Every finding on record at Delhi Post-Acute

Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to honor a resident request to be transferred using a slide board. This affected one (Resident #100) of three residents reviewed for choices. Based on medical record review and staff interview, the facility also failed to honor resident choice in conjunction with completion of Advanced Beneficiary Notifications (ABNs.) This affected four (Residents #65, #94, #113, #115) of four residents reviewed for ABNs. The facility census was 104 residents. Findings include: 1.Review of the medical record for Resident #100 revealed an admission date of 02/18/26 with diagnoses including paraplegia, encephalopathy, and congestive heart failure (CHF.) Review of the Minimum Data Set (MDS) assessment for Resident #100 dated 07/17/26 revealed the resident was cognitively intact and required staff assistance with transfers. Review of the care plan for Resident #100 dated 07/07/26 revealed the resident required staff assistance with activities of daily living (ADLs) and mobility. Interventions included the following: two staff to be present during care, transfer per two-person assist using slide board, Hoyer lift is acceptable for transfers when patient is demonstrating fluctuations in levels of functional abilities and cognition. Review of the physician's orders for Resident #100 revealed an order dated 08/14/26 for two-person Hoyer lift for all transfers every shift and an order dated 08/20/26 for two person sliding board assist for transfers to/from bed/wheelchair every shift for transfers, two person assist Hoyer lift still acceptable for transfers when resident demonstrated fluctuations in functional abilities. Review of the Treatment Administration Record (TAR) for Resident #100 dated August 2026 revealed the order for two person Hoyer lift for all transfers every shift for transfers was signed off daily with the exception of 08/23/26 which was blank. The order for the two-person sliding board transfer was not included in the resident's TAR. Review of the facility in-service sign in sheet titled Slide Board In-Service dated 08/21/26 revealed a total of six Certified Nursing Assistants (CNAs) were trained in the use of the slide board transfer. Interview on 08/26/26 at 10:35 A.M. with Resident #100 confirmed she preferred to use the slide board for transfers, but staff continually refused to use the slide board and used the Hoyer lift instead. Interview on 08/25/26 at 2:31 P.M with the Director of Nursing (DON) confirmed Resident #100 had voiced a preference to use the sliding board for transfers versus the use of the Hoyer lift. The DON verified Resident #100 had an order in place for slide board transfers and Rehabilitation Manager (RM) #391 was supposed to train the nursing staff on the utilization of a safe transfer with a sliding board. Interview on 08/26/26 at 10:35 A.M with RM #391 confirmed Resident #100 had a physician order in place for a sliding board transfer and the resident preferred a slide board transfer over a Hoyer lift transfer. RM #391 verified six of the CNAs had been trained on safe use of the sliding board transfers, but staff had not used the slide board for the resident due to fears that it might not be safe. 2. Review of the ABN forms for Resident #65 dated 08/21/26, Resident #94 dated 06/09/26, Resident #113 dated 07/22/26, and Resident #115 dated 02/27/26 revealed there were three options from which residents could choose and the resident was to check only one box. The top of the form indicated, We can't choose a box for you. The three selections on the form included the following: Option 1. I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary of Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the directions on the MSN. Option 2. I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care, I cannot appeal because Medicare won't be billed. Option 3. I don't want the care listed above. I understand that I am responsible for paying and I can't appeal to see if Medicare would pay. Review of ABNs for Residents #65, #94, #113 and #115 revealed Option 3 had been checked on each of the ABNs. Interview on 08/26/26 at 9:15 A.M. with the Business Office Manager (BOM) #247 confirmed she was responsible for issuing ABNs to residents. BOM #247 verified the ABNs for Residents #64, #94, #113, and #115 all had option 3 checked. BOM #247 confirmed she had guided the residents and/or resident representative to pick Option 3 even though the form read, We can't choose for you. This deficiency represents noncompliance investigated under Complaint Number 3097702.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident medications were available for administration. This affected one (Resident #87) of three residents reviewed for medications. The faciilty census was 104 residents. Findings include: Review of the medical record for Resident #100 revealed an admission date of 02/18/26 with diagnoses including paraplegia, encephalopathy, and congestive heart failure (CHF). Review of the Minimum Data Set (MDS) assessment for Resident #100 dated 07/17/26 revealed the resident was cognitively intact and dependent on staff for medication administration. Review of the physician orders for Resident #100 revealed an order dated 08/01/26 for Tramadol 25 milligrams (mg) by mouth every eight hours as needed for pain. Observation on 08/25/26 at 11:40 A.M. of Resident #100 revealed the resident was rolling back and forth in her bed and appeared to be extremely uncomfortable. Interview on 08/25/26 at 11:40 A.M with Resident #100 verified she was in pain. Resident #100 stated she was due for her pain medication and staff told her the facility was out of her medication. Interview on 08/25/26 at 11:45 A.M. with Certified Medication Technician (CMT) #319 and Assistant Director of Nursing (ADON) #341 confirmed Resident #100 was in pain and was due for pain medication, but the facility was out of the medication, Tramadol 25 mg. CMT #319 stated she attempted to retrieve the medication from the emergency medication (e-box) but the resident's dose of Tramadol was not available. Review of the facility policy titled Administering Medications dated 2001 confirmed medications were administered in a safe and timely manner, and as prescribed. This deficiency represents noncompliance investigated under Complaint Number 3097702.

Based on medical record review and staff interview, the facility failed to develop comprehensive care plans for use of devices. This affected one (Resident #10) of 3 residents reviewed for falls. The facility census was 99 residents.Findings include: Review of medical record for Resident #10 revealed an admission date of 01/11/25 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and osteoporosis and a discharge date of _____ Review of the care plan for Resident #10 dated 12/12/25 revealed the care plan did not include the use of a power wheelchair with a seatbelt. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 12/15/25 revealed the resident had intact cognition and was dependent on staff for all activities of daily living (ADLs). Review of the medical record for Resident #10 revealed it did not include an assessment regarding the appropriateness of the use of a seatbelt in the resident's power wheelchair.Interview on 02/18/25 at 11:34 A.M. with the Director of Nursing (DON) and Director of Rehabilitation (DOR) confirmed Resident #10 used a power wheelchair with a seatbelt for mobility. The DON and the DOR confirmed the facility had not conducted an assessment regarding the use of the seatbelt nor had the facility developed a care plan for the use of the seatbelt with Resident #10's power wheelchair. Further interview confirmed Resident #10's plan of care should have reflected the use of the seatbelt.

Based on medical record review, review of facility Self-Reported Investigations (SRIs), staff interview, and review of the facility policy, the facility failed to ensure allegations involving resident abuse were reported to the Ohio Department of Health (ODH) in a timely manner. This affected one resident (Resident #5) of three residents reviewed for abuse. The facility census was 99 residents. Findings include:Review of the medical record for Resident #5 revealed an admission date of 12/06/24 with diagnoses including chronic obstructive pulmonary disease, vascular dementia unspecified severity with other behavioral disturbance, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 12/12/25 revealed the resident had intact cognition and was dependent on staff for bathing. Review of the facility SRI involving Resident #5 revealed it was created on 02/02/26 at 12:06 P.M and the date of discovery of the allegation was 02/01/26.Interview on 02/18/26 P.M. at 12:24 P.M. with the Director of Nursing (DON) confirmed the facility received the notification of an alleged incident of staff to resident sexual abuse on 02/01/26 at 11:00 AM. The DON confirmed the facility did not report the incident to the state agency until over 24 hours later. Review of the facility policy tilted Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 revealed the facility should report any allegations within timeframes required by federal requirements.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of police reports, resident interview, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were free from abuse. This affected one (Resident #5) of three residents reviewed for abuse. The facility census was 99 residents. Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/06/24 with diagnoses including chronic obstructive pulmonary disease, vascular dementia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 01/05/26 revealed the resident had intact cognition. and required setup or cleanup assistance for bed mobility, transfers, and ambulation. Review of the facility SRI regarding Resident #5 dated 02/02/26 and timed 12:06 P.M. revealed the facility investigated and substantiated an allegation of sexual abuse per Licensed Practical Nurse (LPN) #201 towards the resident. Resident #5 reported to staff that Licensed Practical Nurse (LPN) #201 sent the resident pictures of her exposed breasts and allowed the resident to have sexual contact with her breasts. LPN #201 also videotaped the sexual contact between the nurse and Resident #5 using the resident's personal cell phone. The Director of Nursing (DON) confirmed the video which was viewable on Resident #5's personal phone lasted approximately forty-five seconds and clearly showed LPN #201's face. Interview with Resident #5 on 02/01/26 confirmed he had consented to the sexual contact and also confirmed LPN #201 had touched his genital before but could not recall the date. Interview with LPN #201 denied the allegations of sexual abuse. The local police interviewed LPN #201 on 02/03/26 and reported to the facility that LPN #201 had confessed to the allegations of sexual abuse towards Resident #5. The facility substantiated the allegation of sexual abuse and terminated LPN #201. Review of the police report dated 02/02/26 revealed the facility Director of Nursing (DON) reported Resident #5 sent them a video of the resident engaging in sexual contact with LPN #201. Review of the personnel record for LPN #201 revealed the facility emailed a written termination notice to the nurse on 02/09/26. The termination notice indicated LPN #201 was terminated due to sexual misconduct with a resident. Interview on 02/12/26 at 11:00 A.M with Detective #675 confirmed the local police were investigating LPN #201 for possible charges of sexual battery. Interview on 02/13/26 at 10:45 A.M. with Detective #675 confirmed LPN #201 had confessed she had sexual contact with Resident #5 and they were going to pursue a charge of sexual battery. Interview on 02/17/26 at 11:22 A.M. with LPN #201 confirmed she was notified on 02/01/26 by phone per LPN #301 that she was suspended due to allegation of sexual abuse towards a resident. LPN #201 denied having sexual contact with Resident #5. Observation on 02/17/26 at 12:01 P.M. revealed Resident #5 showed the Surveyor approximately two seconds of a video on his phone which showed LPN #201's face and her exposed breasts. Interview on 02/17/26 at 12:02 P.M. with Resident #5 confirmed that on a date prior to 02/01/26 LPN #201 sent him pictures of her exposed breasts and allowed the resident to suck on her breasts. LPN #201 also videotaped Resident #5 sucking on her breasts using the resident's phone. Resident #5 confirmed he consented to sexual activity with LPN #201. Resident #5 confirmed he reported LPN #201's actions to staff because he was upset as she was not spending as much time with him after the sexual incident had occurred. Interview on 02/17/26 at 12:20 P.M. with the DON, Registered Nurse Manger (RNM) #303, Assisted Director of Nursing (ADON) #306, ADON #307, and Licensed Practical Nurse Manager (LPNM) #308 confirmed the facility investigated the allegation of sexual abuse per LPN #201 towards Resident #5 and concluded abuse had occurred. Further interview revealed LPN #201 was suspended on 02/01/26, the facility did comprehensive assessments of all residents, and started all-staff education on abuse. Interview on 02/17/26 at 1:25 P.M. with the DON and the Administrator confirmed on 02/01/26 they viewed a video on Resident #5's phone of LPN #201 and Resident #5 engaging in sexual contact consisting of Resident #5 sucking on LPN #201's exposed breasts. The video was approximately 45 seconds long and both LPN #201 and Resident #5 were visible. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 revealed the residents had the right to be free from abuse, including sexual abuse. This deficiency represents noncompliance investigated under Complaint Number 2740112 and Complaint Number 2743935.

Based on observation and interview, the facility failed to prepare food in a clean environment. This had the potential to affect all residents of the facility. The facility census was 102 at the time of survey.Findings include:During initial tour of the facility kitchen on 09/25/25, two ceiling vents were observed to have a brown, fuzzy build up on them. One vent was positioned directly over the meal prep area.Interview with Dietary Director #203 on 09/29/25 at 11:10 A.M. confirmed that the vents were dirty and had the potential to blow debris onto the food prep area and contaminate the food.Interview with the Administrator on 09/29/25 revealed that the vents were removed and thoroughly cleaned.This was an incidental finding discovered during the course of the complaint investigation.

Based on interview and record review, the facility failed to maintain clinical records, including medication administration, in accordance with accepted professional standards and practices that are complete, accurately documented, and readily accessible. This affected two residents (#2 and #4) of four residents reviewed. The facility census was 102 at the time of survey.Findings include:1.Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease (CKD), Schizophrenia, and Type II Diabetes Mellitus.Resident #2 had an order for oxycodone-acetaminophen oral tablet 5-325 mg Give 1 tablet by mouth every 6 hours as needed for pain.Review of the July sign-out sheet and medication administration record (MAR) for Resident #2's oxycodone-acetaminophen revealed that the medication was signed out for administration on 07/05/25 at 05:30, 12:15, 08:30, and 15:11 with administration documented at 05:32 and 12:18. On 07/06/25 the medication was signed out for administration at 21:30 with no documentation for administration. On 07/07/25 the medication was signed out for administration at 07:00 and 13:00 with no documentation for administration. 2.Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included Acquired Absence of Left Leg Above the Knee, COPD, and Peripheral Vascular Disease.Resident #4 had an order for oxycodone HCl Oral Capsule 5 mg by mouth every 6 hours as needed for pain.Review of the August sign-out sheet and MAR for Resident #4's oxycodone revealed that the medication was signed out for administration on 08/26/25 at 15:15 and 9:30 P.M. with administration documented at 23:14. On 08/27/25 the medication was signed out at 00:00, 06:00, 14:30, and 8:30 with no documentation of administration. On 08/28/25 the medication was signed out at 14:00, 18:00, and 00:28 with documentation of administration at 18:00.Interview with Director of Nursing on 09/29/25 at 9:12 A.M. revealed that the facility was unaware of medications being signed out and not documented as being given. Interview with Administrator on 09/29/25 revealed that an investigation was initiated and an Self Reported Incident (SRI) was filed regarding the matter. Facility policy titled Administering Medications dated April 2019 states As required or indicated for a medication, the individual administering the medication records resident's medical record the date and time the medication was administered.This deficiency represents non-compliance investigated under Complaint Number 2603422

Based on medical record review, observations, resident and staff interviews, and policy review, the facility failed to timely obtain and implement hospital recommendations for positive airway pressure devices, and the facility failed to have physician orders for positive airway pressure devices. This affected one (Resident #72) of three residents reviewed for positive airway pressure devices. The facility census was 101. Findings include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) and diastolic heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 had moderately impaired cognition, had no behaviors, and did not reject care. Review of the care plan dated 08/05/24 revealed Resident #72 was at risk for complications with the respiratory system due to multiple diagnoses. Resident #72 was noted to adjust her oxygen settings on her own. Interventions included assess/report signs of hypoxia, incentive spirometer as ordered, oxygen therapy as ordered, and remind resident not to adjust her oxygen settings as needed. Resident #72 discharged to the hospital on 09/03/24 and returned to the facility on [DATE]. Review of the hospital discharge summary dated 09/05/24 revealed Resident #72 presented to the Emergency Department (ED) with shortness of breath, increased confusion, and taking off her oxygen per nursing facility on 09/03/24 and was admitted with COPD exacerbation, acute on chronic respiratory failure with hypercapnia and hypoxia, and acute metabolic encephalopathy. Resident #72 was treated with steroids, bronchodilators, and bilevel positive airway pressure (BiPAP), and showed significant improvement, and was back to her baseline at the time of discharge. Resident #72 was weaned to her baseline oxygen of three liters per minute and was recommended to continue using BiPAP while sleeping at the facility. There were no specifications noted on the discharge summary for BiPAP settings. Review of the medical record revealed no progress noted regarding follow-up with the hospital for clarification for BiPAP settings after return to the facility on [DATE]. There were no active or completed physician orders for the use BiPAP for Resident #72. Resident #72 discharged to the hospital on 09/17/24. Review of the hospital paperwork dated 09/17/24 revealed Resident #72 presented to the ED with a complaint of altered mental status (AMS). It was strongly suggested the altered mental status was secondary to medication. While Resident #72 would most likely benefit from BiPAP, it was highly unlikely she would use BiPAP. Since she did not present with acute hypercapnia nor need BiPAP during this admission, recommendations included to hold off on BiPAP after discharge. There were no active or completed physician orders for the use BiPAP for Resident #72. During an interview on 10/01/24 at 2:38 P.M., Registered Nurse (RN) #226 verified Resident #72 had no records for BiPAP in her electronic medical record. RN #226 stated she knew Resident #72 looked in the medical record and verified Resident #72 did not have an order in the chart for BiPAP and the resident had a BiPAP machine in her room. During an interview and observation on 10/01/24 at 2:57 P.M., Resident #72 was observed sitting up in bed with a BiPAP machine on a cart at bedside. Resident #72 stated the machine had been ordered around the beginning of September, date not specified. The resident stated the device originally sat in her room about four to five nights, unused, because none of the staff knew how to apply it. An unidentified nurse set up the device, explained how to use it, and the resident stated she both applied and turned on the device herself at bedtime. During an interview on 10/01/24 at 3:57 P.M., the Director of Nursing (DON) stated she called their supplier last week (09/27/24) in response to family concerns that Resident #72 was not getting her BiPAP. The DON stated Respiratory Therapy (RT) was supposed to come assess the resident first before the machine was delivered to the resident. The DON stated Resident#72 had not been assessed by RT, and the DON was not sure why the BiPAP machine had been delivered to her room. The DON verified Resident #72 used the machine without physician orders. The DON did not know how the machine had been delivered without an order. Observation and interview on 10/02/24 at 10:19 A.M. revealed Resident #73 was seated upright in bed with BiPAP mask on face and machine running. Licensed Practical Nurse (LPN) #154 was standing at bedside with resident adjusting straps to facemask for BiPAP machine. LPN #154 stated Resident #72 had an order for BiPAP to be used at bedtime and as needed (PRN). The nurse stated she walked into the room and Resident #72 was putting on the mask because she said she wanted to take a nap. The nurse stated she had just turned the machine on and was adjusting the straps when this surveyor walked into the room. The nurse verified there was an error message on the machine and removed the mask. LPN # 154 stated she did not know what the settings were supposed to be and stated she had to check the order. LPN # 154 verified Resident #73 did not have an order on file for the BiPAP machine and stated she would have to call the provider for settings before she could apply the mask to the resident. LPN #154 stated she did not know how long Resident #73 had the device. LPN # 154 stated she had just returned from a two-week vacation and believed Resident #72 had the device before she left. Review of the facility document titled CPAP/BiPAP Support, dated 03/2015, revealed prior to using positive air pressure devices, nurses should check the medical record for baseline oxygen saturation levels, review the physician's order to determine oxygen concentration, flow, and Positive End-Expiratory Pressure (PEEP) settings for the machine. This deficiency represents non-compliance investigated under Complaint Number OH00158245.

Based on medical record review, staff interview, and policy review, the facility failed to provide medications as ordered. This affected one (Resident #72) of five residents reviewed for medication administration. The facility census was 101. Findings include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety disorder, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 had moderately impaired cognition and did not reject care. Review of the care plan dated 08/05/24 revealed Resident #72 was at risk for pain or discomfort due to shingles neuropathy, chronic back pain, and right fourth and fifth toe fractures. Interventions included to administer medications as ordered, assess pain every shift and as indicated, and notify physician of unmanageable/intolerable pain. Review of Resident #72's physician orders dated August 2024 revealed an order for Lyrica (generic is pregabalin) oral capsule 75 milligrams (mg) - Give one capsule by mouth three times a day for pain. Review of the Medication Administration Record (MAR) dated August 2024 revealed Resident #72 did not receive doses of Lyrica 75 mg on 08/12/24 (three doses), 08/13/24 (three doses), and 08/17/24 (three doses). Review of the progress notes dated 08/12/24, 08/13/24, and 08/17/24 revealed Lyrica (Pregabalin) 75 mg was not available to be administered. During an interview on 10/01/24 at 2:38 P.M., Registered Nurse (RN) #226 verified Resident #72 did not receive nine doses of Lyrica as ordered on 08/12/24, 08/13/24, and 08/17/24 because the facility did not have medication and the medication was unavailable in the emergency supply. Review of the policy titled Administering Medications dated 04/2019 revealed medications were administered in a safe and timely manner and within one hour of their prescribed time. This deficiency represents non-compliance investigated under Complaint Number OH00158245.

Based on staff interview and facility document review, the facility failed to ensure that the designated director of food and nutrition services met the requirements for a dietary supervisor of a facility kitchen. This had the potential to affect 94 of 95 residents who received meals from the kitchen. Findings include: Interview on 05/20/24 at 9:01 A.M. with the Dietary Director (DD) confirmed she had been in the position since January 2024, and she was in the process of completing her certified dietary manager course. Interview on 05/23/24 at 9:02 A.M. with the Administrator confirmed the DD did not have a food service manager certification. The Administrator stated the DD had only been in the position since January 2024 and was obtaining the certification but had not yet scheduled the exam. Interview on 05/23/24 at 9:08 A.M. with the facility's Registered Dietitian (RD) confirmed that the DD was working on her food service manager certification. The RD stated the DD should have the certification, because she was running a kitchen. Interview on 05/23/24 at 10:15 A.M. with the Administrator confirmed the DD did not meet the qualifications for their position. The Administrator confirmed the DD should have certification as a food service manager. Review of the job description titled Dietary Supervisor signed by the DD on 01/21/24 revealed the job required the employee to be a graduate of an approved dietary manager's course that met the state and federal care regulations.

Based on review of the facility menu, observation, staff interview, facility document review, and facility policy review, the facility failed to follow the planned menu as approved by the dietitian. This had the potential to affect 94 of 95 residents who received meals from the kitchen. Findings include: Review of the facility menu dated 05/21/24 revealed the planned lunch menu included Polish sausage on bun, sauerkraut, garlic mashed potatoes, green beans, and Jello rainbow cake. Observation on 05/21/24 at 11:22 A.M. revealed the lunch trays included a Polish sausage on a bun, mashed potatoes, and sauerkraut. Further observation also revealed lunch trays included an orange (for residents with a regular diet order), canned fruit (for residents with a mechanical soft diet order) and apple slices (for residents with a renal diet order). There was no cake or green beans on the lunch trays. Interview on 05/21/24 at 2:29 P.M. with the Dietary Director (DD) confirmed the lunch trays did not include green beans or cake as outlined on the menu. The DD further confirmed an orange was not an equivalent substitute for cake, and that the cake was not served because they did not have staff available to bake a cake. Interview on 05/22/24 at 12:43 P.M. with the Registered Dietitian (RD) confirmed the current menus were already in use when she started at the facility. The RD stated she had not reviewed the menus because they had been reviewed and approved by the previous RD. The RD stated her expectation was that the facility should follow the menus and an orange was not an appropriate substitute for cake. Interviews on 05/22/24 at 4:32 P.M. with the Director of Nursing (DON) confirmed the kitchen staff should follow the menus, policy, and RD recommendations. Interview on 05/23/24 at 10:49 A.M. with the Administrator confirmed the kitchen should follow the menus or get approval from the RD to change them. Review of the facility policy titled Menus revised October 2008 revealed menus shall meet the nutritional needs of residents, should be prepared in advance, and should be followed. The Dietitian should review and approve all menus.

Based on observation, staff interview, review of facility documents and policies, and review of the United States Food and Drug Administration (USFDA) Code, the facility to ensure kitchen equipment used in resident food preparation was kept clean and free of dust and debris. This had the potential to affect 94 of 95 residents who received meals from the kitchen. Findings include: Observation on 05/20/24 at 9:09 A.M. revealed there was a black and pink substance on the interior ice shield of the ice machine in the kitchen. Observation on 05/21/24 at 10:25 A.M. revealed the black and pink substance remained on the interior shield of the ice machine in the facility kitchen. Observation on 05/21/24 at 10:33 A.M. revealed there was a fan running in the dish room that had dust and dirt buildup on the fan cover. Dust was hanging off the cover and blowing in the wind produced by the fan. The fan was blowing toward the clean dishes in the dish room. Observation on 05/21/24 at 10:52 A.M. revealed there was a metal dish rack being used to store clean water pitchers stored upside down. The rack had dust buildup with small pieces of dust hanging from the metal racks. Interview on 05/22/24 at 10:39 A.M. with the Administrator confirmed the fan and the ice machine were dirty and should be cleaned by the Maintenance Director (MD). The Administrator confirmed the metal dish rack was dirty and should be cleaned as needed by the kitchen staff. Interview on 05/22/24 at 10:56 A.M. with the MD confirmed there was no cleaning log for the fans in the kitchen, and the ice machine was scheduled for cleaning every six months. The MD stated they might need to change the ice machine to a quarterly cleaning schedule. Interview on 05/22/24 at 12:43 P.M. with the Registered Dietitian (RD) stated the kitchen staff should keep kitchen equipment clean to prevent dirt from falling in the food. The RD stated she had told the kitchen staff about the dust hanging off the fan and that it could blow onto the clean dishes. The RD stated she was not aware of the dirty ice machine but had noted some general cleaning needs on a previous visit to the kitchen. Interview on 05/22/24 at 4:32 P.M. with the Director of Nursing (DON) confirmed the kitchen staff should follow the policies for cleaning because it was important for infection control. Review of the facility document titled Daily Kitchen Cleaning Schedule, undated, revealed there were no guidelines for cleaning the ice machine, the kitchen fan, or metal dish racks. Review of the facility document titled Ice Machine Cleaning Schedule, undated, revealed the ice machine should be cleaned every six months and was due to be cleaned next in July 2024. The cleaning schedule indicated staff should check the filters, clean the coils, sanitize the interior, and delime the machine, as necessary. Review of an undated manufacturer's instruction manual for cleaning the ice machine revealed the manufacturer generally recommended two annual cleanings, but some businesses required four major cleanings every year. Further review revealed in between the more thorough cleans, the machine should be wiped down as needed due to spillage or any noticeable internal or external dirtiness. Review of the facility policy titled Sanitization revised November 2022 revealed the food service area should be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas should be kept clean, free from garbage and debris, and protected from rodents and insects. Ice machines and ice storage containers should be drained, cleaned, and sanitized per the manufacturer's instructions. Review of the USFDA Code dated 2022 Chapter 4, Section 4-601.11, revealed nonfood contact surfaces or equipment should be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure staff accurately documented medication administration. This affected one (Resident #40) of 19 sampled residents. The facility census was 95 residents. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE] with a diagnosis of anxiety disorder. Review of the care plan for Resident #40 initiated on 06/08/22 and revised on 01/30/24 revealed the resident received psychotropic medications that included antianxiety medications. Interventions included staff to give medications as ordered. Review of the medication review report for Resident #40 revealed a physician's order dated 06/30/23 for Ativan (an antianxiety medication) one milligram (mg) by mouth every six hours for anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment for Resident #40 dated 04/19/24 revealed the resident was cognitively intact and received antianxiety medications during the assessment period. Review of the Medication Administration Record (MAR) for Resident #40 dated May 2024 revealed Registered Nurse (RN) #03 documented administration of Ativan one mg to the resident on 05/20/24 at 12:00 A.M. and 6:00 A.M. Review of the facility medication error report dated 05/20/24 timed at 1:00 P.M., revealed Resident #40's Ativan supply was exhausted on 05/19/24, which caused the resident to miss four doses of medication between 05/19/24 and 05/20/24. Interview on 05/22/24 at 10:43 A.M. with RN #03 confirmed she did not administer Resident #40's routine doses of Ativan on 05/20/24 at 12:00 A.M. and 6:00 A.M. because she could not access the emergency box. RN #03 stated she documented administration of those doses in error. Interview on 05/23/24 at 11:07 A.M. with the Director of Nursing confirmed nurses should not document administration of a medication unless the medication had actually been administered. Review of the facility policy titled Administering Medications revised April 2019 revealed the individual administering the medication should initial the resident's MAR on the appropriate line after giving each medication and before administering the next one.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure medications were ordered and available for administration as ordered by the physician. This affected one (Resident #40) of 19 sampled residents. The facility census was 95 residents. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE] with a diagnosis of anxiety disorder. Review of the care plan for Resident #40 initiated on 06/08/22 and revised on 01/30/24 revealed the resident received psychotropic medications that included antianxiety medications. Interventions included staff were to give medications as ordered. Review of the medication review report for Resident #40 revealed a physician's order dated 06/30/23 for Ativan (an antianxiety medication) one milligram (mg) by mouth every six hours for anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment for Resident #40 dated 04/19/24 revealed the resident was cognitively intact and had received antianxiety medication during the last seven days of the assessment period. Review of the order audit for Resident #40 revealed the pharmacy dispensed Ativan on 04/28/24. Review of the controlled drug record for Resident #40 revealed the facility received 60 Ativan tablets on 04/29/24. According to the prescription label on the form, the next Ativan refill required a new prescription. Further review of the drug record revealed the last dose of Ativan for Resident #40 was signed out on 05/19/24 at 6:00 A.M. Review of a medication error report dated 05/20/24 timed at 1:00 P.M. for Resident #40 revealed the resident's Ativan supply was exhausted on 05/19/24, which caused the resident to miss four doses between 05/19/24 and 05/20/24. Interview on 05/20/24 at 12:50 P.M. with Resident #40 confirmed the facility ran out of the resident's Ativan on 05/19/24 at 6:00 A.M. Interview on 05/22/24 at 10:43 A.M. with Registered Nurse (RN) #03 confirmed she did not administer Resident #40's 12:00 A.M. or 6:00 A.M. dose of Ativan on 05/20/24 because she did not have access to the facility's emergency medication kit. Interview on 05/22/24 at 6:42 A.M. with Licensed Practical Nurse (LPN) #05 confirmed there had been times when the facility did not have Resident #40's Ativan medication. LPN #05 stated when that happened, she called the pharmacy to make sure it was on the way. LPN #05 stated medications should be reordered at least two days prior to the last dose available to ensure the medication was available to administer as ordered. Interview on 05/22/24 at 2:01 P.M. with LPN #06 confirmed the normal process for reordering medications was to first check to see if the resident had an active prescription. If the resident had an active prescription, the staff could reorder the medication via the resident's electronic health record two to three days prior to the last available dose of the medication to ensure the medication would be available when needed. LPN #06 further confirmed she did not notice Resident #40 was low on Ativan, but if she had, she would have reordered the medication. Interview on 05/22/24 at 1:31 P.M. with the Regional Nurse Consultant (RNC) confirmed that typically the facility should reorder narcotics at least two days prior to the last available dose of medication or when there were 10 doses left to give. The RNC stated the staff should have re-ordered Resident #40's Ativan by 05/17/24, but they had not done so, and Resident #40 missed four doses of Ativan on 05/19/24 and 05/20/24. Interview on 05/23/24 at 11:07 A.M. with the Director of Nursing (DON) confirmed nurses should reorder controlled substances according to the sticker on the medication pack provided by the pharmacy. The DON confirmed nurses should administer medications as ordered and to report to her as soon as possible of any missed doses or difficulty accessing the emergency medication box. Review of the facility policy titled Pharmacy Services Overview revised in April 2019, revealed the facility staff should ensure residents had a sufficient supply of their prescribed medications and that residents received medications (routine, emergency or as needed) in a timely manner. Nursing staff should communicate prescriber orders to the pharmacy and were responsible for contacting the pharmacy if a resident's medication was not available for administration.

Based on medical record review, staff interview and facility document and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #40) of 19 sampled residents. The facility census was 95 residents. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE] with a diagnosis of anxiety disorder. Review of the care plan for Resident #40 initiated on 06/08/22 and revised on 01/30/24 revealed the resident received psychotropic medications that included antianxiety medications. Interventions included staff were to give medications as ordered. Review of the medication review report for Resident #40 revealed a physician's order dated 06/30/23 for Ativan (an antianxiety medication) one milligram (mg) by mouth every six hours for anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment for Resident #40 dated 04/19/24 revealed the resident was cognitively intact and had received antianxiety medication during the last seven days of the assessment period. Review of the order audit for Resident #40 revealed the pharmacy dispensed Ativan on 04/28/24. Review of the controlled drug record for Resident #40 revealed the facility received 60 Ativan tablets on 04/29/24. According to the prescription label on the form, the next Ativan refill required a new prescription. Further review of the drug record revealed the last dose of Ativan for Resident #40 was signed out on 05/19/24 at 6:00 A.M. Review of a medication error report dated 05/20/24 timed at 1:00 P.M. for Resident #40 revealed the resident's Ativan supply was exhausted on 05/19/24, which caused the resident to miss four doses between 05/19/24 and 05/20/24. Interview on 05/20/24 at 12:50 P.M. with Resident #40 confirmed the facility ran out of the resident's Ativan on 05/19/24 at 6:00 A.M. Interview on 05/22/24 at 10:43 A.M. with Registered Nurse (RN) #03 confirmed she did not administer Resident #40's 12:00 A.M. or 6:00 A.M. dose of Ativan on 05/20/24 because she did not have access to the facility's emergency medication kit. Interview on 05/22/24 at 6:42 A.M. with Licensed Practical Nurse (LPN) #05 confirmed there had been times when the facility did not have Resident #40's Ativan medication. LPN #05 stated when that happened, she called the pharmacy to make sure it was on the way. LPN #05 stated medications should be reordered at least two days prior to the last dose available to ensure the medication was available to administer as ordered. Interview on 05/22/24 at 2:01 P.M. with LPN #06 confirmed the normal process for reordering medications was to first check to see if the resident had an active prescription. If the resident had an active prescription, the staff could reorder the medication via the resident's electronic health record two to three days prior to the last available dose of the medication to ensure the medication would be available when needed. LPN #06 further confirmed she did not notice Resident #40 was low on Ativan, but if she had, she would have reordered the medication. Interview on 05/22/24 at 1:31 P.M. with the Regional Nurse Consultant (RNC) confirmed that typically the facility should reorder narcotics at least two days prior to the last available dose of medication or when there were 10 doses left to give. The RNC stated the staff should have re-ordered Resident #40's Ativan by 05/17/24, but they had not done so, and Resident #40 missed four doses of Ativan on 05/19/24 and 05/20/24. Interview on 05/23/24 at 11:07 A.M. with the Director of Nursing (DON) confirmed nurses should reorder controlled substances according to the sticker on the medication pack provided by the pharmacy. The DON confirmed nurses should administer medications as ordered and to report to her as soon as possible of any missed doses or difficulty accessing the emergency medication box. The DON confirmed the facility made a significant medication error for Resident #40 because the resident missed four doses of ordered medication. Review of the facility policy titled Pharmacy Services Overview revised in April 2019, revealed the facility staff should ensure residents had a sufficient supply of their prescribed medications and that residents received medications (routine, emergency or as needed) in a timely manner. Nursing staff should communicate prescriber orders to the pharmacy and were responsible for contacting the pharmacy if a resident's medication was not available for administration.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, interviews, and facility incident report, the facility failed to administer medication as ordered. This affected one (Resident #95) of three residents reviewed for medication administration. The facility census was 94. Findings include: Review of the medical record for Resident #95 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses of lung disease, type II diabetes, osteoporosis, and heart disease. Review of the most recent Minimum Date Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required moderate assistance with care. Review of the physician's orders dated 01/09/24 noted an order for Prolia 60 mg (a medication that helps stop the development of bone removing cells) per injection every six months on the 12th of the month. Review of the 01/24 Medication Administration Record (MAR) revealed the medication was given on 01/12/24. The medication was not due until 04/12/24. Review of the facility incident report dated 01/15/24 revealed the medication was given in error. Interview with the Director of Nursing (DON) on 02/15/24 at 11:00 A.M. verified Resident #95's Prolia was given too soon. The DON noted it was transcribed incorrectly to the MAR. As a result of the incident, the facility took the following actions to correct the deficient practice by 01/22/24. On 01/15/24, Resident #95 was fully assessed by facility nursing and deemed to be in good health; there were no injuries or health declines noted. The doctor was called with orders for labs on 01/22/24. On 01/19/24 the DON provided education to all nursing staff regarding the importance of accurate order entry. The education was completed on 01/22/24. On 01/19/24 audits were conducted on all admissions since 01/01/24. No other errors were found. On 01/19/24, the DON implemented weekly audits for four weeks to ensure medication orders align with resident's current status. This deficiency represents non-compliance investigated under Complaint Numbers OH00150507 and OH00150366.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure wound treatments were completed as physician ordered. This affected one (Resident #8) of four residents reviewed for wound care. The facility census was 101. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type II diabetes mellitus with neuropathy, and partial traumatic amputation of right lower leg. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 05/25/23 revealed Resident #8 was at risk for impaired skin integrity related to cerebrovascular accident (CVA) with left-sided hemiplegia, malnutrition, diabetes, venous insufficiency, cardiac conditions and osteoarthritis. Interventions included to encourage not to self-transfer, notify wound nurse if ulcer develops, pressure reduction mattress, observe skin during daily care, daily preventative skin care, incontinence care as needed, and dietitian review for nutritional recommendations as needed. Review of the physician orders dated 07/01/23 revealed Resident #8 had a wound care order to cleanse the skin tear to the left shin, apply Thera Honey Gel, and cover with bordered gauze every day. Observation on 07/06/23 at 1:50 P.M. revealed Resident #8 had two bordered foam dressings on his left lower leg dated 07/03/23. During an interview on 07/06/23 at 2:16 P.M., Licensed Practical Nurse (LPN) #181 verified the dressing on Resident #8's lower leg were dated 07/03/23 and verified the physician order was for the dressing to be changed daily. Review of the policy titled Wound Care, revised October 2010, revealed the facility provided wound care according to physician orders to promote healing. This deficiency represents non-compliance investigated under Complaint Numbers OH00143849 and OH00143819.

Based on resident and staff interviews, observations, and record reviews, the facility failed to maintain an operating telephone system. This had the potential to affect all 88 residents residing in the facility. Findings: Random observations throughout the survey n 12/15/22 revealed nursing staff making telephone calls on their cell phones related to facility business. An attempt to call the facility from an outside telephone number on 12/15/22 at 9:44 A.M. revealed the facility telephone rang four times and an option menu was offered. A selection was made for the nursing department and a message was received the voicemail was full. During an interview on 12/15/22 at 10:45 A.M. with a Licensed Practical Nurse (LPN) #15, who worked on the fifth floor, she reported the telephones have been broken for months. She stated the telephone would ring half a ring one time and then stop ringing not giving the staff enough time to answer. She reported the telephone call would at times transfer to other floors and they would have to rely on those staff to take information and pass it on to them as the internal and external transferring of telephone calls did not work. She stated facility staff usually tried to make sure messages were relayed but they often had agency staff who would just keep trying to transfer the telephone call until it dropped and then the information as to who was calling was lost. She stated while she was told the facility was working on fixing the problem, they had not been given a time frame and had been offered no alternatives, resources, or plans of action. During interviews on 12/15/22 at 11:00 A.M. with State tested Nurse Aides (STNA) #18 and STNA #20, who worked on the third floor, they stated they thought there had been concerns with the telephone system for about six months and reported the telephone on the third floor did not have a dial tone (which was confirmed). During an interview on 12/15/22 at 3:00 P.M. with the Receptionist #32, she reported the transferring system was not working consistently and she had been asked by some callers not to transfer the telephone call but to take and deliver the messages herself. During an interview on 12/15/22 at 3:53 P.M. with the Administrator and the Director of Nursing (DON), the Administrator reported the telephones had been inconsistent with people being able to successfully call in. The DON stated the telephone situation had gotten worse over the last three months. The Administrator reported the new telephone company was on shut down for Christmas from 12/15/22 to 01/20/22 so the first available live date for the new telephone system was 01/24/23. During an interview on 12/15/22 at 2:36 P.M. with Resident #4 he reported his friend had been unable to call him on the facility telephone for some time. He stated he had been told they were fixing the telephone system and then a cordless phone would be available but it had not yet happened. During an interview on 12/15/22 at 2:45 P.M. with Resident #5, she reported she had tried to use the telephone in her room a few times but it had not worked. During an interview on 12/15/22 at 2:50 P.M. with Resident #1, she reported she was aware her sister had trouble calling in to the facility but she was not sure how long it had been a problem. During an interview on 12/15/22 at 2:56 P.M. with Resident #2, he reported he and his wife had complained about her not being able to call in and talk to him several times over the last several months and they were told it was being worked on but they had seen no changes. He stated he was being told now it would be the end of January before the issue was resolved and he and his wife thought that was too long to have issues with the telephones. Review of the Timeline of Events for telephone service revealed on 09/27/22, the Administrator met with a new company to discuss the possibility of installing a new telephone system. It was documented families were having difficulty reaching residents in the facility. Two weeks ago there was a meeting between the facility and the new telephone company and they were given a go live date for the new phone system of 01/24/23. Review of the Resident Council Meeting minutes from September 2022 to November 2022 revealed at the meeting on 10/25/22 some residents were reporting the telephones were not working properly in their rooms. This deficiency represents non-compliance investigated under Complaint Number OH00138360.

Based on medical record review, staff interviews emergency medical run sheet review, and policy review, the facility failed to accurately document the date and time of nurse practitioner visits and medication administrations. This affected one (#85) of three resident reviewed for chart accuracy. The facility census was 82. Findings include: Review of Resident #85's closed medical record revealed an admitted [DATE]. Resident #85 was discharged to the hospital via 911 on 05/19/22. His diagnoses included diabetes mellitus 2, acquired absence of right leg below knee, heart failure, gastro esophageal reflux disease, anemia, major depressive disorder, anxiety disorder, and schizoaffective disorder. Review of the five-day Minimum Data Set (MDS) assessment for Resident #85, dated 5/10/22, revealed Resident #85 was cognitively intact; required extensive assistance from staff with bed mobility; totally dependent on staff with assistance with transfers, dressing, toilet use, and personal hygiene and required supervision from staff with eating. Review of the nursing progress note for Resident #85 with a created date of 05/19/22 at 7:09 A.M. and entry time of 05/19/22 at 7:36 A.M., revealed Resident #85 was discharged to the hospital by 911, per ambulance. Review of the 911 emergency squad run report dated 05/19/22 at 12:12 A.M., revealed the squad responded to a call at the facility and found Resident #85, unresponsive with clammy hot skin. Resident #85's oxygen saturation was recorded at 83 and body temperature reading was recorded at 103.8. The ambulance arrived at the hospital on 05/19/22 at 12:42 A.M. Review of Resident #85's Medication Administration Record revealed Licensed Practical Nurse (LPN) #500 documented he administered medication including atorvastatin calcium tablet 40 milligram (mg) and insulin glargine-yfgn 100 unit/1 milliliter (ml) insulin pen, inject 35 unit subcutaneous on 05/20/22. Review of the physician visits/nurse practitioner notes for Resident #85 revealed Resident #85 was assessed by the facility Nurse Practitioner (NP) #450 on 05/19/22 at 00:00. Further review of the NP #450 assessment revealed she signed and dated her assessment on 05/19/22 at 12:38 P.M. Interview on 11/17/22 at 12:05 P.M., with NP #450 confirmed she could not have assessed Resident #85 on 05/19/22, if he was discharged to the hospital on that date. NP #450 stated she must have seen him the day prior on 05/18/22. NP #450 stated she no longer works with the company and does not have access to her notes. Interview on 11/17/22 at 3:11 P.M., with the Administrator confirmed Resident #85 was discharged from the facility on 05/19/22 at 12:25 A.M. The Administrator stated the resident did not return to the facility. The Administrator confirmed Resident #85 was not in the facility on 05/19/22 and could not have been assessed by NP #450. The Administrator stated NP #450 no longer works at the facility because she had a lot of errors with reporting. Interview on 11/22/22 at 8:00 A.M., with the Director of Nursing (DON) confirmed NP #450's documentation state Resident #85 was assessed by her at the facility on 05/19/22 at 0:00. The DON confirmed Resident #85 was not in the facility on 05/19/22. The DON state NP #450 is no longer with the facility related to a concern of documentation. The DON confirmed Resident #85's Medication Administration Record revealed Licensed Practical Nurse (LPN) #500 documented he administered medication including atorvastatin calcium tablet 40 mg and insulin glargine-yfgn 100 unit/1 ml insulin pen, inject 35 unit subcutaneous on 05/20/22. The DON confirmed Resident #85 discharged from the facility around midnight on 05/19/22 and did not return to the facility. Review of the policy titled, Charting and Documentation, dated July 2017, revealed documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Based on record review, observation, staff interview, and review of facility policies, the facility failed to ensure staff disposed of isolation room soiled linen appropriately, informed all staff of Coronavirus Disease 2019 (COVID-19) positive residents residing in the facility, maintained appropriate droplet isolation precautions, and performed appropriate hand hygiene for a resident (#15) who tested positive for COVID-19, to potentially prevent the spread of COVID-19. This had the potential to affect 21 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22) residents residing in the secured memory care unit. The census was 76. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #15 dated 10/19/21 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of the nurse progress note for Resident #15 dated 01/ 09/22 timed at 6:30 P.M. revealed staff just received notice that resident had a positive COVID-19 result and was to isolate in room until further notice. Further review of the note revealed the doctor gave order for resident to move to a sister facility with a dedicated COVID-19 unit. Review of physician orders for Resident #15 revealed an order dated 01/09/22 for resident to be in isolation with droplet precautions related to COVID-19 for 14 days. Interview on 01/10/22 at 9:46 A.M. with the Administrator and the Director of Nursing (DON) confirmed Resident #15 had received a positive test result for COVID-19 on 01/09/22 at approximately 6:30 P.M. and there were no other COVID-19 positive residents in the facility. Administrator and DON further confirmed Resident #15 was supposed to be transferred to a sister facility with a COVID-19 unit sometime later in the day on 01/10/22 and was to remain in droplet isolation until the transfer. Observation on 01/10/22 at 10:17 A.M. revealed the door to Resident #15's room was slightly ajar and had a sign indicating resident was in droplet precautions and to see the nurse before entering. There was a cart of personal protective equipment (PPE) outside the resident's door. Further observation revealed there were two large plastic bags of soiled linens sitting directly on the floor outside Resident #15's room. Interview on 01/10/22 at 10:19 A.M. of State tested Nursing Assistant (STNA) #150 confirmed there were no COVID-19 positive residents currently in the facility and she was not sure why the signage regarding droplet isolation was hanging on Resident #15's door. STNA #150 further confirmed the door was ajar and there were two large plastic bags of soiled linens laying on the floor. Interview on 01/10/22 at 10:22 A.M. with Licensed Practical Nurse (LPN) #175 confirmed Resident #15 had tested positive for COVID-19 with results received on 01/09/22 at approximately 6:30 P.M. LPN #175 confirmed Resident #15 was being transferred to another facility later in the day on 01/10/22 and was to remain in her private room in droplet isolation until the transfer could take place. Observation on 01/10/22 at 10:25 A.M. revealed STNA #200 pushed Resident #2 down the hall and was wearing disposable gloves and an isolation gown. STNA #200 went into Resident #2's room with her for approximately one minute. Resident #15's door was now observed to be closed and the two plastic bags of soiled linen were gone. Interview on 01/10/22 at 10:25 A.M. with STNA #200 confirmed she knew Resident #15 had tested positive for COVID-19. STNA #200 further confirmed she had taken the following actions: she changed Resident #15's bed linens and clothing and provided personal care. STNA #200 stated once Resident #15 was dressed and up in her chair she opened the door to set all the soiled linen outside of the resident's room, she then exited Resident #15's room wearing the same gloves and the isolation gown that she had donned when she entered the room, she then took the soiled linen to the soiled linen room and placed it in the appropriate receptacle and then changed gloves before exiting the soiled linen room, she saw that Resident #2 needed to be redirected back to her room so she pushed her wheelchair down the hall wearing disposable gloves and isolation gown, she assisted Resident #2 into bed. STNA #200 confirmed she had not washed or sanitized her hands since she first entered Resident #15's room and she was still wearing the isolation gown she had worn while caring for Resident #15. Interview on 01/10/22 at 2:00 P.M. with the Administrator confirmed the following: all staff should be aware of COVID-19 positive residents, staff should remove isolation gown and gloves and perform hand hygiene before leaving an isolation room, soiled linen from an isolation room should not be placed on the floor outside of the isolation room particularly since Resident #15's room is situated in a secured memory care unit. The facility confirmed there are an additional 21 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22) residents residing in the secured memory care unit. Review of facility policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures undated revealed for a resident with known or suspected COVID-19 staff should wear gloves, isolation gown, eye protection and an N95 or higher-level respirator in resident's room and resident should be placed in a private room with a dedicated bathroom and close the door. Review of facility policy titled Isolation-Initiating Transmission-Based Precautions dated August 2019 revealed when transmission-based precautions are implemented, the Infection Preventionist (or designee) should clearly identify the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used and should provide and/or oversee education regarding the precautions and use of PPE and ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. Review of the facility policy titled Handwashing/Hand Hygiene dated August 2019 revealed the following: the facility considered hand hygiene the primary means to prevent the spread of infections, staff should wash or sanitize hands before and after direct contact with residents, after removing gloves, and before and after entering isolation precaution settings, the use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on closed medical record review, hospital reports, observation, staff interview, review of elopement investigations, and review of the facility elopement policy, the facility failed to provide adequate supervision to prevent the elopement of Resident #95 from a secure dementia unit. This resulted in Immediate Jeopardy for one (#95) of three sampled residents, identified by the facility with wandering behaviors and at risk for elopement, when Resident #95 was found outside the building in the facility's therapy parking lot below an open window approximately 15 feet above ground. The resident sustained [REDACTED]. The facility census was 94. On [DATE] at 4:00 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 8:45 P.M. when Resident #95 left the secure dementia unit unsupervised and was ultimately found outside the facility in the therapy parking lot. The resident suffered injuries which included a lacerated eye brow, a fractured left orbit (eye socket), a fractured left zygomatic arch (cheek bone), laceration to the left thigh with an avulsion fracture of the pelvis (where the tendon tears away from the bone), and a grade 1 (minor) laceration of the liver and spleen. The resident was sent to the hospital for treatment and expired on [DATE]. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: ? On [DATE] at 8:00 A.M., the facility initiated an investigation through the DON and Administrator. ? On [DATE], the facility checked all windows and alarmed doors with delayed egress for proper operation. Each door and window was found to be secure by maintenance staff. All keys that were on hooks at door frames at the janitor's closets were removed and the keys were placed at the nursing station out of reach of residents and visitors. ? On [DATE] at 8:00 A.M., the facility screwed all of the windows shut on the west side of the building. The building is built into a hill and all windows on the west side sit above ground. All chains were checked at the top of the windows including bedrooms #118, #116, the janitor's closet, resident lounge, nursing station and bathroom windows. These windows were secured in this manner as they are the only windows which sit above ground. No such risk was present at any other section of this secure unit. ? On [DATE], staff began reassessing all residents in the facility for elopement risk. All assessments were completed on [DATE]. ? On [DATE], the facility Director of Nursing Designee in-serviced all staff on their "Code Purple" policy, dated [DATE], regarding missing residents. The in-service included what staff should do when a "Code Purple" is called. ? On [DATE], the facility Director of Nursing Designee in-serviced all nursing staff, State tested Nurse Aides (STNA) and housekeeping staff. The training involved care for residents at risk for elopement, securing the units, and the use of Wanderguards. ? On [DATE], elopement was added to the facility Quality Assurance (QA) agenda for review at the February 2013 meeting. ? On [DATE], the facility completed QA reviews to monitor, assess and prevent further elopements from the facility to ensure on-going compliance. ? On [DATE], interviews with Licensed Practical Nurses (LPN) #1, #2, #3, #4 and #5, Registered Nurses (RN) #41 and #42, and STNA's#25, #26, #27, #28, #29 and #30 confirmed they were able to articulate the policy for eloping residents, securing the units, and the use of Wanderguards. Findings include: Review of Resident #95's closed medical record revealed the resident was admitted to the nursing facility on [DATE], after a two week stay at a local psychiatric hospital. The resident was originally admitted to the psychiatric hospital on [DATE] after he left his home, where he lived alone, and was found near the Ohio River. The resident was admitted to the nursing facility with [DIAGNOSES REDACTED]. Review of a psychiatric evaluation on [DATE], after Resident #95's admission to the nursing facility, revealed the resident had a history of [REDACTED]. The resident's care plan on admitted d [DATE] had interventions to maintain the resident's safety and to redirect when needed, speak slowly, give time to respond, arrange environment to meet needs, and remove from area if agitated. Resident #95 did not have a care plan in place for wandering and was not assessed to be an elopement risk at the time of admission. Resident #95 was provided with physical therapy services, prior to his fall, which included fall preventions, muscle strengthening, posture, gait, transfer and balance training, patient education and safety precautions at which time he was discharged from services on [DATE] having met goals at modified levels for gait and transfer training. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE] identified the resident as severely cognitively impaired. Resident #95 was noted to experience hallucinations and delusions one to three days a week, required extensive assistance of one person for bed mobility, transferring, locomotion off the unit, dressing, toilet use and personal hygiene. The resident required limited assistance of one person for walking in his room and the corridor. He was noted to have balance problems related to moving from a seated position, walking, turning around, moving on and off the toilet and surface to surface transferring. He was not steady but could correct himself without staff assistance. Resident #95 had no range of motion limitations and did not use any mobility devices. Review of the nurses notes documented on [DATE] at 8:45 P.M. revealed LPN #1 on the secure care dementia unit called a "Code Purple" when Resident #95 could not be located for five minutes. He was found outside in the parking lot of the therapy area of the facility by STNA #1 at 8:50 P.M. He was walking around, complaining of being cold and of buttock pain. The resident was fully dressed, wearing shoes and a coat. The resident was brought into the facility via wheelchair and further examined. A laceration to his left thigh was discovered. Emergency 911 was called and the resident was sent to the hospital for evaluation and treatment. Review of the hospital report dated [DATE] revealed the resident suffered injuries of a lacerated eye brow, a fractured left orbit (eye socket), fractured left zygomatic arch (cheek bone), laceration to the left thigh with an avulsion fracture of the left pelvis (where the tendon tears away from the bone) and a grade 1 (minor) laceration of the liver and spleen. The resident was discharged from the acute hospital to a rehabilitation hospital on [DATE]. The resident died on [DATE] at the rehabilitation hospital. Interview with STNA #1 on [DATE] at 3:30 P.M. revealed that when she heard the "Code Purple" announcement, she checked her unit on the third floor and went to the reception desk checking the stairwells and front foyer area. She then decided to go outside and turned to the west, which was the direction of Resident #95's room. She found the resident about 10 feet from the outside wall of the therapy entrance, in the parking lot, walking around complaining he was cold. He could not describe what had happened. She stated because it was dark, she initially did not notice blood on his temple until she got him inside. Interview with LPN #1 on [DATE] at 3:40 P.M., who was assigned to the secure care dementia unit at the time of the elopement, revealed he could not find Resident #95 to administer his evening medications. He began searching and found the key in the door knob to the janitor's closet near Resident #95's bedroom. This key to the janitor's closet was kept on a hook outside the locked door. The window in the janitor's room was in the open position on the right side. The chain at the top of the window used to prevent the window from being opened more than four inches was broken. He indicated at this point, he felt that Resident #95 fell out the window down to the parking lot below. He called the "Code Purple" and initiated the search by all staff. Interview with LPN #2 on [DATE] at 3:45 P.M. revealed he heard the commotion outside the facility via a third floor room and went to the lower level service area door to greet STNA #1 and Resident #95 as they returned inside. It was then he noted a laceration on Resident #95's temple, cleaned the wound and briefly assessed the resident. He noted a laceration to his left thigh and no other complaints other than his buttock hurt. He did note the resident was agitated when he looked in his eyes with a flashlight. He was ambulating at the time and was placed in a wheelchair for transfer to the ambulance when it arrived. Interview with STNA #2 on [DATE] at 12:30 P.M. revealed she took Resident #95 to his bedroom and explained it was time for bed. She intended on checking on the resident and assisting him further. Another resident needed care at the time and STNA #2 assisted in the care of that resident, explaining that she was gone long enough to put this other resident to bed and turn off the lights. After leaving the other resident's room, she was informed by another STNA a "Code Purple" was called for Resident #95 because he was missing. Review of the "Code Purple" policy revealed the resident's name and room number on the loud speaker is called out, all nursing units are to conduct a thorough inspection of their units, maintenance will conduct a perimeter search of the building, the resident's picture will be made available at the reception desk, activities and therapy will inspect the basement and dietary will inspect the second floor. When found, all clear will be noted over the loud speaker. This deficiency substantiates Complaint Number OH 908.