS) score 12 or above were educated that if they hear another resident making statements that they wanted to get out of the facility/[NAME] Manor they report to a staff member so that they could implement interventions for resident safety and determine if discharge planning was appropriate. The education was initiated by RDCS #245 and completed by LPN/Charge Nurse #207 43 and LPN/Charge Nurse #243 On 12/05/24 the Administrator contacted the contracted provider (Alta Protection Services) requesting service for the rear door staff entrance and front door due to the identified sensitivity related to the winds setting off the door alarms when no human activity taking place at the doors. Additionally requested a quote for the instillation of an annunciator panel on the third-floor nursing unit. Beginning 12/05/24 second floor staffing distribution, beginning night shift, would assign one team member to remain at the nursing station desk to be available to respond to door alarms. Nursing staff educated on this by the Director of Nursing and indication listed on the daily assignment sheet posting. On 12/09/24 the Administrator purchased audible monitors to be placed in the stairwell by first floor east and first-floor west outside exits, as it was determined that when the hallway door was closed the alarm sounding by the outside exit in the stairwell cannot be heard midway down the hall where the door monitor was located. Beginning 12/05/24 at 1:00 A.M. the Administrator, DON, or Designee would conduct an elopement drill on every shift for 72 hours beginning day shift, then weekly for four weeks, then monthly for two months. Results of the drills would be submitted to the QAPI Committee for further review and recommendations. Beginning 12/05/24 Administrator, DON, or Designee would conduct elopement/ door alarm drills five times per week on various shifts for four weeks then monthly for two months for validation of appropriate staff response to triggered alarms and to ensure that staff are fluent with the alarm response process. Results of the drills would be submitted to the QAPI Committee for further review and recommendation. Beginning 12/05/24 Admissions/ re-Admissions referral information would be reviewed by the Director of Nursing/Designee to ensure risks were identified and interventions implemented. The reviews would continue for four weeks then monthly for two months with the results submitted to the QAPI Committee for further review and recommendation. Beginning 12/05/24 Administrator or Designee would audit scheduled smoking breaks two times per day, five times per week for four weeks then monthly for two months to ensure that residents assessed to smoke with supervision are being supervised during smoke breaks. The results of the audits would be submitted to the QAPI Committee for further review and recommendation. Beginning 12/05/24 Administrator or Designee would interview three residents two times per week for four weeks then monthly for two months to determine if they have heard another resident making statements that they want to get out of the facility/[NAME] Manor and if it was reported to facility staff. The results of the interviews would be submitted to the QAPI Committee for further review and recommendation. Beginning 12/05/24 Administrator or Designee would interview three staff members two times per week for four weeks then monthly for two months related to what they would do in response to door alarms, residents saying they are going smoking and if a resident makes a statement they want to get out of the facility/[NAME] Manor. The results of the interviews would be submitted to the QAPI committee for further review and recommendation. Findings Include: Review of the closed medical record for Resident #33 revealed an admitted [DATE] with diagnosis including muscle weakness, other symbolic dysfunctions, encephalopathy, and abnormalities of gait and mobility. The resident was discharged on [DATE] and did not return to the facility. Review of a progress note dated 12/02/24 at 1:53 P.M. revealed Resident #33 arrived at the facility from the hospital with a past medical history of heart failure, hypertension and memory loss. The resident had his natural teeth, ambulated with a rollator and had a steady gait. Review of the physician's orders dated 12/02/24 revealed Resident #33 was not to go on leave of absence (LOA) without supervision. Review of the Admission assessment dated [DATE] at 2:20 P.M. revealed Resident #33 was attentive, oriented, generally normal to person, place and time, with an intact memory. Review of the Functional Abilities assessment dated [DATE] at 4:43 P.M. revealed Resident #33 required supervision or touching assistance for sit to stand, transfers, and to walk 150 feet. Partial to moderate assistance was needed to go up or down 12 stairs. Review of the baseline care plan dated 12/02/24 revealed Resident #33 would be monitored to minimize risk of wandering and/or elopement and interventions put in place as needed. There were no additional interventions listed. Review of the Elopement assessment dated [DATE] at 9:43 AM revealed Resident #33 was not identified as an elopement risk. Review of the Admission Minimum Data Set (MDS) 3.0 assessment revealed it had not been completed and was in progress. Review of a progress note dated 12/04/24 at 8:30 P.M. authored by Licensed Practical Nurse (LPN) #243 revealed LPN #243 went to obtain vital signs for the resident, he was noted to not be in his room or bathroom, staff looked on the unit and within the facility and it was determined that he was not in the facility. Staff searched the surrounding parking lot area. The Director of Nursing (DON) and Administrator were notified. Resident #33's niece was called and asked if they had taken the resident out, and notified the resident was not at the facility. The Cleveland Police were contacted and informed. The resident's physician was notified. Review of the facility LOA sign-out book revealed Resident #33 did not sign-out when he left the faciity on [DATE]. Review of the National Weather Service forecast at www.weather.gov revealed the weather in the Cleveland area on 12/04/24 included a high temperature of 37 degrees Fahrenheit (F) and low of 21 degrees F. Review of the Self-Reported Incident and related facility investigation, dated 12/04/24, revealed Resident #33 was admitted on [DATE] to a room on the third floor. Per the hospital paperwork he had a history of wandering which was not reflected in the initial elopement observation. Following dinner Resident #33 got on the elevator with a Certified Nursing Assistant (CNA) #217 and they had a normal conversation riding down the elevator. Resident #33 made a statement that he was going out to smoke. CNA #217 primarily worked on the second floor and had not met Resident #33 given he was only at the facility for two days and was unaware that he did not smoke. The CNA got off the elevator on the second floor and Resident #33 remained on the elevator which was going down to the first floor. When the night shift nurse went to obtain vital signs for Resident #33 at 8:24 P.M. it was determined he was not in the room. Facility staff immediately began to search, internally, externally on property by foot and in personal cars searching the surrounding area. Facility administration and regional staff were notified and responded to the facility for support. The Administrator pulled the security camera footage, and determined the resident exited the front door with his rollator at 6:47 P.M. wearing plaid flannel pajama pants, a zip up sweatshirt and a ball cap. He began walking down the street, sat on his rollator at the corner for approximately two minutes then continued walking down the street and out of camera view. Efforts to find the resident continued through the night until the resident was located by his nephew at the resident's own home where he previously resided, in the garage with the garage door closed 12:07 A.M. on 12/05/24. The family alleged that the resident was jumped while he was out indicating that he had a broken nose, all his teeth knocked out and his face all cut up. The recommendation to transport him to the emergency room (ER) for evaluation was made to the family by facility staff. The nephew drove back to the facility with the resident to pick up the resident's niece to go to the emergency room . When facility staff requested to see the resident, the family refused and made threats towards the staff making a statement 38 and hot which was interpreted as a reference to a gun. So, the facility staff was unable to determine if the resident had any injuries and/or the extent of any injuries. Resident #33's niece was given a copy of the face sheet and physician orders to take to the emergency room , and the Director of Nursing called report into the hospital emergency room (ER) related to the situation and family transporting to them. The following morning 12/05/24 at 7:30 A.M. the Director of Nursing called the hospital for a status update on the resident and was told that he was admitted with a diagnosis of dementia, x-rays were negative, there were no fractures identified, and a computed tomography (CT) scan was completed with no findings. The facility was unable to validate if any serious injury resulted, but the resident was not safe when he exited the facility due to the cold, windy and rainy weather on that day. Further review of the facility investigation revealed that based on review of the camera footage, there was a Door Dash delivery car visible on the camera footage, approximately 10 minutes prior to the resident exiting the facility. The Door Dash driver came up the elevator and delivered the food to a resident on the second floor, then left the facility. A staff member that was on the second floor at the time of the food delivery returned to the first floor approximately five to 10 minutes following the door dash driver. When they got to the first floor they heard the front entrance alarm sounding. The staff member reset the front door alarm but did not investigate the reason for it sounding. The facility substantiated that resident neglect did occur. Review of the witness statement dated 12/04/24 and authored by LPN #237 revealed she identified Resident #33 as missing around 7:30 P.M. to 7:45 P.M., initiated the search, called code, contacted the DON and called 911 emergency services. Review of the witness statement dated 12/05/24 and authored by CNA #217 revealed on 12/04/24 she got on the elevator on the third floor with Resident #33. She had a short conversation with him about going out to smoke a cigarette. The elevator opened on the second floor and the CNA got out. She did not remember hearing an alarm sound after that. Interview on 12/17/24 at 11:21 A.M. with the Administrator, DON and RDCS #245 revealed Resident #33 didn't have a designated power of attorney (POA) or guardian. There had not been an evaluation by a Nurse Practitioner (NP) or physician because Resident #33 was only at the facility for a little over 48 hours. The administrative staff revealed the resident's hospital admission record showed history of wandering but stated this was missed on the elopement assessment. Corrective action and education were done with Admission Director, and the facility was currently auditing all admissions for any risk. The facility currently had a staff member assigned as a door monitor 24 hours a day because two exit doors were not connected to the enunciator panel. The facility believed Resident #33's ability to elope was partially caused when there was a food delivery to the second floor, and the delivery person was known to exit. Staff turned off the alarm without investigation assuming it had been the food delivery person. After reviewing the Self-Reported Incident (SRI) the Administrator, DON and RDCS #245 verified the elopement had occurred, they had substantiated the incident had occurred and had developed a plan to prevent it happening again. An interview on 12/17/24 at 11:39 A.M. with LPN/MDS #218 revealed she was on the second floor on 12/04/24 when a Door Dash delivery arrived. When she came back down, the (door) alarm was ringing. LPN #218 stated she knew Door Dash had just left so she turned off the alarm. The LPN/MDS nurse revealed if the release bar (on the door) was held it alarmed and after 15 seconds, it released. She stated a lot of delivery people didn't want to go back up to the second floor and look for someone to let them out. LPN/MDS #218's office was downstairs so some days it happened a lot. Currently the facility had a staff member serving as a door monitor. They monitored if a resident was trying to leave and helped visitors exit. Staff were now expected to investigate, go outside to do a quick check of the perimeter, and call upstairs for staff to do a headcount. An interview on 12/18/24 at 10:00 A.M. with Resident #33's niece revealed the family was unaware the resident had cognitive issues until 11/2024 when he was taken to the hospital after he was found wandering a long way from his house in the middle of the night. The family of Resident #33 decided he wasn't safe living alone, so they moved him into the facility on [DATE]. On 12/04/24 the resident's niece received a call from the facility at 8:34 P.M. asking if she had taken the resident out, as he was not at the facility. She stated she called her mom and brother and then went to the facility. She stated the family searched the facility along with the staff. Resident #33's nephew went out to search the area. There was a severe Winter weather warning going on for Cleveland. The niece watched the video surveillance with the administrator. Resident #33 exited the front door of the facility at 6:47 P.M. without a jacket or gloves. He walked across the street, sat down on his rollator for a couple minutes and then went on down the street and out of sight. A little after midnight the nephew found Resident #33 at his previous address in the garage. The resident's niece stated the resident had been assaulted, his teeth were knocked out and knuckles scraped. The niece stated her brother got Resident #33 in his car, came back to the facility to pick her up at the facility and they took him to the hospital ER. The resident's niece stated the physician said the resident's injuries were consistent with an assault. The niece stated the admission person was aware of her uncle's dementia and stated the facility where the resident had been admitted to was a locked facility, residents were to be monitored and if an alarm went off staff would check. Attempts to obtain the hospital records during the complaint investigation for Resident #33 related to this incident were unsuccessful. On 12/18/24 at 3:39 P.M. interview with LPN #243 revealed she was in the facility on 12/04/24, the day Resident #33 eloped but worked on the second floor. LPN #243 remembered the door alarm went off that evening but then stated it was silenced. After LPN #243 punched out and left the facility another employee called a little after 7:30 P.M. and told her they couldn't find Resident #33. She started driving around the area looking for the resident. Other staff were doing the same. Interview on 12/18/24 at 4:30 P.M. with CNA #217 revealed on 12/04/24 she was assisting staff on the third floor and got on the elevator to go back to her own assignment on the second floor. Resident #33 was already on the elevator when she got on. The CNA stated they (she and the resident) made small talk, and the resident mentioned he was going out to smoke. CNA #217 got off the elevator at the second floor and Resident #33 went down to first. It was the first time the CNA had met Resident #33. The CNA stated she wasn't even sure he was one of the facility residents or a visitor. Interview on 12/19/24 at 10:56 A.M. with LPN #237 revealed on 12/04/24 at around 7:35 P.M. the LPN went to obtain Resident #33's vital signs and then realized the resident was missing. She stated she checked all the rooms on the third floor and then called a code. All staff started looking around the facility for the resident. When he was not found in the building, she stated she called the DON and 911. Review of the facility Elopement Unauthorized Absence Policy dated 08/02/24 revealed the purpose of the policy was to identify a resident's risk for elopement, prevent a resident from exiting the facility without the knowledge of the staff and to delineate the reporting process if an elopement occurs. This deficiency represents non-compliance investigated under Control Number OH00160618.

Based on staff interview, medical record review, review of facility investigations, and review of the facility policy, the facility failed to ensure a resident was free from verbal abuse. This affected one (Resident #35) of three residents reviewed for abuse. The facility census was 33. Findings include: Record review for Resident #35 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included unspecified fracture of the left femur, unspecified fracture of lower end of left ulna, person injured in unspecified motor vehicle accident, bipolar disorder, generalized anxiety disorder, pain in the leg and muscle weakness. Record review of the Comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was cognitively intact. Resident #35 received scheduled and as needed pain medications. Record review of the care plan dated 07/26/24 revealed Resident #35 had potential for pain. Resident was able to verbalize pain. Potential for pain was related to the fracture of the left femur and left ulna. Interventions included administering pharmacological interventions as ordered by the physician and monitor effectiveness. Record review of Resident #35's progress notes revealed there was no progress note for 09/28/24. Review of the progress note for Resident #35 dated 10/01/24 at 10:50 A.M. completed by Mobile Director of Nursing (DON) #246 revealed Interdisciplinary Team (IDT) met and reviewed incident related to alleged verbal abuse. Investigation initiated. Resident declined to be seen by psych services. Resident has a history of making false accusations and being manipulative. Facility will continue to provide a safe environment for resident to reside in. Record review of the Facility Reported Incident (FRI) dated 09/30/24 revealed on 09/30/24, Resident #35 reported to management that she was yelled at and cursed at by Licensed Practical Nurse (LPN) #242. LPN #242 was suspended immediately pending investigation. Statements were gathered from LPN #242 and Resident #35 regarding the incident. Staff and resident interviews were conducted with no negative findings. Based on investigation, the incident was unsubstantiated. When Resident #35 was interviewed, she could not remember what exact day the alleged incident happened, but confirmed it was on the weekend. Resident #35 stated she requested pain medication from LPN #242 but did not receive it. Instead, she received what she believed to be a melatonin pill. Resident #35 says she approached the nurse and was met with attitude and told that she already gave her the pain pill. Resident #35 then proceeded back to her room and said she did not ask again. While in her room, Resident #35 claimed LPN #242 barged in and started yelling and cursing at Resident #35. Resident #35 claimed she was not physically hurt but she was startled by the LPN #242. When LPN #242 was interviewed, she explained she did give Resident #35 her pain medication. LPN #242 explained Resident #35 found her while she was on break and requested her medication. LPN #242 informed her that she already gave her the medication. LPN #242 explained how she has always been kind to Resident #35 and tried helping her. LPN #242 claimed she did not yell or curse at Resident #35 and feels as though Resident #35 is trying to get her in trouble for some sort of reason. Interview on 10/29/24 at 3:11 P.M. with State tested Nurse Aide (STNA) #218 confirmed she worked on 09/28/24 beginning at 7:00 A.M. STNA #218 revealed when she came in at 7:00 A.M., she heard Resident #35 swear and say LPN #242 did not give her medication. Resident #35 returned to her room. LPN #242 walked down the hall swearing loudly and went into Resident #35's room. Both LPN #242 and Resident #35 were cursing and yelling at each other. They both left Resident #35's room and went to the medication cart in the hall, both yelling and swearing at each other. STNA #218 confirmed LPN #242 called Resident #35 multiple degrading names. STNA #218 revealed LPN #201 calmed LPN #242 down. STNA #218 confirmed she was never interviewed about the incident. Phone interview on 10/30/24 at 5:42 P.M. with LPN #201 revealed on 09/28/24, it was the beginning of her shift and the end of LPN #242's shift. LPN #201 revealed Resident #35 made an allegation LPN #242 stole her narcotic. Resident #35 returned to her room and went back to bed. LPN #242 was upset and began cursing and swearing, went to Resident #35's room while cursing down the hall and approached Resident #35 while she was in her bed. LPN #201 revealed she heard LPN #242 yelling at Resident #35 loudly calling her a crack-head and a bitch repeatedly repeating, How dare you, all I do for you, then continuing with calling the resident names. Resident #35 got out of bed and went in the hall. LPN #242 followed her to the hall and continued yelling loudly and swearing at Resident #35. The cursing and yelling went back and forth between Resident #35 and LPN #242. LPN #201 revealed she tried to intervene and calm down LPN #242. LPN #242 continued yelling, I don't give a (explicit language). LPN #201 revealed Resident #35 appeared upset and distraught. LPN #242 eventually left the building. LPN #201 revealed Resident #35 told her she was sad and scared, she was woke up to a nurse standing over her yelling and screaming. Resident #35 then left on a leave of absence. LPN #201 revealed she reported the incident to the previous Mobile DON #246. Review of the facility policy titled, Ohio Resident Abuse Policy, revised 07/11/24 revealed this facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of residents property by anyone. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. This deficiency represents non-compliance investigated under Complaint Number OH00158631.

Based on staff interview, medical record review, review of facility investigations, and review of the facility policy, the facility failed to thoroughly investigate an allegation of verbal abuse. This affected one (Resident #35) of four residents reviewed for abuse. The facility census was 33. Findings include: Record review for Resident #35 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included unspecified fracture of the left femur, unspecified fracture of lower end of left ulna, person injured in unspecified motor vehicle accident, bipolar disorder, generalized anxiety disorder, pain in the leg and muscle weakness. Record review of the Comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was cognitively intact. Record review of Resident #35's progress note revealed there was no progress note for 09/28/24. Review of the progress note for Resident #35 dated 10/01/24 at 10:50 A.M. completed by Mobile DON #246 revealed Interdisciplinary Team (IDT) met and reviewed an incident related to alleged verbal abuse. Investigation initiated. Resident declined to be seen by psych services. Resident has a history of making false accusations and being manipulative. Facility will continue to provide a safe environment for resident to reside in. Record review of the Facility Reported Incident (FRI) dated 09/30/24 revealed on 09/30/24, Resident #35 reported to management that she was yelled at and cursed at by Licensed Practical Nurse (LPN) #242. LPN #242 was suspended immediately pending investigation. Statements were gathered from LPN #242 and Resident #35 regarding the incident. Staff and resident interviews were conducted with no negative findings. Based on investigation, the incident was unsubstantiated. When Resident #35 was interviewed, she could not remember what exact day the alleged incident happened, but confirmed it was on the weekend. Resident #35 stated she requested pain medication from LPN #242 but did not receive it. Instead, she received what she believed to be a melatonin pill. Resident #35 says she approached the nurse and was met with attitude and told that she already gave her the pain pill. Resident #35 then proceeded back to her room and said she did not ask again. While in her room, Resident #35 claimed LPN #242 barged in and started yelling and cursing at Resident #35. Resident #35 claimed she was not physically hurt but she was startled by the LPN #242. When LPN #242 was interviewed, she explained she did give Resident #35 her pain medication. LPN #242 explained Resident #35 found her while she was on break and requested her medication. LPN #242 informed her that she already gave her the medication. LPN #242 explained how she has always been kind to Resident #35 and tried helping her. LPN #242 claimed she did not yell or curse at Resident #35 and feels as though Resident #35 is trying to get her in trouble for some sort of reason. Record review of the daily staff schedule for 09/27/24 7:00 P.M. to 09/28/24 7:00 A.M. revealed the following staff worked: LPNs #242 and #239 and State tested Nurse Aides (STNAs) #238, #243, and #209. Record review of the daily staff schedule for 09/28/24 7:00 A.M. to 7:00 P.M. revealed the following staff worked: LPNs #201 and #244 and STNAs #231, #218, and #236. Review of the facility file/investigation revealed multiple staff interviews were located in the file revealing no concerns related to the allegations. Review of the staff interviews revealed there were no interviews from any staff who worked on 09/27/24 7:00 P.M. to 7:00 A.M. shift (except LPN #242) or 09/28/24 7:00 A.M. to 7:00 P.M. shift. Staff interviews not present in the investigation file included LPNs #239, #201, and #244 and STNAs #238, #243, #209, #231, #218, or #236. Interview on 10/29/24 at 3:33 P.M. with the Administrator and Regional Director of Clinical Services (RDCS) #245 revealed the Administrator and Previous Mobile DON #245 completed the investigation regarding Resident #35 and LPN #242 on 09/30/24. The Administrator revealed Mobile DON #245 was the Acting DON at the time of the investigation. The Administrator and RDCS #245 confirmed there were no interviews in the investigation file for any of the staff when the alleged incident occurred except for LPN #242. The Administrator did not respond as to why none of the staff were interviewed that may have been present during the alleged incident. RDCS #245 confirmed the staff that worked during the time the alleged incident occurred was not interviewed and confirmed only staff that did not work during the alleged incident was interviewed. Interview on 10/29/24 at 3:11 P.M. with State tested Nurse Aide (STNA) #218 confirmed she worked on 09/28/24 beginning at 7:00 A.M. STNA #218 revealed when she came in at 7:00 A.M., she heard Resident #35 swear and say LPN #242 did not give her medication. Resident #35 returned to her room. LPN #242 walked down the hall swearing loudly and went into Resident #35's room. Both LPN #242 and Resident #35 were cursing and yelling at each other. They both left Resident #35's room and went to the medication cart in the hall, both yelling and swearing at each other. STNA #218 confirmed LPN #242 called Resident #35 multiple degrading names. STNA #218 revealed LPN #201 calmed LPN #242 down. STNA #218 confirmed she was never interviewed about the incident. Phone interview on 10/30/24 at 5:42 P.M. with LPN #201 revealed on 09/28/24, it was the beginning of her shift and the end of LPN #242's shift. LPN #201 revealed Resident #35 made an allegation LPN #242 stole her narcotic. Resident #35 returned to her room and went back to bed. LPN #242 was upset and began cursing and swearing, went to Resident #35's room while cursing down the hall and approached Resident #35 while she was in her bed. LPN #201 revealed she heard LPN #242 yelling at Resident #35 loudly calling her a crack-head and a bitch repeatedly repeating, How dare you, all I do for you, then continuing with calling the resident names. Resident #35 got out of bed and went in the hall. LPN #242 followed her to the hall and continued yelling loudly and swearing at Resident #35. The cursing and yelling went back and forth between Resident #35 and LPN #242. LPN #201 revealed she tried to intervene and calm down LPN #242. LPN #242 continued yelling, I don't give a (explicit language). LPN #201 revealed Resident #35 appeared upset and distraught. LPN #242 eventually left the building. LPN #201 revealed Resident #35 told her she was sad and scared, she was woke up to a nurse standing over her yelling and screaming. Resident #35 then left on a leave of absence. LPN #201 revealed she reported the incident to the previous Mobile DON #246. Review of the facility policy titled, Ohio Resident Abuse Policy, revised 07/11/24 included once the Administrator and the DOH are notified, an investigation of the allegation or suspicion will be conducted. The investigation protocol included interviewing the resident, the accused, and all witnesses. Witnesses generally, include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident and employees who worked closely with the accused employee and or the alleged victim the day of the incident. This deficiency was an incidental finding found during the complaint investigation.

Based on medical record review, observation, staff interview, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had two medication errors of 31 opportunities for an error rate of 6.45%. This affected one (Residents #32) of four residents reviewed for medication administration. The facility census was 33 residents. Findings include: Record review for Resident #32 revealed an admitted [DATE]. Diagnoses included chronic idiopathic constipation and centrilobular emphysema. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively intact. Resident #32 required set up or clean up assist with eating, substantial/maximum assist with personal hygiene and dressing. Resident #32 used a wheelchair for mobility. Resident #32 had chronic lung disease. Record review of the care plan for Resident #32 edited 10/11/24 revealed Resident #32 had emphysema. Interventions included to provide nebulizers. Record review of the physician orders for Resident #32 included sennosides-docusate sodium tablet, 8.6-50 milligrams (mg), one tablet twice a day 8:00 A.M. and 4:00 P.M. for constipation dated 10/25/24, and arformoterol solution for nebulization: 15 micrograms (mcg)/two milliliters (ml), give two ml inhalation every 12 hours 9:00 A.M. and 9:00 P.M. for centrilobular emphysema. Observation on 10/29/24 at 9:30 A.M. of medication administration for Resident #32 revealed Licensed Practical Nurse (LPN) #241 confirmed Resident #32's sennosides-docusate sodium tablet, 8.6-50 mg was unavailable for the A.M. administration. LPN #241 also revealed arformoterol solution for nebulization was not stored appropriately and was also unavailable for the A.M. administration. Observation on 10/29/24 at 1:35 P.M. of medication administration for Resident #32 revealed LPN #241 revealed she found the sennosides-docusate sodium tablet for Resident #32 that was due in the A.M. Observation revealed LPN #32 administered geri-kot 8.6 milligrams (mg) to Resident #32. Interview on 10/29/24 at 1:37 P.M. with LPN #241 confirmed the geri-kot (generic for Senna) 8.6 mg did not include the docusate sodium 50 mg. LPN #241 confirmed Resident #32 did not receive the correct dose of sennosides-docusate sodium tablet, 8.6-50 mg and did not receive the arformoterol solution for nebulization per the physicians orders. Review of the facility policy titled, Genera; Dose Preparation and Medication Administration, revised 04/30/24 revealed to verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct time. This deficiency represents non-compliance investigated under Complaint Number OH00158631.

Based on observation, interview, record review, and review of the facility policy, the facility failed to store medication per the manufacturers recommendations. This affected one (Resident #32) of four residents reviewed for medication administration. The facility census was 33. Findings include: Record review for Resident #32 revealed an admitted [DATE]. Diagnosis included centrilobular emphysema. Record review of the care plan for Resident #32 edited [DATE] revealed Resident #32 had emphysema. Interventions included to provide nebulizers. Record review of the physician orders for Resident #32 included arformoterol solution for nebulization: 15 micrograms (mcg)/two milliliters (ml), give two ml inhalation every 12 hours for centrilobular emphysema. Observation on [DATE] at 9:30 A.M. of medication administration for Resident #32 revealed Licensed Practical Nurse (LPN) #241 confirmed the arformoterol solution for nebulization was for Resident #32, and it was stored in the bottom drawer of the medication cart with additional resident medications. LPN #241 confirmed there was one foil pouch (containing 10 doses) unopened and one foil pouch opened with two remaining doses. The date dispensed on both pouches was [DATE]. The expiration date was not visible. Review of the label on the pouches revealed refrigerate - do not freeze, keep arformoterol in the foil pouch it came in and in the refrigerator. Unopened foil pouches can be stored at room temperature for up to six weeks. Throw away any unused medication after six weeks. LPN #241 confirmed the arformoterol solution was not stored appropriately and was unavailable for the A.M. administration. Record review of the facility policy titled, Storage and Expiration Dating of Medications and Biological's, revised [DATE] revealed the facility should ensure that medications and biological's that have an expired date on the label; have been retained longer than recommended by manufacturer or supplier guidelines; or have been contaminated or deteriorated are stored separate from other medications until destroyed or returned to the pharmacy. Once any medication or biological package is opened, facility should follow manufacturer guidelines with respect to opened dates for opened medications. Facility should ensure that medications and biological's are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges and manufacturer guidance. This deficiency is an incidental finding found during the complaint investigation.

Based on observation, staff and resident interviews, and review of the facility policy, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affect 40 residents who received meals in the facility. The facility identified Residents #30 and #32 as receiving no food from the kitchen. The facility census was 42. Findings include: Observation on 03/28/24 at 11:39 A.M. of Dietary Cook #308 taking the temperatures of the lunch meal items prior to food service revealed the chicken tenders were 173 degrees Fahrenheit (F), the [NAME] fries were 165 degrees F, the carrots were 162.1 degrees F, the white slice of bread was room temperature, and the chocolate cake was room temperature. Tray service for hall trays began on 03/28/24 at 11:50 A.M. As the kitchen staff started to load the last tray cart for the third floor at 12:03 P.M., the surveyor asked for a test tray at 12:08 P.M. as the last tray cart for the third floor was three fourths of the way full. A test try was plated at 12:17 P.M. and was placed on top of the steam table wells without a lid while four other uncovered resident trays were plated and sitting on the table next to the steam table while staff waited for Dietary Manager (DM) #307 to bring up a new box of dome lids, which were stored in the basement, and for the new lids to be washed. A dome lid was placed on the test tray and the four other residents' plates and placed into the covered cart at 12:20 P.M. The food cart was taken up to the third floor by DM #307 and arrived at 12:23 P.M. After the last tray was passed at 12:34 P.M., the test tray was removed from the food cart and was taken to the nurse's station counter with the surveyor and DM #307. DM #307 checked the temperatures of the food as the surveyor tasted the food for temperature and palatability. The chicken tenders had a temperature of 116.8 degrees F, had a good flavor, were moist, but tasted lukewarm. The [NAME] fries had a temperature of 115 degrees F, had a good flavor, were moist, but tasted lukewarm. The carrots had a temperature of 117 degrees F, had a good flavor, but tasted lukewarm at 116.8 degrees F. Milk was 51.4 degrees F and tasted warm. Chocolate cake was room temperature, had a good temperature, and was moist. [NAME] bread was room temperature and was palatable without signs of dryness or mold. DM #307 tasted the food and drank the milk and confirmed the food had a good taste but could have been warmer and the milk should have been colder. She stated waiting for the dome lids to be brought up and washed negatively affected the temperature of the food items since the food had already been plated, and the milk was iced but the ice bath should have had salt added to it to help bring down the temperature. An interview conducted on 03/28/24 at 3:30 P.M. with Resident #16 revealed the food was cold when it was delivered to the room. An interview was conducted 03/28/24 at 3:36 P.M. with Resident #39 revealed the food was not hot when it was delivered to the room. An interview conducted on 03/28/24 at 3:45 P.M. with Resident #38 revealed the food was tepid when it was delivered to the room. Review of facility policy Food and Nutrition Services: Meal Service, revised 09/21/20, revealed food would be served at preferable temperatures with hot foods hot and cold foods cold. This deficiency represents non-compliance investigated under Complaint Number OH00151013.

Based on observation, interviews, and review of facility policy, the facility failed to ensure the kitchen was clean and sanitary, food items were appropriately dated, and coffee was covered as required when walking down the third-floor hallways. This had the potential to affect 40 residents who received food from the kitchen. The facility identified two residents (#30 and #32) as receiving no food from the kitchen. The facility census was 42. Findings include: 1. Observation and interview during initial kitchen tour on 03/28/24 from 11:15 A.M. to 11:39 A.M. with Dietary Manager (DM) # 307 revealed the following concerns: On the bread rack was a one gallon unlabeled and undated storage bag full of Danishes. DM #307 stated the Danishes were most likely from yesterday but confirmed the bag was not labeled or dated. In the two-door reach in cooler on the right-hand side was an undated metal pan of a raw pork loin sitting on the second shelf above three crates of individual milk cartons. DM #307 at the time of observation confirmed the pan was undated and shouldn't have been sitting on the shelf above the milk cartons. In the two-door reach in cooler on the left-hand top shelf was an unlabeled clear plastic square container with a green lid three fourth full of an unidentified jelly like purple substance. On top of the lid was a sticker with a date of 02/24/24. DM #307 at the time of observation confirmed the item was grape jelly and the item was not labeled, and the dated sticker was old but could not state when the jelly had been dished into the container. DM #307 stated normal policy was to throw out items after three to seven days. In the two-door reach in cooler on the left-hand side second shelf, there was a white eight-pound round plastic lidded container of fruit salad with a hand written open date of 03/05/24 and a printed manufacturer best before date of 03/14/24. When the lid was opened, there was a fermented smell coming from the fruit. DM #307 at the time of observation confirmed the fermented smell and stated the fruit should have been thrown out. In the dry storage area under a metal shelving unit, there was a white powdered substance on the floor along with two pink sugar substitute packets and two yellow sugar substitute packets. Around the perimeter of the floor of the dry storage unit there was a build up of dirt and debris. There was an open to air bag of basmati rice sitting on the second shelf of the metal shelving unit. DM #307 at the time of observation confirmed the floor of the dry storage area needed cleaning and the open bag of basmati rice should have been sealed when opened. The four hinged lids covering the food on the tray line revealed a build of dried food and debris. DM #307 at the time of observation confirmed the lids did not appear to be clean. Review of facility policy Frozen and Nutrition: Food Production and Food Safety, revised 03/09/24, frozen meat would have a date when pulled from the freezer and placed in the refrigerator to be thawed. Review of facility policy Food and Nutrition Services: Food Production and Food Safety, revised 03/09/24, revealed the ready to eat food would be stored above raw pork, all bulk items would be dated when opened. 2. Observation on 03/28/24 from 12:25 P.M. to 12:24 P.M. revealed at 12:25 P.M. State tested Nursing Aide (STNA) #306 filled a cup of coffee from a hot beverage carafe sitting on a cart in the middle of the hallway and placed the uncovered cup of coffee on a resident's tray and walked it down the hallway to room [ROOM NUMBER]. At 12:30 P.M. License Practical Nurse (LPN) #305 filled a cup of coffee from the same beverage cart and placed the uncovered cup of coffee on a resident's tray and walked it down the hallway to room [ROOM NUMBER]. At 12:34 P.M. STNA #306 filled a cup of coffee from the same beverage cart and placed the uncovered cup of coffee on a resident's tray and walked it down the hallway to room [ROOM NUMBER]. Observation of the drink cart and Interview on 03/28/24 with Dietary Manager (DM) #307 at 12:44 P.M. revealed there were no lids on the drink cart. DM #307 at time of observation confirmed if coffee was being walked down the hallway the coffee should have lids and confirmed there were no lids on the beverage cart. DM #307 stated when she passed food trays, she would take the food cart and beverage cart closer to the residents rooms. Interview on 03/28/24 at 12:55 P.M. with STNA #306 confirmed she had walked the coffee uncovered halfway down the hallway and stated the kitchen didn't normally send lids. This deficiency represents non-compliance investigated under Complaint Number OH00151013.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #10's had a sanitary room free of bed bugs. This affected one resident (Resident #10) out of three residents reviewed for bed bugs. Findings include: Review of Resident #10's medical record revealed an admitted [DATE] and diagnoses included alcohol dependence with alcohol induced persisting dementia and muscle weakness. Review of Resident #10's care plan revised 01/27/22 included Resident #10 had a self-care deficit and his needs would be met. Interventions included to assist Resident #10 with ADL's (Activity of Daily Living). Review of Resident #10's Head to Toe Evaluation dated 11/19/23 included Resident #10 had bed bug bites on his neck and the majority of his back area. The areas had small red splotches all over both areas. Review of the facility Pest Control Company invoices dated 11/20/23 revealed on 11/20/23 bed bugs were found in Resident #10's bed frame in room [ROOM NUMBER]. Resident #10 resided in the bed by the door, and both beds were heated. Resident #10's bed frame, baseboards, restroom and hallway were treated. Placed traps under both beds and would follow-up. Further review of the invoices revealed there was no additional documentation regarding bed bugs until 12/19/23. Review of the Pest Control Company invoice dated 12/19/23 revealed Resident #10's room was retreated for bed bugs. The wall outlet and a crack behind Resident #10's bed was heated. The baseboard in the room and hall was treated with a chemical which targeted bed bugs. The invoice did not have evidence Resident #10's metal bed frame and springs and mattress were inspected for bed bugs. Review of the Pest Control Company invoice dated 12/26/23 included Resident #10's door frame and bed frame were treated with the heat gun. The invoice further stated, treated baseboards in the room and hallway and would follow-up. There was no documentation regarding bed bug activity or if Resident #10's mattress was inspected for bed bugs. Review of the Pest Control Company invoice dated 12/27/23 included bed bugs were reportedly seen in the laundry room. The invoice stated no bed bug activity was found and the basement hall, laundry, utility room, restroom and storage area were treated. Review of Resident #10's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 had no upper or lower extremity impairment and used a walker. Review of the Pest Control Company invoices dated 01/02/24 through 01/10/24 included bed bugs were reportedly seen in resident rooms #202, #205, #207, #208 and the nurses station. Inspection of bagged bedding and mattresses did not reveal bed bug activity. Bed frames were heated and treated. Baseboards in the rooms, hallways, restrooms were treated. Inspection of chairs in the nurses station did not reveal bed bug activity. There was no evidence Resident #10's room, metal bed frame or mattress was inspected for bed bugs. Observation on 01/24/24 at 11:14 A.M. with State tested Nursing Assistant (STNA) #102 of Resident #10 revealed he was lying in bed on a bare mattress. When asked why there were no sheets on his bed Resident #10 said he did not know. Resident #10 got out of bed and stood in the room while STNA #102 donned disposable gloves and lifted the mattress to check for bed bugs. When the mattress was lifted bed bugs were seen crawling on the right lower corner of the mattress. STNA #102 screamed and dropped the mattress and said did you see the bed bugs. Interview on 01/24/24 at 11:25 A.M. of Licensed Practical Nurse (LPN) #112 revealed she saw bed bugs in the facility, but not recently. LPN #112 stated the bed bugs started in Resident #10's room and his room was treated multiple times for bed bugs. LPN #112 stated Resident #10 did not leave the facility or receive visitors so he could not be bringing bed bugs into the facility. LPN #112 stated she noticed bug bites on Resident #10's back and his back was kind of red. LPN #112 indicated when a bed bug was spotted in a resident room the resident's clothes were placed in bags and securely closed and sent to the laundry department, and the resident received a skin assessment and a shower. LPN #112 stated the chairs were also removed from the room. Interview on 01/24/24 at 12:43 P.M. of the Administrator revealed she was aware bed bugs were seen in Resident #10's room and the pest control company representative was on his way to the facility. The Administrator stated bed bugs were seen off and on in the facility, and the pest control company was called immediately when they were spotted. The Administrator indicated when bed bugs were found residents were moved out of their room and given a shower. The contents of the room was packed into bags, clothes were sent to the laundry and washed and dried on high heat. The Administrator stated residents were kept out of their room for 72 hours after the room was treated for bed bugs. The Administrator stated Resident #10 often took the sheets off his bed and she did not know why. Review of Resident #10's progress notes dated 01/24/24 at 1:46 P.M. included bug observed in Resident #10's room and protocol initiated. Area on Resident #10's back had minimal pink pimples observed prior to episode. Review of Resident #10's Weekly Skin Evaluation dated 01/24/24 included Resident #10 had current skin issues. Resident #10's skin was intact and he had red pimples to back, observed prior to incident. Interview on 01/24/24 at 2:01 P.M. of Pest Control Company Representative (PCCR) #143 revealed the facility had a monthly service contract and he would provide preventative maintenance and treat common areas and baseboards for ants. PCCR #143 indicated if he was told about other pests he would treat for that particular pest once he identified it. PCCR #143 stated 11/20/23 was the first time he was notified about bed bugs and they were in Resident #10's room. PCCR #143 stated he inspected the room and found bed bugs on Resident #10's metal bed frame and the bed bugs were also inside the springs of the metal frame. PCCR #143 indicated he treated Resident #10's metal bed frame with a heat gun, and sprayed the baseboards in the room with a chemical specifically made to kill bed bugs. PCCR #143 stated he did not see bed bugs on Resident #10's mattress, did not treat the mattress, and he did not know if the mattress was replaced. PCCR #143 revealed he inspected the furniture and if he did not see signs of bed bugs he did not treat the furniture. PCCR #143 stated he did not write it down on the invoice but he put a bait station for bed bugs under Resident #10's bed. PCCR #143 indicated Resident #10's room was the only room he found bed bugs, and sometimes the staff found bugs they thought were bed bugs but turned out to be another type of bug. PCCR #143 stated he retreated Resident #10's room on 12/26/24 but he did not see evidence of bed bugs and found no evidence of bed bugs in the facility until today. Observation on 01/24/24 at 2:25 P.M. of Resident #10's room with PCCR #143 revealed a bed bug trap was located under the bed and did not have evidence of bed bugs. Further observation of Resident #10's doorframe revealed little black spots along the bottom portion of the door frame and PCCR #143 stated this was evidence bed bugs were in the wall and the door frame and those areas needed treated. PCCR #143 stated he also found live bed bugs around the zipper of the mattress, and under the flap. When asked PCCR #143 stated it would be a good idea to replace the bed frame and the mattress. Interview on 01/24/24 at 3:02 P.M. of PCCR #143 revealed the facility was going to replace the mattress and the metal bed frame. PCCR #143 stated on 12/19/23 he treated Resident #10's door and cracks and crevices in the room for bed bugs because he saw activity. PCCR #143 stated on 12/19/23 he did not see bed bug activity on the mattress. PCCR #143 stated bed bugs stayed where the host was and could stay confined to one room because they did not move around unless they hitchhiked. Interview on 01/24/24 at 4:09 P.M. of the Administrator revealed the facility did not replace Resident #10's metal bed frame on 11/20/23 because PCCR #143 did not recommend they do that until 01/24/24. Interview on 01/25/24 at 9:43 A.M. of Maintenance Supervisor (MS) #116 revealed he was not aware and was not told Resident #10's metal bed frame and springs had bed bugs detected on them on 11/20/23. MS #116 stated if he was told he would have immediately taken Resident #10's mattress and metal frame out of the room. MS #116 stated he might not have been told because he was out of the building for some reason, and PCCR #143 usually gave him a summary of his visit. MS #116 stated he replaced Resident #10's mattress on 11/20/23 but no one mentioned finding bed bugs on the metal bed frame or bed bugs were hiding in the springs of the bed frame. MS #116 stated he inspected Resident #10's room the day after it was treated and did not see signs of bed bugs. Interview on 01/25/24 at 11:33 A.M. of PCCR #143 revealed when he treated a room for bed bugs he followed up on it and documented when he returned and inspected the room. PCCR #143 stated he did not remember if he told the Administrator or MS #116 bed bugs were found in Resident #10's metal bed frame springs. PCCR #143 stated he always gave a summary of his visit to the Administrator or MS #116 but did not always document who he spoke to. Review of the facility policy titled Pest Control Policy dated 02/01/19 included routine pest control procedures would be in place to prevent pest infiltration. Appropriate action would be taken to eliminate any reported pest situation in the department. This deficiency represents non-compliance investigated under Complaint Number OH00149630.

Based on interview, record review, review of the facility policy, review of the facility fall investigation, and review of the Emergency Medical Services report the facility failed to ensure care and services and individualized care planned interventions for Resident #38 were implemented resulting in a fall. This affected one resident (Resident #38) out of three residents reviewed for falls. The facility census was 37. Findings include: Review of Resident #38's medical record revealed an admitted [DATE] and diagnoses included burn of third degree of left lower limb, burn of third degree of multiple sites of left shoulder and upper limb, morbid obesity and atrial fibrillation. Review of Resident #38's Admission, Readmission Evaluation dated 11/28/23 revealed Resident #38 was high risk for falls. Review of Resident #38's care plan dated 11/28/23 included Resident #38 was at risk for falls characterized by history of falls, injury and or multiple risk factors. Resident #38 would have minimized risk for falls and minimized injuries related to falls through the next review. Interventions included implement preventative fall interventions, devices; maintain call bell within reach; maintain resident's needed items within reach. There was no evidence of individualized fall interventions for Resident #38 including an air mattress or a perimeter mattress. Review of Resident #38's care plan revised 11/30/23 included Resident #38 had and ADL (Activity of Daily Living) self-care deficit related to third degree burns and decreased mobility. Resident #38's needs would be met with staff assistance as needed. Interventions included Resident #38 required assistance of two staff members for bathing, bed mobility, toileting, and transfers using a mechanical lift. Review of Resident #38's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had severe cognitive impairment. Resident #38 had impairment on both sides of her upper and lower extremities. Resident #38 used a wheelchair and was dependent on staff for Activities of Daily Living, bathing, bed mobility and transfers. Resident #38 was always incontinent of bowel and bladder. Review of the facility Fall Committee Meeting Minutes dated 12/05/23 revealed Resident #38 was a new resident, a high fall risk, and new interventions were air mattress and perimeter mattress. Review of Resident #38's physician orders dated 12/05/23 revealed alternating air pressure mattress. Review of Resident #38's physician orders dated 12/05/23 through 01/15/24 did not reveal orders for a perimeter mattress. Review of Resident #38's Physical Therapy Discharge Summary dated 12/11/23 included Resident #38 had minimal to no attempts to initiate bed mobility tasks and was significantly limited by pain and impaired cognition, resulting in poor carryover and difficulty participating in mobility tasks. Resident #38 required 24 hours a day, seven days a week hands on assist for all mobility tasks. Interventions provided included therapeutic exercises, therapeutic activities, nursing staff education and training, positioning and pressure relief techniques and bed mobility training. Review of Resident #38's physician orders dated 12/19/23 revealed pleasure foods diet, pureed texture. Review of Resident #38's local city EMS (Emergency Medical Services) Patient Care Report dated 01/15/24 revealed a 911 call was received on 01/15/24 at 6:56 A.M. and EMS was on scene at 7:14 A.M. Upon arrival Resident #38 was found sitting in a chair at the nurse's station. Resident #38 was alert to normal per staff, had a fall at 6:00 A.M. from her bed and was found prone on the floor by staff. Resident #38 complained of head pain via the fall and denied LOC (loss of consciousness). Resident #38 was on Eliquis (anticoagulant) and had a small contusion to her forehead. Vital signs were obtained (136/52 blood pressure, strong and regular pulse of 80, respirations 16) and Resident #38 was transported to the local hospital Emergency Department. Staff said they called at 6:00 A.M. when Resident #38 fell but the 911 call time was 6:56 A.M. Review of Resident #38's progress notes dated 01/15/24 included a nursing assistant called for the nurse due to Resident #38 fell out of bed and was laying on the floor. Vital signs were taken and were wnl (within normal limits) and Resident #38 was assisted off the floor and cleaned up. Resident #38 did not complain of pain, her physician was contacted and an order to send Resident #38 to the local hospital was obtained. Review of Resident #38's Post Fall Huddle Form dated 01/16/24 included Resident #38's fall was located in her room and she said she was looking for her brother. Resident #38 was last visualized at 4:30 A.M. and she was lying in bed. It was unknown when Resident #38 was last toileted and Resident #38's undergarment was wet. Resident #38 was wearing Prevalon boots. It was unknown if all current interventions were in place. Resident #38 was assisted off the floor using a mechanical lift. The five whys and root cause stated to center resident in bed, utilize two people, height of bed, and fluids. Review of Resident #38's fall investigation dated 01/17/24 included Resident #38 was transferred to the hospital on 01/15/24 following being found on the floor. Resident #38 received continuous tube feeding and her head of the bed was elevated. The State tested Nursing Assistant (STNA) and Licensed Practical Nurse (LPN) both indicated Resident #38 was calling out for water during the night and the head of her bed was raised to give her water orally. When the STNA observed Resident #38 on the floor between the bed and window on the side of the bed the tube feeding was positioned she noted the head of the bed was in an elevated position like when Resident #38 received water orally. Resident #38 did not have adequate upright trunk control and was dependent on staff for all aspects of ADL and mobility. If the head of Resident #38's was elevated, she could not maintain upright posture and if she leaned forward or coughed or had a spasm and her upper body moved forward she would be unable to reposition herself and gravity might have resulted in Resident #38 falling forward from the bed. When Resident #38 was observed on the floor she was in the face down position with her chin resting on the tube feeding pole and one hand was around the pole. The actual cause of the fall was unable to be determined but this could be a plausible explanation. Interview on 01/24/24 at 12:31 P.M. of Registered Nurse/Regional Director of Clinical Services (RN/RDCS) #144 revealed Resident #38 had a fall on 01/15/24 and was transferred to the local hospital Emergency Department. RN/RDCS #144 stated Resident #38's communication was inconsistent and she mumbled. RN/RDCS #144 stated the fall investigation was inconclusive, Resident #38 was dependent on staff for care and did not have upright trunk control. RN/RDCS #144 stated Resident #38 received tube feeding, the head of her bed was elevated due to tube feeding and she could have pureed pleasure foods. RN/RDCS #144 stated Resident #38's bed did not have grab bars and when her weight shifted forward she was not able to stop herself. RN/RDCS #144 stated she interviewed the staff who cared for Resident #38 when she fell and the head of her bed might have been up at approximately 60 degrees and the fall was unwitnessed. RN/RDCS #144 indicated the aide who cared for Resident #38 said she put the head of Resident #38's bed up earlier in the night, but lowered it after she provided care. RN/RDCS #144 stated the nurse (LPN #145) said she raised the head of the bed to give Resident #38 water and she might have forgotten to put the head of her bed down afterwards. Interview on 01/24/24 at 4:03 P.M. of Licensed Practical Nurse/Minimum Data Set (LPN/MDS) #106 confirmed Resident #38 was a high fall risk and there were no individualized interventions in her care plan. LPN/MDS #106 stated Resident #38's interventions included to have her call light in reach and have needed items in reach. LPN/MDS #106 stated Resident #38 did not have a fall yet and after she had a fall LPN/MDS #106 would build more individualized interventions into her care plan. Interview on 01/25/24 at 11:38 A.M. of Director of Rehab (DOR) #142 revealed Resident #38 was evaluated by Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) while she resided in the facility. DOR #142 stated ST recommended to allow Resident #38 to have pleasure foods with feeding assistance and supervision, and tube feeding was primary form of nutrition. DOR #142 indicated Resident #38 was in a lot of pain and was unable to participate with OT and PT. DOR #142 stated Resident #38 was totally dependent on staff for mobility, was unable to perform static sitting (maintain one alignment for a prolonged period of time, sitting upright and stationary), and would fall over because she could not stay upright. DOR #142 stated Resident #38 would not be able to tolerate sitting. DOR #142 stated Resident #38 was recommended to have an air mattress with a perimeter mattress around the air mattress. DOR #142 indicated the perimeter mattress was around the air mattress because the air mattress was a slippery surface and it would be easy for Resident #38 to slide out of the neutral position. DOR #142 stated pillows were used for positioning for edema management and would not typically keep a resident in bed. DOR #142 stated a perimeter mattress was recommended with an air mattress to keep Resident #38 from sliding out of bed. Interview on 01/25/24 at 12:29 P.M. of STNA #138 revealed Resident #38 required two staff for her care and could not sit up on her own. STNA #138 stated Resident would not be able to right herself if she fell over. Interview on 01/25/24 at 1:01 P.M. of RN/RDCS #144 confirmed Resident #38 was a high fall risk and an intervention would be to ensure call lights were in reach and the bed was in low position when care not being provided. RN/RDCS #144 stated Resident #38's bed was in the low position when she fell but confirmed there was no evidence the bed was in low position in Resident #38's medical record including care plan, fall investigation and progress notes. RN/RDCS #144 confirmed Resident #38's care plan did not have individualized interventions, and confirmed there was no evidence Resident #38 had a perimeter mattress including in the care plan, physician orders and progress notes. Interview on 01/25/24 at 1:42 P.M. of STNA #104 revealed Resident #38 asked for water about 40 minutes before she fell , she did not raise the head of her bed higher and brought the water cup with a straw to Resident #38's lips so she could drink the water. STNA #104 stated she left Resident #38's room after she gave her water to provide care for other residents and did not know what happened after that until she walked by Resident #38's room and did not see her in the bed. STNA #104 stated she asked LPN #145 if she knew where Resident #38 was and she said no, and STNA #104 went back to her room and found Resident #38 on the floor, face down, holding the tube feeding pole. STNA #104 indicated the head of Resident #38's bed was elevated more than when she was in the room giving her water. STNA #104 stated LPN #145 told her she gave Resident #38 water before she fell . STNA #104 stated Resident #38 did not have a perimeter mattress on the bed or grab bars and she wished she did because she was so upset and cried when she found Resident #38 on the floor. Review of the facility policy titled Fall Prevention and Management Policy dated 12/09/19 included residents would be assessed for fall risk on admission, quarterly, after any fall, and as needed. Individualized interventions would be implemented based on the assessment and care planned accordingly. Providers would be consulted regarding risks and interventions, feedback and any further approaches recommended. This deficiency is an example of continued non-compliance from the survey dated 12/28/23.

Based on observation, staff interview, interview with contracted pest control staff, and review of the facility policy the facility failed to ensure food storage areas were free from pests. This had the potential to affect all residents except for Resident #5 identified by the facility as receiving no food from the kitchen. The facility census was 39. Findings include: On 12/26/23 from 8:39 A.M. to 8:51 A.M., the initial tour of the kitchen and food storage areas with Dietary Director #834 revealed there were multiple small black insects flying around and on the walls of the dry food storage room located in the kitchen. This was verified at the time of observation by Dietary Director #834, who identified the insects as either gnats or drain flies. On 12/27/23 at 12:21 P.M., interview with Pest Control Services Representative #902 confirmed he treated the facility's kitchen for drain flies on 12/26/23 and he stated, the facility staff needed better sanitation practices in the kitchen to prevent future issues with pests. Review of the pest control logs for December 2023 revealed routine pest control services were performed in the kitchen on 12/06/23 and there was no indication that treatments were specific to drain flies or fruit flies until 12/26/23. Review of the facility policy titled Pest Control Policy, dated 08/12/18, revealed routine pest control procedures would be in place to prevent pest infiltration and appropriate actions would be taken to eliminate any reported pest situation in the kitchen or dietary department.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, review of a facility self-reported incident, facility policy review and interview, the facility failed to prevent unauthorized videos from being taken and shared on social media by a staff member of Resident #20 and Resident #23. This affected two residents of three residents reviewed for abuse. Findings include: Record review for Resident #23 revealed an admitted [DATE] with diagnoses including syncope and collapse. Record review of the Medicare Five Day Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact. The assessment revealed Resident #23 had no behaviors of inattention or disorganized thinking. Review of the closed medical record for Resident #20 revealed an admitted [DATE] with diagnoses including chronic pulmonary embolism, asthma, schizoaffective disorder, gastroesophageal reflux disease, depression, hypertension, anemia, seizures, hyperlipidemia, and alcohol dependence with withdrawal delirium. Resident #20 was discharged on [DATE]. Review of a progress note dated 12/11/23 at 10:33 A.M. revealed Resident #20 had an incident with an unnamed other guy and he was not aware of any video taken. Resident #20 reported he did not care and it was not a big deal to him. A note dated 12/11/23 at 6:51 P.M. revealed Resident #20's representative was notified of the situation that occurred. Review of a facility self-reported incident dated 12/11/23 at 4:48 P.M. and created by Regional Director of Clinical Services (RDCS) #845 revealed Administration was informed on 12/11/23 at approximately 2:30 P.M. that a dietary staff member (Dietary Assistant #846) video recorded two residents on Friday 12/08/23 at approximately 6:00 P.M. outside in the smoking area when the two residents were having a disagreement and were having words. It was reported the video was posted to Instagram and air dropped to other staff. The one staff member who the video was air dropped to said she had no idea on her phone about air drop or even how to retrieve anything. Human Resource Director (HRD) #822 did check the phone and the video was air dropped and the staff member said she had no idea. The video was then deleted from the phone. When the alleged wrong doer was interviewed, he denied taking any video and when security camera footage was pointed out to him he said well what does it matter, you are going to fire me anyway and got up and walked out of the facility and did not cooperate with the remainder of his interview. Interview on 12/26/23 at 10:49 A.M. with Resident #23 revealed, They filmed me and placed it on social media, I didn't know at the time that was what was going on but I saw the video later that night, hell yea it bothered me, I don't do social media for a reason, they had no right, it makes me mad and upset. It was me and another guy, a resident, we got in an argument, it did not get physical but it was about to but it didn't, he's gone now. They had no right putting it on social media. Resident #23 reiterated the incident of being video recorded and placed on social media was very upsetting. The resident stated his picture had never been on social media and he never wanted it to be. Interview on 12/26/23 at 12:48 P.M. with Regional Director of Clinical Services (RDCS) #845 and the Administrator revealed an incident was brought to their attention on 12/11/23 that Dietary Assistant #846 videotaped on his phone two residents, Resident ##20 and #23 outside near the smoking area of the facility having words. Resident #20 threw his cane in the direction of Resident #23 (no contact was made). Dietary Assistant #846 then posted the video of the two residents to his Instagram (social media account) and air dropped it to other staff. RDCS #845 revealed when a staff member who worked that day, State tested Nursing Assistant (STNA) #801, was interviewed, the video of Resident #20 and #23 having the altercation was on her phone. Review of the facility cameras confirmed Dietary Assistant #846 had his phone placed in front of him pointing towards the two residents, Resident #20 and #23, during the resident's altercation. Review of the facility policy titled, Ohio Resident Abuse Policy, revised 07/14/20 revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The deficiency was corrected on 12/12/23 when the facility implemented the following corrective action: On 12/11/23 a facility self-reported incident was initiated and submitted to the State agency. On 12/11/23 an investigation of the incident was initiated by the Administrator and RDCS #845. The investigation included interviews of all interviewable residents including Resident #20 and #23. All residents revealed they felt safe at the facility. On 12/11/23 staff were interviewed. STNA #801 still had the video on her phone. Dietary Cook #812 revealed Dietary Assistant #846 showed her the video. On 12/11/23 staff education was initiated 12/12/23 for all staff on Resident Rights, HIPPA Compliance and Abuse. Staff education was completed on 12/12/23. On 12/12/23 Resident #20 was discharged to home. On 12/12/23 five staff member files were reviewed including Dietary Assistant #846 to ensure compliance of HIPPA, Social Networking Media Policy, and Abuse training. The facility implemented a plan for Resident #23 to have weekly follow up with SWD #822. Interview on 12/27/23 between 7:54 A.M. and 4:00 P.M. with LPN #815, STNA #801 and #808 confirmed they received training on Resident Rights, HIPPA Compliance and Abuse. No additional concerns related to abuse or staff video recording residents was identified to occur between 12/12/23 and 12/28/23.

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure care planning conferences were conducted at least quarterly. This affected two (Residents #6 and #27) of three reviewed for care planning. The facility census was 39. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including alcohol dependence with alcohol induced persisting dementia, muscle weakness, foot drop, and personal history of COVID-19. Review of care plan conference summary dated 10/26/23 revealed Resident #6 had signed as an attendee. Further review of the medical record revealed there was no documentation of care conferences conducted for Resident #6 between October 2022 and October 2023. Interview on 12/26/23 at 10:24 A.M. of Resident #6 confirmed he had not been invited to care planning conferences. Interview on 12/27/23 at 11:03 A.M. with Admissions Coordinator/Social Worker Designee (AC/SWD) #842 confirmed she was unaware that the facility should conduct care conferences with residents. Interview on 12/27/23 at 1:54 P.M. AC/SWD #842 and Registered Nurse (RN) #845 confirmed the facility could provide no documentation of care conferences for Resident #6 between October 2022 to October 2023 except for the care conference completed on 10/26/23. 42011 2. Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including systemic inflammatory response syndrome, bacteremia, dependence on renal dialysis, anemia, acute hepatitis C, sepsis, depression, dementia with other behavioral disturbances, and end stage renal disease. Record review of the admission Minimum Data Set (MDS) assessment for Resident #27 dated 11/14/23 revealed the resident was cognitively intact. Review of the medical record for Resident #27 from 02/09/23 through 12/28/23 revealed there was no documentation regarding care conferences being held for the resident. Review of the nurse progress note for Resident #27 dated 07/12/23 completed by Licensed Practical Nurse (LPN) #815 revealed a care conference was held for the resident 07/12/23 at 11:00 A.M with both the resident and the resident's guardian in attendance. Interview on 12/27/23 at 11:03 A.M. with AC/SWD #842 confirmed Resident #27 did not have an initial care conference and had only one quarterly care conference (on 07/12/23) since admission on 02/09/23. AC/SWD #842 confirmed Resident #27 should have had an initial care conference upon admission and then a care conference each quarter while residing in the facility. Review of the facility policy titled Comprehensive Care Planning Policy, dated 07/19/19 revealed the facility care plan coordinator was responsible for resident care plan conferences. The policy also indicated care planning conferences would be conducted weekly to include new admissions within the previous seven days, residents who returned from the hospital within the previous seven days, residents who had a significant change within the previous seven days, and residents who had a 90-day assessment or annual assessment completed within the previous seven days.

Based on record review, observation, staff and resident interview, and review of the facility policy, the facility failed to complete assessments and care plans regarding resident smoking. This affected one (Resident #42) of three residents reviewed for smoking. The facility census was 39. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral vascular disease affecting left dominant side, pathological fracture of the hip, and chronic obstructive pulmonary disease (COPD.) Review of the admission Minimum Data Set (MDS) assessment for Resident #42 dated 11/16/23 revealed the resident was cognitively intact and required substantial assistance with upper body dressing and personal hygiene and was dependent for lower body dressing. Review of the care plan for Resident #42 undated revealed there was no care plan for smoking. Review of safe smoking assessment for Resident #42 dated 11/10/23 completed by Licensed Practical Nurse (LPN) #901 revealed the resident did not smoke, was a non-smoker, and intended not to smoke. Record review of the physician orders for Resident #42 revealed an order dated 11/11/23 for resident to receive a transdermal nicotine patch to be applied once daily for smoking cessation for 24 hours and remove per schedule. The order was discontinued on 12/22/23. Review of the November and December Medication Administration Records (MARs) for Resident #42 revealed on 11/13/23, 11/14/23, 11/15/23, 11/25/23, 12/20/23, 12/21/23, and 12/22/23 the nicotine patch was either not available or refused by the resident. Review of the MAR for Resident #42 revealed the nicotine patch was discontinued on 12/22/23. Observation on 12/26/23 at 2:44 P.M. revealed LPN #901assisted Resident #42 outside to the smoking area and lit the resident's cigarette. Further observation revealed Resident #42 was not wearing a smoking apron while he smoked. Interview on 12/26/23 at 2:44 P.M. of LPN #901 confirmed Resident #42 smoked cigarettes and required staff assistance to and from the smoking area and to light his cigarettes. Interview on 12/26/23 at 3:21 P.M. with Resident #42 confirmed he quit smoking [AGE] years prior to admission to the facility, and then he started smoking cigarettes again in August 2023. Resident #42 confirmed he had been smoking cigarettes since he was admitted to the facility in November 2023 and staff assisted him with smoking. Interviews on 12/26/23 at 3:24 P.M. and on 12/28/23 at 11:01 A.M. with the Director of Nursing (DON) confirmed when Resident #42 was admitted to the facility he did not smoke cigarettes and he wore a nicotine patch. The DON confirmed Resident #42 had expressed a desire to begin smoking around 12/22/23 and his nicotine patch was discontinued. Further interview with the DON confirmed the facility did not complete an updated smoking assessment for Resident #42 nor did they implement a care plan with safe smoking interventions for the resident. The DON confirmed the smoking assessment should be completed prior to residents' smoking to determine if the resident needed a smoking apron or other safety interventions and what level of supervision with smoking was required. Interview on 12/28/23 at 11:01 A.M. with Activity Director (AD) #820 confirmed she and her assistants took residents out to smoke several times a day as an activity for them. AD #820 confirmed she had taken Resident #42 outside to smoke on several occasions since admission. Review of the facility policy titled Resident Smoking Policy dated 12/20/22 revealed during the admission process the nursing staff would ask residents if they smoked or if they had a desire or intent to smoke while in the facility. Anyone answering yes was further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The smoking assessment was to be completed thereafter on readmission, quarterly, or and with any significant change in the resident's condition.

Based on record review, staff interview, and resident interview, the facility failed to provide suprapubic catheter site care for one (Resident #5) of one resident reviewed for catheter care. The facility census was 39. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and neuromuscular dysfunction of the bladder. Record review of the admission Minimum Data Set (MDS) assessment for Resident #5 dated 11/15/23 revealed the resident had moderate cognitive impairment and functional impairment to the upper and lower extremity on one side and required substantial assistance with personal hygiene. Review of the care plan for Resident #5 dated 10/31/23 revealed the resident had a neurogenic bladder. Interventions included staff should provide catheter care per routine. Review of the physician orders for Resident #5 dated 11/08/23 revealed an order to cleanse the suprapubic site with soap and water, pat dry, and leave open to air every shift. Review of the admission/readmission evaluation for Resident #5 dated 12/14/23 revealed the resident was admitted to the hospital on 12/04/23 with diagnoses of aspiration and hypoxia and was readmitted to the facility on [DATE] with a suprapubic catheter still in place. Review of the physician orders for Resident #5 dated 12/14/23 revealed there were no orders for daily suprapubic catheter care. Interview on 12/27/23 at 2:00 P.M. with Regional Director of Clinical Services (RDCS) #845 confirmed the facility staff did not obtain orders for Resident #5 for catheter care to his suprapubic catheter site upon the resident's readmission to the facility on [DATE]. Interview on 12/28/23 at 8:49 A.M. with Registered Nurse (RN) #900 confirmed Resident #5 did not have orders for catheter care to his suprapubic catheter site. RN #900 further confirmed she was an agency nurse and didn't know the residents well. RN #900 confirmed she had worked at the facility one day a week ago and did not provide catheter care for Resident #5 on that date or on 12/28/23 because there were no orders to do so. Interview on 12/28/23 at 9:00 A.M. with Resident #5 confirmed staff did not perform suprapubic site care upon after his return from the hospital on 12/14/23.

Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed up on in a timely manner. This affected three residents (#22, #25, and #26) of five residents reviewed for unnecessary medications. The facility census was 39. Findings include: 1. Review of the medical record for Resident #22 revealed admitted [DATE] with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, and viral hepatitis. Review of the pharmacy consultation report dated 11/13/23 revealed the pharmacy recommended discontinuing Famotidine (acid reducer) medication as Resident #22 was already receiving Omeprazole (acid reducer), and evidence supporting combination gastroprotective therapy was limited. There was no physician signature; however, it was noted the physician was contacted via phone on 12/26/23 and agreed to discontinue Famotidine. Review of the physician orders revealed Famotidine 20 milligrams (mg) remained an effective order as of 12/28/23 at 8:01 A.M. Interview on 12/28/23 at 8:45 A.M. with Regional Registered Nurse (RN) #845, Director of Nursing (DON), and Administrator revealed they had identified issues regarding pharmacy recommendations. Regional RN #845 confirmed the pharmacy recommendation for Resident #22 was not followed up on in a timely manner. 2. Review of the medical record for Resident #25 revealed admitted [DATE] with diagnoses including schizophrenia, intellectual disabilities, overactive bladder, diabetes mellitus, and hypertension. Review of the pharmacy consultation report dated 05/12/23 revealed the pharmacy recommended to change Oxybutynin (bladder relaxant) medication for overactive bladder to Tolterodine (bladder relaxant) as Oxybutynin had highly anticholinergic effects and may increase the risk of adverse events. The physician agreed to change medication to Tolterodine and signed pharmacy recommendation on 06/20/23. Review of the physician orders revealed Oxybutynin 15 mg remained an effective order until 07/19/23, and Tolterodine 4 mg was not started until 07/19/23. Interview on 12/28/23 at 8:45 A.M. with Regional RN #845, DON, and Administrator revealed they had identified issues regarding pharmacy recommendations. Regional RN #845 confirmed the pharmacy recommendation for Resident #25 was not followed up on in a timely manner. 3. Review of the medical record for Resident #26 admitted [DATE] with diagnoses including hyperlipidemia, chronic pulmonary edema, recurrent depressive disorders, and dementia without behavioral disturbance. Review of the physician orders revealed Resident #25 had an order for a complete blood count (CBC) and basic metabolic panel (BMP) labs starting 10/14/22 and then every six months. The order remained in effect until 06/26/23. Review of the pharmacy consultation report dated 05/12/23 revealed the pharmacy identified Resident #26 had order for CBC and BMP lab draw due in April 2023, and the labs were not available in the medical record for review. The facility noted a CBC and BMP lab draw were scheduled for 05/19/23. There was no documented evidence of a CBC and BMP lab collected for 05/19/23. Review of the pharmacy consultation report dated 06/15/23 revealed the pharmacy recommended Resident #26 had order for CBC and BMP every six months which was last drawn 10/14/22. There were no labs available in the medical record for review. The facility noted a CBC and BMP lab draw were scheduled 06/20/23. Review of laboratory results for a CBC and BMP revealed specimen was collected on 06/20/23. Interview on 12/28/23 at 8:45 A.M. with Regional RN #845, DON, and Administrator revealed they had identified issues regarding pharmacy recommendations. Regional RN #845 confirmed the pharmacy recommendation for Resident #26 was not followed up on in a timely manner.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure weights were documented accurately for Resident #41. This affected one resident (#41) of three residents reviewed for nutrition. The facility census was 39. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including third degree burns to multiple sites of the left shoulder and upper limb, third degree burns to the left lower limb, gastrostomy status, hypertension, morbid obesity, protein-calorie malnutrition, and history of pulmonary embolism. Review of the hospital summary dated 11/28/23 revealed Resident #41's weight was measured at 238 pounds on 11/25/23. Review of the facility weight records for Resident #41 indicated she weighed 238 pounds on 11/28/23, 239 pounds on 12/05/23, 215 pounds on 12/12/23, and 215 pounds on 12/19/23. On 12/28/23 at 10:08 A.M., interview with Registered Dietitian (RD) #847 and the Administrator stated Resident #41's initial weight on 11/28/23 was obtained from the hospital records, the weight on 12/05/23 was self-reported because Resident #41 refused to be weighed due to pain from her burn wounds, and the weights on 12/12/23 and 12/19/23 were the only weights obtained in house. RD #847 stated the weights on 12/12/23 and 12/19/23 were more accurate because they were obtained in house. Review of the facility policy titled Resident Weight Policy, dated 12/12/23, revealed residents would be weighed no later than 24 hours after admission, weekly for the first four weeks after admission, and monthly or more often if risks were identified, or as ordered. The policy indicated nursing was responsible for obtaining weights, and weights would be recorded in the electronic health record.

Based on interview, record review, review of the facility policy and Centers for Disease Control and Prevention (CDC) guidelines the facility field to ensure pneumococcal vaccinations were offered and provided as recommended by the CDC. This affected three residents (#11, #21, and #26) of five residents reviewed for pneumococcal vaccinations. The facility census was 39. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including diabetes mellitus, cerebral infarction, chronic kidney disease, moderate protein calorie malnutrition, congestive heart failure, and chronic obstructive pulmonary disease. Review of the progress note dated 12/18/23 revealed Resident #11 was noted to be lethargic, had a productive cough, and had rattling sounds audible upon breathing with continuous oxygen. The Nurse Practitioner assessed Resident #11 and provided prophylactic treatment for pneumonia due to worsening respiratory symptoms. Review of the physician's order dated 12/18/23 revealed Resident #11 was receiving Levaquin (antibiotic) for pneumonia prophylaxis for ten days. Review of the immunization report dated 12/27/23 revealed Resident #11 had received Pneumovax 23 on 02/15/21. There was no additional evidence of pneumococcal vaccinations provided. Review of the undated CDC Pneumococcal Vaccine Timing for Adults factsheet revealed Pneumovax 15 or Pneumovax 20 would be recommended at least one year after last dose of Pneumovax 23 to complete vaccination series. Interview on 12/28/23 at 10:08 A.M. with Interim Infection Preventionist (IP) #845 revealed she was unsure why Resident #11 had not been offered additional doses of pneumococcal vaccination as recommended by CDC. Interim IP #845 confirmed Resident #11 would be eligible for a dose of pneumovax 20. A follow up interview on 12/28/23 at 11:08 A.M. with Interim IP #845 revealed Resident #11 was agreeable to receiving Pneumovax 20, and Resident #11's hospice services were also in agreement. 2. Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including epilepsy, chronic migraine, malignant neoplasm of brain stem, and conversion disorder with seizures or convulsions. Review of the immunization report dated 12/27/23 revealed Resident #21 was not eligible for Pneumovax 20 vaccination. Review of the undated CDC Pneumococcal Vaccine Timing for Adults factsheet revealed Pneumovax 15 or Pneumovax 20 would be recommended for an adult with an immunocompromising condition such as malignancy. Interview on 12/28/23 at 10:08 A.M. with Interim IP #845 revealed she was unsure why Resident #21 had not been offered dose of pneumococcal vaccination as recommended by CDC. A follow up interview on 12/28/23 at 11:08 A.M. with Interim IP #845 revealed Resident #21 had no reported allergies or contraindication for use of pneumococcal vaccination. Interim IP confirmed Resident #21 would be eligible for a dose of Pneumovax 20. Resident #21 was agreeable to receiving Pneumovax 20. 3. Review of the medical record for Resident #26 revealed an admitted [DATE] and diagnoses including personal history of malignant neoplasm of breast, chronic pulmonary edema, dementia, cardiomegaly, and asthma. Review of the immunization report dated 12/27/23 revealed Resident #26 had received Pneumovax 23 on 02/11/21. There was no additional evidence of pneumococcal vaccinations provided. Review of the undated CDC Pneumococcal Vaccine Timing for Adults factsheet revealed Pneumovax 15 or Pneumovax 20 would be recommended at least one year after last dose of Pneumovax 23 to complete vaccination series. Interview on 12/28/23 at 10:08 A.M. with Interim IP #845 revealed she was unsure why Resident #26 had not been offered additional doses of pneumococcal vaccination as recommended by CDC. Interim IP confirmed Resident #26 would be eligible for a dose of Pneumovax 20. A follow up interview on 12/28/23 at 11:08 A.M. with Interim IP #845 revealed Resident #26 was agreeable to receiving Pneumovax 20. Review of the facility policy Pneumococcal Vaccine Policy - Resident, dated 08/19/20, revealed administration of pneumococcal vaccinations or revaccinations would be made in accordance with current CDC recommendations.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of a facility self-reported incident (SRI), review of the facility Cardiopulmonary Resuscitation (CPR) policy and interviews, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #37, who was found unresponsive, without a pulse/heartbeat and identified as a full code status. This resulted in Immediate Jeopardy that was actual harm on [DATE] when Resident #37 did not receive CPR, EMS were not contacted for medical services and the resident subsequently expired. This affected one resident (#37) of two residents reviewed for death in the facility. The facility census was 34 residents. On [DATE] at 10:07 P.M. the Administrator, Mobile Director of Nursing (DON)/Registered Nurse (RN) #152 and Regional Director of Clinical Services (RDCS) were notified that Immediate Jeopardy began on [DATE] at approximately 1:30 P.M. when Licensed Practical Nurse (LPN) #150 found Resident #37, who had advanced directives for a full code status, not breathing. Prior to the incident, LPN #150 last saw Resident #37 alive between 11:30 A.M. and 12:45 P.M. when she provided a wound treatment and fed the resident lunch. LPN #150 confirmed the absence of Resident #37's vital signs but failed to initiate CPR or call 911. LPN #150 indicated she did not think to check Resident #37's medical record to determine code status, initiate CPR or call 911 due to Resident #37 having passed away. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 10:00 A.M., the facility Administrator, Regional [NAME] President of Operations, (RVPO), Regional Director Clinical Services (RDCS) and Clinical Quality Specialist (CQS) were made aware of CPR not being initiated at the time of the occurrence during a facility meeting. On [DATE] at 10:15 A.M., LPN #150, the nurse on duty at the time of the occurrence, was removed from the unit. The facility completed an interview and obtained a statement from the LPN related to the situation. At 10:30 A.M. LPN #150 was suspended pending further investigation. On [DATE] at 11:00 A.M., the facility obtained statements from the State tested Nursing Assistants (STNAs) who were on duty at the time of the occurrence. On [DATE] at 11:30 A.M., the Interim Director of Nursing (IDON) initiated immediate in-house education for all licensed nurses on the facility policies and procedures for identifying a change of condition, initiating CPR and crash cart validation. Those staff not on duty were contacted via telephonic means. This education was completed on [DATE] at 12:45 P.M. On [DATE] at 12:00 P.M., all staff were in serviced by the Administrator and Mobile DON, on Abuse, Neglect and Misappropriation, monitoring and reporting, the overhead paging policy, the phone system, the use of walkie talkies for urgent situations. Staff not on duty were serviced by telephonic means. This was completed on [DATE] at 8:00 P.M. On [DATE] the facility identified the phone system did not have overhead paging capability. The phone system was fixed on [DATE] at 1:30 P.M. On [DATE] all current resident medical records were audited by the Social Service Designee (SSD) to ensure appropriate documentation of current code status and advance directive status. This was completed on [DATE] at 2:30 P.M. On [DATE] at 2:30 P.M., the RDCS in-serviced the Administrator, IDON, Mobile Director of Nursing, Minimum Data Set (MDS) nurse, SSD and the Assistant Director of Nursing (ADON) on validation of code status at the time of expiration notification. On [DATE] at 2:42 P.M. the facility administrator purchased six walkie talkies for nurses and managers to utilize to communicate to staff as needed. They arrived at the facility on [DATE] at 3:41 P.M. On [DATE] at 3:30 P.M., the attending physician was notified Resident #37 had a full code status and CPR was not initiated. On [DATE] at 3:40 P.M., the IDON and Administrator notified Resident #37's wife that the resident's full code status was not honored or initiated on [DATE]. On [DATE], two crash carts were checked to ensure all supplies were available for CPR by the IDON and Mobile DON. There were several missing items that were replaced. A shift-to-shift sign off sheet for CPR cart validation was initiated on [DATE] at 4:00 P.M. On [DATE] at 5:10 P.M., the Human Resource (HR) Director audited all licensed nursing staff files to ensure current CPR certification. Beginning on [DATE] the facility implemented a plan for the Mobile DON or Charge Nurse to conduct a mock code blue drill every shift for three days, then once weekly for four weeks, and once monthly for two months. Mock drills were completed on [DATE] at 6:19 P.M., [DATE] at 9:35 P.M., [DATE] at 5:38 P.M., [DATE] at 9:20 P.M., [DATE] at 5:58 P.M., [DATE] at 9:45 P.M., [DATE]/ at 5:10 P.M. On [DATE] at 7:40 P.M., the RDCS completed an audit of all in-house deaths from [DATE] to current date to ensure resident advance directives were followed. Audits would continue monthly for three months. Beginning on [DATE] the facility implemented a plan for the Administrator/designee to conduct three resident interviews for neglect twice weekly for four weeks. Interviews were completed on [DATE], [DATE], [DATE]. Interviews on [DATE] between 10:01 A.M. and 11:04 A.M. and on [DATE] at 4:09 P.M. with two Registered Nurses (RN), RN #136 and RN #138, and State tested Nursing Assistants (STNAs) #108, #113, #118, #121, and #151, revealed no concerns related to advance directives and/or code status. Each staff member interviewed revealed they were trained on the facility's policy for advance directive, change of condition and CPR. Findings include: Review of the closed medical record for Resident #37 revealed an admitted [DATE] with diagnoses including chronic viral hepatitis C, pressure ulcer of sacral region, acquired absence of left leg above the knee. The record indicated Resident #37 passed away on [DATE] at 1:30 P.M. The resident was in his room unresponsive and absent of vital signs. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #37, dated [DATE], revealed the resident had intact cognition. The assessment indicated the resident did not have a condition or chronic disease that would result in a life expectancy of less than six months. Review of the plan of care for Resident #37 revealed the resident had advanced directives that indicated a Full Code. Interventions included involving the physician in advanced directives conversations and reviewing advanced directives with the resident/family. Review of a hospital discharge summary paper dated [DATE] revealed Resident #37 was a full code status and was discharged to a skilled facility with diagnosis of sepsis and an order for an antibiotic, Levofloxacin for three days. Review of the resident's re-admission physician orders, dated [DATE] revealed the resident did not have a physician order related to advance directives. Review of the admission progress note dated [DATE] at 5:41 P.M. revealed Resident #37 was readmitted from the hospital with a full code status. Review of a note dated [DATE] at 2:17 P.M. revealed at 1:30 P.M. LPN #150 found Resident #37 unresponsive and absent of vital signs. The note indicated postmortem care was provided by STNAs. At 1:35 P.M. the Administrator, family and physician were notified Resident #37 expired. At 2:00 P.M. the family visited. At 2:15 P.M. the family notified the facility of the funeral home arrangements. Review of the nursing progress note revealed no evidence the resident exhibited dependent lividity, rigor mortis, decapitation, or transaction. Review of progress note dated [DATE] at 4:45 P.M. revealed the funeral home removed the resident's body. Review of a progress note dated [DATE] at 9:06 P.M. revealed Resident #37 expired and full code status was not followed. No CPR was initiated. Notification was made to the medical director, physician, and family that CPR was not initiated. Review of a facility self-reported incident (SRI) report, tracking number 239053 dated [DATE] at 2:06 P.M. revealed the facility reported an allegation of neglect involving Resident #37. The SRI noted based on the comprehensive investigation that was completed by the facility which included resident record review, hospital record review and staff interviews the allegation of neglect was verified when Resident #37 was identified without vital signs and designated full code directives which were not followed, and CPR was not initiated. Review of the SRI investigation revealed a statement provided by LPN #150 on [DATE] which revealed at approximately 12:45 P.M. she administered a treatment and assisted Resident #37 with lunch. At 1:30 P.M. Resident #37 was observed without vital signs. Two STNAs came into the room to perform postmortem care, LPN #150 notified the physician, family, Administrator, and IDON of Resident #37 death. LPN #37 arranged with the funeral home to pick up the resident's body. A follow up phone interview on [DATE] with LPN #150 by the RDCS revealed she did not check Resident #37's code status. LPN #150 had readmitted the resident (from the hospital) three days prior and remembered he was a full code. LPN #150 told the RDCS she was rushed and forgot to follow protocol. Interview on [DATE] at 10:22 A.M., with STNA #118 revealed she provided care to Resident #37 on [DATE], the morning he passed. The STNA stated Resident #37 was at his normal baseline status. The STNA revealed later that day, LPN #150 asked her and STNA #121 to provide postmortem care for the resident. STNA #118 stated she had informed LPN #150 Resident #37 was a full code. LPN #150 responded to her that the resident had passed. Interview on [DATE] at 1:23 P.M., with LPN #150 revealed on [DATE] at approximately 11:30 A.M. she administered Resident #37's wound treatment and fed him some lunch. The LPN revealed Resident #37 was alert and smiling. At 1:30 P.M., LPN #150 stated she went back into Resident #37's room and found him unresponsive and without vital signs. LPN #150 did not initiate CPR; however, she did tell STNA #118 and #121 to provide postmortem care. LPN #150 provided notification to the physician, Administrator and family and she arranged for removal of the body. LPN #150 stated she panicked and did not think about full code status or initiating CPR. She stated Resident #37 had passed and his body was cool. LPN #150 stated she did remember re-admitting Resident #37 from the hospital and seeing the full code status on the discharge summary. LPN #150 stated she notified the IDON of the resident's death and was told to write a good nurse's note. The LPN revealed the IDON did not mention to check for the resident's code status. Interview on [DATE] at 3:36 P.M., with STNA #121 revealed she delivered Resident #37's lunch tray and he appeared to be sleeping. At approximately 1:30 P.M. LPN #150 informed her Resident #37 passed away and postmortem care needed to be provided. STNA #121 stated she assisted to provide postmortem care to Resident #37. Interview on [DATE] at 9:21 A.M., with Resident #37's physician, Physician #155 revealed he did not recall addressing any change in the resident's code status (following his re-admission to the facility on [DATE]). He verified LPN #150 had notified him Resident #37 had no pulse and was absent of breath sounds. Interview on [DATE] at 2:00 P.M., with the Mobile DON, revealed [DATE] was his first day of employment. The Mobile DON revealed in the morning meeting on this date, he reviewed Resident #37's full code status and identified CPR was not initiated. Interview on [DATE] at 5:00 P.M., with the Administrator revealed it was unfortunate LPN #150 did not follow Resident #37's advanced directives. The Administrator verbalized the measures the facility had taken following the incident to ensure they had a good system in place to prevent a similar reoccurrence. Interview on [DATE] at 9:26 A.M., with IDON #154 revealed LPN #150 had notified her of Resident #37 death on [DATE]. IDON #154 stated she did not ask about code status but assumed LPN #150 took the appropriate actions according to the resident's advanced directives. Interview on [DATE] at 8:28 A.M., with the medical director (MD), MD #156 revealed facility had very few resident deaths. He stated he was notified Resident #37 did not receive CPR and indicated he expected staff to follow each residents' code status. The MD stated he was involved in developing a corrective action plan for the facility following the incident. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR), revised [DATE] revealed CPR would be provided to all residents who experience cardiopulmonary arrest unless one or more of the following is present. A valid advance directive requesting withholding of CPR. A properly executed ad witness Do Not Resuscitate (DNR) order. Documented verbal wishes by the resident/surrogate decision maker indicating the desire to be DNR but physical order pending. Dependent lividity, rigor mortis, decapitation, or transaction. This deficiency represents non-compliance investigated under Control Number OH00146486.