Every finding on record at Divine Rehabilitation and Nursing at Canal Pointe

Based on observation, interview, and policy review the facility failed to provide food at appetizing temperatures. This had the potential to affect 108 residents receiving meals from the kitchen. The facility identified three residents (#31, #51, and #108) who received nothing by mouth (NPO). The facility census was 111.Findings include:An interview on 09/09/25 at 10:06 A.M. with Dietary Supervisor (DS) #100 revealed there had been residents complaining about hot foods being served cold. An observation was conducted on 09/09/25 at 10:46 A.M. of the kitchen tray line being set-up for the lunch meal service. The lunch meal consisted of corn, Spanish rice, chicken enchilada, and enchilada sauce. Temperatures at the start of tray line service were recorded as followed by [NAME] #306 between 11:15 A.M. and 11:16 A.M.: the corn was 158 degrees Fahrenheit (°F), Spanish rice was 170 °F, chicken enchilada was 170 °F and enchilada sauce was 170°F. During the tray line observation there were no plate warmers nor hot pellets used to help conserve food temperature after the foods were plated for service. The chicken enchiladas were being held for service on a baking sheet that was placed uncovered on a cart next to the steam table. No method of heat conservation was observed, as the enchiladas remained on the cart instead of on the steam table. The temperature of the last chicken enchilada being served from the uncovered baking sheet was taken at 11:33 A.M. by [NAME] #306, and the temperature was 130°F. The chicken enchilada was then put on a plate, placed in a tray cart, and sent to the fourth floor to be served. Observation of the the lunch tray line meal service continued and [NAME] #306 was observed removing additional pans of chicken enchiladas from the oven and setting them out next to the tray line for meal service. At 12:02 P.M. the last tray for the second floor was plated. The final serving temperature of the chicken enchilada was 160°F, mashed potatoes taken from the steam table was 120°F, and green beans taken from the steam table was 80°F taken by [NAME] #306. A plate cover was then placed over the dish and placed on the tray cart. The tray cart left the kitchen at 12:05 P.M. and was served to Resident #4 at 12:15 P.M. Permission was given by Resident #4 for DS #100 to take the final temperature of their food items. At 12:15 P.M. the temperature of the meal was observed to be chicken enchilada 115°F, mashed potatoes 115°F, and green beans 95°F. The findings above were verified by DS #100 at the time of the observation. An interview on 09/09/25 at 2:50 P.M. with Certified Nurse Aid (CNA) #356 revealed residents had been complaining about hot foods being served cold. An interview on 09/09/25 at 3:14 P.M. with Resident #4 revealed he preferred a warmer chicken enchilada. An interview on 09/10/25 at 10:09 A.M. with Resident #33 revealed the hot food was often served cold. Review of the facility policy titled Food Preparation Guidelines, dated 2025, revealed food should be at an appetizing temperature including serving hot foods hot and addressing resident complaints about food. Review of the facility policy titled Record of Food Temperatures, dated 2025, revealed hot foods will be held at 135°F.

Based on observation, interview, record review and policy review the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect 108 residents receiving meals from the kitchen. The facility identified three residents (#31, #51, and #108) as receiving nothing by mouth (NPO). The facility census was 111. Findings include: Review of pest control invoices dated 07/15/25 to 08/27/25 revealed pest control serviced for kitchen insects and existing rodent bait stations on 07/15/25, and on 08/27/25 extra service was provided for rodents. An interview on 09/09/25 at 10:06 A.M. with Dietary Supervisor (DS) #100 revealed they were aware of an existing problem with small, flying insects in the kitchen. An observation was conducted on 09/09/25 at 10:46 A.M. with DS #100 and revealed the following concerns: ten small, flying insects were hovering above the handwash sink. Two small, flying insects were hovering around the dishwasher. Six small, flying insects were flying near a hanging dish cabinet, and three small, flying insects were flying near the oven which demonstrated a pervasive insect problem throughout the kitchen. There were multiple areas of chipped or bubbled paint and damaged drywall near the handwash sink and in food preparation areas. There was a moderate collection of food debris on the vertical food storage rack and on the wall near the standing mixer. There was an area of standing water on the floor near the dishwasher. Also, the following areas were observed to have a layer of moderate to heavy black grime: the oven doors, the range top, a pipe near the top of the range, various areas of the kitchen floor, the nozzles of the range hood fire suppression system, and the horizontal surface of the sprinkler pipes. The above findings were verified by DS #100 at the time of the observations. An observation was conducted on 09/09/25 at 2:22 P.M. of the second floor kitchenette and revealed a rodent bait box against the wall near the microwave stand. Multiple rodent droppings were noted to be around the bait box on the floor and on the microwave stand behind the microwave. An interview on 09/09/25 at 2:25 P.M. with the Assistant Director of Nursing verified the above findings in the second floor kitchenette. Review of the facility policy titled Sanitation Inspection, dated 2025, revealed all food service areas should be kept clean, sanitary, and protected from rodents and insects. Noted within the policy was that inspections should be conducted weekly to ensure the main production area and food preparation area were clean and comply with sanitation and food service regulations. This deficiency represents non-compliance investigated under Complaint Number 2611175.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were securely stored. This affected one resident (Resident #212) and had the potential to affect all residents residing at the facility. The facility also failed to discard expired medications. This had the potential to affect all of the residents residing in the facility. The facility census was 111 residents. Findings include: 1. Review of the medical record for Resident #212 revealed an admission date of 05/02/25 and a readmission date of 05/16/25 with diagnoses including anxiety disorder, depression, post-traumatic stress disorder, and borderline personality disorder. Review of the Minimum Data Set (MDS) dated for Resident #212 dated 05/23/25 revealed the resident was cognitively intact and was independent with mobility. Record the medical record for Resident #212 revealed it did not include a physician's order or other documentation indicating the resident was capable of self-administration of medications. Observation of Resident #212's room on 06/05/25 at 4:18 P.M. with Licensed Practical Nurse (LPN) #461 revealed there was an albuterol inhaler and a Trelegy inhaler unsecured at the resident's bedside. Interview on 06/05/25 at 4:19 P.M. with LPN #461 confirmed nursing staff were to store and administer all of Resident #212's medications and the inhalers should not be left at the resident's bedside. Interview on 06/05/25 at 5:27 P.M. with Certified Nurse Practitioner (CNP) #517 confirmed Resident #212 should not have medications, including inhalers, unsecured in her room. 2.Observation of the 200-hall medication storage room on 06/04/25 at 8:37 A.M. with the Director of Nursing (DON) revealed the following: a COVID-19 test with an expiration date of 11/09/24, four boxes of glucose test strips with an expiration date of 02/01/25, a bottle of magnesium with an expiration date of December 2024. Observation of the medication room on the third floor with the DON revealed the following: an opened bottle Bisacodyl tablets with an expiration date of March 2025, an opened box of guaifenesin with an expiration date of April 2024, a container of omeprazole with an expiration date of January 2025. Interview on 06/04/25 at 8:50 A.M. with the DON confirmed the 200 Hall medication storage room and the third-floor medication room contained expired house stock items which should have been discarded. Review of the facility policy titled Medication Storage undated revealed all drugs and biologicals would be stored in locked compartments under proper temperature controls. The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued or outdated medications. The deficiency represents noncompliance investigated under Master Complaint Number OH00165919.

Based on observation, interview, review of the facility policy and record review the facility failed to ensure foods in unit refrigerators were labeled, dated and not retained when expired and stored in a clean environment. This had the potential to affect 108 residents receiving meals from the kitchen as three residents (#63, #104 and #106) were ordered nothing-by-mouth (NPO). Facility census was 111. Findings include: Observation on 06/02/25 with Dietary Manager (DM) #425 starting at 9:58 A.M. revealed the following areas of concern: • In the third floor nourishment refrigerator, there was an expired bottle of soy sauce dated 11/29/24, an expired container of 2% milk dated 05/04/25, an undated bowl of mashed potatoes, an undated bowl containing a piece of cake, a bag labeled with Resident #112's name and the date 05/19/25, a container with Resident #32's name and no date, three bags of various takeout/fast foods with no name and no date, a wilted salad with no date, an expired container of apples dated 05/23/25, an expired container of potato salad dated 04/07/25 and a expired Trix yogurt dated 05/25/25. The base of the refrigerator was moderately stained with an unidentifiable pink substance. • In the fourth floor nourishment refrigerator, there was a red sticky substance and crumbs inside along with an expired bottle of hot sauce dated 04/09/25 and two containers of takeout/fast food dated 05/24/25. In the freezer compartment there was an expired frozen entrée dated 04/18/25. • In the second floor nourishment refrigerator, there was an expired bowl of cut cantaloupe dated 05/21/25, a bag of cut watermelon with no date, an undated lunch bag with brown apples and an undated bag of takeout/fast food. There was an unidentifiable spilled substance on the base of the refrigerator. A sign posted to the exterior of the refrigerator read that every Sunday, the refrigerator would be cleaned and foods would be thrown out. Interviews with DM #425 verified the above findings at the time of observation. DM #425 stated foods should be labeled, dated and not retained when expired. Interview on 06/02/25 at 10:26 A.M. with the Administrator and Quality Assurance Registered Nurse (QARN) #513 present revealed it was housekeeping staff's task to clean the unit refrigerators every three days. The Administrator and QARN #513 were made aware of the condition of the three unit refrigerators at the time of the interview. Review of the facility policy, Use of Storage of Food Brought in by Family or Visitors, dated 2025 revealed all food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. The prepared food must be consumed by the resident within three days and if not consumed, will be thrown away by facility staff. All items not maintained are subjected to being thrown away if not removed by the resident and/or resident representative. Review of the facility policy, Date Marking for Food Safety, dated 2025 revealed foods shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. Prepared foods that are delivered to the nursing units shall be discarded within two hours, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified. Review of the facility diet list dated 06/02/25 identified three residents (Residents #63, #104 and #106) as NPO.

Based on review of personnel files and interviews with staff, the facility failed to ensure employees received the required annual training. This affected 13 of 13 employees reviewed for personnel files and had the potential to affect all 111 residents residing in the facility. Findings include: Review of the personnel files with Human Resource Director (HRD) #423 revealed the employees were receiving two packets of in-services. One was titled Yearly In-services listing 9.5 hours' worth of in-services. By signing, employees acknowledged they had read and reviewed all in-services listed above. The other one was titled Annual Inservice Packet with 12.5 hours. By signing, employees acknowledged they had read and reviewed all in-services listed above. The second page of this packet stated This packet of annual mandatory in-services has been developed to help remind you of important policies and practices. Please take time to read them and sign the forms included. Review of the personnel files for the Administrator, Dietary #404, Dietary #410, Maintenance #422, Dietary Supervisor #425, Activity Director #428, Houskeeper #436, and Certified Nurse's Aide (CNA) #487 all signed upon hire. Licensed Practical Nurse (LPN) #445, LPN #464, CNA #474, CNA #501 and CNA #512 signed two copies: one upon hire and one on their annual due date. The packets were provided for the upcoming year therefore they were signed in advance of reading the information. Interview on 06/05/25 at 11:30 A.M. with HRD #423 stated the facility stopped using an on-line training program and came up with these packets. She stated she did not know how to track the education otherwise. Interview on 06/05/25 at 1:00 P.M. with the Administrator revealed she reviewed other training/education provide by the Director of Nursing (DON) throughout the year but stated it was not enough as they were not held every month. Interview on 06/09/25 at 11:42 A.M. with two of the above employees, who wish to remain anonymous, revealed one who stated they briefly reviewed everything all at once but said they could review further on their own time. One stated, I don't even know what I did with my packet. The other thought her packet was in her car.

Based on review of personnel files and interviews with staff the facility failed to provide regular training for the certified nursing assistants (CNAs) for their 12 in-services annually. This had the potential to affect all 111 residents residing in the facility. Findings include: Review of the personnel files for CNA #474 with hire date of 06/23/22, CNA #501 with hire date of 02/28/24 and CNA #512 with the hire date of 05/15/24 revealed there was no evidence they received regular training throughout the year for their required 12 hours of in-services annually. Interview on 06/05/25 at approximately 11:30 A.M. with Human Resource Director (HRD) #423 revealed the facility stopped using an online training program over a year ago. The facility provided staff with a stack of in-services for the whole year at one time upon orientation and annually. The first page was signed by the employee. It listed all of the in-services. The rest of the packet was information on each topic. HRD #423 stated she was not sure how to track in-services otherwise and verified there was no system in place to follow up with the employees to ensure they actually read and completed the training packet annually.

Based on record review, observation, interview and review of the facility policy, the facility failed to ensure residents had a safe, clean, homelike environment. This affected two (Residents #3 and #6) reviewed for their bedroom environment and had the potential to affect an additional 78 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #17, #18, #20, #21, #22, #23, #24, #26, #27, #28, #29, #30, #32, #33, #34, #37, #38, #39, #40, #41, #42, #44, #45, #47, #49, #50, #52, #53, #56, #58, #59, #60, #61, #62, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #77, #78, #82, #85, #86, #87, #88, #89, #90, #91, #92, #93, #96, #97, #103, #104, #112, #211, #212, #213, and #311) residing on the second and third floor of the facility. The facility census was 111. Findings include: 1. Record review for Resident #3 revealed an admission date of 07/03/24. Diagnosis included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired. Resident #3 required set up/clean up assistance with meals, toileting hygiene, bathing and personal hygiene. Observation on 06/02/25 at 8:58 A.M. revealed Resident #3 was resting in bed. Resident #3's closet door had a broken panel, the floor was covered with potato chip crumbs and other food crumbs, a buildup of dirt and grime throughout, toilet paper, and soiled clothing. The bedside table had a thick buildup of dust. There were dried spills of colored liquids on the arm and leg of the table. The bedside stand had a thick buildup of dust. The privacy curtain was pink with the bottom half discolored from dirt, food and liquid spills. The window curtains were soiled with multiple dried spills and dust buildup. The air conditioner unit had multiple dried spills, and a thick dirt/dust buildup. The dresser had multiple dried spills, and the bottom drawer was broken and unusable. The bathroom had a foul odor. There was dried stool on the inside of the toilet bowl and on the lid. The floor and sink had a large amount of dirt and grime buildup. Resident #3 stated, No one cleans. Licensed Practical Nurse (LPN) #458 confirmed each identified concern at the time of the observation. 2. Record review for Resident #6 revealed an admission date of 03/05/20. Diagnoses included attention deficit hyperactivity disorder (ADHA) and dementia. Review of the annual MDS assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. Resident #6 required set up or clean up assistance with eating and bathing. Observation on 06/02/25 at 9:18 A.M. revealed Resident #6 was lying in bed. The top dresser drawer was broken and unusable. There were multiple dried liquid spills down the front of the dresser. The air conditioning unit had multiple dried liquid spills and dust/grime buildup. The window curtain was soiled and dangling from the rod. The recliner had multiple stains and dried spills. There was a large brown substance on the seat of the chair. The footboard of the bed was broken and unsecured. Observation and interview on 06/02/25 at 9:24 A.M. with LPN #429 of Resident #6's room confirmed each identified item. LPN #429 revealed, I see it dirty every day. Interview on 06/05/25 at 8:05 A.M. with Housekeeper #442 revealed rooms were cleaned daily. The facility only deep cleaned rooms if a major mess. Housekeeper #442 revealed he had been doing housekeeping at the facility for nine months, and they never clean the edges of floors to remove buildup. Interview on 06/05/25 at 8:19 A.M. with Lead Housekeeper #436 revealed there was no schedule or routine cleaning for wall or privacy curtains. Observation on 06/05/25 at 8:22 A.M. with Certified Nursing Assistant (CNA)/Scheduler #420 of the shower room on the second floor revealed the shower stall ceiling had a large brown/gray area that appeared wet. The floors were very dirty throughout with thick scum buildup that was worse on all edges and corners. The bedside commode had rusted peeling legs. CNA #420 confirmed residents used the bedside commode. The floor around the toilet bowl had scum/grime buildup. The ceiling in the corner near the linen had a large brown/black area and the paint was peeling large strips. CNA #420 revealed all residents on the second floor used the shower room. Observation on 06/05/25 at 8:28 A.M. with Housekeeper #442 verified the condition of the shower room and shower room ceiling. Housekeeper #442 revealed the shower room ceilings had been in the same condition since he started working at the facility nine months ago and revealed the black on the ceiling was mold. 3. Observation of the third-floor resident's lounge revealed two sitting chairs that were very worn with material that was ripped on the arms and the seats of the chairs. Interview on 06/05/25 at 10:34 A.M. with Maintenance Director #422 verified the chairs were very worn. He agreed he would not have those in his own home. Review of the undated facility policy titled Safe and Homelike Environment revealed the environment was defined as any area frequented by the residents. Staff were to report any furniture in disarray to maintenance and report any unresolved environmental concerns to the Administrator. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The deficiency represents noncompliance investigated under Master Complaint Number OH00165919 and Complaint Numbers OH00163815 and OH00163417.

Based on interview, record review, self-reported incident (SRI) review and policy review, the facility failed to thoroughly investigate allegations of abuse. This affected four (Residents #48, #50, #58, #214) of four residents reviewed for abuse. The facility census was 111. Findings include: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, heart disease, major depressive disorder, post-traumatic stress disorder (PTSD), left below the knee amputation, and an internal cardiac defibrillator. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact, refused aspects of care daily, and needed no assistance with personal care. Review of SRI tracking number 260710, dated 05/21/25, was filed with the State agency for an allegation of physical abuse. Resident #48 and Resident #214 were in the facility's lobby waiting for the elevator after a smoke break. Too many residents attempted to get on the elevator at the same time, and Resident #214 attempted to pull a female resident in a wheelchair out of the elevator so he could get his own wheelchair on the elevator. Resident #48 attempted to stop Resident #214 from removing the female, and Resident #214 swung and hit Resident #48. Resident #48 hit Resident #214 back and both residents ended up on the floor hitting each other. Staff separated the two residents and both residents were placed on one-to-one supervision. Another staff member called the police, and Resident #214 was transported to a local hospital by the police after Nurse Practitioner (NP) #517 wrote an order for a mandatory psychiatric admission. The Administrator went to the hospital to give Resident #214 an immediate discharge notice due to being a threat to himself, other residents, and staff. Resident #214 refused to see the Administrator, so the discharge notice was sent to him by certified mail. Resident #214 signed himself out of the hospital against medical advice (AMA) and returned to the facility. The police were called again and escorted the resident from the property. Review of the SRI revealed the facility did not list any witnesses to the incident nor any perpetrator. The facility unsubstantiated the allegation of abuse. Interview with the Administrator on 06/04/25 at 4:00 P.M. revealed the facility did not substantiate the allegation of abuse as they were unable to determine who started the resident-to-resident altercation. Review of the nurse's notes revealed on 05/21/25 at 11:59 P.M. Licensed Practical Nurse (LPN) #454 documented Resident #48 attempted to stop Resident #214 from attempting to remove a female resident in a wheelchair from the elevator so he could go to his room first. Resident #214 then swung his fist at Resident #48 and both residents fell out of their wheelchairs and continued their altercation on the floor. On 05/22/25 at 7:10 A.M. Licensed Social Worker (LSW) #419 met with Resident #48 to provide psychosocial-emotional support. The resident said he had no concerns or distress after the previous night's altercation with Resident #214. Resident #214 was admitted to the facility on [DATE] with diagnoses including paraplegia and male erectile dysfunction. He was discharged from the facility and sent for an involuntary psychiatric admission on [DATE] where he was given an immediate discharge from the facility. Review of the comprehensive admission MDS assessment dated [DATE] revealed Resident #214 was cognitively intact. The resident had numerous behaviors including physical aggression towards others four to six times during the seven-day assessment period. He was also verbally aggressive daily. Resident #214's behaviors significantly interfered with the resident's care and participation in daily activities. His behaviors put others at significant risk of physical injury, significantly intruded on other residents' privacy and daily activities, and significantly disrupted care and the living environment. He rejected care daily. Review of the progress notes from admission through discharge for Resident #214 revealed he was physically aggressive, verbally threatening, and disrespectful of other residents and staff daily. The resident refused counseling with the psychiatric services and refused to take his medication. He frequently requested pain medication which was not ordered for him. When staff were working with others, Resident #214 would interrupt and insist his needs be dealt with immediately. Review of Resident #214's care plans revealed the resident had behaviors of aggression, attacking staff, trapping staff in rooms, anger and foul language. Interview with the Administrator on 06/04/25 at 4:00 P.M. revealed despite Resident #214's continuous verbal threats and physical aggression, they did not place him on the secured unit as he was his own responsible party, and he refused to agree to be placed on the secured unit. The Administrator said she took an immediate discharge notice to the hospital to present it to him, but he refused to see her and called security to have her removed from the hospital. The facility sent the immediate discharge notice to him via certified mail. The Administrator said a few days later, Resident #214 returned to the facility after leaving the hospital against medical advice demanding to be allowed to return. The police were called and again escorted the resident off facility grounds. Interview with the Administrator on 06/09/25 at 2:00 P.M. revealed there was a hearing on Resident #214's immediate discharge appeal, and they maybe should have admitted the resident to the secured unit due to his behaviors towards residents and staff and to protect the residents from Resident #214. Review of the facility's undated Abuse, Neglect and Exploitation policy revealed the facility must protect the residents from abuse. The Quality Assessment and Performance Improvement (QAPI) committee will review the risk factors that contributed to the abuse (a history of aggressive behaviors, environmental factors) and if there is a need for further systemic action such as tracking patterns of similar occurrences. The facility must protect the residents from further abuse. 2. Resident #50 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, major depressive disorder, convulsions, panic disorder, vascular dementia with mood disturbance, high blood pressure, traumatic brain injury (TBI), and anxiety disorder. Review of the comprehensive annual MDS assessment dated [DATE] revealed Resident #50 was moderately cognitively impaired, had behaviors which significantly interfered with the resident's participation in activities or social interactions, behaviors which significantly intrude on the privacy or activity of others, and rejected care daily. Review of the progress notes for Resident #50 revealed on 04/03/25 at 5:42 P.M. the resident made sexually explicit comments toward LSW #419. On 04/11/25 at 5:15 P.M. LPN #452 documented that Resident #50 became irritate with another resident on the unit and attempted to hit him. Staff separated the residents and talked to Resident #50 until he was calmer. Staff kept the two residents apart for the rest of the shift. On 04/24/25 at 12:51 P.M. LPN #515 documented that Resident #50 was waiting for a smoke break and became agitated with an activity staff member and threw his cigarette and towel at the staff member. LPN #515 attempted to redirect the resident to his room, and he grabbed the wall railing and punched the wall three times. Assistant Director of Nursing (ADON) #429 also responded and notified psychiatric Nurse Practitioner (NP) #517 who ordered the antipsychotic medication Haldol to be administered every 12 hours intramuscularly (IM) as needed for aggressive behavior. On 05/13/25 at 1:51 P.M. the Director of Nursing (DON) documented Resident #50 was separated and emotional support was given. Interview with the Administrator on 06/06/25 at 1:00 P.M. revealed the facility did not file an SRI for the incident which occurred on 05/13/25. The Administrator said LPN #515 documented the incident incorrectly in the nurses' notes. Review of the facility's Physical Aggression Report dated 05/13/25 indicated the incident occurred at 12:30 P.M. LPN #515 authored the report. Resident #50 was sitting in his wheelchair in front of the elevator waiting for smoke break. Resident #6 was also at the elevator waiting for smoke break and accidentally spit on Resident #50 while he was talking. Resident #50 believed Resident #6 spit on him on purpose. Resident #50 became angry and pursued Resident #6, grabbed his shirt and attempted to punch him. Resident #50 was removed from the area by a nurse who explained Resident #6 did not purposefully spit on him. Staff kept Residents #50 and #6 apart from each other for the rest of the shift. The staff took the residents down for smoke break in two separate groups with Resident #50 in one group and Resident #6 in the other. The predisposing situational factors of the incident were listed as a resident-to-resident altercation in which physical contact was made. The Administrator interviewed Resident #50 on 05/13/25 who said he thought Resident #6 had spit on him on purpose, but the nurse spoke with him and he now thinks it was not on purpose. The only documentation on the incident was the DON documenting the residents were separated and all parties made aware. Both residents lived on the same floor. Review of the facility's undated Abuse, Neglect and Exploitation policy revealed all allegations of abuse must be investigated and the resident must be protected from abuse during the investigation. 3. Resident #58 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, major depression disorder, schizophrenia, high blood pressure, and mood disorder. Review of the comprehensive annual MDS dated [DATE] revealed Resident #58 was severely cognitively impaired, has delusions, and had behaviors which significantly interfere with the resident's care and social interaction, they significantly intrude on the privacy or activity of others, and behaviors that significantly disrupt the living environment. Review of the nursing progress notes for Resident #58 revealed on 05/28/25 at 10:56 A.M. NP #517, who is the facility's psychiatric nurse practitioner, evaluated the resident. The resident reported to NP #517 that she lifted her shirt up, and a peer touched her breast. The resident denied being assaulted in any fashion. Interview with the Administrator on 06/04/25 at 2:00 P.M. revealed she was unaware of NP #517's evaluation and staff did not inform her about the allegation of sexual abuse, so it had not been investigated. Review of the facility's undated Abuse, Neglect and Exploitation policy revealed the facility revealed all allegations of abuse must be investigated and the resident protected during the investigation. This deficiency represents non-compliance investigated under Complaint Number OH00163815.

Based on record review, observation, interview and review of facility policies, the facility failed to ensure comprehensive care plans were in place relative to residents' medical, psychosocial and mental needs. This affected five (Residents #6, #46, #69, #102 and #107) out of 37 resident records reviewed. The facility census was 111. Findings include: 1. Review of Resident #107's medical record revealed an admission date of 04/08/25 with diagnoses including malignant neoplasm of prostate, chronic obstructive pulmonary disease, anxiety and hypertension. Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #107 was cognitively intact and receiving hospice services. Oxygen was not coded on the MDS assessment. Review of Resident #107's care plans as of 06/02/25 revealed no plan of care was in place for the use of oxygen. Observation on 06/02/25 at 2:00 P.M. revealed Resident #107 was up and awake in his bed. Oxygen was in use, and no date was noted on the tubing connected to Resident #107. Follow-up observation on 06/04/25 at 7:58 A.M. of Resident #107 with Licensed Practical Nurse (LPN)/Unit Manager (UM) #416 revealed Resident #107 was lying in bed and his oxygen cannula was in his nose with the oxygen concentrator noted to be in use. Follow-up interview on 06/04/25 at 8:54 A.M. with LPN/UM #416 verified Resident #107 did not have a care plan in place for the use of oxygen, and he should have. Review of the policy, Oxygen Administration, dated 2025, revealed oxygen was administered under the orders of a physician, except in the case of an emergency. The resident's care plan shall identify the interventions for therapy, based on the resident's assessment and orders, such as but not limited to a) the type of oxygen delivery system, b) when to administer, such as continuous or intermittent and/or when to discontinue, c) equipment setting for the prescribed flow rates, d) monitoring of oxygen saturation levels and/or vital signs as ordered and e) monitoring for complications associated with the use of oxygen. 2. Review of Resident #102's medical record revealed an admission date of 12/15/24 with diagnoses including bilateral osteoarthritis of hip, muscle weakness, anemia, acute kidney failure, and hypertension. Review of a quarterly MDS assessment dated [DATE] revealed Resident #102 was moderately cognitively intact, was dependent on staff for bathing, required set up for eating and required partial assistance for personal hygiene. Resident #102 received anticoagulant, antiplatelet, anticonvulsant and opioid medications. Review of Resident #102's physician's orders as of 06/04/25 revealed an order dated 12/15/24 for apixaban oral tablet 5 milligrams (mg) by mouth twice a day for deep vein thrombosis (DVT) and an order dated 12/16/24 for anticoagulant-monitor for side effects (blood in urine/stool, black stool, severe bruising, prolonged nosebleeds, bleeding gums, vomiting/coughing up blood) every shift and complete documentation in progress note if side effects noted. Review of Resident #102's care plans as of 06/04/25 revealed no plan of care in place for his high-risk anticoagulant medication. Interview on 06/04/25 at 5:31 P.M. with the Director of Nursing (DON) verified Resident #102 received anticoagulant medication and monitoring but no plan of care relative to his high-risk medication was in place as required. 3. Review of Resident #46's medical record revealed an admission date of 10/09/23 with diagnoses including depression, human immunodeficiency virus (HIV), chronic hepatitis C, insomnia, paraplegia, anxiety, colostomy, post-traumatic stress disorder and neuromuscular dysfunction of bladder. Review of a quarterly MDS assessment dated [DATE] revealed Resident #46 was cognitively intact, had a colostomy and a catheter, utilized a wheelchair and was independent with toileting. Review of Resident #46's plan of care dated 10/18/23 in place for colostomy revealed interventions including change colostomy bag once a week and as needed (PRN); apply skin barrier, center the pouch over stoma and apply to skin, press area directly around stoma to ensure adherence and apply closure clip to bag; empty ostomy bag each shift and PRN; observe stoma and surrounding skin for irritation and notify nurse; and odor control: rinse pouch, keep pouch tail free of stool and avoid creating pinholes in pouch. Review of Resident #46's plan of care dated 10/18/23 in place for suprapubic catheter revealed interventions including position catheter bag and tubing below the level of the bladder and away from entrance room door; provide catheter care as ordered; change catheter drainage bag monthly and PRN; change suprapubic catheter monthly and PRN if dislodged or plugged and unable to clear with irrigation; check tubing for kinks PRN/as indicated; monitor and document urine output; monitor/document for pain/discomfort due to catheter; and monitor/record/report to physician for signs/symptoms of urinary tract infection (pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns). Interview on 06/02/25 at 1:56 P.M. with Resident #46 revealed he had a catheter which he cleaned himself daily as well as a colostomy. Interview on 06/05/25 at 12:13 P.M. with Licensed Practical Nurse (LPN) #448 revealed when she cared for Resident #46, he completed his own colostomy and catheter care. Interview on 06/05/25 at 12:18 P.M. with LPN/UM #416 verified Resident #46 completed his own catheter and colostomy care at the facility. Nursing staff would provide catheter supplies, and Resident #46 would change out his catheter with nurse oversight. LPN/UM #416 confirmed Resident #46's care plans related to his colostomy and suprapubic catheters did not reflect his self-management of these areas and should have. 4. Record review for Resident #6 revealed an admission date of 03/05/20. Diagnoses included attention deficit hyperactivity disorder and dementia. Review of the annual MDS assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. Record review of the physician orders dated 04/01/25 revealed Resident #6 received an order for enhanced barrier precautions (EBP) due to chronic wounds. Check signage and personal protective equipment (PPE) every shift. Resident #6 received an order dated 05/30/25 to cleanse the right shin with normal saline, apply oil emulsion, cover with island dressing daily and as needed. Record reviews of the medical record revealed there was no care plan for EBP for Resident #6. Interview on 06/03/25 at 5:07 P.M. with the DON revealed Resident #6 should have a care plan for EBP, and DON confirmed Resident # 6 did not have a care plan in the medical record for EBP. 5. Review of the medical record for Resident #69 revealed an admission date of 02/16/24. Diagnoses included chronic respiratory failure, dementia, post-traumatic stress disorder (PTSD) and depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively impaired. Review of the psychiatric note dated 04/22/25 revealed current stressor as being at the nursing home and an alleviating factor was watching television. Review of the care plan for Resident #69 revealed PTSD was not fully addressed. The goal was blank and there was only one intervention of allowing a quiet area alone to calm down when overwhelmed dated 11/12/24. The care plan did not indicate the triggers of PTSD or what may alleviate his symptoms. Interview on 06/09/25 at 10:51 A.M. with Licensed Social Worker (LSW) #419 verified the care plan was incomplete by not personalizing his triggers and what helped him specifically. Review of the policy, Comprehensive Care Plans, dated 2025, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and medical and psychosocial needs and ALL services that are identified in a resident's comprehensive assessment and meet professional standards of quality.

Based on record reviews, interviews and facility policy review, the facility failed to timely assess and/or accurately assess residents for smoking. This affected four (Residents #22, #58, #64 and #86) of four residents reviewed for smoking. The census was 111. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 03/30/12. Diagnoses included alcoholic cirrhosis of liver, asthma, anemia and viral hepatitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively impaired. The Brief Interview for Mental Status (BIMS) score was six out of 15, indicating severe cognitive impairment. Review of the June 2025 orders revealed Resident #22 was okay to smoke without supervision. The order was dated 06/04/25 at 7:00 P.M. Review of the smoking safety screen for Resident #22 dated 06/04/25 revealed the question Does resident have cognitive loss? with an answer marked as No. Review of the care plan initiated on 04/12/12 revealed: 1) Resident #22 was able to use tobacco products without supervision, last revised on 04/29/25; 2) Resident #22 was at risk for delirium due to disease process as evidenced by inattention and disorganized thinking and 3) Resident #22 had a self-care deficit where his activities of daily living could fluctuate. 2. Review of the medical record for Resident #86 revealed an admission date of 08/04/23. Diagnoses included chronic obstructive pulmonary disease, alcohol-induced dementia and viral hepatitis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #86 was cognitively impaired. The BIMS score was four out of 15, indicating severe cognitive impairment. Review of the June 2025 orders revealed Resident #86 was okay to smoke without supervision. The order was dated 06/04/25 at 7:00 P.M. Review of the smoking safety screen for Resident #86 dated 06/04/25 revealed the question Does resident have cognitive loss? with an answer marked as No. Review of the care plan initiated on 09/08/23 and revised on 04/10/25 revealed: 1) Resident #86 does not need to be supervised for tobacco use, 2) Resident is/has potential to be physically aggressive related to history of harm to others and poor impulse control, and 3) Resident has impaired cognitive function, decision making and short-term memory loss. 3. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, major depression disorder, schizophrenia, high blood pressure, and mood disorder. Review of the comprehensive annual MDS assessment dated [DATE] revealed Resident #58 was severely cognitively impaired, has delusions, and has behaviors which significantly interfere with the resident's care and social interaction, they significantly intrude on the privacy or activity of others, and behaviors that significantly disrupt the living environment. Review of Resident #58's smoking assessment revealed a smoking assessment had not been completed for the previous 12 months. The resident was listed as a supervised smoker. Review of the progress note dated 04/10/25 at 7:59 A.M. revealed Licensed Social Worker (LSW) #419 documented Resident #58 was a supervised smoker as determined by the nursing smoking assessment. 4. Review of the medical record for Resident #64 revealed an admission date of 10/10/21. Diagnoses included cardiac arrhythmia, major depressive disorder and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #64 was cognitively intact. The BIMS score was 14 out of 15, indicating intact cognition. Review of the assessments tab revealed the last smoking safety screen was completed on 05/05/23 for Resident #64. Review of a Social Service progress noted dated 04/10/25 at 8:39 A.M. revealed Resident #64 was currently a smoker and was determined by the nursing staff assessment not needing to be supervised for safety reasons at this time. Interview on 06/05/25 at 11:03 A.M. with Registered Nurse (RN) #416 revealed they did smoking assessments quarterly. When she was shown there was no assessment for two years for Resident #64, she stated they had not been getting done. Her expectation of completing smoking assessments was at least annually. A subsequent interview at 12:27 P.M. with RN #416 revealed she assessed residents for the smoking safety screen. When asked why smoking assessments were marked as no for cognitive impairment for Resident #22, Resident #58 and Resident #86, RN #416 stated I know them. When asked about the cognitive status, based on information in the MDS, which reflected cognitive impairment, she stated another cognitive test was more accurate. When asked to see a copy of the other test, she stated Speech Therapy will sometimes do the more detailed test. No other cognitive test was provided for Resident #22, Resident #58 or Resident #86. Interview on 06/05/25 at 11:21 A.M. with Licensed Social Worker #419 revealed smoking assessments were reviewed at risk meetings which was where she got the information for her progress note dated 04/10/25 via verbally and review of assessment. When shown that Resident #64's last assessment was from 2023, she responded oops, you caught us. Interview on 06/05/25 at 1:42 P.M. with the Administrator revealed what the BIMS scores meant: 13-15 cognitively intact, eight-12 moderately cognitively impaired and seven or below was severely cognitively impaired. Review of the undated facility policy titled Resident Smoking revealed all residents will be asked about tobacco use during admission process and each quarterly or comprehensive MDS assessment. Residents who smoke would be further assessed using Resident Safe Smoking assessment.

4.Review of the medical record for Resident #48 revealed an admission date of 01/25/23 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, and diabetes mellitus. Review of the MDS assessment for Resident #48 dated 04/01/25, revealed the resident was cognitively intact. Review of the MAR for Resident #48 dated May 2025 revealed medications were administered several hours after the medication was ordered: metoprolol, Entresto, Lasix, Ativan, gabapentin, spironolactone, Macrobid scheduled for 05/04/25 at 9:00 A.M. were given at 11:27 A.M., Macrobid, Colchicine, Eliquis, trazodone scheduled for 05/04/25 at 9:00 P.M. were given at 11:27 P.M., insulin Lispro scheduled for 05/04/25 at 8:00 A.M. was given at 10:46 A.M., Depakote, metoprolol, Entresto, Tamsulosin scheduled for 05/04/25 at 9:00 P.M. were given at 11:24 P.M., insulin Glargine scheduled for 05/05/25 at 9:00 A.M. was given at 11:23 A.M., Gabapentin, Tamsulosin, Entresto, metoprolol, Depakote, trazodone, Eliquis, Colchicine, Macrobid and insulin Glargine scheduled for 05/05/25 at 9:00 P.M. were given at 11:36 P.M., insulin Lispro and insulin Glargine scheduled for 05/06/25 at 8:00 A.M. were given at 10:26 A.M., insulin Lispro scheduled for 05/07/25 was given at 11:31 A.M., insulin Lispro scheduled for 05/07/25 at 12:00 P.M. was given at 2:29 P.M., insulin Lispro scheduled for 05/08/25 at 12:00 P.M. was given at 1:48 P.M., insulin Lispro and Gabapentin scheduled for 05/10/25 at 5:00 P.M. was given at 7:23 P.M., insulin Lispro scheduled for 05/17/25 at 12:00 P.M. was given at 2:34 P.M., Gabapentin, metoprolol, Depakote, Entresto, Tamsulosin, Colchicine, Eliquis, trazodone, and insulin Glargine scheduled for 05/17/25 at 9:00 P.M. were given 05/18/25 at 12:34 A.M., insulin Lispro and Gabapentin scheduled for 05/18/25 at 5:00 P.M. were given at 7:45 P.M., Gabapentin, Entresto, Tamsulosin, metoprolol, Depakote, trazodone, Colchicine, and insulin Glargine scheduled for 05/19/25 at 9:00 P.M. were given on 05/20/25 at 3:31 A.M., Depakote, Entresto, Lasix, Eliquis, Colchicine, Ativan, Gabapentin, metoprolol, and Tamsulosin scheduled for 05/23/25 at 9:00 P.M. were given at 11:25 P.M., metoprolol, Gabapentin, trazodone, Ativan, Colchicine, and Eliquis scheduled for 05/24/25 at 9:00 P.M. were given on 05/25/25 at 12:19 A.M. , insulin Lispro scheduled for 05/26/25 at 8:00 A.M. was given at 11:51 A.M., insulin Lispro scheduled for 05/26/25 at 12:00 P.M. was given at 2:06 P.M., Entresto, Lasix, Gabapentin, Eliquis, Ativan, and Colchicine scheduled for 05/30/25 at 9:00 A.M. were given at 1:02 P.M., insulin Lispro scheduled for 05/30/25 at 12:00 P.M. was given at 3:45 P.M., trazodone, Depakote, Tamsulosin, Entresto, Ativan, insulin Glargine, Colchicine, Gabapentin scheduled for 05/30/25 at 9:00 P.M. were given on 05/31/25 at 5:56 A.M. Interview on 06/04/25 at 4:10 P.M. with the DON confirmed multiple medications for Resident #48 were administered over an hour late on 05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/08/25, 05/10/25, 05/17/25, 05/18/25, 05/19/25, 05/20/25, 05/23/25, 05/25/25, 05/26/25, 05/30/25, 05/31/25. 5. Review of the medical record for Resident #102 revealed an admission date of 12/15/24 with diagnoses including bilateral osteoarthritis of hip, muscle weakness, anemia, acute kidney failure and hypertension. Review of the MDS assessment for Resident #102 dated 03/24/25 revealed the resident was moderately cognitively intact and was dependent on staff assistance with activities of daily living (ADLs.) Review of the MAR for Resident #102 dated May 2025 and June 2025 revealed the following medications were administered late: Eliquis and Gabapentin scheduled for 05/04/25 at 9:00 A.M. were given at 11:28 A.M., Eliquis and Gabapentin scheduled for 05/05/25 at 9:00 P.M. were given at 10:46 P.M., Eliquis and Gabapentin scheduled for 05/06/25 at 9:00 A.M. were given at 10:41 A.M., Eliquis and Gabapentin scheduled for 05/14/25 at 9:00 A.M. were given at 11:05 A.M., Eliquis and Gabapentin scheduled for 05/16/25 at 9:00 P.M. were given on 05/17/25 at 12:30 A.M., Robaxin scheduled for 05/16/25 at 10:00 P.M. was given on 05/17/25 at 12:30 A.M., Eliquis and Gabapentin scheduled for 05/17/25 at 9:00 P.M. were given on 05/18/25 at 12:43 A.M., Robaxin scheduled for 05/17/25 at 10:00 P.M. was given on 05/18/25 at 12:43 A.M., Eliquis and Gabapentin scheduled for 05/20/25 at 9:00 A.M. were given at 11:01 A.M., Eliquis and Gabapentin scheduled for 05/23/25 the 9:00 A.M. were given at 10:51 A.M., Eliquis and Gabapentin scheduled for 05/23/25 at 9:00 P.M. were given at 11:28 P.M., Robaxin scheduled for 05/23/25 at 10:00 P.M. was given at 11:28 P.M., Eliquis and Gabapentin scheduled for 05/24/25 at 9:00 P.M. were given at 10:43 P.M., Eliquis and Gabapentin scheduled for 05/26/25 at 9:00 P.M. were given at 11:19 P.M., Robaxin and Gabapentin scheduled for 05/31/25 at 2:00 P.M. were given at 3:42 P.M., Robaxin scheduled for 06/01/25 at 6:00 A.M. was given at 9:02 A.M., Eliquis and Gabapentin scheduled for 06/02/25 at 9:00 P.M. were given on 06/03/25 at 4:47 A.M., Robaxin scheduled for 06/02/25 at 10:00 P.M. was given on 06/03/25 at 4:47 A.M. Interview on 06/02/25 at 11:22 A.M. with Resident #102 confirmed his medications were often late, and at times he would get his 6:00 A.M. medications with his 9:00 A.M. medications. Interview on 06/04/25 at 4:10 P.M. with the DON confirmed Resident #102's Eliquis, Gabapentin, and Robaxin were late on multiple dates in May and June 2025. Review of the facility policy titled Medication Administration undated revealed medications should be administered within 60 minutes prior to or after the scheduled time. This deficiency represents noncompliance investigated under Complaint Number OH00165919 and Complaint Number OH00163185. Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected five (Residents #19, #48, #72, #102, #111) of nine residents reviewed for medication administration. The facility census was 111 residents. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 07/27/22 with a diagnosis of diabetes mellitus with diabetic nephropathy. Review of the Minimum Data Set (MDS) assessment for Resident #72 dated 04/02/25 revealed the resident was moderately cognitively impaired, had diabetes mellitus, and received insulin injections seven days per week. Review of the care plan for Resident #72 dated 07/29/24 revealed the resident had diabetes mellitus. Interventions included staff to administer diabetes medication as ordered by doctor. Review of the physician's orders for Resident #72 revealed an order dated 05/15/25 for Humalog insulin inject per sliding scale (one unit for a blood sugar of 151 to 200, two units for a blood sugar of 201 to 250, three units for a blood sugar of 251 to 300) subcutaneously with meals and inject six units one time a day with breakfast. Observation on 06/03/25 at 8:06 A.M. of medication administration for Resident #72 per Licensed Practical Nurse (LPN) #455 revealed the resident was in bed and had consumed his entire breakfast meal. Resident #72 told LPN #455 he had consumed 100 percent (%) of his breakfast. LPN #455 administered 9 units of Humalog insulin to Resident #72 and did not prime the insulin pen prior to administration. Interview on 06/03/25 at 8:16 A.M. with LPN #455 confirmed she administered 9 units of Humalog insulin to Resident #7 based on the six units ordered at breakfast and 3 units per sliding scale. LPN #455 confirmed she did not check the resident's blood sugar before the resident consumed his breakfast, and she also did not prime the insulin pen prior to administration. 2. Review of the medical record for Resident #19 revealed an admission date of 10/10/14 with a diagnosis of type two diabetes mellitus with diabetic neuropathy. Review of the care plan for Resident #19 updated 05/13/20 revealed the resident was at risk for hypo/hyperglycemia related to type two diabetes mellitus. Interventions included staff to monitor blood sugar levels as ordered. Review of the care plan for Resident #19 updated 05/24/23 for Resident #19 revealed the resident had diabetes mellitus and was at risk for complications. Interventions included staff to administer diabetes medication as ordered by doctor. Review of the physician's orders for Resident #19 revealed an order dated 04/29/24 for Humalog insulin inject 10 units subcutaneously two times a day and to hold if the blood sugar was less than 100. Review of the MDS assessment for Resident #19 dated 05/02/25 revealed the resident was moderately cognitively impaired, had diabetes mellitus, and received insulin injections seven days a week. Observation of medication administration for Resident #19 on 06/03/25 at 8:30 A.M. per LPN #453 revealed Resident #19 told LPN #453 she had consumed 100% of her breakfast. LPN #453 checked Resident #19's blood sugar at 136 and administered 10 units of Humalog insulin. Interview on 06/03/25 at 9:35 A.M. with the Director of Nursing (DON) confirmed blood sugar checks should be completed prior to meals. Review of the facility policy titled Insulin Pen undated revealed insulin pens should be primed prior to administration of each dose. 3. Review of the medical record for Resident #111 revealed an admission date of 01/20/24, a readmission date of 02/22/24 and a discharge date of 02/26/25 with diagnoses including hypertension, chronic obstructive pulmonary disease (COPD), anxiety disorder, and insomnia. Review of the physician's orders for Resident #111 dated February 2025 included orders for the following medications: trazadone 50 milligram (mg) one time a day at 9:00 P.M., Mucinex 1200 mg two times a day at 9:00 A.M. and 9:00 P.M., Atorvastatin 80 mg one tablet at 9:00 P.M., Montelukast 10 mg one time a day at 9:00 P.M., Primidone 50 mg two times a day at 9:00 A.M. and 9:00 P.M., metoprolol tartrate 12.5 mg two times a day at 9:00 A.M. and 9:00 P.M. Review of the Medication Administration Record (MAR) for Resident #111 dated February 2025 revealed the following medications were scheduled for administration at 9:00 P.M. but were not administered timely: trazodone, Mucinex, Atorvastatin, Montelukast, Primidone, metoprolol tartrate. Medications scheduled for on 02/03/25 at 9:00 P.M. were given on 02/04/25 at 1:33 A.M., medications scheduled for 02/04/25 at 9:00 P.M. were given on 02/05/25 at 3:19 A.M., medications scheduled for 02/06/25 at 9:00 P.M. were given on 02/07/25 at 12:15 A.M., medications scheduled for 02/18/25 at 9:00 P.M. were given on 02/19/25 at 3:04 A.M., medications scheduled for 02/25/25 at 9:00 P.M. were given on 02/26/25 at 1:13 P.M. Interview on 06/04/25 at 4:10 P.M. with the Director of Nursing (DON) confirmed medications should be administered one hour before or after the scheduled time. The DON confirmed if a medication were given outside of that two-hour window this was considered a medication error. The DON confirmed Resident #111 had multiple medication errors due to late administration of medications (9:00 P.M. doses of trazodone, Mucinex, Atorvastatin, Montelukast, Primidone, and metoprolol tartrate) on 02/03/25, 02/04/25, 02/06/25, 02/18/25, and 02/25/25.

Based on observation, interview, menu review and review of the menu spreadsheet, the facility failed to provide food items at the designated portions as written. This affected 101 residents receiving food from the kitchen as three residents (#63, #104 and #106) were ordered nothing-by-mouth (NPO) and seven residents (#9, #10, #24, #54, #74, #95 and #112) were observed to receive alternate meals during the observation. The facility census was 111. Findings include: Review of the menu for week three, dated as Spring/Summer 2025, revealed for lunch on Tuesday (06/03/25), the meal to be served included Polish sausage, potato wedges, sauteed peppers and onions, choice of roll, choice of cookie, milk and coffee/tea. Review of the menu spreadsheet for the lunch meal on 06/03/25 revealed the following portions were to be served: Polish sausage, one each; potato wedges, three ounces; sauteed peppers and onions, four ounces; choice of roll, one each; choice of cookie; one each. The diet extension for mechanical soft diets revealed these residents were to receive a #6-scoop (two thirds of a cup) of ground Polish sausage with two ounces of gravy. An interview on 06/02/25 at 11:22 A.M. with Resident #102 revealed the facility portions were not what they should be and residents did not get enough food to eat at times. Observation on 06/03/25 starting at 11:15 A.M. revealed [NAME] #409 took the temperatures of the foods to be served using an analog stick thermometer. Utensils and portions were observed at this time to be as follows: Polish sausage, one each; potato wedges, a large tongs grab (three ounces); onions and peppers, three-ounce spoodle; buns, one each; mechanically ground sausage, one #12-scoop (one third of a cup); green beans, four ounces; gravy, two ounces; and mashed potatoes, #8-scoop (a half of a cup). Trayline started at 11:23 A.M. Observations during this time revealed [NAME] #409 used a tan-gray three-ounce spoodle to serve peppers and onions and used a green #12-scoop for the ground sausage. [NAME] #409 was not observed to provide multiple scoops of food on plates unless the resident was ordered double protein at meals but continued to use the utensils identified above. During an interview on 06/03/25 at 12:06 P.M. Dietary Manager (DM) #425 verified [NAME] #409 did not serve the correct portions of onions and peppers (one ounce short per serving) and ground sausage (one third of a cup short per serving). DM #425 accompanied the surveyor to re-check the serving utensils used for the lunch meal which included a green #12-scoop for the ground sausage and a tan-gray three-ounce spoodle for the main vegetable as observed above and caused the facility to under-serve food at the lunch meal. Review of the facility diet list dated 06/02/25 identified three residents (Residents #63, #104 and #106) as NPO. This deficiency represents noncompliance investigated under Master Complaint Number OH00165919.

Based on record review, interview, and review of the facility policy, the facility failed to ensure the physician and resident's responsible party were notified when lab draws were not completed according to the physician/certified nurse practitioner (CNP) orders. This affected one (Resident #66) of three residents reviewed for notification. The facility census was 111. Findings include: Record review for Resident #66 revealed an admission date of 04/01/24. Diagnoses included vascular dementia, cerebral infarction, personal history of transient ischemic attack (TIA), and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was severely cognitively impaired. Review of the care plan dated 04/13/24 revealed Resident #66 had a cerebral vascular accident (CVA/Stroke) related to embolism. Interventions included administering medications as ordered by the physician. Review of the Pharmacy Medical Record Review dated 04/16/25 completed by Consultant Pharmacist #610 revealed Resident #66 was currently receiving Eliquis (blood thinner) 5 milligrams (mg) two times a day (BID). Although the resident's age and weight supported a 5 mg BID dose, renal function may not. Creatinine clearance was estimated to be between 15-29 milliliters per minute (ml/min) for which there was evidence to suggest a 2.5 mg BID dose should be considered. Physician Response documented on the Pharmacy Medical Record Review dated 04/23/25 completed by CNP #516 revealed an order for a complete metabolic panel (CMP), complete blood count (CBC), and renal function panel. Medical Record Review for Resident #66 revealed the CMP, CBC, and renal function panel ordered 04/23/25 was not available in the medical record and there was no documented evidence available in the medical record to indicate why the ordered labs were not completed. Interview on 06/05/25 at 8:48 A.M. with Assistant Director of Nursing (ADON) #429 revealed the order for Resident #66 for a CMP, CBC, and renal function panel was ordered 04/23/25. The lab was scheduled to complete the blood draw on 05/02/25. Review of the lab requisition for Resident #66 dated 05/02/25 revealed the blood specimen was not collected, Resident (#66) was combative/refused. No qualified personnel were available. The reschedule date/signature on the lab requisition was left blank. ADON #429 revealed the lab tech came to the facility on [DATE] (untimed) and attempted to draw Resident #66's blood for the ordered labs. Resident #66 refused. The lab tech should have gone to the floor nurse and the floor nurse would go with the lab tech and attempt to obtain the lab. This never occurred so the nurse was not aware the lab was not obtained and did not document the lab was not completed or reattempted. The labs orders were not followed up on, and there was no documented evidence that the physician/CNP and responsible party were notified. Review of the undated facility policy titled, Notification of Changes revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there was a change requiring such notification. Circumstances requiring notification include circumstances that require a need to alter treatment.

Based on medical record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to prevent resident-to-resident between Residents #48 and #214. This affected two (Residents #48 and #214) of four residents reviewed for abuse. The facility census was 111. Findings Include: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, diabetes, heart disease, major depressive disorder, post-traumatic stress disorder (PTSD), a left below the knee amputation, and an internal cardiac defibrillator. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact, refused aspects of care daily, and needed no assistance with personal care. Review of SRI tracking number 260710, dated 05/21/25, filed with the State agency for an allegation of physical abuse. Resident #48 and Resident #214 were in the facility's lobby waiting for the elevator after a smoke break. Too many residents attempted to get on the elevator at the same time, and Resident #214 attempted to pull a female resident in a wheelchair out of the elevator so he could get his own wheelchair on the elevator. Resident #48 attempted to stop Resident #214 from removing the female, and Resident #214 swung and hit Resident #48. Resident #48 hit Resident #214 back and both residents ended up on the floor hitting each other. Staff separated the two residents, and both residents were placed on one-to-one supervision. Another staff member called the police, and Resident #214 was transported to a local hospital by the police after Nurse Practitioner (NP) #517 wrote an order for a mandatory psychiatric admission. The Administrator went to the hospital to give Resident #214 an immediate discharge notice due to being a threat to himself, other residents, and staff. Resident #214 refused to see the Administrator, so the discharge notice was sent to him by certified mail. Resident #214 signed himself out of the hospital against medical advice (AMA) and returned to the facility. The police were called again and escorted the resident from the property. Review of the SRI revealed the facility did not list any witnesses to the incident nor any perpetrator. The facility unsubstantiated the allegation of abuse. Interview with the Administrator on 06/04/25 at 4:00 P.M. revealed the facility did not substantiate the allegation of abuse as they were unable to determine who started the resident-to-resident altercation. Review of the nurse's notes revealed on 05/21/25 at 11:59 P.M. Licensed Practical Nurse (LPN) #454 documented Resident #48 attempted to stop Resident #214 from attempting to remove a female resident in a wheelchair from the elevator so he could go to his room first. Resident #214 then swung his fist at Resident #48 and both residents fell out of their wheelchairs and continued their altercation on the floor. On 05/22/25 at 7:10 A.M. Licensed Social Worker (LSW) #419 met with Resident #48 to provide psychosocial-emotional support. The resident said he had no concerns or distress after the previous night's altercation with Resident #214. 2. Resident #214 was admitted to the facility on [DATE] with diagnoses including paraplegia and male erectile dysfunction. He was discharged from the facility and sent for an involuntary psychiatric admission on [DATE] where he was given an immediate discharge from the facility. Review of the comprehensive admission MDS dated [DATE] revealed Resident #214 was cognitively intact. The resident had numerous behaviors including physical aggression towards others four to six times during the seven-day assessment period. He was also verbally aggressive on a daily basis. Resident #214's behaviors significantly interfered with the resident's care and participation in daily activities. His behaviors put others at significant risk of physical injury, significantly intruded on other residents' privacy and daily activities, and significantly disrupted care and the living environment. He rejected care daily. Review of the progress notes from admission through discharge for Resident #214 revealed he was physically aggressive, verbally threatening, and disrespectful of other residents and staff daily. The resident refused counseling with the psychiatric services and refused to take his medication. He frequently requested pain medication which was not ordered for him. When staff were working with others, Resident #214 would interrupt and insist his needs be dealt with immediately. Review of Resident #214's care plans revealed the resident had behaviors of aggression, attacking staff, trapping staff in rooms, anger, and foul language. Interview with the Administrator on 06/04/25 at 4:00 P.M. revealed despite Resident #214's continuous verbal threats and physical aggression, they did not place him on the secured unit as he was his own responsible party and he refused to agree to be placed on the secured unit. The facility was going to present him with a behavior contract at his care plan conference which was scheduled for the day the resident was discharged to the psychiatric unit of a local hospital. The Administrator said she took an immediate discharge notice to the hospital to present it to him, but he refused to see her and called security to have her removed from the hospital. They sent the immediate discharge notice to him via certified mail. The Administrator said a few days later, Resident #214 returned to the facility after leaving the hospital AMA demanding to be allowed to return. The police were called and again escorted the resident off facility grounds. Interview with the Administrator on 06/09/25 at 2:00 P.M. revealed there was a hearing on Resident #214's immediate discharge appeal, and they maybe should have admitted the resident to the secured unit due to his behaviors towards residents and staff. Review of the facility's undated Abuse, Neglect and Exploitation policy revealed the facility must protect the residents from abuse. The Quality Assessment and Performance Improvement (QAPI) committee will review the risk factors that contributed to the abuse (a history of aggressive behaviors, environmental factors) and if there is a need for further systemic action such as tracking patterns of similar occurrences.

Based on record review, interview and facility policy review, the facility failed to report an allegation of resident-to-resident sexual abuse to the State agency for one (Resident #58) of four residents reviewed for abuse. The facility census was 111. Findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, major depression disorder, schizophrenia, high blood pressure, and mood disorder. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was severely cognitively impaired, had delusions, and had behaviors which significantly interfered with the resident's care and social interaction, significantly intruded on the privacy or activities of others, and had behaviors that significantly disrupted the living environment. Review of the nursing progress notes for Resident #58 revealed on 05/28/25 at 10:56 A.M. Nurse Practitioner (NP) #517, who is the facility's psychiatric NP, evaluated the resident. Resident #58 reported to NP #517 that she lifted her shirt up and a peer touched her breast. The resident denied being assaulted in any fashion. Interview with the Administrator on 06/04/25 at 2:00 P.M. revealed she was unaware of NP #517's evaluation as neither the nurse or NP #517 said anything to her about the allegation of sexual abuse, so it had not been reported to the State agency, had not been investigated, and Resident #58's guardian was not notified. A self-reported incident (SRI) was filed by the facility to the State agency on 06/06/25 at 10:12 A.M. Review of the facility's undated Abuse, Neglect and Exploitation policy revealed the facility must report all allegations of abuse to the State agency, the police if required, and investigate while keeping the resident safe from further abuse. This deficiency represents non-compliance investigated under Complaint Number OH00163815.

Based on interview and record review, the facility failed to monitor Resident #66's daily fluid intake and daily urine output related to a diagnosis of urinary retention requiring the use of an indwelling urinary catheter and discontinuation of the indwelling urinary catheter. This affected one (Resident #66) of two residents reviewed for indwelling catheters. The facility census was 111. Findings include: Record review for Resident #66 revealed an admission date of 04/01/24. Diagnoses included vascular dementia, cerebral infarction, neuromuscular dysfunction of bladder, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was severely cognitively impaired. Resident #66 had an indwelling urinary catheter and required set up or clean up assistance with personal hygiene. Review of the progress note dated 12/31/24 at 6:19 A.M. revealed Resident #66 was observed coming to the nurse's station to speak with the nurse. Resident #66 then went back towards his room when a loud noise was heard. Resident #66 was found lying on the floor. The documentation included that the resident was assessed with a change in condition. The Nurse Practitioner (NP) was notified, and Resident #66 was sent to the emergency room (ER). Review of the progress note dated 12/31/24 at 6:45 P.M. revealed Resident #66 returned from ER. He was noted to have urinary retention, and a Foley (indwelling) urinary catheter was in place. Review of the care plan dated 01/02/25 revealed Resident #66 had an indwelling urinary catheter due to neurogenic bladder. Interventions included monitoring and documenting intake and output per facility policy. Review of the progress note dated 01/30/25 at 3:31 P.M. completed by Unit Manager #416 revealed Resident #66 was observed in the hallway holding the Foley catheter in hand. Resident #66 refused to have the catheter replaced at this time. The NP was notified, and orders were received to discontinue (d/c) the Foley catheter and monitor input and output at this time. Review of the medical record for Resident #66 from 12/31/24 through 06/05/25 revealed Resident #66's daily fluid intake and daily urine output was not documented to assure Resident #66 had adequate output due to urinary retention diagnosis. Record review and interview on 06/05/25 at 10:33 A.M. with the Director of Nursing (DON) confirmed Resident #66's amount of daily fluid intake and daily urine output was not documented and should have been documented and monitored, both while having the indwelling urinary catheter and after discontinuing the indwelling urinary catheter, to ensure Resident #66 had adequate output due to a diagnosis of urinary retention.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure Resident #67 received all nutritional interventions recommended by the registered dietitian to treat and prevent significant weight loss. This affected one resident (Resident #67) of three residents reviewed for nutrition. The facility census was 111. Findings include: Record review for Resident #67 revealed an admission date of 06/13/24. Diagnoses included Alzheimer's disease, type one diabetes mellitus, and dysphagia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was severely cognitively impaired. Resident #67 required set up or clean up assistance with meals, had weight loss and was not on a prescribed weight loss regimen. Review of the care plan for Resident #67 dated revised 04/17/25 revealed the resident had nutritional problem or potential nutritional problem related to forgetfulness related to Alzheimer's/dementia. Diagnoses including type one diabetes mellitus, hypothyroidism, dysphagia, unspecified psychosis, and anxiety which may affect nutritional status. Interventions included to provide and serve diet as ordered. Monitor intake and record every meal, regular texture, thin liquids, plus sugar substitute, prefers side of soup with lunch and dinner. Review of the physician orders revised 04/29/25 for Resident #67 revealed regular diet, regular texture, thin consistency provide soup on tray with lunch and dinner. Review of Resident #67's weight history revealed from 03/05/25 through 06/02/25 Resident #67 had a 6.72 % weight loss. Interview on 06/05/25 at 11:54 A.M. with Certified Nursing Assistant (CNA) #508 revealed Resident #67 always ate his meals in the dining room and was able to feed himself. Observation on 06/05/25 at 12:06 P.M. revealed Resident #67 ambulated independently to the dining room. Resident #67 was served the lunch tray of rice, vegetable, chicken, roll and cake. No soup was observed on the tray. CNA #508 confirmed there was no soup on Resident #67's lunch tray and revealed, He normally don't get soup with his meals. CNA #508 revealed she worked routinely with Resident #67 for the past several weeks. Resident #67 ate one bite of rice then stood to leave the dining room. Licensed Practical Nurse (LPN) #455 asked Resident #67 if he was done. Resident #67 said yes. LPN #455 did not say anything more, picked up Resident #67's lunch tray while Resident #67 returned to his room. LPN #455 never offered Resident #67 soup and never encouraged Resident #67 to eat his lunch. Interview on 06/05/25 at 12:58 P.M. with Registered Dietitian (RD) #426 confirmed Resident #67 had a significant weigh loss of 6.72 %. RD #426 revealed she had been working with the Speech Therapist due to Resident #67's weight loss. Through discussion and assessment due to weight loss, RD #426 stated we added soup every lunch and dinner. RD #426 revealed she would expect staff to encourage Resident #67 to eat his meals and offer an alternative if he did not eat what was served. Observation on 06/05/25 at 5:17 P.M. revealed Resident #67 was sitting in the dining room. At 5:20 P.M. Resident #67 was served the dinner meal by CNA #508. Observation revealed there was no soup on the tray. CNA #508 confirmed there was no soup on Resident #67's meal tray and confirmed Resident #67 had a ticket on the tray revealing soup with lunch and dinner. CNA #508 revealed she don't read the tickets. Interview on 06/05/25 at 5:24 P.M. with LPN #455 who was located at a different dining room revealed she was not sure if Resident #67 was to get soup with lunch and dinner. LPN #455 revealed she did not have a computer right now but will check into it. Review of the facility policy titled, Nutritional Management undated revealed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systemic approach was used to optimize each resident's nutritional status. A comprehensive nutritional assessment will be completed by the dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow up assessments will be completed as needed. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's nutritional needs. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure orders were in place for the administration of oxygen and failed to date oxygen tubing as required. This affected one resident (#107) of one resident reviewed for oxygen and had the potential to affect an additional 13 residents (#1, #57, #65, #69, #74, #80, #84, #89, #97, #99, #106, #262 and #311) the facility identified as receiving oxygen in the facility. Facility census was 111. Findings include: Review of Resident #107's medical record revealed an admission date of 04/08/25 and diagnoses including malignant neoplasm of prostate, chronic obstructive pulmonary disease, anxiety and hypertension. Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #107 was cognitively intact and receiving hospice services. Oxygen was not coded on the MDS assessment. Review of Resident #107's physician's orders as of 06/02/25 revealed no orders were in place relative to oxygen. Observation on 06/02/25 at 2:00 P.M. revealed Resident #107 was up and awake in his bed. Oxygen was in use and no date was noted on the tubing connected to Resident #107. Interview on 06/02/25 at 2:00 P.M. with Resident #107 revealed he recently got oxygen. Interview on 06/04/25 at 7:54 A.M. with Licensed Practical Nurse (LPN)/Unit Manager (UM) #416 verified Resident #107 did not have orders for oxygen in place in the paper or electronic medical records and indicated there were always to be orders relative to oxygen administration. Follow-up observation on 06/04/25 at 7:58 A.M. of Resident #107 with LPN/UM #416 revealed Resident #107 was laying in bed and his oxygen cannula was in his nose with the oxygen concentrator noted to be in use. The oxygen tubing connected to Resident #107 lacked a date. Follow-up interview on 06/04/25 at 7:58 A.M. with LPN/UM #416 verified Resident #107's oxygen tubing should have been dated. Review of the policy, Oxygen Administration, dated 2025 revealed oxygen was administered under the orders of a physician, except in the case of an emergency. Staff shall document the initial and on-going assessment of the resident's condition warranting oxygen and the response to oxygen therapy .other infection control measures include change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on interview and record review the facility failed to obtain communication from the dialysis provider after each dialysis treatment. This affected one resident (Resident #94) of one resident reviewed for dialysis. The facility census was 111. Findings Include: Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including acute osteomyelitis of the left ankle and foot, diabetes with diabetic neuropathy, end stage renal disease dependent on dialysis, congestive heart failure, high blood pressure, Tourette's disorder, schizophrenia, and anxiety. Review of the physician's orders revealed Resident #94 attended dialysis on Mondays, Wednesdays, and Fridays. The resident was on a fluid restriction of 2000 milliliters (ml) per 12 hour shift. Review of the comprehensive annual Minimum Data Set (MDS) 3.0 , dated 05/20/25, revealed Resident #94 was cognitively intact, received daily insulin medications and diuretics, and received dialysis. Review of the pre and post dialysis assessments for Resident #94 revealed the facility was completing the assessments on each day the resident received dialysis. Review of the nurses' notes for Resident #94 revealed he was noncompliant with care including attending dialysis appointments and with his fluid restrictions. Interview with the Assistant Director of Nursing (ADON on 06/04/25 at 4:35 P.M. revealed the facility did not receive communication from the dialysis center after each treatment. The ADON was not certain how often the facility received communication from dialysis but it was not after each visit. Interview with Resident #94 on 06/04/25 at 4:40 P.M. revealed the dialysis center had never given him any paperwork to give to the facility upon completion of his treatment. On 06/05/25 at 12:00 P.M. a request for the dialysis information provided to the facility after each dialysis treatment was made to the Administrator. On 06/05/25 at 5:00 P.M. no information had been provided. On 06/09/25 at 7:30 A.M. the facility provided a monthly summary of Resident #94's lab work and his weights. No communication was provided indicating the facility was being updated by the dialysis center after each treatment. The facility's dialysis policy was requested for review but the policy was never provided throughout the survey process.

Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure a safe environment for Resident #212. This affected one (Resident #212) of one resident reviewed for suicidal ideations. The facility census was 111. Findings include: Record review for Resident #212 revealed an admission date of 05/02/25 and a readmission date of 05/16/25. Diagnoses included anxiety disorder, depression, post-traumatic stress disorder, gender identity disorder, and borderline personality disorder. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #212 was cognitively intact. Resident #212 had little interest or pleasure in doing things, feeling down, depressed or hopeless, feeling bad about herself/himself or a failure or have let herself/himself or her/his family down, and had trouble concentrating on things such as reading the newspaper or watching television. Resident #212 used a manual wheelchair, had no impairments of the upper or lower extremity, was independent with bed mobility, sit-to-stand and wheelchair mobility. Review of the Progress Note for Resident #212 dated 05/12/25 at 12:45 P.M. completed by Nurse Manager #416 revealed, This nurse was called to therapy gym d/t (due to) Resident #212 having a tearful anxious episode. While speaking with the resident, the resident verbalized wanting to die stating I don't want to do this anymore, I don't have a purpose, there is no point to me being here. All I need is 3-5 (three to five) minutes alone in my room. This writer asked the resident, if she had a plan resident verbalized I was researching on my phone things I could use to sharpen my butter knives with or different ways to end my life with the limited resources I have in here. Psych NP (Nurse Practitioner) was notified and orders received to send the resident to the ED (Emergency Department) for suicidal ideations with intent. Resident was notified and agreeable. Review of the Progress Note dated 05/16/25 at 6:50 P.M. completed by Licensed Practical Nurse (LPN) #455 revealed Resident #212 return from the hospital. Resident states she has recently had thoughts of harming self but currently does not and was feeling ok at this time. Resident #212 was alert and oriented to person, place and time. Interview on 06/05/25 at 2:59 P.M. with Resident #212 revealed, I want to hurt myself, but if I do, I will be without a place to live. I think about it all the time, I got a razor upstairs, all I have to do is tear it apart and I can use that. On 06/05/25 at 3:12 P.M. the Administrator was notified of Resident #212's statement. Interview on 06/05/25 at 3:44 P.M. with the Director of Nursing (DON) confirmed three disposable razors were removed from Resident #212's room. The DON revealed the hospital cleared her, so she has rights. Interview on 06/05/25 at 4:09 P.M. with Certified Nursing Assistant (CNA) #512 confirmed he worked with Resident #212 and revealed he was unaware of any precautions used for Resident #212 due to suicidal thoughts. Interview on 06/05/25 at 4:11 P.M. with CNA #485 confirmed she worked with Resident #212 and revealed she didn't know her very well. CNA #485 confirmed Resident #212 had asked her for razors, but she only gave them to her when she showered then disposed of them. Interview on 06/05/25 at 4:18 P.M. with LPN #461 confirmed she was Resident #212's primary charge nurse. LPN #461 revealed Resident #212 had suicidal tendencies. LPN #461 revealed, I don't know of any interventions. LPN #461 revealed nursing staff was to store and administer all Resident #212's medications. Observation with LPN #461 revealed there was an albuterol inhaler (bronchodilator) visible on Resident #212's bedside table. In the top drawer of the nightstand was a trelegy (once daily inhaler that includes three drug classes including corticosteroid, long-acting muscarinic antagonist, and a long-acting beta 2 adrenergic agonist) inhaler. In the bathroom was a full sharps container that was filled with used needles and syringes to the top, above the fill line. LPN #212 confirmed the inhalers and sharps container revealing she should not have the inhalers in her room then left the room leaving the inhalers on the bedside table. Interview on 06/05/25 at 4:23 P.M. with CNA #476 confirmed she also worked with Resident #212. CNA #476 revealed she helped transfer Resident #212 to the shower and washed her back, but she pretty much did everything else herself. Interview on 06/05/25 at 4:27 P.M. with DON confirmed the sharps container in Resident #212's room was full above the full line. Per DON that was not appropriate, and the sharps container should have been emptied. Interview on 06/05/25 at 5:27 P.M. with Certified Nurse Practitioner (CNP) #517 revealed Resident #212 was admitted for taking too much hormone therapy, she stated she wanted the transition process to progress faster. After she came, she had chronic suicidal ideation's and should not have medications, including inhalers, razors, or sharps containers unsecured in her room. Interview on 06/09/25 at 8:30 A.M. with the DON who revealed the sharps container was hanging on the wall in Resident #212's bathroom it was full, but it was not the facilities. The DON revealed he was unsure how it got there. Also, the inhalers that were in her room were hers from home and staff cannot take them without her permission. Observation and interview on 06/09/25 at 9:13 A.M. with LPN #461 confirmed the sharps container that was in Resident #212's room was the same container as when she was admitted to the room. Observation revealed LPN #212 had the key to unlock the sharps containers to remove it from the walls. Observation revealed LPN #212 unlocked the sharps container in a nearby room stating all the rooms have sharps containers, you cannot remove them or replace them without the key, the nurses carry the key on their key ring with other facility keys. LPN #461 revealed residents did not have access to the keys to remove the sharps containers. Interview on 06/09/25 at 9:25 A.M. with the DON to review the observation with LPN #461 which required a key to hang or remove a sharps container. DON stated, Oh. Review of the undated facility policy titled, Behavioral Health Services revealed Behavioral Health encompasses a resident's whole emotional and mental well-being, which includes but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goal for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety.

Based on observations, interviews, record review, elopement investigation review, police report review, facility policy review and review of weather information from accuweather.com, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #7) who had diagnoses including [CONDITION(S)], [CONDITION(S)] disorder, mild cognitive impairment, unspecified cataract, major depressive disorder and type two diabetes. This resulted in Actual Harm that was Immediate Jeopardy when Resident #7 left the second-floor secured unit without staff knowledge on 04/24/21 following a fire alarm. Staff realized Resident #7 was missing at approximately 6:00 A.M. and his whereabouts and condition were unknown until he was found by police, lost and confused, on a busy two-lane road in a city approximately 18 miles away on 04/24/21 at 5:58 P.M Immediate Jeopardy also resulted on 05/06/21 when Resident #1, who had known history of substance abuse and a Wanderguard (a device that causes the door to alarm upon exit), left the facility without staff knowledge and crossed a busy four-lane road in order to go to the bus stop 0.2 miles away. This affected two residents (Resident #1 and Resident #7) of five residents reviewed for elopement. The facility identified four residents at risk for elopement (Resident #1, Resident #7, Resident #52 and Resident #57). The facility census was 92 residents. On 05/13/21 at 2:36 P.M. the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #300 were notified Immediate Jeopardy began on 04/24/21 at 6:00 A.M. when Resident #7, who resided on the facility's secured behavior unit, was identified as missing from the facility following a fire alarm that occurred earlier on 04/24/21 and had deactivated the secured unit's stairwell doors. Resident #7 had last been seen at 5:19 A.M. by Registered Nurse (RN) #303 during medication administration. Resident #7 ambulated alone and unsupervised throughout a busy [NAME] environment until he was found by police in a city 18 miles away on 04/24/21 at 5:58 P.M. The resident was returned to the facility by staff. Resident #7 had been admitted to the facility's secured unit due to eloping from another nursing facility. Additionally, Resident #1 exited the facility without staff knowledge on 05/06/21 through the door to the enclosed smoking courtyard and went through a hole in the fence to cross four lanes of traffic to reach a bus stop in front of a hospital 0.2 miles away. Resident #1 happened to be seen by off-duty RN #215 and State tested Nursing Assistant (STNA) #314 and was returned to the facility. It was unknown and undocumented when staff last interacted with Resident #1 prior to her elopement. The Immediate Jeopardy was removed on 05/15/21 when the facility implemented the following corrective actions: · On 04/24/21 at 3:30 P.M. the Administrator/designee developed education and began education to all facility staff on the facility's wandering/elopement policy and fire drill protocol. Any staff not in the facility on 04/24/21 were in-serviced by phone by the Administrator/designee. No disciplinary actions were issued regarding Resident #7's elopement from the facility. · On 04/24/21 at 8:00 P.M. the DON completed a full body assessment on Resident #7 with no negative findings. · On 04/28/21 at 2:55 P.M. Director of Maintenance (DOM) #301 conducted a fire drill with 26 participants. · On 05/04/21 the facility policy was updated to include the fire drill cheat sheet which was also distributed to all staff on 05/04/21. The sheet indicated staff were to report to the first floor to monitor exit doors and staff would have to have a visual on the second floor's exit doors that would be unlocked as a result of the fire alarm. · On 05/04/21, Contractor #313 conducted a fire drill audit to verify 24 staff followed the fire drill policy and expectations during a fire drill. · On 05/06/21 at 7:00 P.M. the DON completed a full body assessment on Resident #1 with no negative findings. · On 05/06/21 at 7:30 P.M. the facility's smoking area/courtyard fence was patched so it could not be passed through and the white gate was secured. · On 05/10/21 a fire drill was conducted. Fire drills will continue weekly for four weeks, then twice a month for two months and randomly thereafter. · On 05/11/21 at 3:00 P.M. an elopement drill was conducted with no issues noted. Drills to be completed weekly for four weeks, monthly for two months and randomly thereafter by the DON. · On 05/13/21 at 2:51 P.M., the DON contacted the facility ' s medical director, Physician #330, by phone for consultation for residents to be re-evaluated for wandering risk with no residents identified. · On 05/13/21 from 3:30 P.M. to 11:59 P.M. the Administrator/designee developed education on wandering/elopements and the facility ' s fire drill protocol. All staff in the facility were in-serviced in person and any staff not in the facility were in-serviced by phone by the Administrator, DON, Director of Rehabilitation (DOR) #320, Licensed Social Worker (LSW) #311, Registered Dietitian (RD) #304, STNA #310 and Business Office Manager (BOM) #334. The one agency staff currently contracted with the facility was also educated by phone. Shall the facility contract with any additional agency staff education will be reviewed with staff prior to working in the facility by the DON/designee. · On 05/13/21 at 3:36 P.M. three residents identified by the facility to be at risk for elopement (Residents #1, #7 and #52) were evaluated by Nurse Practitioner (NP) #306. · On 05/13/21 (no time given) a quality assurance performance improvement (QAPI) meeting was held. Future QAPI meetings to discuss facility processes were scheduled for 05/21/21, 05/28/21, 06/04/21 and 06/11/21. · On 05/13/21 from 4:11 P.M. to 4:38 P.M. the Administrator toured to ensure the white gate off the smoking courtyard alarmed for safety. · On 05/13/21 at 4:30 P.M. the facility's staffing agencies were made aware of necessary education needed prior to next shift. Education will be available to all agency staff to be educated prior to working their shift. · On 05/13/21 by 8:00 P.M., all residents in the facility including residents on the second floor secured unit and residents with Wanderguard devices were re-evaluated for wandering risk by the DON, ADON/LPN #300, Licensed Practical Nurse (LPN)/Unit Manager (UM) #327 and LPN/UM #312. This documentation was added to the residents' medical records. · On 05/13/21 by 8:00 P.M. all three Wanderguards were checked for appropriate function by the DON with no concerns identified. · On 05/13/21 by 11:59 P.M. the DON/designee completed wandering assessments for all residents in the facility. · On 05/14/21 the facility updated their Happy Feet elopement binders and the binders included Residents #1, #7, #52 and #57. · On 05/14/21 at 10:30 A.M. the DON re-evaluated Resident #57 and determined he did not meet the criteria for a Wanderguard. Physician #330 was contacted and agreed. Resident #57's Wanderguard was removed on 05/14/21 at 12:00 P.M. · On 05/14/21 at 11:19 A.M. the company that serviced the facility's Wanderguard system was contacted to install the Wanderguard system on five additional doors including the smoking/courtyard area, East entrance door, ambulance entrance, service entrance door and main dining room door, covering all exit doors on the first floor. The Administrator signed the installation contract on 05/14/21 at 12:55 P.M. Until installation was completed, Resident #1, Resident #7 and Resident #52 would remain on 15-minute checks. · On 05/14/21 by 2:30 P.M. all Wanderguard orders were audited and verified in Point Click Care (the facility's electronic medical record) by ADON/LPN #300. · On 05/14/21 at 5:00 P.M. the Administrator walked all exit doors in the facility to ensure all doors were properly secured. · On 05/18/21 at 4:04 P.M. the Administrator shared via e-mail the company that serviced the Wanderguard system would send the facility a quote on 05/19/21 and seek to schedule installation of the additional Wanderguards after that. · On 05/19/21 from 8:04 A.M. to 11:48 A.M. interviews with Housekeeper #337, STNA #333, Maintenance Assistant (MA) #317, RD #304, DOR #320, STNA #310, Dietary Aide (DA) #335, STNA #343 and LPN #336 revealed they were in-serviced on elopement and the facility's updated fire drill protocol and were knowledgeable on the facility's Happy Feet binders. · On 05/19/21 from 8:22 A.M. to 8:41 A.M. observation of the facility with LPN/ADON #300 verified the current Wanderguard sensor on the front door was fully functional and verified the two remaining residents with Wanderguards (Resident #1 and Resident #52) had fully operational devices in place. All four floors were visited and noted to have a Happy Feet elopement binder in place. Although the Immediate Jeopardy was removed on 05/15/21, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #7's medical record revealed an admitted [DATE] with diagnoses including type two diabetes, major depressive disorder, hypertension, [CONDITION(S)], mild cognitive impairment, [CONDITION(S)] disorder and unspecified [CONDITION(S)]. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #7 had a brief interview for mental status (BIMS) score of eight indicating moderate cognitive impairment. Resident #7 displayed inattention, disorganized thinking, and delusions. Resident #7 was not coded as wandering but had verbal behaviors, other behaviors and rejected care in the last one to three days of the seven-day lookback period. Resident #7 required limited assistance of one staff for bed mobility and was supervision level assistance for dressing. Resident #7 required supervision for ambulation on and off the unit. Resident #7 had a legal guardian. Review of May 2021 physician's orders revealed Resident #7 received 1.5 milligrams [MEDICATION(S)] (an anti-psychotic) twice a day for [CONDITION(S)]. An order dated 05/05/21 for shift behavior charting included behaviors exit seeking, pacing by doorways, watching for code access and number of times noted. Interventions included provide activity and snack time away from exit ways, one on one and rest and relax in room. Review of Resident #7's assessments indicated a quarterly wandering risk scale completed on 03/05/21 that classified the resident as a low risk to wander with the notation, resides on secured male behavior unit. There was no re-assessment of elopement risk completed on 04/24/21. Review of Resident #7's care plan revealed a plan revised 06/11/18 that indicated Resident #7 was noted to have episodes of yelling and screaming and was delusional in thought process. A care plan revised 11/22/16 indicated Resident #7 required secured unit placement due to elopement risk, wandering and having no safety awareness. A care plan revised 06/27/20 indicated Resident #7 was at risk for injury related to elopement/wandering/[CONDITION(S)], had expressed intent on leaving the facility, impaired cognition, [CONDITION(S)], paranoia and was unaware of safety needs. A care plan revised 03/06/20 indicated Resident #7 had impaired decision making, long term memory loss, short term memory loss and used [CONDITION(S)] medications. Review of Resident #7's admission social service notes dated 09/19/16 and 09/21/16 revealed Resident #7 was admitted to the facility from the hospital after eloping from another facility and being found passed out on a sidewalk. Resident #7's placement on the secured unit was appropriate due to the resident ' s history of elopement in his previous facility. Review of a nurses' note dated 04/24/21 at 5:19 A.M. and written by RN #303 indicated Resident #7 took 6:00 A.M. medications without difficulty and at 6:00 A.M. the resident was not in his room for blood sugars. All rooms and common areas on the unit were searched and the resident was not found. RN #303 searched the first floor and smoking area and other unit staff were notified at 6:30 A.M. to search for the resident. The Administrator was notified via voicemail. Unit managers were called and notified via voicemail's. Local city police were called to file a report. RN #303 attempted to notify Resident #7's guardian but only office numbers were available. RN #303 attempted to notify the resident ' s sister but was unable to leave voicemail. Resident #7's physician was notified at 8:03 A.M. Review of a progress note dated 04/26/21 at 3:08 P.M. written by RD #304 revealed the note was for 04/24/21. RD #304 received notification at 5:58 P.M. that Resident #7 needed a ride back to the facility from the police department that found the resident. RD #304 offered to go pick him up and got to the police station at 6:30 P.M. The police officer requested Resident #7's lighter and cigarettes and these were given to RD #304. Resident #7 got into RD #304's car at 6:37 P.M. During the drive RD #304 asked what he was doing, and Resident #7 stated he had called his family to talk to them and his sister had hung up on him. He wanted to see his father and others in his family. He had stopped at a convenience store to buy cigarettes and a lighter. He was hungry so RD #304 stopped at a fast-food restaurant. Resident #7 returned to the facility on [DATE] at 7:16 P.M. He returned with no injuries. Review of historical weather data from www.accuweather.com revealed on 04/24/21 the high temperature was 54 degrees Fahrenheit (F) and the low temperature was 36 degrees F. Review of an incident log for April 2021 and May 2021 revealed no elopements or unauthorized absences from the facility were documented. Review of the facility's investigation for the 04/24/21 elopement revealed a hand-written timeline, which was unauthored and indicated at 7:15 A.M. RN #303 called the Administrator to inform her Resident #7 was not in the facility. RN #303 had searched the facility and notified police. Resident #7's guardian and the nurse practitioner were notified, and a head count was completed. At 7:25 A.M. a message was sent out to all department heads to meet at the building to begin a search of the surrounding area. At 10:30 A.M. department heads met back up at the facility and calls were placed to all staff members to educate on proper procedure during fire drills to prevent elopements. At 5:26 P.M. RN #303 received a call from the police department indicating Resident #7 had been picked up and went willingly with the police department. The investigation contained a hand-written skin assessment and BIMS assessment that were unauthored and indicated Resident #7 had a BIMS score of 10 and told staff he knew he should not have left but wanted to go spend time with his friends. Resident #7 was educated on safety and staff notification if he desires to leave the unit. The investigation included the two nurses' notes from Resident #7 ' s chart and 10 staff statements from LPN #340, LPN #312, RD #304, ADON/LPN #300, RN #331, STNA #310, DOM #301, Activity Director (AD) #341, DOR #320 and Dietary Manager (DM) #342. Review of the staff schedule from 04/23/21 revealed second floor staff that worked from 7:00 P.M. on 04/23/21 until 7:00 A.M. on 04/24/21 included RN #303, STNA #326 and STNA #328. No staff statements were available in the facility ' s investigation from these staff. Review of a local police report for a missing person/runaway dated 04/24/21 at 7:57 A.M. revealed Resident #7 walked out of the facility without being detected from the secure wing and had resided in the nursing home since 09/14/16. Review of the locating city's police report dated 04/24/21 at 5:17 P.M. revealed police were dispatched to a report of an elderly male walking down the street who seemed lost and confused. Officers found the male and identified him as a missing male from a nursing home. The nursing home was contacted, and the male was picked up. Observation of the facility on 05/12/21 from 10:22 A.M. to 11:31 A.M. revealed the East side door was the only entrance currently in use and required a key code to enter and exit. The front main entrance was locked but had a Wanderguard alarm on it. The hall leading out to the smoking area had a keypad on the wall on the left side that connected to the white gate that activated an alarm if it was opened. Interview on 05/12/21 at 1:45 P.M. with ADON/LPN #300 explained the security behind the second floor; three stairwell doors had keypads to enter. A metal key was needed for the left facility elevator to get it to stop at the second floor. To get off the second floor, a card had to be swiped. Interview on 05/12/21 at 3:50 P.M. with the Administrator revealed someone had pulled the fire alarm on 04/26/21 and Resident #7 got out of the facility. It had been determined Resident #7 got out of the facility as the doors on the secured unit unlocked during a fire alarm and staff were not in place to monitor the doors during that time. The Administrator felt this constituted an unauthorized leave and not an elopement since Resident #7 chose to leave but agreed it should have been on the facility ' s incident log. Interview on 05/12/21 at 5:12 P.M. with STNA #305 revealed she worked day shift after Resident #7 got out of the facility, but he had been gone at that point. STNA #305 stated there had been no elopement book on the unit for staff to refer to. Interview on 05/12/21 at 5:46 P.M. with the DON and the Administrator revealed the facility did not consider the 04/24/21 incident with Resident #7 to be an elopement due to cognition status. The DON stated Resident #7 stated he knew where he was going and walked the entire way. The DON stated the facility did not reassess for elopement when Resident #7 returned to the facility as they did not consider the incident to be an elopement. Someone (not named) had pulled the fire alarm on 04/24/21 and Resident #7 got out after that point, so the facility had changed its fire drill protocols to include monitoring exit doors and educated staff. Interview on 05/12/21 at 7:07 P.M. with NP #306 revealed she had been notified on 04/24/21 at 5:30 A.M. or 6:00 A.M. of a fire alarm at the facility and that Resident #7 was missing. NP #306 stated she had to consider this an elopement as Resident #7 was on the locked unit for a reason and she could not state for sure he knew where he was going. Resident #7 was alert and oriented times two and would go back to speaking Spanish which was his primary language. Interview on 05/12/21 at 11:00 A.M. with Resident #7 revealed he was always here at the facility and denied leaving the facility at any time. Interview on 05/13/21 at 8:27 A.M. with the Administrator revealed prior to 04/24/21 the facility did not have a procedure in place regarding monitoring the exit doors during a fire drill or alarm. Interview on 05/13/21 at 11:46 A.M. with LSW #311 revealed department heads were called to the facility on [DATE] to help search for Resident #7 and helped to re-educate staff. LSW #311 stated Resident #7 could be difficult to understand as English was not his primary language and he was alert to person and place with confusion to time. Due to the language barrier, Resident #7 would require supervision out in the community. LSW #311 stated Resident #7 should not have been able to exit the secured unit without supervision. LSW #311 shared Resident #7 could be a high elopement risk going forward. Interview on 05/13/21 at 12:26 P.M. with Resident #7's Legal Guardian (LG) revealed she had never been notified of Resident #7's elopement on 04/24/21 and she became upset. The LG explained facility staff would often call the office number and she had provided her cell phone number to the facility since it ensured she could be notified in a timely manner. The LG told the surveyor Resident #7 had eloped from another nursing home in 2016 walking from one large city to another and had been gone several days. The LG reiterated Resident #7 was on the facility's secured unit because of prior elopements. The LG shared Resident #7 was preoccupied with leaving the facility since he wanted his own apartment and stated Resident #7 was alert to self but not to place. Interview on 05/13/21 at 2:48 P.M. with RD #304 verified her written statement. RD #304 stated she was geographically close to where Resident #7 was found so she picked him up and returned him to the facility on [DATE]. RD #304 stated she did not ask the police for any details of how police found Resident #7 and shared Resident #7 was happy to see her and talkative. Resident #7 had told her he wanted to see his father and sister but when he called them on the phone his sister had hung up on him. RD #304 shared Resident #7 shared with her some of his family past and his own which included a history of alcohol abuse. RD #304 reiterated Resident #7 walked the whole way and told the surveyor some of the streets he traveled on but still was unsure how he arrived in the city police picked him up in. After 9:30 A.M. on 04/24/21 RD #304 stated she and RN #331 went to a local gas station (0.6 miles away from the facility) with Resident #7's photo and staff at the gas station told her he had been there around 6:00 A.M. to 6:15 A.M. and had bought three packs of cigarettes and a lighter and went on his way. Interview on 05/13/21 at 3:10 P.M. with RN #303 revealed the facility was short-staffed so she came in to work on the second floor 3:00 A.M. to 7:00 A.M. on 04/24/21. RN #303 recalled she passed her 6:00 A.M. medications starting at 5:00 A.M. and had seen Resident #7 then. RN #303 recalled giving Resident #7 [MEDICATION(S)] (blood pressure medication) at 5:20 A.M. RN #303 stated Resident #56 had pulled the fire alarm between 4:30 A.M. and 4:45 A.M. RN #303 explained LPN #322 came down to the second floor to try to shut the fire alarm off and told her the fire department would shut the alarm off. RN #303 did not know the exit doors on the hallway would unlock during the fire alarm. At 6:00 A.M. RN #303 stated she went into Resident #7's room to do a blood sugar check and he was not in the room. She started to search for Resident #7 including the outdoor smoking area and noted the white gate was open. RN #303 denied hearing an alarm for the white gate. RN #303 started to call management staff and the police. RN #303 denied having to write a statement for the facility's elopement investigation. Interview on 05/13/21 at 4:38 P.M. with LPN/UM #312 revealed Resident #7 had a guardian, could not read English, and had family in a neighboring city. LPN/UM #312 stated elopement risk was assessed quarterly and annually; residents on the second-floor secured unit could not leave the unit without staff with them. Interviews were attempted with LPN #322 on 05/17/21 at 9:44 A.M., on 05/18/21 at 12:28 P.M. and on 05/19/21 at 2:08 P.M. but were unsuccessful. Interview on 05/17/21 at 10:33 A.M. with LPN/UM #327 revealed to determine elopement risk, the facility looked at a resident's BIMS score, if they had a guardian and if they had exit-seeking behaviors. Interview on 05/18/21 at 10:50 A.M. with STNA #328 verified they worked the overnight shift from 04/23/21 into 04/24/21. STNA #328 stated Resident #7 would sometimes pace the halls when agitated. STNA #328 recalled the fire alarm went off between 5:30 A.M. and 6:00 A.M. as they were providing a shower to another resident at that time. STNA #328 recalled doing rounds at 5:15 A.M. with no issues but between 5:45 A.M. and 6:00 A.M. did a head count and could not find Resident #7 and told this to RN #303. STNA #328 described Resident #7 as having a language barrier and shared when he could not communicate his needs, he would get frustrated and then pace. STNA #328 thought Resident #7 would need a translator in the community to be safe. Interview on 05/18/21 at 12:20 P.M. with STNA #316 revealed she worked overnight from 04/23/21 at 7:00 P.M. until 04/24/21 at 7:00 A.M. STNA #316 stated Resident #7 was not her assigned resident during the shift. STNA #316 recalled the fire alarm was pulled on 04/24/21 at 6:00 A.M. and she had last seen Resident #7 around 5:00 A.M. or so, walking back and forth on the unit doing what they do. STNA #316 stated STNA #328 had seen Resident #7 walking back and forth with his coat on and didn't think anything of it. STNA #316 stated day shift staff had shared Resident #7 was going to try to get out if he had the chance after he returned to the facility on [DATE]. STNA #316 said prior to the incident, they did not know who would be at risk for elopement as no one had ever tried to get out during their shift. Interview on 05/19/21 at 7:22 A.M. with Resident #56 verified he pulled the fire alarm on 04/24/21 but did not recall what time that occurred. Review of the facility's consent form for the secured unit, dated February 2020, revealed the above named resident has been assessed by the interdisciplinary team and found to have conditions or needs that require the resident be placed on the facility's secured Olive unit which is a specialized locked unit that restricts the resident ' s freedom of movement throughout the facility. Benefits included increased supervision as well as the existence of a stable and secure environment. 2. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses including hypertension, falls, type two diabetes, alcohol abuse, [CONDITION(S)] without behavioral disturbance, [CONDITION(S)] disorder depression, post-traumatic stress disorder (PTSD), [CONDITION(S)] and [CONDITION(S)]. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and required supervision for activities of daily living except for bathing, which Resident #1 required the assistance of one staff member. Review of the physician's orders revealed an order dated 04/09/21 for Wanderguard, check function of Wanderguard to right ankle every shift Review of electronic Medication Administration Records (eMARs) and electronic Treatment Administration Records (eTARS) revealed documentation was not available regarding the Wanderguard orders being signed off every shift. Review of Resident #1's wandering risk scale assessments revealed the admission assessment dated [DATE] classified Resident #1 as at a low risk to wander. A quarterly wandering risk scale assessment dated [DATE] revealed Resident #1 was at risk to wander with the notation, Resident is an elopement risk. Review of Resident #1's assessments indicated no re-assessment of elopement risk was completed on 05/06/21. Review of a smoking safety screen for Resident #1 dated 04/08/21 and completed by LSW #311 revealed Resident #1 had cognitive loss, smoked in the afternoons and evenings and the facility stored her lighter and cigarettes. Resident #1 exhibits cognitive decline throughout the day. She becomes more confused as is at risk of elopement. The screen indicated Resident #1 was safe to smoke with supervision. Review of Resident #1's care plans revealed a plan of care revised 04/05/21 that indicated Resident #1 was an elopement risk/wanderer due to history of leaving facility unattended, Resident #1 wandered aimlessly and had cognitive impairment. Family had stated they want her to reside in facility long-term. Attempted to leave by calling a cab. A plan of care revised 04/14/21 revealed Resident #1 had impaired cognitive function or impaired thought processes related to dementia. Resident #1 is more alert and oriented during the day but sundowned. A plan of care revised 04/09/21 revealed Resident #1 wanted to discharge to the community, but the family stated Resident #1 was homeless and can ' t take care of herself. Review of Resident #1's preadmission hospital paperwork dated 03/09/21 revealed Resident #1 had polysubstance abuse with alcohol and cocaine being her drugs of choice. Resident #1 had fallen off the stairs and walked three miles to the emergency room where she was positive for cocaine. Resident #1 was a difficult patient due to noncompliance and continuous drug and alcohol abuse. Review of a social service note dated 03/17/21 and written by LSW #311 revealed Resident #1 had history of substance abuse and was alert and oriented but exhibited poor decision-making skills. Review of a social service note dated 03/26/21 and written by LSW #311 revealed Resident #1 presented as alert and oriented but exhibited inattention and delayed response when answering questions. Review of a nurses' note dated 04/02/21 at 11:15 A.M. and written by the DON revealed Resident #1 was walking around the building stating she was leaving, and her son and sister would be picking her up. Call placed to son who stated Resident #1 was confused and no one would be picking her up. The son wished for Resident #1 to stay at the facility due to declining cognition and wished for a Wanderguard to be applied. Review of a social service note dated 04/02/21 at 1:05 P.M. and written by LSW #311 revealed Resident #1 exhibited changes in cognitive skills throughout the day. Resident #1 gets fixated on leaving, will wander around with her book bag stating she is leaving. Review of a nurses' note dated 04/02/21 at 2:18 P.M. and written by the DON revealed a Wanderguard was applied to Resident #1 ' s right ankle. Review of a nurses' note dated 04/02/21 at 8:24 P.M. and written by RN #345 revealed Resident #1 stated she wanted to leave the building by taxicab. Review of a social service note dated 04/08/21 at 3:25 P.M. and written by LSW #311 revealed she spoke with Resident #1's son regarding the need to look for a secured female unit as Resident #1 exhibited significant changes in cognition and sundowned. LSW #311 asked about a referral to a neighboring city but the son wanted her to stay in this area. Review of a social service note dated 04/12/21 at 4:04 P.M. and written by LSW #311 revealed Resident #1 visited her and wanted to discharge. Resident #1 had cognitive issues and the son did not agree with her being discharged . Review of a social service note dated 05/10/21 at 1:33 P.M. and written by LSW #311 revealed a message was left for Resident #1's son regarding alternate placement for the resident. Review of nurses' notes revealed no evidence Resident #1 left the faciity on [DATE]. Review of historical weather data from www.accuweather.com revealed on 05/06/21 the high was 69 degrees F and the low was 52 degrees F. Review of an incident log for April 2021 and May 2021 revealed no elopements or unauthorized absences from the facility were documented. Review of a paper file on Resident #1 dated 05/06/21 and not part of the resident's medical record revealed a typed timeline and three staff statements from LPN #307, LPN #308, and Housekeeping Director (HD) #309. The DON revealed a call from LPN #315 on 05/06/21 at 6:45 A.M. (wrong time) stating she had seen Resident #1 walking to the bus stop. LPN #315 turned her car around and saw STNA #314 standing with the resident at the bus stop. STNA #314 had just exited the bus and was coming into work. The DON requested a head count of the building and all residents were accounted for. LPN #315 asked Resident #1 where she was going, and she stated she was going to see her sister. LPN #315 got Resident #1 to return to the facility. Once back, Resident #1 was interviewed (staff not identified) and stated she wanted to leave to visit her family and did not tell someone as she had not at other facilities. Resident #1 was re-educated by LPN #315 on sig [TRUNCATED]

Based on record review, interview and observation the facility failed to ensure supervision was provided during smoke breaks. During an unsupervised smoke break an altercation occurred between Resident #55 and Resident #108. Actual Harm occurred when Resident #55 punched Resident #108 with a closed fist knocking out two teeth. This affected two of 44 residents who smoke on the third and fourth floor. Finding Include: Review of the medical record for Resident #55 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had intact cognition and no behaviors. Review of the care plan dated 12/02/20 revealed Resident #55 was a smoker and experienced alteration in mood and behavior. The smoking assessment dated [DATE] revealed the resident was safe to smoke with supervision. Review of the nurses note dated 12/20/20 at 9:00 P.M. revealed staff was alerted Resident #55 was in a physical altercation with Resident #108. Resident #108 grabbed Resident #55's wheelchair and attempted to hit him but did not. Resident #55 reported he punched Resident #108 in the face several times. On assessment Resident #108 denied pain and his skin was intact. The physician was notified. The police were called and took a statement. Review of the medical record for Resident #108 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the smoking assessment dated [DATE] revealed Resident #108 was safe to smoke with supervision. Review of the care plan dated 12/16/20 revealed the resident was smoker and had the potential to be verbally aggressive. Review of the MDS assessment dated [DATE] revealed Resident #108 had impaired cognition and verbal behaviors directed at others. Review of the nurses notes dated 12/20/20 at 9:00 P.M. revealed at approximately 9:00 P.M. the nurse was alerted Resident #108 was in a physical alteration with Resident #55 in the common area and was attacked and punched. On assessment Resident #108 was alert and holding a tooth in his hand and another tooth was found in the elevator. Resident #108's left eye was swollen and starting to close. Resident #108 refused to go to the emergency room . The police were called and arrived at 9:30 P.M. and reported there was not enough evidence to charge Resident #55 with assault. Interview on 12/22/20 at 2:13 P.M. with Resident #108 revealed on 12/20/20 he was on an unsupervised smoke break when Resident #55 stood up from his wheelchair and snatched him out of his chair and started beating him and knocked out a tooth. The police came and did not press charges. Observation at the time of the interview revealed the area below Resident #108's left eye was slightly swollen with no discoloration. Observation of the smoking area on 12/22/20 at 5:07 P.M. revealed Resident #4, Resident #58, and Resident #98 were smoking without supervision. Interview on 12/22/20 at 5:07 P.M. with the scheduler verified residents were smoking in the designated smoking area without supervision. The scheduler said the residents were non-compliant with smoking rules. Interview on 12/22/20 at 5:20 P.M. with Resident #55 revealed he was in the smoking area when three Afro-American men were threatening to beat him. Resident #108 started coming towards him in a wheelchair and tried to hit him and missed. Resident #55 got up and punched him. Interview on 12/23/20 at 9:38 A.M. with the Administrator revealed Resident #55 started using the N word and believes that was the basis of the altercation. He was unsure of who threw the first punch the investigation was still in progress. Interview on 12/23/20 at 11:58 P.M. with the Director of Nursing (DON) revealed at approximately the same time as the altercation on 12/22/20 a resident on the secured unit pulled the fire alarm and the STNAs were pulled to guard the exits and elevators which left no STNA to supervise the smoking break. The DON also indicated the residents were non-compliant with smoking rules. Interview on 12/23/20 at 1:15 P.M. with State tested Nursing Assistant (STNA) #207 revealed he was called to the first floor due to an altercation between Resident #55 and Resident #108 that started in the smoking room and filtered out into the hallway. STNA #207 separated Resident #55 and Resident #108 in the hallway. While STNA #207 began gathering information from Resident #49, Resident #55 knocked Resident #108 out of his chair and was punching him in the face. STNA#207 broke up the fight and separated the two. Further interview with the DON on 12/23/20 at 2:30 P.M. verified there was no smoking supervisor during the smoke break the night of the altercation between Resident #55 and Resident #108. Interview on 12/29/20 at 9:31 A.M. with Resident #49 revealed she was smoking in the enclosed area and right outside of the entrance when she saw Resident #55 start punching Resident #108 in the face. Resident #49 did not know how the altercation started. Review of the fourth-floor smoking schedule revealed the evening smoking breaks were scheduled from 7:15 P.M. to 7:30 P.M. and from 10:30 P.M. to 10:45 P.M. Interview on 12/29/20 at 11:30 A.M. with Licensed Practical Nurse (LPN) #222 revealed she was working the fourth floor when Resident #108 came off the elevator and showed her his missing tooth. LPN #221 called the police, Resident #108 wanted to press charges however there was not enough evidence. Review of the facility's undated policy titled Smoking revealed all resident were to supervised while smoking.

Based on closed medical record review, police report review, hospital record review and staff interview the facility failed to ensure Resident #150 was free from physical abuse. Actual harm occurred when State tested Nursing Assistant (STNA) #1 was involved in a physical altercation with Resident #150 and hit the resident in the face. Resident #150 sustained a laceration above the eye and was transferred to the emergency room for evaluation. This affected one resident (Resident#150) of six residents who were reviewed for abuse. Findings include: Review of Resident #150's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a a plan of care, dated 02/01/19 identified concerns of past history of physical aggression, verbal aggression, short-temper, easily angered, impulsivity, paranoia, unkempt appearance and poor hygiene. The resident had a history of [REDACTED]. Review of hospital records revealed a note from the emergency room (ER), dated 02/07/19 which revealed the resident was brought to the emergency room due to a physical confrontation with a staff member at the nursing facility. The resident had a visual abrasion above the left eye. The ER records revealed the staff member reportedly hit the resident back. Review of a facility self reported incident (SRI), tracking number, 1, dated 02/07/19 revealed on 02/07/19 STNA #1 self report an incident involving Resident #150. STNA #1 was interviewed and reported he was encouraging Resident #150 to take a shower as he had a history of [REDACTED]. Resident #150 lunged toward STNA #1 and punched him in the face. STNA #1 alleged that when Resident #150 punched him, STNA #1 saw black and reflexively lunged towards him without deliberation or intent. STNA #1 stated he was attempting to grab Resident #150's arms to prevent repeated blows. The police were notified and came to the facility. Review of the police report of the incident revealed the facility administrator told the police officer he spoke to both parties separately and they admitted to the incident. The administrator stated STNA #1 told him he was trying to assist Resident #150 with hygiene tasks and Resident #150 became argumentative and struck STNA #1 in the face with a closed fist. STNA #1 struck back, striking Resident #150 in the face above the eye. By the time the officer arrived at the facility, Resident #150 was transported to the hospital for evaluation and treatment. In an interview on 02/27/19 at 11:56 A.M. the facility director of nursing (DON) stated that on 02/07/19 STNA #1 got her out of a meeting. STNA #1 was very frazzled and upset and said he didn't know what happened and kept saying he hit me, he hit me. STNA #1 stated he blacked out and said I lost it. The DON took STNA #1 to the administrator's office and went to the secured unit to assess Resident #150. Resident #150 had blood on his face and would not talk to her, nor allow her to assess him. The nurse practitioner convinced Resident #150 to go to the emergency room for evaluation and treatment. In an interview on 02/27/19 at 12:50 P.M. the administrator revealed on 02/07/19, STNA #1 was in his office, very distraught after the incident on 02/07/19. STNA #1 stated he didn't know he hit the resident until he saw the blood on his face. The administrator interviewed Resident #150 who stated he hit STNA #1 who then hit him back. A written statement from the administrator dated 02/12/19 documented STNA #1 stated that when Resident #150 hit him in the face his mind was fussy and he just reacted by striking back. This was verified with the administrator who stated it was to clarify the police report. STNA #1 resigned from the facility. The above findings were also verified during an interview with the DON on 02/27/19 at 4:06 P.M. This deficiency substantiates Control Number OH 701.

Based on record review and interview, the facility failed to assure one resident's alternating air mattress was properly inflated in order to prevent the development of three unstageable pressure ulcers on the resident's buttocks and outer leg. This affected one (#12) of five residents reviewed for pressure ulcers. The facility census was 111 residents. Findings include: The medical record review for Resident #12 revealed the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The annual comprehensive assessment Minimum Data Set 3.0 (MDS) assessment, dated 12/21/11, revealed Resident #12 was cognitively intact; required extensive assistance of two plus persons for bed mobility; and was totally dependent with the assistance of one person for toileting needs. Resident #12 was functionally impaired on one side of the upper extremities, and had functional impairment of both lower extremities. Resident #12 had an urinary catheter and a [MEDICAL CONDITION] in place. Resident #12 had one Stage II and one Stage III pressure ulcer present at that time. The discharge assessment dated [DATE] revealed Resident #12 had three unstageable pressure ulcers. The plan of care for Resident #12, initiated 01/05/12 and last revised 04/12/12, revealed the resident was at risk for impaired skin integrity due to [MEDICAL CONDITION]; impaired mobility; flap to "bottom" that often re-opens; refusing to lay on left side due to pain; history of multiple wounds to bottom and legs; crossing legs; bedfast per choice; and being non-compliant with turning and repositioning. Interventions included inspecting the skin daily during routine care; skin assessments weekly and as needed; pillows for repositioning; pressure reducing devices; treatments as ordered; turn and reposition every two hours and as needed; float left leg off bed; and an alternating pressure mattress to the bed. Progress notes dated 04/12/12 revealed when the nurse entered Resident #12's room to administer medications, the resident complained of pain in his buttocks. The nurse noticed the air mattress was deflated and the plug was not completely in the wall. Resident #12 was observed lying on a flat hard surface. The nurse plugged the bed in and did a skin assessment of Resident #12. The resident stated to the nurse he told a state tested nurses assistant (STNA) on the previous Saturday (04/07/12) that the bed was deflated and had not told anyone else since. Review of the Resident #12's skin grids dated 04/17/12 revealed a weekly wound description of an area on the left outer leg for Resident #12, which was not present upon admission to the facility. The original date of the pressure area was 04/12/12. Measurements of the area were 5.5 centimeters (cm) in length by 2.5 cm in width; no depth was recorded. There was a moderate amount of thin drainage. The description of the wound per the certified nurse practitioner (CNP) indicated the area was worse with soft black eschar to the entire wound, and staging of the wound was declined to unstageable. The physician was notified of the decline. Resident #12's 04/17/12 skin grid also included a weekly wound description of an area to the right buttock, which was also not present upon admission to the facility. The onset date was 04/12/12. Measurements were 13 cm by 7.0 cm with no depth recorded. A large amount of foul smelling serous drainage was documented. The wound had soft black eschar that easily peeled with yellow slough present. A third pressure area with an origin date of 04/12/12 was also documented on the weekly wound description. This pressure area was on the left buttock, and was not present upon admission to the facility. Measurements of the area were 12 cm by 7.0 cm, with no depth recorded. The area had soft black eschar easily separated with yellow slough present. The CNP wound assessment dated [DATE] documented that on 04/12/12, staff noticed an extensive unstageable wound across the buttocks of Resident #12 after a malfunction of an alternating pressure mattress (the mattress was found unplugged). Blood cultures and wound cultures were taken. Record review of the nutritional assessment dated [DATE] multiple nutritional interventions were added related to the poor skin integrity and the depressed poor protein store. Dietary supplements, iron and vitamins were initiated. An interview with STNA #18 on 06/05/12 at 8:50 A.M., revealed that each air mattress has a normal and a low pressure light. If the pressure is low, they check the electrical cord and the cables. If within a minute, the problem isn't found, then they tell the nurse. STNA #18 said she was not aware of any malfunctioning air beds. According to Resident #12, STNA #18 worked the Saturday Interview with STNA #17 on 06/05/12 at 8:55 A.M. revealed that she does not do anything with the air mattress. If an air mattress was deflated, she would check the plug and cables and report it to the nurse. On 06/05/12 at 9:13 A.M., Interview with STNA #16 revealed Resident #33's air mattress was always set at "5", and the setting would be in the care plan or a physician's orders [REDACTED]. STNA #16 worked the Saturday (04/07/12) indicated by Resident #12. This deficiency substantiates Complaint Number OH 765.

Based on observation, interview and record review, the facility failed to ensure that nutritional interventions were implemented, resulting in significant, unplanned weight loss for Resident #70. This affected one of three residents reviewed for nutrition. The facility census was 111 residents. Findings include: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #70's quarterly Minimum Data Set 3.0 assessment dated [DATE], revealed the resident was severely cognitively impaired. Review of his nutritional risk care plan dated 11/21/11, and updated through 08/11/12, revealed the resident was at risk for alteration in nutrition. The resident had a self-care deficit care plan dated 11/29/11, and updated through 08/11/12, related to pain in his hands and that he "may need more assistance with meals." Review of Registered Dietitian #27's initial note dated 11/21/11, revealed that the resident was on a Regular diet with a frozen nutritional supplement twice a day with lunch and supper. The note indicated the resident fed himself and had "good intake." The resident weighed 160.3 pounds on admission (11/16/11). On 11/21/11, he weighed 158.7 pounds; on 11/28/11, he weighed 155.9 pounds; on 12/05/12, he weighed 159.2 pounds; on 01/05/12, he weighed 152 pounds; and on 02/03/12, he weighed 146.1 pounds. The next dietitian's note after 11/21/11 was dated 02/13/12, and verified that the resident had had significant weight loss of 8.8 percent (% ) in 3 months. The note indicated that the loss was unplanned. The note indicated that the resident's supplements would be increased to three times a day. Review of the resident's weights revealed that he continued to lose weight, and he weighed 144.3 pounds on 03/07/12; 141.2 pounds on 04/06/12; and 139 pounds on 05/04/12. Review of the meal tracking records for February through May 2012, revealed they were incomplete with no documentation for the intake of many meals, as well as 50% or less of his food consumed at many meals. Review of the next dietitian's note dated 05/04/12, revealed the resident with continued unplanned weight loss. The note indicated that extra margarine and sugar would be added to his meal tray to boost his nutritional content. A quarterly dietitian note dated 05/08/12, revealed that due to the significant weight loss sustained by the resident, larger portions of entrees would also be ordered for the resident. A note dated 05/09/12, by the dietitian verified these interventions and indicated that the resident's physician would be notified of his weight change. Further review of the resident's weights revealed that he weighed 138 pounds on 05/14/12, and 136 pounds on 06/04/12. No further dietitian notes were found in the medical record. The surveyor observed the resident in his room at meal times with his meal tray on his bedside table. The resident was eating by himself. Interview with State tested Nursing Assistant (STNA) #21 on 06/06/12 at 5:00 P.M., revealed the resident always ate by himself in his room. STNA #20 was interviewed on 06/07/12 at 11:00 A.M., and also indicated that Resident #70 ate by himself in his room. The resident was confused and was unable to answer the surveyor questions, sitting in a wheelchair which he propelled by himself. Interview with Registered Dietitian #27 on 06/07/12 at 7:40 A.M., revealed that she was aware of the resident's weight loss and had ordered the extra large portions and added margarine and sugar to his meals to boost his intake. She verified that the nutritional supplement ordered three times a day was given at meal times. The dietitian also verified that the meal intake tracking records were incomplete and that many meals revealed the resident taking less than 50% of his meals. She further verified that Resident #70 sustained a continued weight loss through the weights documented to 06/04/12. Registered Dietitian #27 verified that the increase in food on the meal trays for Resident #70 may not be an effective intervention, as the resident had less than 50% intake of his meals prior to providing an increased amount of food. She also verified that it might be difficult to monitor the resident's intake, with the incomplete intake tracking. She further verified that there was no indication of assessment of the resident's ability to feed himself, and that supervision at meal time was not provided to ensure the resident was encouraged to eat. She further verified that the resident has continued to lose weight.