Every finding on record at Divine Rehabilitation and Nursing at Sylvania

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the pre-planned menu was followed. This affected all 67 residents who received food from the facility kitchen. The facility census was 67.Findings include: 1. Review of the facility menu and meal tickets for the lunch meal on 07/13/26 revealed residents were supposed to receive baked beans with the lunch meal. Observation on 07/13/26 at 12:10 P.M. of the lunch meal service revealed residents received a pork loin, mixed vegetables, and corn bread. Residents did not received baked beans with the lunch meal.Interview and observation on 07/13/26 at 12:16 P.M. with Resident #31 revealed the resident did not receive baked beans with their lunch meal, although their meal ticket listed baked beans as an item that would be served. The resident reported they never knew what they were going to have for meals.Interview and observation on 07/13/26 at 12:21 P.M. with Resident #34 revealed the resident did not receive baked beans with the lunch meal, although their meal ticket listed baked beans as an item that would be served. The resident reported the meal tickets often did not reflect what was actually served for meals.Interview and observation on 07/13/26 at 12:23 P.M. with Resident #51 revealed the resident did not receive baked beans with the lunch meal, although their meal ticket listed baked beans as an item that would be served. The resident reported the meal ticket was not accurate.Interview on 07/13/26 at 12:30 P.M. with Dietary Aide #195 verified residents did not receive baked beans with the lunch meal and should have. Dietary Aide #195 reported a new company recently took over, and staff did not always know what was supposed to be served for meals, so they just had to make something up.2. Review of the facility menu and meal tickets for the lunch meal on 07/15/26 revealed residents were supposed to receive meatloaf, mashed potatoes, cooked zucchini, a dinner roll, and cherry cheesecake. Observation on 07/15/26 at 11:57 A.M. of the lunch meal revealed the facility served meatloaf, mashed potatoes, cooked squash with minimal zucchini, a dinner roll, and strawberry shortcake.An interview on 07/15/26 at 12:10 P.M. with Dietary Manager #196 verified the vegetable served contained mostly squash rather than zucchini as listed, and strawberry shortcake was served rather than cherry cheesecake. Dietary Manager #196 reported the facility had not had these substitutions approved by the dietitian.This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on medical record review, observation, resident, staff, and family interview, review of the facility policy, review of the facility assessment, and review of staffing schedules, the facility failed to have sufficient staffing to meet the care needs of all residents. This directly affected three residents (#41, #34, and #30) and had the potential to affect all residents residing in the facility. The facility census was 67. Findings Include:1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes Mellitus, hypertension, depression, respiratory failure, chronic kidney disease, difficulty in walking, and muscle weakness.Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #41 was cognitively intact. The resident was frequently incontinent of urine and was dependent on assistance from staff for the activities of daily living.Observation on 07/13/26 at 10:50 A.M. revealed Resident #41's call light was activated and there was a light illuminated above the door to the resident's room.Interview on 07/13/26 at 10:53 A.M. with Resident #41 revealed they had been waiting to have their incontinent brief changed and it had not been changed since 10:30 P.M. on 07/12/26. Resident #41 reported they were incontinent of urine and needed help from staff to get cleaned up and to have their brief changed. Resident #41 reported they had been activating their call light since 10:30 P.M. on 07/12/26 and staff had not yet come in to help. Resident #41 reported there were not enough aids to assist residents with care when needed.Interview on 07/13/26 at 10:55 A.M. with Resident #41's husband, who also resided in room revealed the same information and concerns.Observation on 07/13/26 at 11:01 A.M. revealed the call light system located at the nursing station showed how long call lights had been activated. Resident #41's call light had been activated for 41 minutes at this time.Interview on 07/13/26 at 11:14 A.M. with Certified Nursing Assistant (CNA) #148 revealed the unit the staff member had been working on contained a long hallway and a short hallway, both with resident rooms. The staff member had been assigned to the long hallway and did not know until sometime within the last half hour that the CNA assigned to the short hallway had walked out shortly after 6:00 A.M. and CNA #148 was supposed to cover that staff member's assigned area in addition to their own assigned area. Resident #41 resided on the short hallway and had not been changed or assisted with incontinence care from at least 6:00 A.M. until a few minutes prior to this interview. CNA #148 verified Resident #41's incontinence brief was full and that the resident had not been provided with incontinence care in a timely manner. CNA #148 also reported that she was not able to answer call lights and assist other residents with incontinence care in a timely manner due to there not being enough staff.Review of the facility policy titled Nursing Services and Sufficient Staff, dated 09/22/26, revealed the facility would provide sufficient staff with appropriate competencies.2. Interview on 07/23/26 at 12:03 P.M. with Resident #34 revealed there were not always enough aides and therefore her call light was not answered in a timely manner.Observation on 07/13/26 at 12:56 P.M. revealed Resident #34's call light had been activated for 50 minutes before staff entered the resident's room.Interview on 07/13/26 at approximately 1:00 P.M. with CNA #148 verified Resident #34's call light was not answered in a timely manner. CNA #148 reported they were only one person and could not help all residents in a timely manner.Interview on 07/13/26 at 3:33 P.M. with CNA #181 revealed there were supposed to be two CNAs assigned to the unit and she was often the only one working due to staffing shortages. CNA #181 reported she had approximately 11 to 12 residents who required incontinence care, and she was often not able answer call lights in a timely manner, or to provide timely incontinence care to residents.Interview on 07/14/26 at 5:35 A.M. with Registered Nurse (RN) #146 revealed there were not enough CNAs and residents often did not receive assistance with care in a timely manner.Review of the facility policy titled Nursing Services and Sufficient Staff, dated 09/22/26, revealed the facility would provide sufficient staff with appropriate competencies.3. Interview on 07/13/26 at 11:32 A.M. with Resident #30 whom the facility identified as being incontinent, revealed the resident was incontinent and was often not provided with incontinence care in a timely manner. Resident #30 reported often going between 12 and 13 hours without their incontinence brief being changed. Resident #30 reported this was due to staffing shortages and there were not enough CNAs.Interview on 07/13/26 at 11:53 A.M. with Resident #39 whom the facility identified as being incontinent, revealed the resident was incontinent and often waited a prolonged period of time for their brief to be changed when needed. Resident #39 reported they would activate their call light and wait hours for assistance with care. Resident #39 reported this was due to there not being enough aides to assist with care.Interview on 07/13/26 at 3:33 P.M. with CNA #181 revealed there were supposed to be two CNAs assigned to the unit and she was often the only one working due to staffing shortages. CNA #181 reported she had approximately 11 to 12 residents who required incontinence care and she was often not able to answer call lights in a timely manner or to provide timely incontinence care to residents.Interview on 07/14/26 at 5:35 A.M. with Registered Nurse (RN) #146 revealed there were not enough CNAs and residents often did not receive assistance with care in a timely manner.Review of the most recent facility assessment revealed there would be a ratio of between one CNA for every nine residents, to one CNA for every 12 residents.Review of the staffing schedules for 06/27/26 through 07/12/26 revealed there was one CNA assigned to care for 22 residents on 06/29/26 from 2:00 P.M. to 10:00 P.M. with no CNA between 4:45 P.M. and 6:00 P.M., one CNA assigned to care for 22 residents on 07/04/26 from 2:00 P.M. to 10:00 P.M., one aide assigned to care for 18 memory care residents on 07/04/26 from 10:00 P.M. to 6:00 A.M., one CNA assigned to care for 22 residents on 07/05/26 from 10:00 P.M. to 6:00 A.M., one CNA assigned to care for 18 memory care residents on 07/05/26 from 10:00 P.M. to 6:00 A.M., no CNAs assigned to care for 11 residents on 07/06/26 from 10:00 P.M. to 6:00 A.M., one CNA assigned to care for 22 residents on 07/07/26 from 2:00 P.M. to 10:00 P.M., one aide assigned to care for 22 residents on 07/10/26 from 2:00 P.M. to 10:00 P.M., one CNA assigned to care for 18 memory care residents on 07/10/26 from 10:00 P.M. to 6:00 A.M., no CNA assigned to care for 11 residents on 07/12/26 from 2:00 P.M. to 10:00 P.M., one CNA assigned to care for 18 memory care residents on 07/12/26 from 10:00 P.M. to 6:00 A.M., and one CNA assigned to care for 22 residents on 07/13/26 from 2:00 P.M. to 10:00 P.M.Review of the facility policy titled Incontinence, dated 06/01/24, revealed all residents who were incontinent would receive appropriate treatment and services.Review of the facility policy titled Nursing Services and Sufficient Staff, dated 09/22/26, revealed the facility would provide sufficient staff with appropriate competencies.This deficiency represents non-compliance investigated under Complaint Number 3069054, and Complaint Number 3070777.

Based on observation, staff interview, and review of the facility policy for environment, the facility failed to maintain a clean, safe, and homelike environment. This directly affected Resident #55 and had the potential to affect 18 residents who resided on the memory care unit (#60, #61, #62, #63, #64, #65, #66, #67, #68, #69. #70, #71, #72, #73, #74, #75, #76, and #77). The facility also failed to ensure cleanliness of shower chairs. This had the potential to affect all but 13 residents (#13, #16, #17, #19, #22, #29, #31, #40, #53, #58, #63, #66, and #69) in the facility who were identified to not utilized shower chairs. The facility census was 67.Findings include: 1. Observation on 07/13/26 at 10:32 A.M. of the living room located on the memory care unit revealed there were three lightly colored walls and one blue accent wall. The blue wall had thick gouges that were past the first layer of drywall, a dark substance smeared across the wall, a broken outlet cover with the top portion missing, and torn edges of drywall all along the bottom of the wall where the drywall meets the baseboard heater. An interview on 07/13/26 at 10:35 A.M. with Registered Nurse (RN) #158 confirmed the above concerns. RN #158 stated she was unsure of how long the areas of concern have been that way, although it looked like it had been awhile. 2. Observation on 07/13/26 at 10:41 A.M. of Resident #55's room revealed there were puddles of water on the floor and some of the floor tile was broken and crumbling. An interview on 07/13/26 at 10:36 A.M. revealed Certified Nursing Assistant (CNA) #180 reported the floor tiles had been broken for awhile and the puddles on the floor were from a shower chair used earlier in the day. 3. Observation on 07/13/26 at 11:14 A.M. of a shower chair located in the shower room on Evergreen Hall revealed a dried brown substance on the support bar under the open seat of the chair. Interview on 07/13/26 at 11:15 A.M. with Maintenance Manager #150 confirmed there was a dried brown substance on the shower chair. Subsequent observation revealed he obtained cleaning supplies and was able to remove the dried brown substance. Review of facility policy titled Resident Rights, dated 06/01/24, revealed residents had the right to a clean and homelike environment. Review of the facility policy titled Safe and Homelike Environment, dated 02/01/25, revealed the facility would provide a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Complaint Numbers 3075845, 3070777 and 3069054.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure infection control measures were followed. This affected two residents (#46 and #48) of three residents observed during medication administration, two residents (#32 and #46) of two residents observed while obtaining vital signs, one resident (#46) of three residents observed during medication preparation, and one resident (#55) of one resident observed during incontinence care. The facility census was 67.Findings include:1. Review of the medical record for Resident #46 revealed he was admitted on [DATE] with diagnoses including right sided hemiplegia, hypertension, alcohol use, and cognitive communication deficit.Review of the annual Minimum Data Set 3.0 dated 05/27/26 revealed he was cognitively impaired and did not display any behaviors nor refusals of care at the time of the assessment. He utilized a wheelchair and required maximal assistance to dependence with activities of daily living.Review of the medical record for Resident #48 revealed he was admitted on [DATE] with diagnoses including congestive heart failure, hypertension, Type Two Diabetes Mellitus, and malignant neoplasm of the prostate.Review of the admission Minimum Data Set 3.0 dated 05/08/26 revealed he was cognitively impaired and did not display any behaviors nor refusals of care at the time of the assessment. He utilized a wheelchair and required maximal assistance to dependence with activities of daily living.Observation on 07/14/26 at 7:35 A.M. of Licensed Practical Nurse (LPN) #172 during medication administration for Residents #46 and #48 revealed she did not perform hand hygiene prior to or after preparing and administering medications to Resident #46 and Resident #48.Interview on 07/14/26 at 8:10 A.M. with LPN #172 confirmed she did not perform hand hygiene prior to or after preparing and administering medications to Residents #46 and #48.Review of facility policy titled Medication Administration, dated 08/22/22, revealed hand hygiene wound be performed prior to preparing medications and after administering medications to residents.2. Review of the medical record for Resident #32 revealed he was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, schizophrenia, Type Two Diabetes Mellitus, and depression.Review of the quarterly Minimum Data Set 3.0 dated 06/29/26 revealed he was cognitively intact, displayed behaviors toward others, and rejected care daily. He utilized a wheelchair and required partial assistance with activities of daily living.Review of the medical record for Resident #46 revealed he was admitted on [DATE] with diagnoses including right sided hemiplegia, hypertension, alcohol use, and cognitive communication deficit.Review of the annual Minimum Data Set 3.0 dated 05/27/26 revealed he was cognitively impaired and did not display any behaviors nor refusals of care at the time of the assessment. He utilized a wheelchair and required maximal assistance to dependence with activities of daily living.Observation on 07/14/26 at 7:35 A.M. of LPN #183 revealed she obtained a blood pressure reading for Resident #46 using a computerized vital sign machine on wheels by placing the blood pressure cuff on his bare left upper extremity and did not clean the blood pressure cuff prior to or after using the cuff.Observation on 07/14/26 at 8:05 A.M. of LPN #183 revealed she obtained a blood pressure reading for Resident #32 using the same computerized vital sign machine on wheels by placing the blood pressure cuff on his bare right upper extremity and did not clean the blood pressure cuff prior to or after using the cuff.Interview on 07/14/26 at 8:10 A.M. with LPN #183 and LPN #172 confirmed the blood pressure cuff was not cleaned between uses for Residents #32 and Resident #46. Subsequent observation revealed disinfecting wipes were added to the basket on the vitals machine.Interview on 07/15/26 at 9:30 A.M. with the Director of Nursing confirmed the blood pressure cuff should be cleaned between residents.Review of facility policy titled Routine Cleaning and Disinfection, dated 2022, revealed routine surface cleaning and disinfection will be conducted with detailed focus on visibly soiled surfaces and high tough areas to include but not limited to blood pressure cuffs, intravenous (IV) poles, sinks and faucets, monitor control panels, touch screens and cables, bed rails, and call buttons. 3. Review of the medical record for Resident #46 revealed he was admitted on [DATE] with diagnoses including right sided hemiplegia, hypertension, alcohol use, and cognitive communication deficit.Review of the annual Minimum Data Set 3.0 dated 05/27/26 revealed he was cognitively impaired and did not display any behaviors or refusals of care at the time of the assessment. He utilized a wheelchair and required maximal assistance to dependence with activities of daily living.Observation on 07/14/26 at 7:35 A.M. of LPN #172 preparing medications for Resident #46 revealed she placed a pill in a medication cup and accidentally knocked it over causing the pill to spill on the medication cart. LPN #172 proceeded to use her bare contaminated hand to pick the pill up and put it back into the medication cup.Interview on 07/14/26 at 8:10 A.M. with LPN #172 confirmed she touched a pill prepared for Resident #46 with her bare contaminated hand that had been in contact with the top of the medicaton cart and administered the pill to Resident #46.Interview on 07/15/26 at 9:30 A.M. with the Director of Nursing confirmed pills should not be touched by hands while preparing and administering medications to residents.Review of facility policy titled Medication Administration, dated 08/22/22, revealed medications should not be touched with bare hands.4. Review of the medical record for Resident #55 revealed she was admitted on [DATE] with diagnoses including anoxic brain damage, malnutrition, gastrostomy status, and anemia.Review of the quarterly Minimum Data Set 3.0 (MDS) dated [DATE] revealed she was cognitively impaired and did not display any behaviors or refusals of care. She was dependent for all activities of daily living, transfers, and mobility. She was incontinent of bowel and bladder and had a feeding tube.Review of physician orders for Resident #55 revealed an order dated 12/26/25 for Enhanced Barrier Precautions to be utilized during high touch care, including incontinence care and bathing.Observation on 07/14/26 at 10:50 A.M. of Certified Nurse Assistant (CNA) #105 and CNA #118 providing incontinence care and a gown change for Resident #55 revealed they did not wear gowns while providing care as required by Enhanced Barrier Precautions.Interview on 07/14/26 at 11:00 A.M. with CNA #105 and CNA #118 confirmed they did not wear gowns while providing incontinence care and a gown change for Resident #55. Both acknowledged they should have worn gowns.Review of facility policy titled Enhanced Barrier Precautions, dated 07/13/22, revealed gowns would be worn by staff while providing high-contact resident care including changing briefs and dressing.This deficiency represents non-compliance investigated under Complaint Number 3070777.

Based on medical record review, observations, staff interviews, and review of facility policies, the facility failed to ensure fall interventions were in place for one (#28) out of two residents reviewed for falls. The facility also failed to ensure hazardous items were secure. This had the potential to affect 21 residents (#15, #20, #23, #24, #27, #31, #35, #37, #42, #43, #48, #61, #63, #64, #65, #66, #68, #69, #72, and #77) identified by the facility as cognitively impaired and independently mobile. The facility census was 67.Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic pain, depression, anxiety, muscle spasm, tremors, weakness, and seizures. Review of the plan of care, revised 05/12/26, revealed Resident #28 was at risk for falls related to weakness, loss of function, impaired judgement, impulsive behavior, would not wait for assistance to transfer, and had been known to throw themselves on the floor when angry. Interventions included mattress with bolsters attached to bed and to encourage the resident to keep their bed in the lowest position. Observation on 07/16/26 at 11:55 A.M. revealed Resident #28 was lying in bed and their bed was extremely high in the air. The resident was yelling out for help and stated they were trying to get out of bed. There were no bolsters observed on the bed. Interview on 07/16/26 at 10:02 A.M. with Certified Nursing Assistant (CNA) #132 verified Resident #28's bed was high in the air and not at the lowest level. CNA #132 reported the resident controlled the height of their bed and staff did not mess with it. Observation and interview on 07/16/26 at 10:30 A.M. with the Director of Nursing (DON) confirmed there were no bolsters on Resident #28's bed. 2. Observation on 07/15/26 at 12:33 P.M. of a floor care storage closet adjacent to [NAME] Hall nurse's station revealed it was unlocked and accessible to anyone. Inside the closet was observed a three-liter bottle of odor remover labeled as an eye and skin irritant, a three-liter bottle of floor cleaner labeled as an eye irritant and harmful if swallowed, and a three-liter bottle of disinfectant cleaner labeled danger to keep out of reach of children and contact poison control if swallowed or contact with skin or eyes occurred. Observation on 07/15/26 at 12:33 P.M. of a biohazard storage closet adjacent to [NAME] Hall nurse's station revealed a key was in the door handle and the closet was accessible to anyone. Inside the closet was a biohazard bin with five full sharps containers, a one-quart size bottle of window cleaner, a gallon of spray polish, and a gallon of buffer cleaner marked harmful if swallowed. Observation on 07/15/26 at 12:33 P.M. of a housekeeping storage closet adjacent to [NAME] Hall nurse's station revealed it was unlocked and accessible to anyone. Inside the closet was a full bag of hand soap labeled keep out of reach of children and to contact poison control if swallowed, a half-gallon bucket, three-quarters full, of an unidentified clear substance, a mop bucket three-quarters full of a brown colored liquid, one 28 ounce opened can of scouring powder labeled as an eye irritant and do not swallow, a one-quart bottle of antibacterial cleaner labeled as a moderate eye irritant and not to be ingested, and wash cloths. Interview on 07/15/26 at 12:45 P.M. with Licensed Practical Nurse #172 confirmed the three closets were unlocked. She stated the housekeeping closet should be locked and confirmed the key was typically housed in the door handle of the biohazard storage closet. Interview on 07/15/26 at 12:50 P.M. with Maintenance Manager #150 revealed he was instructed by the Housekeeping Manager to lock all three doors. Interview on 07/15/26 at 1:00 P.M. with Housekeeping Director #101 revealed the doors to the biohazard closet, and housekeeping closet adjacent to [NAME] Hall nurse's station should be locked, but the floor care closet is typically unlocked. Review of facility policy titled Chemical Storage, dated May 2016, revealed all chemicals for cleaning would be locked at all times and if staff observed a door to an area securing chemicals as unlocked, staff would correct the situation immediately. This deficiency represents non-compliance investigated under Complaint Number 3069054.

Based on medical record review, observation, interview, and review of facility policy, the facility failed to ensure urinary catheter securement devices were utilized. This affected two residents (#14 and #59) of two residents reviewed for urinary catheters. Additionally, the facility failed to ensure urinary catheter care was completed each shift. This affected one resident (#59) of two residents with urinary catheters. Finally, the facility failed to ensure residents received assistance with incontinence care in a timely manner. This affected one resident (#41) out of three residents reviewed for incontinence care. The facility census was 67.Findings include: 1. Review of the medical record for Resident #14 revealed she was re-admitted to the facility on [DATE] with diagnoses including osteomyelitis of lumbar vertebra, acute endocarditis, heart failure, alcoholic cirrhosis of the liver, rheumatic mitral valve disease, and neurogenic bladder. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a wheelchair and required moderate assistance to dependence with activities of daily living. She did not have an indwelling catheter at the time of this assessment and was frequently incontinent of bowel and bladder. Review of the care plan dated 07/02/26 for Resident #14 revealed an intervention to utilize a catheter securement device with the urinary catheter. Observation on 07/14/26 at 1:10 P.M. of indwelling urinary catheter care for Resident #14, provided by Licensed Practical Nurse (LPN) #146, revealed there was not a catheter securement device in place. Interview on 07/14/26 at 1:17 P.M. with LPN #146 confirmed the absence of a catheter securement device and indicated one should be there. 2.Review of the medical record for Resident #59 revealed she was admitted on [DATE] with diagnoses including Type Two Diabetes Mellitus, local infection of the skin, gangrene, anxiety, chronic obstructive pulmonary disease, and neurogenic bladder. She was admitted to hospice care on 04/28/26. Review of the significant change Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #59 experienced mild cognitive impairment and did not display any behaviors nor refusals of care during the assessment period. She was dependent for activities of daily living and required maximal assistance with transfers and mobility. She had an indwelling urinary catheter. Review of physician orders for Resident #59 revealed an order dated 03/03/26 to secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction, and an order dated 03/03/26 to change the indwelling urinary catheter every month and as needed and on 07/13/26 for catheter care every shift and as needed. Review of the Treatment Administration Records (TAR) for March 2026 through July of 2026 for Resident #59 revealed the absence of documented indwelling urinary catheter care. Observation and interview with Certified Nurse Assistant #118 on 07/14/26 at 1:34 P.M. of Resident #59's indwelling urinary catheter revealed she did not have a securement device in place. Certified Nurse Assistant #118 confirmed the absence of a catheter securement device and indicated one should be there. Interview on 07/15/26 at 9:30 A.M. with the Director of Nursing confirmed urinary catheter securement devices should be in place and this is a standard of practice. Interview on 07/15/26 at 10:40 A.M. with the Assistant Director of Nursing confirmed there was no evidence urinary catheter care was being completed each shift for Resident #59. Review of facility policy titled Catheter Care, dated 03/02/22, revealed the facility would provide catheter care every shift and as needed. 3. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes Mellitus, hypertension, depression, respiratory failure, chronic kidney disease, difficulty in walking, and muscle weakness. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #41 was cognitively intact. The resident was frequently incontinent of urine and was dependent on assistance from staff for the activities of daily living. Observation on 07/13/26 at 10:50 A.M. revealed Resident #41's call light was activated and there was a light illuminated above the door to the resident's room. An interview on 07/13/26 at 10:53 A.M. with Resident #41 revealed they had been for their incontinent brief to be changed and stated they had not been changed since 10:30 P.M. on 07/12/26. Resident #41 reported they were incontinent of urine and needed help from staff to get cleaned up and to have their brief changed. Resident #41 reported they had been activating their call light since 10:30 P.M. on 07/12/26 and staff had not yet come in to help. An interview on 07/13/26 at 10:55 A.M. with Resident #41's husband, who also resided in room revealed the same information and concern. Observation on 07/13/26 at 11:01 A.M. revealed the call light system located at the nursing station showed how long call lights had been activated. Resident #41's call light had been activated for 41 minutes at this time. Interview on 07/13/26 at 11:14 A.M. with Certified Nursing Assistant (CNA) #148 revealed the unit the staff member had been working on contained a long hallway and a short hallway, both with resident rooms. The staff member had been assigned to the long hallway and did not know until sometime within the last half hour that the CNA assigned to the short hallway had walked out shortly after 6:00 A.M. and CNA #148 was supposed to cover that staff member's assigned area in addition to their own assigned area. Resident #41 resided on the short hallway and had not been changed or assisted with incontinence care from at least 6:00 A.M. until a few minutes prior to this interview. CNA #148 verified Resident #41's incontinence brief was full and that the resident had not been provided with incontinence care in a timely manner. CNA #148 also reported she was not able to assist other residents with timely incontinence care due to there not being enough staff. Interview on 07/13/26 at 11:32 A.M. with Resident #30 whom the facility identified as being incontinent, revealed the resident reported they had incontinence and were often not provided with incontinence care in a timely manner. Resident #30 reported often going between 12 and 13 hours without their incontinence brief being changed. Interview on 07/13/26 at 11:53 A.M. with Resident #39 whom the facility identified as being incontinent, revealed the resident reported they had incontinence and often waited a prolonged period of time for their brief to be changed when needed. Resident #39 reported they would activate their call light and wait hours for assistance with care. Interview on 07/13/26 at 3:33 P.M. with CNA #181 revealed there were supposed to be two CNAs assigned to the unit and she was often the only one working due to staffing shortages. CNA #181 reported there were approximately 11 to 12, check and changes and she was often not able to provide timely incontinence care to residents. Interview on 07/14/26 at 5:35 A.M. with Registered Nurse (RN) #146 revealed there were not enough CNAs and residents often did not receive assistance with incontinence care in a timely manner. Review of the facility policy titled Incontinence, dated 06/01/24, revealed all residents who were incontinent would receive appropriate treatment and services. This deficiency represents non-compliance investigated under complaint numbers 3075845, 3070777, and 3069054.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure protected health information was secured. This affected one resident (#50) of six residents reviewed for secured health information. The facility census was 67.Findings include:Observation on 07/13/26 at 4:00 P.M. revealed a written podiatry order dated 07/13/26 for Resident #50 on the nurse desk at [NAME] Hall. The order was face-up, visible to anyone who would pass by the desk. The desk was approximately three feet high and did not have anything obstructing the view of the desktop.Interview on 07/13/26 at 4:05 P.M. with the Director of Nursing confirmed the order for Resident #50 should not have been face-up on the nurse station desk. Subsequent observation revealed she turned the order over and moved it away from the accessible part of the desk.Observation on 07/15/26 at 4:50 P.M. revealed a written provider order dated 07/15/26 for Resident #50 on the nurses' desk at [NAME] Hall. The order was face-up, visible to anyone who would pass by the desk. The desk was approximately three feet high and did not have anything obstructing the view of the desktop.Interview on 07/15/26 at 4:52 P.M. with LPN #183 confirmed the order for Resident #50 was face-up on the nurse station desk. Subsequent observation revealed LPN #183 relocated the order to an area of the desk that was not visible to people walking past the desk.Review of facility policy titled HIPAA Security Measures, dated 01/01/25, revealed the facility would implement reasonable measures to protect residents' electronic identifiable information and protected health information.Interview on 07/15/26 at 9:01 A.M. with Regional Director of Clinical Services #192 confirmed the facility's HIPAA (Health Insurance Portability and Accountability Act) policy was also applicable to paper documents.

Based on medical record review, staff interview, observation, and facility policy review, the facility failed to ensure a resident who was dependent on staff for Activities of Daily Living (ADLs) received assistance with eating. This affected one (#23) of one resident reviewed for assistance with eating. The facility census was 67.Findings Include:Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes Mellitus, dementia, hyponatremia, hypertension, Alzheimer's disease, and dysphagia.Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. The resident was dependent on staff for eating.Review of the plan of care dated 06/29/26 revealed Resident #23 had a nutritional problem or potential nutritional problem related to diagnoses and required total assistance with feeding themself. Interventions included observing for, documenting, and reporting as needed signs or symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appearing concerned during meals.Observation on 07/15/26 at 12:00 P.M. revealed Resident #23 was sitting in the facility dining room and there were no staff members or other residents present in the room. Resident #23 was seated in a wheelchair with a table in front of him, containing a plate full of pureed carrots and pureed meatloaf. A spoon was stuck and indented into the pureed food items on the plate. Resident #23 was holding a cup sideways and there was spilled, thickened liquid on the floor in front of him with a large puddle underneath of his right foot/slipper. There were also pureed carrots on the front of his pants and down the front of a clothing protector he was wearing. Resident #23 picked up a bowl of vanilla pudding and was unsuccessfully attempting to drink and lick the substance out of the bowl. Dietary Aide #195 entered the area at approximately 12:07 P.M. and pushed Resident #23's wheelchair into a nearby hallway.Interview on 07/15/26 at 12:17 P.M. with Dietary Aide #195 and Dietary Aide #197 verified Resident #23 required assistance for eating and had been sitting there attempting to feed himself until he was rolled away in his wheelchair. Dietary Aide #197 stated Resident #23 had made a mess all over and needed help eating.Interview on 07/16/26 at approximately 12:30 P.M. with Certified Nursing Assistant #132 revealed Resident #23 was totally dependent on staff for feeding assistance.Review of the facility policy titled Activities of Daily Living (ADLs), dated 10/01/22, revealed residents who were unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.This deficiency represents non-compliance investigated under Complaint Number 3070777.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to answer call lights in a timely manner. This affected two (#34 and #38) of two residents reviewed for call light response. The facility census was 67.Findings include:Review of the medical record for Resident #34 revealed she was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, Type Two Diabetes Mellitus, left-sided hemiplegia, and atherosclerotic heart disease.Review of the annual Minimum Data Set 3.0 dated 04/23/26 revealed Resident #34 was cognitively impaired and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a wheelchair and required partial to maximal assistance with activities of daily living.Review of the medical record for Resident #38 revealed he was admitted on [DATE] with diagnoses including right sided hemiplegia, chronic obstructive pulmonary disease, repeated falls, and dementia.Review of the quarterly Minimum Data Set 3.0 dated 04/10/26 revealed Resident #38 was cognitively impaired and did not display any behaviors nor refusals of care. He was dependent for activities of daily living.Observation on 07/13/26 at 12:02 P.M. of the call light console at [NAME] Hall nurse station revealed two call lights were alarming, one for Resident #34 and one for Resident #38. The call light display revealed Resident #34's call light had been on for 27 minutes and Resident #38's call light had been on for 10 minutes.Observation on 07/13/26 at 12:04 P.M. at the [NAME] Hall nurse station revealed Certified Nurse Assistant (CNA) #107 exited the employee restroom adjacent to the [NAME] Hall nurse station and walked off of the unit without acknowledging the alarming call lights.Observation on 07/13/26 at 12:10 P.M. of the call light console at [NAME] Hall nurse station revealed the call lights for Resident #34 and Resident #38 were still alarming. The call light display revealed Resident #34's call light had been on for 35 minutes and Resident #38's call light had been on for 18 minutes.Observation on 07/13/26 at 12:12 P.M. at the [NAME] Hall nurse station revealed CNA #105 and CNA #148 walked by the nurse station without acknowledging the alarming call lights. The two aides walked toward a meal tray cart that was being distributed by two other staff members and began passing meal trays while the call lights for Residents #34 and #38 continued to alarm.Interview on 07/13/26 at 12:18 P.M. with the Director of Nursing confirmed the resident's call lights should be prioritized, the DON confirmed the call lights were alarming and verified call lights should not be ignored by staff.Interview on 07/13/26 at 2:00 P.M. with the Administrator revealed the facility was unable to run a call light audit report for review. Interview on 07/13/26 at 3:28 P.M. with the Director of Nursing revealed a written counseling had been completed for CNA #107 regarding not acknowledging the call lights for Residents #34 and #38. DON revealed CNA#107 had stated she heard the call light alarms and did not answer them. Review of facility policy titled Call lights: Accessibility and Timely Response, dated 04/01/22, revealed all staff who saw or heard an activated call light were responsible for responding.This deficiency represents non-compliance investigated under Complaint Number 3070777.

Based on medical record review, staff interview, and review of facility policy, the facility failed to timely implement wound care orders. This affected one resident (#14) of three residents reviewed for wound care. The facility census was 67.Findings include:Review of the medical record for Resident #14 revealed she was re-admitted on [DATE], initial admission was on 02/13/26 with diagnoses including osteomyelitis of lumbar vertebra, acute endocarditis, heart failure, alcoholic cirrhosis of the liver, rheumatic mitral valve disease, and pneumonia.Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a wheelchair and required moderate assistance to dependence with activities of daily living. She had one stage four pressure ulcer which was present when she was admitted to the facility.Review of wound care visit notes and orders for Resident #14, dated 07/08/26, revealed a new order for negative pressure wound therapy.Observation on 07/15/26 at 11:00 A.M. of Resident #14 resting in bed revealed no negative pressure wound therapy was in place.Review of orders, treatment administration records, and nursing progress notes dated 07/08/26 to 07/15/26 for Resident #14 revealed no indication negative pressure wound therapy was in place.Interview on 07/15/26 at 2:35 P.M. with the Assistant Director of Nursing confirmed negative pressure wound therapy was ordered for Resident #14 on 07/08/26 and the therapy had not yet been implemented as she was unsure where to obtain the equipment.Review of facility policy titled Wound Treatment Management, dated 12/01/21, revealed the facility would provide wound treatment in accordance with physician orders, including the type of dressing.This deficiency represents non-compliance investigated under Complaint Numbers 3069054 and 3070777.

Based on medical record review, observations, staff interview, and review of the facility policy, the facility failed to ensure all safety injury prevention interventions were in place as care planned for residents identified at risk for falls. This affected one (#35) of three residents reviewed for falls. The facility census was 60. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic pain syndrome, anxiety, muscle spasm, tremor, altered mental status, weakness, seizures, and schizophrenia. Review of the fall risk assessment dated [DATE] revealed Resident #35 was at risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired. Resident #35 was dependent on assistance from staff for the activities of daily living. Review of the plan of care, revised 05/12/25, revealed Resident #35 was at risk for falls. Interventions included enabler bars attached to bed, body pillow for positioning, and being sure call light was within reach. Observation on 06/16/25 at 9:55 A.M. revealed Resident #35 was lying in bed. There were no enabler bars attached to the resident's bed. There was also no body pillow on the resident's bed or visible within the resident's room. The resident's call light cord was stretched across the room and the button used to activate the call light was sitting on their wheelchair, which was not within the resident's reach. Interview on 06/16/25 at 10:05 A.M. with Certified Nursing Assistant (CNA) #448 verified Resident #35's call light was out of reach. CNA #448 also verified Resident #35 did not have a body pillow or enabler bars in place or in the room. CNA #448 reported they were assigned to care for Resident #35 on a regular basis and they had no knowledge of the resident ever having a body pillow. Subsequent observations on 06/18/25 at 10:36 A.M. and 3:23 P.M. revealed Resident #35 was lying in bed. There were no enabler bars attached to the resident's bed, and there was no body pillow on the resident's bed or visible within the resident's room. Interview on 06/18/25 at 3:34 P.M. with CNA #295 revealed the staff member was assigned to care for Resident #35 on a regular basis. CNA #295 verified Resident #35 did not have a body pillow or enabler bars in place. CNA #295 reported the resident did not have a body pillow at all, and only had regular pillows to use for positioning. Review of the facility policy titled Fall Prevention Program, revised 09/26/24, revealed the facility would provide interventions as needed. This deficiency represents non-compliance investigated under Master Complaint Number OH00166561.

Based on observation, interviews with facility staff and the wound physician, review of the medical record, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and policy review, the facility failed to ensure a resident's skin impairment was identified timely and a treatment initiated. This resulted in Actual Harm to Resident #68 on 01/30/25 when the facility failed to assess a resident's wound and obtain physician orders for wound treatments resulting in Resident #68 developing an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) requiring debridement. This affected one (#68) of two residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. The facility census was 75. Findings include Review of the medical record revealed Resident #68 had an admitted [DATE] and a readmitted [DATE]. Diagnoses included dementia, heart failure, and type two diabetes mellitus. Review of the hospital progress notes dated 01/30/25 revealed Resident #68 had excoriation to the buttocks. There was no documentation the resident had a pressure ulcer to the coccyx. Review of a nursing admission skin assessment dated [DATE] revealed Resident #68 was noted with skin impairment to the coccyx and right and left inner buttocks. There was no wound assessment completed. There was no description of the impaired skin area to the coccyx, no description of the wound bed or type of wound, and no wound measurements. There was no documentation a wound assessment had been completed until 02/05/25. Review of a skin risk assessment dated [DATE] revealed Resident #68 was at high risk for skin breakdown. Review of the physician orders dated 01/30/25 revealed no orders for treatments to the coccyx. No physician orders were placed for a wound treatment to the coccyx for two days until 02/01/25. Review of a physician order dated 02/01/25 at 7:00 P.M. revealed an order to cleanse the coccyx with wound cleanser, pat dry, apply Triad, cover with silicone dressing every shift for wound care for 30 days. There was no baseline care plan-initiated addressing Resident #68's high risk for skin breakdown. A care plan was initiated on 02/10/25, five days after the unstageable pressure ulcer was found. Review of the medication administration record (MAR) and treatment administration record (TAR) revealed no wound treatments were completed for the coccyx wound until 02/01/25 after 7:00 P.M. Further review of the record revealed no treatment was completed on first shift on 02/04/25. Review of a physician wound assessment completed on 02/05/25 revealed Resident #68 had an unstageable full thickness pressure ulcer to the coccyx. The wound measured 3.3 centimeters (cm) in length, by 6.4 cm in width, and a depth of 0.2 cm with moderate serous drainage. The wound had 20 percent slough, 20 percent necrotic tissue, 10 percent intact skin, and 50 percent granulation tissue. The physician debrided the wound of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm at a depth of 0.3 cm. The physician ordered a new wound treatment to cleanse coccyx with wound cleanser, pat dry, apply medihoney, calcium alginate with silver and cover with gauze island and border dressing. The physician also recommended a group two mattress (air loss mattress.) Review of a nutritional assessment dated [DATE] revealed the assessment included no documentation of the resident's new pressure ulcers or nutritional interventions for the resident's pressure ulcers. Review of the MAR revealed the low air loss mattress ordered on 02/05/25 was not in place until 02/10/25 after 7:00 P.M. Review of the care plan initiated 02/10/25 for pressure ulcers revealed Resident #68 had an unstageable pressure ulcer to the coccyx. Interventions include completing treatment to all wounds as ordered, keeping skin clean and well lubricated, turn and reposition frequently, low air loss mattress, and wounds to be monitored by the wound care group. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had severe cognitive impairment. Resident #68 was dependent on staff for toileting, bed mobility and transfers. Resident #68 was always incontinent with bowel and bladder. Resident #68 had unhealed pressure ulcers including one stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed), one unstageable pressure ulcer, and one deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue). The resident was at risk for skin breakdown. Interview on 03/04/25 at 3:36 P.M., the Director of Nursing (DON) stated Resident #68 had skin impairment upon readmission to the facility. The DON stated the hospital documentation only noted excoriation to the buttocks. The DON verified she was unable to find any hospital documentation indicating the resident had a pressure ulcer while in the hospital. The DON verified there was no documentation in the nurse's admission skin assessment of the type of wound, assessment of the wound or wound measurements. Further interview on 03/06/25 at 9:01 A.M., the DON verified a wound treatment was not initiated for Resident #68's coccyx wound until 02/01/25. The DON stated the nurses were probably waiting for the physician to respond with a wound care order. The DON verified that the low air loss mattress was not implemented until 02/10/25. The DON stated the facility had no air loss mattresses and had to order it. The DON verified the wound treatment on day shift on 02/04/25 was not documented as completed. The DON stated the facility dietitian no longer worked at the facility. Interview on 03/05/25 at 10:41 A.M., Consultant Dietetic Technician (CDT) #640 stated she had not yet been to the facility to assess residents. CDT #640 stated if a resident had skin breakdown, then it should be noted in the nutritional assessment and the resident should be ordered double protein at meals or protein supplements for healing. Interview on 03/05/25 at 11:26 A.M., Registered Nurse (RN) #345 stated a resident's wound should be assessed and measured on admission. RN #345 stated the facility would not allow a Registered Nurse to stage a pressure ulcer wound. RN #345 verified Resident #68 had no additional nutritional interventions in place for wound healing. Interview on 03/05/25 at 11:38 A.M., Wound Physician (WP) #710 stated Resident #68 had an unstageable pressure ulcer to the coccyx which was now a stage three pressure ulcer. WP #710 stated the pressure ulcer to the coccyx was currently showing improvement. Observation on 03/05/25 at 11:45 A.M., of wound care with WP #710 revealed Resident #68 had a stage three pressure ulcer to the coccyx. The wound measured 3.2 cm in length, 1.1 cm in width, and 0.2 cm in depth. The surrounding wound was intact and showed improvement per WP #710. The wound had no odor and minimal serosanguinous drainage, there was no tunneling or undermining. WP #710 administered wound treatment per physician orders. Interview on 03/05/25 at 1:19 P.M., Licensed Practical Nurse (LPN) #398 stated she completed Resident #68's admission skin assessment. LPN #398 stated she usually measured and assessed wounds and was not sure why she had not completed the wound assessment for the resident's coccyx. LPN #398 stated upon admission, Resident #68 had an area to the coccyx that looked like an open skin tear or skin flap. LPN #398 stated the area was not deep maybe 0.1 cm and was just red in color with no drainage. LPN #398 stated there was no slough or eschar in the wound upon readmission. LPN #398 stated the area to the coccyx was approximately one-half inch by one-half inch. LPN #398 thought she had spoken with wound care and had an order for cream or something for the area. Review of the facility policy titled Documentation of Wound Treatments, dated 08/01/22 revealed the facility would complete accurate documentation of wound assessments upon admission and weekly and as needed when wound condition deteriorates. A wound assessment would include the type of wound, the wound stage, wound measurements including height, width, depth, undermining, tunneling, and a description of the wound characteristics including the color of the wound bed, type of tissue in the wound bed, condition of the surrounding skin, drainage amount and characteristics, presence or absence of odor and pain. Review of the facility policy titled Pressure Injury Prevention and Management, revised 09/26/24, revealed the facility would establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. Training in the completion of pressure injury risk assessment, full body skin assessment, and pressure injury assessment would be provided as needed. Review of the NPUAP guidelines dated 2014 revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.

Based on medical record review, resident and staff interview, and review of facility policy, the facility failed to ensure care plan conferences were conducted quarterly for the resident and/or resident representative. This affected six (#14, #18, #43, #49, #58 and #60) of seven residents reviewed for care plan conferences. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses included injury at T1 level of thoracic spinal cord, paralytic syndrome, diffuse traumatic brain injury with loss of consciousness of unspecified duration, paraplegia, major depressive disorder, and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired. Review of the care plan conferences, from 01/01/24 to 03/04/25, revealed Resident #14 had two care conferences on 02/05/24 and 12/25/24. Interview on 03/05/25 at 8:35 A.M. with Social Services #401 verified Resident #14 had only two care conferences the past year. 2. Review of the medical record revealed Resident #18 was admitted on [DATE]. Diagnoses included unspecified dementia, dysphagia oropharyngeal phase, cognitive communication deficit, type two diabetes mellitus without complications, major depressive disorder recurrent, hypothyroidism, and essential hypertension. Review of the Minimum Data Set (MDS) assessment, dated 01/03/25, revealed Resident #18 was moderately cognitively impaired. Review of care plan conferences from 01/01/24 to 03/04/25 revealed Resident #18 had one care conference on 02/15/24. Interview on 03/05/25 at 8:35 A.M. with Social Services #401 verified Resident #18 had only one care conference the past year. 3. Review of the medical record revealed Resident #43 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, heart failure, muscle weakness, and major depressive disorder recurrent. Review of the Minimum Data Set (MDS) assessment, dated 02/10/25, revealed Resident #43 was moderately cognitively impaired. Review of care plan conferences from 01/01/24 to 03/04/25 revealed Resident #43 had two care conferences on 01/17/24 and 11/26/24. Interview on 03/05/25 at 8:35 A.M. with Social Services #401 verified Resident #43 had only two care conferences the past year. 4. Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses included Parkinson's disease with dyskinesia, neurocognitive disorders with lewy bodies, dementia, major depressive disorder recurrent, and essential hypertension. Review of the Minimum Data Set (MDS) assessment, dated 12/30/24, revealed Resident #49 was moderately cognitively impaired. Review of care plan conferences from 01/01/24 to 03/04/25 revealed Resident #49 did not have a care conference during this time period reviewed. Interview on 03/03/24 at 10:42 A.M. with Resident #49 stated she did not have knowledge of care conferences. Interview on 03/05/25 at 8:35 A.M. with Social Services #401 verified Resident #49 did not have any care conferences the past year. 5. Review of the medical record revealed Resident #58 was admitted on [DATE]. Diagnoses included primary generalized osteoarthritis, acute kidney failure, essential hypertension, hyperlipidemia, delusional disorders, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 02/27/25, revealed Resident #58 was cognitively intact. Review of care plan conferences from 01/01/24 to 03/04/25 revealed Resident #58 had two care conferences on 02/11/24 and 02/21/25. Interview on 03/06/25 at 9:26 A.M. with Social Services #401 verified Resident #58 had only two care conferences in the past year. 6. Review of the medical record revealed Resident #60 was admitted on [DATE]. Diagnoses included hemiplegia affecting left dominant side, acute cholecystitis, cerebral infarction, acute kidney failure, chronic atrial fibrillation, and chronic systolic congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact. Review of care plan conferences from 01/01/24 to 03/04/25 revealed Resident #60 had one care conference on 02/28/24. Interview on 03/06/25 at 9:26 A.M. with Social Services #401 verified Resident #60 had only one care conference in the past year. Review of the policy titled Care Planning- Resident Participation dated 2024 revealed the facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences and allow them to see the care plan, initially at routine intervals, and after significant changes. The facility will make an effort to schedule the conferences at the best time of the day for the resident/resident's representative.

Based on observation, medical record review, resident and staff interview and facility policy review, the facility failed to monitor effectiveness of medications utilized to manage the resident's mood and behavior. This affected five of five residents (#10, #15, #26, #34, and #45) reviewed for unnecessary medications in a facility census of 75. Findings include: 1. Medical record review revealed Resident #26 admitted to the facility on [DATE]. Diagnoses included anxiety disorder, borderline personality disorder, major depression disorder, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition, no behaviors, and received antianxiety, antidepressant, antibiotic, hypoglycemic, and anticonvulsant medications. Review of the physician orders noted Resident #26 to receive the following medications: 03/03/25 venlafaxine extended release 75 milligrams (mg) once daily for major depressive disorder with psychotic symptoms, 02/24/25 trazodone 175 mg at bedtime for the treatment of insomnia administered at bedtime, 03/03/25 bupropion 150 mg once daily for depression, 02/06/25 sertraline 100 mg once daily for anxiety disorder, 02/22/25 buspirone 5.0 mg three times daily for anxiety. On 06/25/24, a nursing plan of care was implemented to address Resident #26's behavior problem related to refusing medications, including diabetic medications. Accusatory toward staff. Making false allegations about missing money. Manufactures and manipulate facts to elicit or desire a response from desired authority. Instigates and provoke other residents with passive aggressive or condescending response to obtain a negative response. Interventions included the following; The resident needs encouragement and active support by family/caregivers when the resident was having episodes of behaviors. Monitor the resident for safety. The resident was taking antianxiety medications which were associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. Resident #26 uses antidepressant medication related to depression. Monitor/document side effects and effectiveness every shift. Educate the side effects and/or toxic symptoms of anti-depressant drugs being given. Monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy. Resident #26 uses psychotropic medications related to Borderline Personality Disorder. Monitor for side effects and effectiveness every shift. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. Resident #26 has mood problem related to borderline personality disorder. Has episodes of impulsiveness, self injury, mood swings, anger, unstable self image and sense of self and episodes of attention seeking. The medical record did not have any behavior tracking contained in the medical record indicating behavior medications were being monitored for effectiveness or the availability of non-pharmacological interventions when undesirable behaviors occur. Interview with Unit Manager Licensed Practical Nurse (LPN) #390 on 03/06/25 at 8:04 A.M. verified no tracking documented in the medical record regarding resident behaviors or mood. In addition no documentation indicated non-pharmacological interventions were attempted to address Resident #26's insomnia and increased depressed mood. 2. Record review revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, extrapyramidal and movement disorder, schizoaffective disorder-bipolar type, anxiety disorder, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition, feeling down, dressed, or hopeless, trouble falling asleep or staying asleep, or sleeping too much, social isolation sometimes. Resident #45 received antipsychotic, antidepressant, diuretic, opioid, and anticonvulsant medications. On 07/10/24, a plan of care was revised to address Resident #45's behavior problem related to refusing to go to scheduled appointments, refusing medications, showers, activity of daily living care, and refusing to wear non skid footwear. Interventions included to monitor/document for side effects and effectiveness. The resident needs encouragement and active support by family/caregivers when the resident use these strategies. Additionally on 07/24/24, a plan of care was revised to address Resident #45's psychotropic medication related to suicidal ideations, major depressive disorder, generalized anxiety disorder with an intervention including to monitor for side effects and effectiveness every shift. On 07/24/24, a plan of care was also revised to address Resident #45's antidepressant medication related to depression with interventions including to monitor/document side effects and effectiveness every shift. The medical record lacked documented evidence Resident #45's mood and behavior medications were being monitored for effectiveness. Review of the physician orders revealed Resident #45 was receiving the following medications: 06/08/23 trazodone 200 milligrams (mg) by mouth at bedtime for depression with insomnia; 04/13/23 wellbutrin extended release 24-hour 300 mg one time a day for depression; 04/08/23 viibryd oral tablet 20 mg in the morning for depression; and 01/25/22 invega tablet extended release 24-hour three mg give one tablet by mouth one time a day related to recurrent moderate major depressive disorder. Review of behavioral health certified nurse practitioner (CNP) evaluation notes dated 01/23/25 noted Resident #45 alert and oriented times four (person, place, time, and circumstance) and able to name current president. Resident #45 stated feeling a little depressed lately and still has insomnia with trouble getting to sleep and staying asleep. Resident #45 was not a candidate of a gradual dose reduction (GDR) at this time. Assessment and plan noted schizoaffective disorder, bipolar type plan continue invega, trazadone, wellbutrin, viibrd- for mood disorder, has depression at this time. Continue to document any changes in mood or behavior. Encourage non-pharmaceutical techniques including sunlight exposure, regular human contact, and reducing stimulants. Primary insomnia plan continue melatonin, trazodone for difficult sleeping, effective in treatment of insomnia. No changes- will monitor. Encourage increased activity, good sleep hygiene, balanced diet, sunlight exposure, practice relaxation technique, and monitor. No documentation contained in the medical record indicated mood or behavior medications were being monitored to ensure effectiveness or non-pharmacological interventions were attempted to address Resident #45 ongoing complaint of depressed mood and associated insomnia. On 03/04/25 at 10:55 A.M., observation of Resident #45 noted the resident on her bed, in a dark room. Resident #45 was noted with a flat affect and stated she had been unable to sleep for the past five days. Resident #5 also reported increased depression and had informed the nurse (unable to state name). Additional observations discovered the resident exhibiting the same behavior on 03/05/25 at 6:23 A.M. and 03/06/25 at 7:45 A.M. On 03/05/25 at 6:58 A.M., an interview with Licensed Practical Nurse (LPN) #386 verified she was assigned to Resident #45's care the past two nights, stated no concerns regarding sleep had been reported to her by the resident. LPN #386 went on to state Resident #45 has been depressed for some time (no time determined) since a friend passed away. No attempts to inform the physician or implement non-pharmacological interventions had been attempted. On 03/05/25 at 7:50 A.M., an interview with Unit Manager LPN #390 confirmed Resident #45 experienced the death of a friend in December 2024 and confirmed no documentation contained in the medical record indicated Resident #45's mood or behavior medications were being monitored for effectiveness. On 03/06/25 at 8:04 A.M.,a subsequent interview with Unit Manager LPN #390 verified no tracking documented in the medical record regarding resident behaviors or mood. In addition, no documentation indicated non-pharmacological interventions were attempted to address Resident #45's insomnia and increased depressed mood. 35033 3. Review of the medical record revealed Resident #15 had an admitted [DATE]. Diagnoses included schizophrenia, bipolar disorder, depressive disorder, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Review of the plan of care last revised 07/18/24 revealed Resident #15 was resistive to care at times related to anxiety and schizophrenia disorder. The resident was on an antipsychotic medication, antianxiety medication, and antidepressant medication for anxiety, depression, behavior, and schizophrenia. The care plan noted the resident had behavior problems including pacing, repetitive questions, focus on bowel function and weight. Interventions included to monitor medication effectiveness, monitor and record behaviors symptoms/interventions and alternate therapies attempted and their effectiveness. Review of the monthly physician orders dated 07/21/24 revealed an order for Ativan 0.5 milligrams (mg) every morning and bedtime for anxiety. An order dated 07/20/24 for clozapine 50 mg daily for anxiety, and 200 mg at bedtime for schizophrenia. An order dated 07/20/24 for paroxetine 10 mg in the morning for depression. Review of the nursing notes and medication administration records from 11/01/24 through 03/04/25 revealed no documentation Resident #15 had received daily monitoring for behaviors and medication effectiveness. Interview on 03/06/25 at 2:20 P.M. with the Director of Nursing (DON) stated the nurses charted by exception. The DON verified the nurses were not charting daily on behaviors and medication effectiveness. The DON stated currently the facility had no process in place for monitoring behaviors for psychotropic medications. 41528 4. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included vascular dementia and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment, dated 11/29/24, revealed Resident #34 was cognitively intact and medications included insulin, antipsychotic, antidepressant, diuretic, hypoglycemic, and anticonvulsant. Review of the most recent care plan revealed Resident #34 takes psychotropic medication. Interventions included to monitor/record target behavior symptoms including pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. Review of the Medication Administration Review (MAR) and Treatment Administration Review (TAR), dated since 02/01/25, revealed no monitoring or recording of resident behaviors. Further review of the medical record review revealed no documentation of monitoring or recording of resident behaviors. Interview on 03/06/25 at 1:00 P.M. with the Director of Nursing (DON) verified the facility did not document or record Resident #34's behaviors. 44815 5. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including depression, anxiety, vascular dementia, and mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition. Review of the physician orders dated 04/15/24 revealed Resident #10 was ordered Donepezil HCl (hydrochloride) oral tablet five milligrams (mg) by mouth at bedtime for cognition, Depakote oral tablet delayed release 250 mg. one tablet by mouth two times daily for borderline personality disorder, bupropion HCl 150 mg. by mouth twice daily for depression, buspirone HCl five mg by mouth three times daily for anxiety, and trazodone HCl 50 mg once daily for sleep disturbance. Review of a consulting behavioral care Nurse Practitioner (NP) progress note, dated 12/20/24, revealed the NP wrote new orders to increase Wellbutrin (generic: bupropion HCl) from 150 mg twice daily to 200 mg twice daily due to increased depression. Review of a consulting behavior care NP progress note dated 01/20/25 revealed Resident #10 continued with some depression and recommended continuing non-pharmacological interventions such as creating a calm environment and removing stressors when possible; implementing soothing rituals; and limiting caffeine use. Review of the current care plan for Resident #10 revealed she used an antidepressant medication due to depression and personality disorder. Interventions included monitoring, documenting, and reporting, as needed, adverse reactions, including change in behavior/mood/cognition. Resident #10 used anti-anxiety medications. Interventions included monitoring/documenting/reporting as needed any adverse reactions, including mania, rage, and aggressive or impulsive behaviors. Review of Resident #10's medical record revealed no evidence of ongoing behavior monitoring related to Resident #10's use of psychotropic medication. Additionally, no evidence of staff using non-pharmacological interventions was documented. Interview on 03/10/25 at 8:19 A.M. with the Director of Nursing (DON) confirmed no behavior or side effect monitoring was in place for Resident #10. Subsequent interview on 03/10/25 at 10:19 A.M. with the DON confirmed Resident #10's dose of Wellbutrin (bupropion HCl) was not increased per the NP's progress note. The DON stated the consulting NP was responsible for entering her own orders in the electronic medical record. Review of the facilities Use of Psychotropic Medication policy reviewed/revised 09/26/24 revealed psychotropic medications are to be used only when the practitioner determines the medication is appropriate to treat a residents specific, diagnoses and documented condition and the medication is beneficial to the resident. The indications of initiating, maintaining, or discontinuing medication(s), as well as the use of non-pharmacological approaches will be determined by the physician through evaluation which may included but not limited to resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, taking into account the relative benefits and risks, and the preferences and goals for treatment. The attending physician/designee will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team. The effects of the psychotropic medication on a resident's physical, mental, and psychosocial well-being with be evaluated on an ongoing basis. The resident's response to medication (s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record.

Based on observation and staff interview, the facility failed to ensure staff hand sanitized between serving resident's meals. This affected four (#1, #33, #44, and #45) of 26 residents reviewed for dining services. The facility census was 75. Findings include: Observation on 03/03/25 at 11:24 A.M. revealed meal trays delivered to the 200 hall. Unit Manager Licensed Practical Nurse (LPN) #390 was observed passing the meal tray to Resident #44 without prior hand sanitizing. LPN #390 touched the bedside table and used cup then placed the meal tray on the bedside table. LPN #390 did not hand sanitize then passed the meal tray to Resident #45. LPN #390 was observed adjusting the bedside table and setting up the meal tray. LPN #390 was observed to not hand sanitize then entered Resident #1 and Resident #33's room with two meal trays and provided the meal tray. LPN #390 exited without hand sanitizing. Interview on 03/03/25 at 11:33 P.M. with LPN #390 verified she did not complete hand sanitizing between serving the resident's meal trays to their room.

Based on observation, staff and resident interview, review of a job description, and facility policy review, the facility failed to maintain a clean and functional environment for the residents. This affected seven (#2, #9, #12, #29, #39, #70, and #72) of thirteen residents reviewed for physical environment. Findings include: 1. Observation on 03/04/25 at 11:07 A.M. of Resident #9's room revealed the blinds on the window were broken. Interview on 03/04/25 at 3:07 P.M. with Maintenance Supervisor (MS) #375 verified the broken window blinds for Resident #9. Interview on 03/05/25 at 1:38 P.M. with Resident #9 stated she would prefer her blinds to be repaired. 2. Observation on 03/04/25 at 11:10 A.M. revealed Resident #72 had broken window blinds. There gloves placed in the holes of window blinds. Interview on 03/04/25 at 3:07 P.M. with Maintenance Supervisor (MS) #375 verified the broken window blinds for Resident #72. Interview on 03/05/25 at 1:34 P.M. with Resident #72 stated she had placed the gloves in the window because she does not like the sun coming through the window. Resident #72 also stated she had not liked the window blinds being broken. 3. Observation on 03/04/25 at 11:12 A.M. revealed Resident #2 had broken window blinds. Interview on 03/04/25 at 3:07 P.M. with Maintenance Supervisor (MS) #375 verified the broken window blinds for Resident #2. Interview on 03/05/25 at 1:43 P.M. revealed Resident #2 stated she does not like having broken window blinds. 4. Observations on 03/03/25 at 9:58 A.M. and 03/04/25 at 8:29 A.M. revealed Resident #70's window was slightly opened and there was excess buildup of dirt on the windowsill. Observation on 03/04/25 at 11:05 A.M. revealed loose wiring on the wall above Resident #12's bed and the blinds on the window were broken. Observation on 03/04/25 at 11:30 A.M. revealed Resident #29 had broken window blinds. Observation on 03/04/25 at 11:31 A.M. revealed Resident #39 had broken window blinds. Interview on 03/04/25 at 3:07 P.M. with Maintenance Supervisor (MS) #375 verified the broken window blinds for Residents #12, #29 and #39. MS #375 verified the loose wiring on the wall above Resident #12's bed. Interview on 03/04/25 at 3:17 P.M. with Housekeeping Supervisor (HS) #351 confirmed there was dirt buildup on Resident #70's windowsill. HS #351 stated housekeeping was supposed to clean rooms everyday including windowsills. Review of the undated job description titled Maintenance Director Job Description revealed maintenance would ensure the entire facility was in good working order and maintained in accordance with company standards, and ensure timely response and resolution to all maintenance concerns for the facility. Review of the undated policy titled Resident Environmental Quality revealed it was the responsibility of the facility to provide equipment for comfort and privacy of residents.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure residents were treated in a dignified manner. This affected one (#31) of three residents reviewed for dignity. The facility census was 75. Findings include: Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included polyosteoarthritis, dementia, and presence of cerebrospinal fluid drainage device. Review of the Minimum Data Set (MDS) assessment, dated 01/29/25, revealed Resident #31 was severely cognitively impaired. Resident #31 required set-up or clean-up assistance with eating. Review of the most recent care plan revealed Resident #31 required assistance with activities of daily living and needs supervision and set up assistance with all meals. Observation on 03/05/25 at 8:11 A.M. revealed Certified Nursing Assistant (CNA) #353 standing over Resident #31 while in bed providing him a bite of a banana and two spoonfuls of yogurt. Interview on 03/05/25 at 8:16 A.M. with CNA #353 stated Resident #31 at times needs assistance with eating and will come and go out of his room to offer a few bites to eat at a time. CNA #353 verified standing over Resident #31 while assisting him with the breakfast meal. Review of the policy titled Promoting/Maintaining Resident Dignity dated 2024 revealed all staff members are involved in providing care to residents to promote and maintain resident dignity and respect for resident rights. This deficiency represents non-compliance investigated under Complaint Number OH00161509.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure call lights were accessible to residents. This affected two (#49 and #70) of two residents reviewed for call lights. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses included Parkinson's disease with dyskinesia, neurocognitive disorders with lewy bodies, dementia, and major depressive disorder. Review of the care plan, revised 07/04/24, revealed Resident #49 was at risk for falls due to gait/balance problems, Parkinson's disease, dementia with lewy body, arthritis, and required assistance with transfers and incontinence. Interventions include to educate the resident on the use of walker and call light and to reinforce the resident to call for assistance. Review of the Minimum Data Set (MDS) assessment, dated 12/30/24, revealed Resident #49 was moderately cognitively impaired and required partial/moderate assistance with toileting, showers, and upper and lower body dressing. Observation on 03/05/25 at 8:00 A.M. revealed Resident #49 was lying in bed with the head of the bed in an upright position with pillows behind the resident's head. Resident #49 appeared to be in an uncomfortable position. The bed remote was observed to be hung above the foot of the bed near the door and the call light was unreachable on the floor on the other side of the bedside table. Interview on 03/05/25 at 8:01 A.M. with Resident #49 stated she was uncomfortable and was unable to adjust the bed due to the bed remote being unreachable. Resident #49 stated the call light was out of reach because the staff do not like her. Interview on 03/05/25 at 8:05 A.M. with Unit Manager Licensed Practical Nurse (LPN) #390 verified the bed remote and call light were inaccessible to Resident #49. 51528 2. Review of the medical record for Resident #70 revealed an admitted [DATE]. Diagnoses included anoxic brain damage, myocardial infarction, tracheostomy status, and generalized idiopathic epilepsy and epileptic syndromes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 has moderate cognitive impairment and was dependent on staff for all activity of daily living (ADLs). Review of Resident #70's care plan dated 11/13/24 revealed an intervention to ensure Resident #70's call light device was always placed in her right hand and encourage the resident to use the call light for assistance as needed. Observation on 03/03/25 at 10:00 A.M. revealed Resident #70 was lying in bed with her call light on the left side of bed around bed rail hanging towards the ground. Interview on 03/03/25 at 10:05 A.M. with Licensed Practical Nurse (LPN) #500 confirmed Resident #70's call light was not within reach. LPN #500 stated Resident #70 was unable to use the call light. LPN #500 stated she was not aware Resident #70 couldn't use her right side. Observation on 03/04/25 at 8:30 A.M. revealed the facility had changed Resident #70's call light from a call button to a tap call light. The call light remained on the left side. Additional observation on 03/04/25 at 10:45 A.M. and 3:04 P.M. revealed the call button continued on the left side of Resident #70. Interview on 03/04/25 at 3:22 P.M. with LPN #313 confirmed Resident #70's call light was on the left side of the bed. LPN #313 stated the reason it was on the left side was because it could not reach to the right side. LPN #313 stated Resident #70 could use both hands equally. LPN #313 was not aware of the care plan stating to keep the call light on the right side of the bed. Interview on 03/04/25 at 3:29 P.M. with the Director of Nursing (DON) confirmed Resident #70's call light should be placed on the right side of the resident. Review of the policy titled Call Lights: Accessibility and Timely Response dated 09/26/24 revealed all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Staff will ensure the call light is within reach of the resident and secured, as needed.

Based on medical record review, resident and staff interview, and review of facility policy, the facility failed to provide timely access to medical records as requested. This affected one (#26) of 24 residents reviewed for medical record access in a facility census of 75. Findings include: Review of Resident #26's medical record revealed the was resident was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, borderline personality disorder, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition, and had no behaviors recorded. On 03/03/25 at 11:19 A.M., an interview with Resident #26 revealed he was experiencing dental pain and concerns. Resident #26 had requested access and copies of dental information contained in his medical record. Resident #26 indicated the verbal request was made to the Director of Nursing (DON) approximately two weeks ago and no access had been provided. Interview with the DON on 03/04/25 at 11:32 A.M. confirmed Resident #26 had requested copies of dental records from his medical record approximately two weeks ago. The DON indicated she had not yet provided copies as requested. Review of the facility's undated policy titled Release of Medical Records revealed requests for records should be referred to Director of Nursing or Administrator, or another staff member previously designated by the facility. The resident's record is accessible to him/her within 24 hours (excluding weekends and holidays) notice, following an oral or written request.

Based on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) were provided with adequate assistance with grooming and hygiene. This affected three (#14, #42 and #60) of 24 residents reviewed for ADL. The facility census was 75. Findings include: 1. Medical record review for Resident #42 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes mellitus, morbid obesity, acute and chronic respiratory failure, depression, lymphedema, congestive heart failure, and anxiety disorder. On 07/23/24, a nursing plan of care was implemented to address Resident #42's ADL self-care performance deficit related to activity intolerance, shortness of breath with exertion, morbid obesity, heart failure, and unable to reach all body parts. Interventions included Resident #42 required physical assistance of staff with bathing. Provide sponge bath when a full bath or shower cannot be tolerated. Needs physical assistance of staff to turn and reposition in bed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition and had no behaviors or refusal of care, Resident #42 required substantial to maximal assistance with ADL including bathing/showering. Resident #42 required supervision to touching assistance with personal hygiene. Review of the certified nursing assistance (CNA) task for Resident #42 revealed Resident #42 was to receive scheduled showers on day shift Wednesday and Saturday. Review of comprehensive CNA shower review documentation revealed Resident #42 was provided with bed baths on 02/05/25, 02/08/25, 02/12/25, 02/15/25, 02/19/25, 02/22/25, and 02/26/25. No documentation recorded a bath provided on 03/01/25. There was no documentation indicating Resident #42's hair was washed or facial hair was removed. Observation on 03/03/25 at 11:38 A.M. revealed Resident #42 was lying in bed. Resident #41 stated she did not get bed baths twice weekly as scheduled and had not had her hair washed in an undetermined amount of time. Resident #42 was noted with long orange facial hair to the chin and upper lip. Resident #42's hair appeared long, matted and greasy. Resident #42 stated she preferred to have facial hair removed. Interview on 03/04/25 at 3:13 P.M. with Unit Manager Licensed Practical Nurse (UMLPN) #390 verified no information was available indicating when Resident #42's facial hair was last groomed or hair washed. In addition, Resident #42 was not provided with a documented bath as scheduled on 03/01/25. 41528 2. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses included injury at T1 level of thoracic spinal cord, paralytic syndrome, diffuse traumatic brain injury with loss of consciousness of unspecified duration, and paraplegia. Review of the Minimum Data Set (MDS) assessment, dated 02/09/25, revealed Resident #14 was moderately cognitively impaired and dependent on staff for showers/bathes. Review of the care plan, revised on 08/19/24, revealed Resident #14 had an ADL self-care performance deficit due to paraplegia, weakness, and pain. Resident #14 was totally dependent on one staff to provide showers and a sponge bath should be provided when a full bath or shower cannot be tolerated. Review of the shower task list, revealed Resident #14 was scheduled for a shower every Monday, Wednesday, and Friday. Review of the shower task, reviewed the last thirty days, revealed three showers (02/10/25, 02/12/25, and 03/05/25), three bed baths (02/19/25, 02/26/25, and 03/04/25), and one sponge bath (03/03/25) was provided. Interview on 03/03/25 at 1:36 P.M. with Resident #14 stated it had been a while since he had been provided a shower. Resident #14 stated he always prefers a shower but staff often provided a bed bath instead. Subsequent interview on 03/10/25 at 9:04 A.M. with Resident #14 stated he was never offered a shower on Friday 03/07/25. Interview on 03/10/25 at 10:18 A.M. with the Director of Nursing (DON) verified Resident #14 did not receive showers as scheduled. The DON reported Resident #14 will often refuse and verified there was no documentation of resident refusals. 3. Review of the medical record revealed Resident #60 was admitted on [DATE]. Diagnoses included hemiplegia affecting left dominant side, acute cholecystitis, cerebral infarction, acute kidney failure, chronic atrial fibrillation, and chronic systolic congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 01/23/25, revealed Resident #60 was cognitively intact and was dependent on staff for showers/baths. Review of the care plan, revised 06/2024, revealed Resident #60 had an ADL self-performance deficit due to activity intolerance, congestive heart failure, cardiomyopathy, cirrhosis, hemiplegia, and cerebrovascular accident. Resident #60 was dependent on staff for bathing/showering. A sponge bath should be provided when a full bath or shower cannot be tolerated. Review of the shower task list revealed Resident #60 was scheduled for a shower every Tuesday and Friday. Review of the shower task, reviewed the last thirty days, revealed three bed baths (02/11/25, 02/14/25, and 03/04/25) were provided. No showers were provided to Resident #60 in the last 30 days. Interview on 03/04/25 at 7:56 A.M. with Resident #60 stated he was scheduled showers two times a week but rarely receives a shower. Resident #60 stated he has not received a shower since 01/17/25. Resident #60 stated the aides report the shower cot was broken and a shower cannot be provided. Interview on 03/05/25 at 3:39 P.M. with Certified Nursing Assistant (CNA) #374 stated the shower cot Resident #60 uses has a stuck wheel and the other shower chairs were not safe for the resident so he has only been provided bed baths for some time. Interview on 03/05/25 at 4:11 P.M. with Unit Manager Licensed Practical Nurse (LPN) #390 verified the shower cot was available for use and had no knowledge of a broken or stuck wheel. Subsequent interview with CNA #385 stated the shower cot wheel may stick and be difficult to use with weight however two staff would be able to assist Resident #60 safely on the shower cot. CNA #385 stated there was also another shower chair option that would be appropriate for Resident #60. Interview on 03/06/25 at 8:35 A.M. with the Administrator and Director of Nursing (DON) verified Resident #60 had four bed baths and no showers in the last thirty days. Review of the ADL facility policy last reviewed/revised on 09/26/24 revealed care and services will be provided for the following ADLs: Bathing, dressing, grooming, and oral care. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, medical record review, review of hospital medical records, review of the emergency department record, review of the Abuse/Neglect policy and procedure, review of the Wound Treatment Management policy, review of the Skin Assessment policy, resident interview, Medical Director interview and staff interviews, the facility failed to ensure Resident #59, who was admitted to the facility on hospice care, was free from a situation of neglect when facility staff failed to provide ongoing wound assessments, care and services to prevent a significant decline in a wound, and notification to the physician when there was a decline in the wound. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm with negative health outcomes when emergency services were called for Resident #59 on 03/22/24 due to a deteriorating mental status and Hospice Nurse #215 checked the left leg wound and it was getting worse. Consequently, Resident #59 required an inpatient hospital admission from 03/22/24 to 03/29/24 for which Resident #59 was treated for an infected necrotic wound of the left lower extremity. Surgical debridement was required and occurred on 03/25/24 which resulted in a large skin flap on the lateral aspect of the wound to be removed. Cultures revealed polymicrobial, proteus, methicillin-resistant staphylococcus aureus (MRSA) and enterococcus organisms were present in the wound requiring prolonged oral and intravenous (IV) antibiotic therapy through 04/07/24. In addition, the facility failed to provide ongoing wound assessments for Resident #42, including weekly skin assessments with wound measurements and descriptions according to policy, that placed the resident at potential risk for more than minimal harm that was not Immediate Jeopardy. This affected two (#42 and #59) of three residents reviewed for abuse and neglect. The facility census was 85. On 04/04/24 at 12:38 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 03/22/24 when hospice Resident #59 was transferred to the hospital due to an altered mental status and was found to have an infected left lower extremity wound. Upon Resident #59's admission to the facility on [DATE] a blister to the left knee was noted, and there was no documented evidence of ongoing monitoring or documentation related to the blister or to a left lower leg wound contained within Resident #59's medical record. Subsequently, Resident #59 was admitted to the hospital on 03/22/24 for an infected necrotic wound of the left lower extremity requiring surgical intervention, ongoing wound treatments, and IV antibiotic therapy. The Immediate Jeopardy was removed on 04/04/24 when the facility implemented the following corrective actions: On 04/04/24 at 2:09 P.M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting and Immediate Jeopardy (IJ) Review was held with the Administrator, DON, and Medical Director #600 to review the facility polices for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, Change in Condition, Skin Assessment, and Completion of Wound Care. No policy changes were made as a result of the review. On 04/04/24, the DON educated the nurse managers on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation and the need to report immediately any concerns, on skin assessments and wound monitoring including education on monitoring for weekly skin assessments being completed on all residents and individual wound monitoring for each individual wound a resident has. On 04/04/24, the DON educated the facility nurses and nursing assistants on Skin Assessments being completed weekly on all residents and to document in the resident's medical record the location, appearance, and size of any skin condition, on Wound Management policies, including the management and documentation of a wound to include size, appearance, measurement and drainage, and the documentation of such wounds, and with any new skin conditions the unit managers are to be notified. Education on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, including how to identify and prevent situations of neglect, identification of change in condition, including how to timely identify situations when care cannot be or is not provided to residents in the facility and to know when to seek medical attention, and completion of wound care per orders. On 04/04/24, the Administrator educated Staffing Coordinator #105, Director of Admissions #107, Business Office Manager #121, Human Resources Director #130, Social Services #131, Receptionist #133 and #213, the DON, Maintenance Supervisor #134 and Maintenance Helper #162, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #191, Director of Dining Services #190, Maintenance Director #603, Housekeeping Manager #148, Director of Recreation #104, Recreation Assistant #123, and Director of Rehabilitation #132 on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. On 04/04/24, Director of Rehabilitation #132 educated one physical therapist, four occupational therapists, two speech therapists, four physical therapy assistants and two occupational therapy assistants on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. On 04/04/24, Director of Dining Services #190 educated four cooks and one dietary aide on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. On 04/04/24, Housekeeping Manager #148 educated six housekeeping and laundry staff on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. On 04/04/24, the DON, Registered Nurse Unit Manager #181 and Licensed Practical Nurse Unit Manager #214 completed head-to-toe body assessments on all 85 current residents to ensure no evidence of negligence in care resulting in skin impairments had occurred. No new skin or wound issues were noted and review of the medical record for skin and wound assessments had been completed and documented in the last seven days; however, Residents #06, #25 and #84 did not have skin assessments documented in the last seven days, so these records were updated to include the head-to-toe assessment completed on 04/04/24. Beginning on 04/04/24, an ongoing audit four times a week for four weeks completed by the DON/Designee to ensure individual wounds have been assessed no less than weekly and any negative change in a wound will have physician notification. Beginning 04/08/24, an ongoing audit will be completed by the Nurse Managers/Designee four to five times a week for four weeks to ensure skin assessments/observations are completed at least weekly, then randomly thereafter. Interviews conducted on 04/08/24 from 6:47 A.M. to 9:10 A.M., with Occupational Therapist #101, Director of Dining Services #190, Housekeepers #104 and #113, Laundry #103, and Director of Recreations #164 verified education received on resident abuse and neglect with all staff able to verbalize the importance of reporting immediately any concerns related to resident abuse and neglect. Interviews with Licensed Practical Nurses (LPN) #110, #128, #140, #167 and #168, State tested Nursing Assistants (STNA) #155, #170, #167 and #168, and Registered Nurses (RN) #138 and #179 verified they received education on monitoring of skin conditions and reporting as well as resident abuse and neglect. The nurses interviewed (RNs and LPNs) also verified education received on the completion and documentation of weekly skin assessments on all residents, wound assessments to include measurements, and with each dressing change a note in regard to a description of the wound needs to be made, and any changes in a resident's skin or wound needs to be reported immediately to the physician. Although the Immediate Jeopardy was removed on 04/04/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #59 revealed an admitted [DATE] from the acute hospital. Resident #59 had diagnoses including anemia, sleep apnea, chronic obstructive pulmonary disease, chronic respiratory failure, morbid obesity, hypertension, atrial fibrillation, heart failure, anxiety disorder, depression, type II diabetes mellitus, chronic kidney disease, atherosclerosis of native artery left lower extremity with ulceration of calf, and cardiomyopathy. Review of the hospital record revealed Resident #59 had presented on 03/01/24 with a complaint of not feeling well and a main complaint of left thigh pain and swelling. Resident #59 reported to have experienced several falls, winded with activities of daily living (ADLS), and a concern for inability to care for self. Review of the wound documentation dated 03/04/24 at 11:12 A.M. (from the resident's hospitalization prior to admission) revealed Resident #59 had five wounds: A right pretibial wound that was bleeding a moderate amount with a pink/red wound bed, tissue around the wound was blanchable, red in color with fragile warm skin, the wound had defined edges and measured 2.8 centimeters (cm) long by 1.9 cm wide by 1.0 cm deep; a right distal pretibial wound with a small amount of drainage with a pale pink, red base with the surrounding tissue warm and intact with defined edges. The measurements for the right distal pretibial wound were 2.2 cm long by 1.2 cm wide by 0.1 cm deep; a left posterior elbow wound which appeared to be a ruptured blister with small amount of drainage, measurements were 6.2 cm long by 7.1 cm wide by 0.1 cm deep; a left lower posterior arm wound with a pink, red wound bed with a small amount of drainage, measurements 2.0 cm long by 3.2 cm wide by 0.1 cm deep; and a left anterior-medial knee wound identified as a fluid filled blister that measured 13.3 cm long by 0.8 cm wide by 0.1 cm deep, fluid filled blister. Review of the continuation of care paperwork for Resident #59 dated 03/05/24 and timed at 11:16 A.M., revealed the following treatment orders dated 03/06/24 for each of the wounds: left forearm, cleanse with saline, pat dry, apply skin prep to the wound edge, apply foam dressing, every three days; left posterior elbow, cleanse with saline, pat dry and apply skin barrier to wound edges, apply foam dressing, change every three days for wound healing; right distal pretibial, cleanse with normal saline, pat dry, apply skin barrier to wound edges, apply foam dressing, change every day shift every other day and as needed; right proximal pretibial, cleanse with saline, pat dry, apply barrier cream to around the wound, cover with calcium alginate and apply foam dressing, change every day shift every other day and as needed; and left medial knee blister, cleanse with saline, pat dry, cover with Adaptic gauze, cover with abdominal pad and secure with roll gauze. Change every other day shift and as needed. Review of the nursing admission assessment completed on 03/05/24 at 6:45 P.M., revealed Resident #59 had an unstageable vascular wound to the left lower extremity with measurements of 13.5 cm long by 1 cm wide; the assessment noted Resident #59 was unable to tolerate range of motion to the left lower leg due to pain and the leg had discoloration. The assessment also noted a stage II pressure ulcer to the right shin measuring 2.7 cm long by 1.8 cm wide by 0.9 cm deep, a right outer ankle blister 2.5 cm long by 2.0 cm wide, a left elbow pressure ulcer, stage II, measurements 6.3 cm long by 7.9 cm wide., and a left lower arm pressure ulcer, stage 1 with measurements 2 cm long by 3.2 cm wide. Review of Admission orders for Resident #59 dated 03/06/24 included the left forearm to be cleansed with saline, patted dry, skin prep applied to the wound edge, and covered with foam dressing every three days, the left forearm was to be cleansed with saline, patted dry, skin prep to the wound edge, and covered with a foam dressing every three days, the left elbow was to be cleansed with saline, patted dry and skin barrier to wound edges and covered with foam dressing every three days, the right proximal pretibial (right shin) had orders to cleanse with saline, pat dry, apply barrier cream to peri-wound, cover with calcium alginate and cover with foam dressing every day shift every other day and as needed, and for the left medial knee blister to be cleansed with saline, patted dry, covered with Adaptic and abdominal pad and secured with roll gauze every other day shift and as needed. Review of the History and Physical completed on 03/07/24 at 2:10 P.M. for Resident #59 was incomplete, not signed, and did not reference any skin conditions or wounds. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively intact, required maximal assistance for activities of daily living and moderate to maximal assistance for mobility with functional impairments to both lower extremities. Resident #59 was noted to have no pressure ulcers and did not have the application of nonsurgical dressings and had Hospice services for chronic respiratory failure. Review of the Care Area Assessment (CAA) Summary revealed ADL functional potential, urinary incontinence, psychosocial well-being, mood, activities, falls, nutritional status, psychotropic drug use and pressure ulcers triggered. Review of both the admission and the comprehensive care plan revealed no mention of skin conditions or wounds. Review of the assessment completed for skin breakdown on 03/06/24 and 03/15/24 revealed Resident #59 was at risk for skin breakdown. Review of the progress notes from 03/05/24 to 03/22/24 revealed no skin concerns, and no mention of wounds. Review of the medical record for the weekly skin assessments revealed they were absent. Review of the medication and treatment administration records for March 2024 revealed treatments were documented as administered as ordered. Review of Nurse Practitioner #216's medical visit dated 03/18/24 at 2:06 P.M., noted a hematoma to the left knee with dressing clean dry and intact and a recommendation to continue pressure bandage over wound. Review of the Hospice notes (sent to the facility on [DATE]) revealed Hospice Nurse #215 was called for an unplanned visit to reassess a stage 4 pressure wound to the left knee. Hospice Nurse #215 visited on 03/18/24 at 6:30 P.M. and wrote orders to cleanse the wound area with normal saline, pat dry, apply [NAME] honey to open wound (until honey alginate arrives), cover necrotic area with Adaptic dressing and cover with abdominal pad and secure with border gauze every two days or as needed if dressing is soiled, saturated, or loosened. Hospice Nurse #215 returned on 03/19/24 to reassess the left knee wound dressing and found a moderate amount of bright red dried blood saturated on the gauze dressing. A dressing change was completed, and redness noted to the outer edge of the wound. The wound measured 2 cm with tunneling at 12 to 3 o'clock and outer edges of open wound were beefy red. Review of the Hospice notes by Hospice Nurse #215 dated 03/20/24 revealed the left knee wound measured 12 cm by 4 cm by 2 cm (length by width by depth), was irregular in shape, and had distinct edges with 51 to 75 percent of the tissue necrotic. There was a moderate amount of bloody drainage and the skin surrounding the wound was red with nonpitting edema. The treatment order was changed to cleanse the wound with normal saline, pat dry, apply 4-inch ribbon of Medi honey to the open wound, cover open area with oil emulsion dressing and apply iodine solution with a gauze to the eschar area of the wound, cover with abdominal dressing and wrap with gauze dressing and secure with tape. The wound dressing was ordered to be changed daily and if soiled or saturated. Review of a follow up and reassessment of the wound by Hospice Nurse #215 on 03/21/24 revealed the left leg wound had been deteriorating and the dressing to the left leg was in place but appeared to be soiled with bloody drainage. The dressing was removed, and the wound was odorous with large dark eschar within the deep wound bed that had dark bloody drainage with clots that appeared to be jelly-like. Wound edges were red and macerated with slough present with edema around the wound. The dressing was replaced, and a new order was written to cleanse the left knee wound with quarter strength Dakin's solution, pat dry, apply betadine to the eschar areas, paint around pink wound edges with Medi honey and loosely pack the wound bed with calcium alginate, cover wound with abdominal pad, wrap with kerlix and secure with tape, change every 48 hours and as needed if soiled. Review of the nurse progress notes on 03/22/24 revealed at 3:26 A.M. Resident #59 experienced increased agitation, was climbing out of bed and confusion was noted. At 8:17 A.M., Resident #59 was found on the floor, and noted to have confusion. At 9:19 A.M., Resident #59 was again agitated and attempted to climb out of bed, Ativan 0.5 mg was administered. At 1:20 P.M., Resident #59 was sent to the hospital for evaluation. Review of the Emergency Department (ED) medical record dated 03/22/24 revealed Resident #59 was sent for a wound check and evaluation of deteriorating mental status. Resident #59 was alert only to person and place upon arrival to the ED. Review of the ED Physician assessment dated [DATE] and timed 2:45 P.M., revealed Resident #59 had a large wound to the left knee with surrounding erythema, with a foul smell. In assessing the wound an attempt to remove the dressing noted the gauze that had clotted and appeared entangled in the wound, at which time the wound was recovered without gauze removed due to concerns of heavy bleeding. Resident #59 was started on antibiotics (intravenous Rocephin and Vancomycin) and given fluids due to concerns for sepsis and encephalopathy. Review of the radiography (X-ray) of the left knee completed on 03/22/24 revealed a large region of soft tissue prominence and subcutaneous air medial thigh indicating substantial cellulitis and potential subcutaneous abscess. Review of the hospital medical record dated 03/22/24, revealed Resident #59 was admitted to the hospital with diagnoses that included toxic metabolic encephalopathy, necrotic soft tissue of the left medial thigh and calf with infectious disease, and vascular and wound care consults made for surgical debridement of the wound. Review of the computed tomography (CT) scan of the left knee of Resident #59 completed on 03/23/24 revealed the presence of a complex gas containing fluid collection in the medial soft tissues of the distal thigh extending past the knee joint into the proximal lower leg measurements at least 19.8 cm in length. In addition, there was a soft tissue laceration extending to the fluid collection with no involvement of the muscular compartments seen, with a mass effect upon the vastus medialis muscle of the distal thigh. Review of the operative note for Resident #59 dated 03/25/24 revealed a diagnosis of infected necrotic wound, left lower extremity with an excisional debridement completed. The wound extended from the mid distal thigh to the proximal calf and involved the medial aspect of the thigh and knee. Large eschar over the wound with purulent drainage. The procedure involved a large skin flap on the lateral aspect of the wound was removed, tunneling seen proximally at the 12 o'clock position about 5 cm, and after debridement the wound measured 15 cm x 9 cm x 1 cm (length by width by depth). Cultures revealed polymicrobial, proteus, methicillin-resistant staphylococcus aureus (MRSA) and enterococcus organisms. Review of the Infectious Disease progress note dated 03/27/24 and times 3:33 P.M., recommended treatment of Levaquin 500 milligrams (mg) once a day by mouth and intravenous vancomycin 2,000 mg once daily through 04/07/24. Review of the hospital discharge summary and the continuation of care paperwork dated 03/29/24 and timed 5:16 P.M., revealed Resident #59 was to return to the facility with treatment that included a wound vacuum to the left medial knee. Orders included for the left medial knee wound that included to cleanse the wound and the area around the wound with soap and water after removing old dressing. Dry intact skin completely, apply skin prep to peri-wound then drape, using black foam to cover wound bed, including to make sure the foam is tucked into the tunneling noted at 12 o'clock. The wound vacuum is to be set at 125 millimeters of mercury (mmHg) continuously, at medium intensity, with the track pad to be placed off the wound to a non-pressure area. The dressing was ordered to be changed twice a week and as needed with the wound vacuum machine kept in upright position, and the cannister changed weekly and as needed. Additional orders included Levaquin 500 mg once a day by mouth and intravenous vancomycin 2,000 mg once daily through 04/07/24 and to follow up with wound care. Observation on 04/03/24 at 9:15 A.M. of Resident #59 revealed staff at bedside due to an increase in the confusion. Resident #59 was sitting on the side of the bed talking to self, dressing noted to the left knee was dated 04/03/24 and was clean dry and intact with black foam visible in the center of the wound with tubing extended out the left side of the dressing connected to a portable wound vacuum under Resident #59's bed. The wound vacuum was set at 125 mmHg per orders. Interview on 04/03/24 at 12:23 P.M. with the facility Medical Director #600, who is Resident #59's primary physician, verified knowledge of Resident #59 having a blister to the left knee upon admission. Medical Director #600 stated no other communication had been received in regard to Resident #59's left knee blister/wound. Medical Director #600 further verified no knowledge of the left knee blister breaking open and had he been called he would have seen the resident. Interview on 04/03/24 at 2:35 P.M. with the DON revealed she could not find documentation in Resident #59's medical record reflecting the monitoring and ongoing assessments of Resident #59's wounds and further verified the medical record for Resident #59 lacked documentation of the wound measurements, wound changes, or notification of change in condition. The DON stated Resident #59 did not have a care plan for either skin alterations or wounds. Observations on 04/04/24 at 11:00 A.M. and 3:00 P.M. found Resident #59 in bed, with head of bed elevated, call light within reach and dressing to left knee clean dry and intact with wound vacuum under the left side of the bed draining brownish colored fluid. The wound vacuum was functioning at 125 mmHg. On 04/08/24 at 9:00 A.M., Resident #59 was observed in bed on the right side with a wound vacuum intact and functioning at 125 mmHg. Interview on 04/04/24 at 3:00 P.M. with Licensed Practical Nurse (LPN) #156 verified Resident #59 had a fluid filled blister on left knee with skin surrounding the blister red in color. LPN #156 stated she never had to call a provider about the wound, remembered the specifics related to the dressing changes and verified dressing changes were completed. LPN #156 verified she did not complete wound documentation when completing the dressing change and further verified the weekly skin assessments for Resident #59 were not completed and the care plan did not reflect the care needs related to the skin conditions Resident #59 had. 2) Review of the medical record for Resident #42 revealed an admitted [DATE]. The resident had diagnoses including acute kidney failure, acute respiratory failure, hypertension, heart failure, diarrhea, morbid obesity, and perforated intestine requiring surgical intervention. Review of the nursing admission assessment dated [DATE] revealed Resident #42 had an abdominal surgical incision that measured 15 cm by 0.3 cm by 0 cm (length, width, depth). Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had mild cognitive impairment, required maximal assistance for activities of daily living and had a surgical wound. Review of the care plan for Resident #42 revealed an actual impairment to skin integrity due to a surgical wound. Interventions included to follow facility protocols for treatment of injury, encourage good nutrition, and weekly treatment documentation to include measurement of each area of skin breakdown to include length, width and depth, type of tissue and exudate and any other notable changes or observation. Review of the current physician order for Resident #42's surgical incision was written on 02/24/24 for the abdominal incision to be cleansed with normal saline, pat dry, apply calcium alginate with silver wound dressing to the wound bed and cover with transparent adhesive dressing once daily and as needed. Review of the treatment record for Resident #42 revealed treatments were documented as being completed as ordered. Review of the weekly nursing skin assessments and wound assessments for Resident #42 revealed the following: on 01/16/24, the abdominal surgical wound measured 6.0 cm by 4.0 cm by 0.1 cm with no description; on 01/19/24, the assessment references three abrasions to the abdomen with no measurements or description; on 01/26/24, the abdominal surgical incision had granulation tissue present and measured 12.7 cm by 5.2 cm by 0.1 cm; on 02/02/24 and 02/09/24 an abdominal surgical incision was noted, no measurements or description; on 02/02/24, the surgical wound measurement was 11.8 cm by 4.8 cm by 0.1 cm without a description; on 02/09/24, measurements were 12.6 cm by 5 cm by 0.1 cm with the wound well approximated; on 02/16/24, the abdominal surgical incision measured 13.2 cm by 6.5 cm by 0.1 cm; on 02/16/24 the surgical incision measured 13.2 cm by 6.5 cm by 0.1cm; on 02/23/24 the weekly skin assessment was blank; on 02/23/24, stated the overall impression was unchanged and measurements were 14 cm by 5 cm by 0.1 cm; on 02/29/24, stated the wound was well approximated and the tissue surrounding the wound was intact, measurements were 14 cm by 4.2 cm by 0.1 cm; on 03/01/24, the assessment referenced abdomen with no description on measurements present; on 03/08/24, the assessment was blank; on 03/19/24, the assessment listed a surgical incision, no measurements; and on 03/28/24 the skin assessment was blank. Review of the Nurse Practitioner note dated 03/08/24 documented the midline abdominal wound dressing was saturated with serosanguineous fluid. Review of the Nurse Practitioner note dated 03/27/24 documented the skin around the surgical incision was excoriated. Observation on 04/04/24 at 10:30 A.M. of Resident #42 revealed a clean dry transparent dressing with a white material laying underneath the transparent dressing dated 04/03/24 on the left abdomen and a colostomy draining brown liquid to the right abdomen. The skin around both the ostomy and the dressing were noted to be red and excoriated. Interview with Resident #42, at the time of the observation, revealed skin is excoriated from the colostomy breaking open and leaking. Resident #42 stated different bags are being used and doing better and the staff are applying a cream to the abdomen. Interview on 04/04/24 at 4:00 P.M. with the Director of Nursing verified weekly skin assessments, wound monitoring including the measurements, and appearance of Resident #42's surgical wound did not occur and further verified the last assessment of Resident #42's wound was on 02/29/24. Review of the undated policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed neglect was defined as failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the undated policy titled Wound Treatment Management, noted wound treatments are completed to promote wound healing by providing evidenced based treatments in accordance with current standards of practice and physician orders. Wound dressings will be provided in accordance with physician orders, including cleansing method, type of dressing and frequency of dressing change. Wound treatments will be documented in the treatment administration record or in the electronic health record. The effectiveness of treatments will be monitored thorough ongoing assessment of the wound. Considerations for needed modifications include lack of progression toward healing, changes in characteristics of the wound and changes in the resident's goals and preferences. Review of the undated policy titled Skin Assessment, directed full body assessments are part of the systematic approach to pressure injury prevention and management. Full body assessments, head to toe skin assessment will be conducted by a licensed nurse upon admission, re-admission, daily for three days and then weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury. Documentation of the skin assessment includes the date and time of the assessment, documentation of observations, document of wounds, description of wound including measurement, color, type of tissue in the wound bed, drainage odor, pain, and any other information as indicated and appropriate. Review of the undated policy titled Notification of Changes, directed the resident's physician should be notified promptly of any circumstance which requires a need to alter treatment, including the initiation of a new treatment, or a negative or decline in a wound presentation. This deficiency represents non-compliance investigated under Complaint Number OH00152361.

Based on medical record review, staff interviews, review of the facility investigation, review of a personnel file, review of an emergency medical services (EMS) run report, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, review of the American Heart Association Journal, review of a job description for Licensed Practical Nurses (LPNs), and review of the cardiopulmonary resuscitation (CPR) certifications, the facility failed to timely initiate CPR for one resident (Resident #05) found unresponsive, without a pulse or blood pressure, and who was identified as a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm, and/or death when Resident #05 did not receive timely CPR after she was discovered with no pulse or blood pressure. This affected one (#05) of three residents (#05, #06, #07) who expired unexpectedly at the facility. Additionally, the facility failed to ensure five [LPNs #101, #123, #134, #141, and Registered Nurse (RN) #138] of 31 nurses employed by the facility had a current CPR certification for Healthcare Providers. This placed all 39 current residents (#11, #12, #14, #15, #18, #22, #23, #24, #25, #28, #29, #31, #32, #35, #36, #38, #39, #40, #41, #44, #45, #48, #49, #52, #54, #56, #59, #60, #61, #64, #67, #70, #72, #74, #78, #80, #81, #83, and #86) designated with a Full Code resuscitation status at potential risk for more than minimal harm that is not Immediate Jeopardy. The facility census was 79. On [DATE] at 4:05 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 10:15 P.M. when Resident #05, who was a Full Code resuscitation status, was found unresponsive by State tested Nurse Aide (STNA) #113. STNA #113 notified LPN #225 of Resident #05 being unresponsive, and EMS was notified at 10:22 P.M. LPN #225 assessed Resident #05 who was absent of vital signs and was pale. LPN #225 chose to exit the memory care unit and ran down the hall yelling for assistance from other staff members, passing a crash cart on the nearest unit. LPN #226 and Registered Nurse (RN) #147 went to Resident #05's room and she was found lying on the bed alone. No other staff were in the room and life-saving measures had not been initiated. RN #147 and LPN #226 placed Resident #05 on the floor and began chest compressions and staff followed with a crash cart. Resident #05 was left alone without CPR initiated for approximately two minutes per interview with RN #147. Through investigation, it was discovered LPN #225 refused to perform chest compression on Resident #05 due to a shoulder issue; however, no such shoulder issue was noted in LPN #225's personnel file. EMS arrived at 10:31 P.M. and took over life-saving interventions. The EMS physician called the time of death at 11:09 P.M. The physician and Resident #05's family were notified of the resident's death and notified the funeral home, who picked up Resident #05 on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], LPN #225, who did not perform CPR on Resident #05, was suspended pending investigation. LPN #225 was informed she could not return to work until further notice. On [DATE], disciplinary action was taken with LPN #225 for not initiating CPR for a resident with a Full Code resuscitation status. LPN #225 was called on [DATE] by Human Resources (HR) #192, the DON, and the Administrator, with the intention of terminating employment. LPN #225 would not answer the phone or return the calls. LPN #225 then texted the facility on [DATE] after hours and resigned without notice. On [DATE], the Administrator notified Medical Director #300 of the incident. On [DATE], the DON and the Administrator reported LPN #225 to the Ohio Board of Nursing. On [DATE], the DON/Designee completed an audit of all residents that expired in the past six months to ensure that their Code Status was followed with no concerns identified. On [DATE], the DON/Designee completed an audit of all current residents and compared the advance directives to the physician order for accuracy with no concerns noted. On [DATE], the DON/Designee completed an audit of all licensed nurses to ensure CPR certifications were current. The facility identified five (LPNs #101, #123, #134, #141, and RN #138) nurses did not have current CPR certifications for Healthcare Providers as a result of the audit. On [DATE], the DON/Designee completed an audit of all current staff to ensure all are available and able to perform job duties. On [DATE], the DON/Designee completed all staff education on abuse/neglect and misappropriation. All staff were educated in person or via telephone and all education was completed on [DATE]. On [DATE], the DON/Designee completed all staff education on the importance of initiating CPR immediately on full code residents. All staff were educated in person or via telephone and all education was completed on [DATE]. On [DATE], the DON/Designee completed all staff education on the necessity of informing management in the event you cannot fully perform job duties. All staff were educated in person or via telephone and all education was completed on [DATE]. On [DATE], a Code Blue drill was conducted with no concerns identified. On [DATE], a Quality Assurance Performance Improvement (QAPI) meeting was held, and a Performance Improvement Plan (PIP) was implemented following notification of Medical Director #300 via phone by the Administrator. The Administrator, Social Service Director (SSD) #194, the DON, Minimum Data Set (MDS) Coordinator #197, Unit Manager LPN #166, Unit Manager RN #148, Unit Manager RN #136, Business Office Manager (BOM) #193, Maintenance Director (MD) #196, Admission Director (AD) #191, HR #192, Physical Therapy Director (PTD) #251, and Chief Operating Officer (COO) #500 were present for the meeting. The DON will monitor for code status compliance by interviewing licensed nurses about the facility's CPR policy and procedure, as well as requesting return demonstration of the CPR process. Compliance checks will be conducted on three nurses two times weekly for three months. The findings will be reviewed at the monthly QAPI committee meeting. The DON/Designee will audit all new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will be conducted four to five times a week for three months. The findings will be reviewed monthly at the QAPI committee meeting. The DON/Designee will perform Code Blue drills three times a month for three months and will cover all shifts. The findings will be reviewed at the monthly QAPI committee meeting. On [DATE], the medical records for Resident #06 and Resident #07, who expired unexpectedly at the facility, were reviewed and staff responded appropriately. On [DATE], between 7:15 A.M. to 12:00 P.M., interviews with LPN #108, LPN #134, LPN #141, LPN #159, STNA #109, STNA #137, STNA #150, and STNA #156 verified all were educated on the facility's abuse and neglect policy, the CPR policy and importance of initiating CPR timely, and importance of notifying the facility if unable to fully perform job duties. Interview with all staff members confirmed each possessed adequate knowledge and retention of the policies, procedures, and expectations of the education provided. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and non-compliance due to five nurses working at the facility that had expired CPR certification. Findings included: Review of Resident #05's medical record revealed an original admitted [DATE] and a readmitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, dementia, bipolar disease, and fibromyalgia. Review of a physician order dated [DATE] revealed Resident #05 had a Full Code resuscitation status. Review of Resident #05's care plan dated [DATE], revised on [DATE], revealed the resident had a Full Code resuscitation status. An intervention included to initiate CPR in the absence of a pulse. Review of a progress note dated [DATE] revealed Resident #05's code status was reviewed during a care conference and Resident #05's family wished for the resident to remain a Full Code resuscitation status at that time. Review of nursing progress notes dated [DATE] at 2:10 P.M. revealed Resident #05 was very anxious and agitated during the shift. Staff members attempted to provide redirection activities with little success. A nurse practitioner was notified and provided new orders that were implemented. At 3:36 P.M., an antianxiety medication was administered due to continued anxiousness and agitation and was noted as ineffective at 4:28 P.M. A nurse practitioner with psychiatric services was contacted and provided new orders. At 5:19 P.M., Resident #05 was administered an antipsychotic medication due to continued behaviors. At 6:15 P.M., Resident #05 was noted to continue with the same behaviors of yelling out, restlessness, and anxiousness. Resident #05 complained of being short of breath, but continuously took her nasal cannula off which supplied supplemental oxygen, and the resident was reminded several times to keep the oxygen on. Resident #05's lung sounds were clear throughout, and oxygen saturation levels were at 94 percent (%). A nurse practitioner was contacted and gave orders for a chest x-radiation (x-ray) diagnostic image and a urinalysis to be obtained. Resident #05's responsible party was made aware of the resident's behavior and the new orders. Review of a progress note dated [DATE] revealed on [DATE] Resident #05 was checked on between 9:30 P.M. and 10:00 P.M. and was last seen with her nasal cannula on watching television in bed. A nurse aide (STNA #113) noticed Resident #05 looked pale and noticed her nasal cannula was not in her nose and she was holding it in her hand. The nurse aide notified the nurse (LPN #225) of Resident #05's condition and found Resident #05 was unresponsive and vital signs were absent. The nurse told the nurse aide to contact EMS and CPR was started immediately until EMS staff arrived and took over life saving measures. Resident #05 expired at 11:09 P.M., and notifications were made to the on-call physician, unit manager, family, and funeral home. Review of the facility investigation initiated on [DATE] revealed the DON obtained a statement via an interview from LPN #225 regarding Resident #05's death who resided on the locked memory care unit. Further review of the investigation revealed LPN #225 instructed STNA #113 to call EMS. LPN #225 then left the memory care unit, running and yelling down the hall, and passed a crash cart on the nearest unit. RN #147 and LPN #226, from another unit, ran a crash cart back to the memory care unit to Resident #05's room. Chest compressions were started on Resident #05 by LPN #226 and RN #147 while LPN #225 refused to complete chest compressions. LPN #225 informed the DON she could not do chest compressions due to shoulder issues. It was determined there was no documentation in LPN #225's personnel file indicating any restrictions to performing regular or essential job duties. The investigation determined chest compressions were not immediately started on Resident #05 when she was found absent vital signs, was unresponsive, pale, and had a Full Code resuscitation status in place. Review of an EMS run report dated [DATE] revealed Resident #05 experienced cardiac arrest at 10:20:00 P.M. on [DATE]. EMS received the telephone call from the facility at 10:24:37 P.M., the call was dispatched at 10:25:20 P.M., and EMS staff were enroute to the facility at 10:27:04 P.M. EMS staff arrived at the facility at 10:29:03 P.M. and reached Resident #05 at 10:31:00 P.M. Further review of the EMS run report revealed staff indicated the last known time Resident #05 was well was at 9:30 P.M. and facility staff found Resident #05 unresponsive at 10:20 P.M. When EMS staff arrived, Resident #05 was laying on the floor with staff performing chest compressions when EMS staff took over life-saving measures. Resident #05 was noted to be pulseless, and the resident was not breathing. EMS continued with life saving measures for approximately 30 minutes and Resident #05 continued to have no heartbeat. A physician was contacted to request life-saving efforts be discontinued, and time of death was given at 11:09 P.M. Interview on [DATE] at 9:51 A.M., with the Administrator and the DON revealed on [DATE] Resident #05 was found unresponsive, and LPN #225 refused to perform CPR. LPN #225 instructed STNA #113 to call EMS and then left the unit to get assistance from other nurses. Two nurses from other units responded and began CPR. The DON was not aware how long it took the staff to respond to Resident #05 and CPR to be initiated. The DON confirmed CPR was delayed by LPN #225's refusal to begin chest compressions. Telephone interview with RN #147 on [DATE] at 1:25 P.M. revealed, on [DATE], she was assigned to the [NAME] unit of the facility, and LPN #226 was assigned to the Evergreen unit. RN #147 stated she saw LPN #225 coming down the hall and heard LPN #225 yelling for assistance on the secured memory care unit. RN #147 stated a nurse aide from [NAME] unit got the crash cart, and when the staff arrived at Resident #05's room on the memory care unit, the resident was alone in the room lying in the bed. RN #147 stated she and the nurse aide placed Resident #05 on the floor and began CPR while STNA #113 was on the telephone with EMS. RN #147 stated LPN #225 stood in the doorway of the room and refused to assist with CPR. RN #147 estimated it took the staff two minutes to reach Resident #05's room after being alerted of the incident. Review of STNA #113's written statement, obtained through interview with the DON, dated [DATE] revealed STNA #113 entered Resident #05's room and noticed the resident looked very pale. STNA #113 and LPN #225 both could not get Resident #05 to respond to them, so LPN #225 told STNA #113 to call EMS. STNA #113 indicated LPN #225 then left the memory care unit and would be heard yelling for help. Two different nurses returned to the memory care unit and began life-saving measures on Resident #05 while LPN #225 left the unit to talk to EMS and let them in the door. Review of LPN #225's personnel file revealed a hire date of [DATE]. Further review revealed LPN #225 had a current basic life support (BLS) certification on file with an expiration date of [DATE]. There was no documentation in LPN #225's personnel file related to work restrictions or changes to job duties because of shoulder issues. Review of a disciplinary action document dated [DATE] revealed LPN #225 was terminated based on the facility policy to begin procedures for a resident that was in need of medical attention right away, as being charge nurse of a whole unit. Further review revealed a resident (#05) was unresponsive on the memory care unit where LPN #225 was the charge nurse. LPN #225 instructed STNA #113 to call EMS, but LPN #225 left the unit yelling and calling for help while passing a crash cart on the nearest unit. A crash cart was taken to the memory care unit and two different staff members began chest compressions while LPN #225 refused to perform chest compressions citing shoulder issues. There was nothing in LPN #225's personnel file indicting any job restrictions preventing LPN #225 from performing essential job duties. LPN #225 was noted to be BLS certified, and the facility determined LPN #225 did not immediately start chest compressions on Resident #05. Review of the facility policy titled, Cardiopulmonary Resuscitation, revised [DATE], revealed it is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding CPR. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to arrival of emergency medical services, and in accordance with the resident's advance directives. CPR certified staff will be available at all times. Staff will maintain current CPR certification for healthcare providers through CPR provided who evaluates proper technique through in-person demonstration of skills. CPR certification which included an online knowledge component yet still requires in-person demonstrations to obtain certification or recertification is also acceptable. Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.970905, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. 2. Review of the documentation provided by the facility revealed 31 nurses were currently employed by the facility. Of those 31 nurses, four LPNs (#101, #123, #134, #141) and one RN (#138) had expired CPR certification for Healthcare Providers. Interview on [DATE] at 12:54 P.M., with the DON verified five facility-employed nurses (LPNs #101, #123, #134, #141, and RN #138) had expired CPR certification. Review of the undated facility job description for Licensed Practical Nurses (LPNs) revealed LPNs must identify resident problems and emergency situation and initiate emergency care and lifesaving measures in the absence of a physician. This deficiency represents non-compliance investigated under Master Complaint Number OH00151169.

Based on medical record review, Self-Reported Incident review, hospital record review, staff interview, and policy review, the facility failed to prevent an incident of resident-to-resident abuse with injury. This resulted in actual harm when Resident #23 was found on top of Resident #12, punching him and bit the tip of Resident #12's finger off. Subsequently, requiring Resident #12 to have surgical interventions to reattach the fingertip, pain medication and antibiotic therapy. This affected one (Resident #12) of three resident reviewed for potential abuse. The facility census was 92. Findings included: Review of Self-Reported Incident Number 229152 dated 09/14/23 revealed both patients (Resident #12 and Resident #23) were roommates and resided in the memory care unit. Both were in their room that morning. A nurse aid heard a bang sound and walked into their room to find Resident #23 sitting on top of Resident #12. Resident #23 had noticeably bitten Resident #12's right pinkie finger tip off. The nurse removed Resident #23 from the room. The nurse called 911 and administered care to Resident #12. Resident #12 could not provide meaningful information about what happened. Resident #23 declared that when he went to the bathroom and came out it was black, and he had no memory of the incident. Resident #12 was taken to hospital. Resident #23 was taken to hospital and returned later this day with a care plan. The families and physician were notified for both patients. Resident #23 will not be returned to this unit. Resident #12 was monitored for pain and emotional distress but did not show any at that time. Review of Resident #23's medical record revealed an admitted [DATE], diagnoses including dementia, mild behavioral disturbances, and atrial fibrillation. Resident #23 had resided on the memory care unit. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a low cognitive function. No negative behaviors were identified. Review of Resident #23's care plan dated 07/19/22 revealed the resident was at risk for having the potential to be physically aggressive related to dementia and poor impulse control. Interventions included: to intervene before agitation escalated, guide away from the source of distress, and to engage calmly in conversation; if the response was aggressive staff were to walk calmly away and approach later. Review of Resident #23's progress note dated 09/14/23 at 8:33 A.M., revealed the nurse observed Resident #23 on top of roommate (Resident #12), punching him. Resident #23 had roommate's (Resident #12) tip of the finger in Resident #23's mouth. Resident #12's (fingertip) was chewed and bit off. The nurse immediately pulled the residents apart and notified EMS/Police while assessing the roommate's injury. All management team, physician and emergency contacts were notified of the incident. Resident #23 was sent to the emergency room for evaluation and treatment. Review of Resident #23's emergency room record dated 09/14/23 revealed the resident arrived from the nursing home with a report that he bit off a roommate's finger. The resident would not speak for the Registered Nurse but spoke for the officer at his bedside. The resident was noted with blood on his clothing, his beard, and the left side of his face. The final diagnosis was aggressive behavior due to dementia. Review of Resident #12's medical record revealed an admitted [DATE], with diagnoses including: dementia and atrial fibrillation. Resident #12 resided on the memory care unit. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed the resident had a high cognitive function. He was not documented as having any negative behavior. Review of Resident #12's care plan dated 10/17/22 revealed the resident had the potential to be physically aggressive. Resident #12 asserted male dominance in situations with other male residents due to anger, dementia, and depression. Interventions included: to de-escalate by redirecting with activities. Review of Resident #12's progress note dated 09/14/23 at 8:17 A.M., revealed the resident-to-resident altercation occurred at 5:55 A.M. The nurse found Resident #12 to be a victim of physical aggression by roommate (Resident #23). The nurse was able to get the roommate off the resident, but noticed the resident's fingertip was in their roommate's mouth. The nurse immediately put pressure on the resident's wound and called emergency medical services (EMS) and police. All management personnel were notified. The physician and resident's daughter were notified of the incident. Resident #12 was sent to the emergency room for evaluation and treatment. Review of Resident #12's emergency room hospital note dated 09/14/23 revealed Resident #12 arrived at the hospital via EMS with the tip of his finger bitten off. Resident #12's final diagnosis was: bite wound to finger and open displaced fracture of the distal phalanx of right little finger. Prescriptions for pain medications and antibiotic therapy were provided. Review of Resident #12's progress note dated 09/21/23 at 6:14 P.M., revealed Resident #12 had an appointment today with plastic surgeon regarding resident having surgery on pinky finger. Resident #12's daughter transported the resident to the appointment. Resident #12 is back at the facility in a pleasant mood, no complaints of or signs and symptoms of pain at the present time, resident remains on antibiotic therapy and temperature of 98.4 degrees Fahrenheit. Review of Resident #12's progress note dated 09/21/23 11:54 P.M., revealed the resident had an appointment today with plastic surgeon regarding resident having surgery to necrotic finger. Resident #12 complained of pain and was given (narcotic pain medication) and the finger was wrapped to give cushioning and support. Resident continues on antibiotics and is afebrile (without temperature). Review of Resident #12's progress note dated 09/26/23 at 2:47 P.M., revealed the resident went with daughter. Resident #12 has no present complaints of or signs and symptoms of pain or distress. Resident #12 has been given additional as needed over the counter pain medications for 7 day. Interview on 10/06/23 at 7:32 A.M., with the Director of Nursing (DON) revealed after the incident on 09/14/23, Resident #23 stated he blacked out for a minutes then when he awoke, he realized that he bit off Resident #12's finger. Residents #12 and #23 were roommates for a long time and had done well together. Resident #12's finger was reattached but didn't heal well and the fingertip may have to be removed. Resident #12 continues to go to surgical follow up appointments and was forgetful as to what happened to his finger. Interview on 10/06/23 at 11:16 A.M., with the Administrator revealed Residents #12 and #23 were roommates for a long time and had no issues. Resident #23 informed the Administrator that he was remorseful for injuring Resident #12. Review of the undated policy titled Abuse, Neglect and Exploitation revealed the facility was to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This deficiency represents non-compliance investigated under Complaint Number OH00146662.

Based on medical record review, observation, resident interviews, staff interviews, community member interviews, review of the facility's Self-Reported Incident (SRI), review of the facility's investigations, review of a police incident detail report, review of maintenance exit door operation tests, and review of facility polices regarding elopement, wandering residents, and resident alarms, the facility failed to provide adequate supervision for Resident #10, who was at risk for wandering and had a history of wandering/elopement. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #10 eloped from the facility, without staff knowledge, and the facility staff failed to respond appropriately. The lack of adequate supervision and timely response to interventions resulted in Resident #10 leaving the facility through an alarmed door, and by the time staff responded to the alarm, Resident #10 had crossed a two-lane road and was picked up in a vehicle by a neighbor of the facility approximately one-tenth of a mile, north of the facility. This affected one (Resident #10) of three residents reviewed for elopement. The facility's census was 86. On [DATE] at 4:05 P.M., the Administrator and Director of Nursing (DON) #407 were notified Immediate Jeopardy began on [DATE] at 10:57 A.M. when Resident #10 was not located on the secured unit of the facility and staff discovered Resident #10 had eloped from the facility. Resident #10 was found by a neighbor of the facility walking north on a two-lane road on the opposite side of where the facility was located. The weather was overcast with intermittent rain and the road pavement and grass on either side of the road was wet and covered with wet fallen tree leaves. Resident #10 previously eloped from the facility on [DATE] due to a visitor letting him out unbeknownst to staff members, and interventions were put into place to prevent future potential elopements at that time. Resident #10 was able to elope a second time on [DATE] through an alarmed exit door that was equipped with a 15-second delayed egress locking mechanism (the door alarms and remains locked for 15 seconds after pressure is applied to the door in the path of egress) without staff intervention. The Immediate Jeopardy was removed on [DATE] at 11:14 A.M., when the facility implemented the following corrective actions: On [DATE], Resident #10 returned to the facility and was assessed with no injuries, pain, or change in condition, and vital signs were within normal limits. Resident #10 was placed on every 15-minute observations until one-to-one observations were initiated on [DATE] at 12:00 P.M. Resident #10's one-to-one observation would be performed by nurses and nurse aides and would continue until [DATE], at which time Resident #10 would be re-assessed to determine appropriateness for continued one-to-one observation. Resident #10's observation level status would continue to be reviewed daily until [DATE] and bi-weekly thereafter until Resident #10's discharge from the facility. Observation on [DATE] at 11:10 A.M., revealed Licensed Practical Nurse (LPN) #409 was on a direct one-to-one observation with Resident #10 in his bedroom. On [DATE], Resident #10 was re-assessed for wandering and was assessed at high risk. On [DATE], the facility initiated an SRI and investigation related to Resident #10's elopement on [DATE]. On [DATE] at 2:00 P.M., all 11 exit doors of the facility were tested by Maintenance Director #342 for the operation of the doors, locks, and alarms with no concerns identified. Maintenance Director #342 tested all 11 exit doors again on [DATE] at 8:00 A.M. with no concerns identified. The facility would continue to test the operation of all 11 exit doors five times weekly for two weeks. On [DATE], the facility conducted an elopement drill to assess staff response to resident elopement. The drill was conducted by DON #407 with 10 staff members participating in the drill. There were no concerns identified during the elopement drill. The facility would conduct elopement drills weekly for one month and findings would be discussed during the next Quality Assurance and Performance Improvement (QAPI) meeting scheduled for [DATE]. On [DATE], all nine residents (#01, #04, #08, #10, #26, #35, #59, #63, and #81) the facility identified as at risk for elopement, had their elopement and wandering care plans reviewed and revised by Regional Minimum Data Set (MDS) Coordinator #416. The audit was to ensure all at risk residents had appropriate interventions in place to prevent elopement from the facility. On [DATE], the facility held a QAPI meeting with all department heads, managers, the Administrator, and the Medical Director to discuss root cause analysis of Resident #10's elopement, review the admission process for respite stay residents, and discuss the facility's resident elopement, wandering, and resident alarms policies. On [DATE], the Administrator compiled education materials regarding resident elopement, wandering, and resident alarms. On [DATE], the Administrator, DON #407, Director of Dietary Services #386, Admissions Assistant #356, Therapy Director #333, LPN Unit Manager #398, and LPN Unit Manager #411 educated a total of 115 staff members on the policies and procedures of the facility related to resident elopement, wandering residents, and response to resident alarms. All staff members were educated in person, by telephone, or by electronic media by [DATE]. The facility leadership would conduct audits two times weekly for four weeks to assess staff knowledge of the education provided. The results would be discussed in the next QAPI meeting scheduled on [DATE]. On [DATE], review of the medical records for Resident #04 and Resident #63 revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. On [DATE], between 10:53 A.M. and 11:14 A.M., four nurses (LPN #317, LPN #397, Registered Nurse (RN) #369, LPN #409) and three State tested Nurse aides (STNAs) (STNA #379, STNA #349, STNA #353) verified they were educated on resident elopement and wandering as well as responding to resident alarms. All staff members interviewed were knowledgeable of the content of each education provided by the facility. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #10's medical record revealed an admitted [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, diabetes mellitus type II, mild cognitive impairment, [CONDITION(S)], and essential hypertension. Review of an admission referral sent to the facility via facsimile (fax) on [DATE] revealed the referring agency talked to Resident #10's family member and indicated during the recent hurricane in the southern part of the United States, Resident #10 and his family lost their home and relocated to the state where the facility resided until their home could be fixed, which could take between three to six months. Resident #10's family member indicated Resident #10 had dementia and would get restless daily around 4:00 P.M., tried to leave the house, and needed to always have someone with him because he was an elopement risk. Resident #10's family member stated Resident #10 had respite services in the southern state and would like to have a respite stay in the state where the facility was located as well so Resident #10's wife could run errands as needed. Resident #10's family member indicated Resident #10 was independent with activities of daily living (ADLs). Review of an admission nursing assessment dated [DATE] revealed Resident #10 was admitted to the facility for a respite stay. Resident #10 was alert and oriented to person and situation but not time or place. Resident #10 was confused and exhibited short term memory problems. Resident #10 was assessed with a normal gait and no abnormalities were identified during the physician assessment. Resident #10 was assessed as independent with bed mobility, transfers, walking, and locomotion with no assistive devices required. Review of a wandering risk scale assessment completed [DATE], revealed Resident #10 was able to follow instructions, was ambulatory, could communicate, had a history of wandering, and a medical diagnosis of dementia or cognitive impairment. Resident #10 was assessed at high risk for wandering based on the results of the assessment. Review of the resident census data, from the electronic medical record, dated [DATE], revealed Resident #10 was admitted to the secure unit of the facility. Review of the comprehensive care plan initiated on [DATE], and revised on [DATE], revealed Resident #10 was an elopement risk and wanderer related to impaired safety awareness, disorientation to surroundings, history of attempts to leave the facility unattended and aimless wandering. The facility implemented interventions including to distract Resident #10 from wandering by offering pleasant diversions and structured activities, monitor Resident #10 for fatigue, and identify patterns of wandering and intervene as needed. Review of a nursing progress note dated [DATE] at 8:20 P.M. revealed a nurse administered medications to Resident #10 at approximately 8:00 P.M. and at approximately 8:20 P.M. a nurse aide approached the nurse who was concerned about the whereabouts of Resident #10. There were no exit doors alarming at that time. The secured unit was searched, as well as the entire interior and exterior grounds of the facility and Resident #10 was not located. The nurse contacted emergency services to report a missing person and contacted the facility administration. Resident #10 was located by local law enforcement and the police officers indicated they received a call of a man walking the ramp of the highway. The nurse met the police officers and transported Resident #10 back to the facility at approximately 9:00 P.M. Resident #10 was pleasantly confused, was assessed with no injuries, and was in no distress. Review of a police incident detail report dated [DATE] revealed a call was received on [DATE] at 8:35:04 P.M. of a missing person (Resident #10) and a physical description was provided. The police incident detail report lacked specific information and details about where and when Resident #10 was found or how Resident #10 returned to the facility. The incident was logged as closed on [DATE] at 8:58:00 P.M. Review of a skin assessment completed [DATE] revealed Resident #10 had no skin impairments. Review of a nursing progress note dated [DATE] revealed the on-call nurse practitioner and Resident #10's family were notified of the elopement. The maintenance department arrived at the facility to check the function of all door alarms. Resident #10 was placed on every 15-minute observations and a WanderGuard (an alarming devise worn by a person that triggers alarms and can lock monitored doors to prevent the person from leaving unattended) was placed on Resident #10's ankle. Review of an updated wandering risk scale assessment completed [DATE] revealed Resident #10 remained at high risk for wandering. Review of an SRI dated [DATE], revealed Resident #10 eloped from the facility on [DATE] at approximately 8:20 P.M. Resident #10 was found by local police and returned to the facility on [DATE] at approximately 9:00 P.M. with no injuries or change in condition. The maintenance department checked all exit doors on [DATE] and all locks and alarms were working appropriately. The facility began education with staff about resident elopement and procedures for incidents of elopement at that time. Resident #10 also had a WanderGuard placed to his right ankle and was placed on every 15-minute observations. Review of a written statement dated [DATE] from Resident #82 revealed on [DATE] she saw two men, one of the men was carrying a suitcase, and walked past her bedroom around the time of the incident on [DATE]. Review of a written statement from a visitor indicated he visited his girlfriend (Resident #23) on [DATE] on the secured unit. The visitor indicated he was approached by a man at the exit door, and they began a conversation with each other. The visitor indicated the man was clean cut, oriented to himself, and had a normal conversation with him. The visitor asked the man where he was going, and the man indicated he was leaving to go to another part of the state to see his daughter. The visitor indicated at the time the man had a suitcase in his hand. The visitor stated he entered the code to exit the door from the secured unit and he and the man exited together, continued talking while in the hallway, and again put in the door code in the main lobby, and he and the man exited together. The visitor indicated when he got to his car to leave, he looked back and did not see the man, so he thought he had gotten into his car and left. The visitor was not aware the man he talked to on [DATE] was a resident of the facility, admitted to the secured unit, and the man was Resident #10. Further review of the SRI dated [DATE] revealed the visitor who let Resident #10 out of the facility was educated on not allowing any person he did not know to exit any secured areas or outside the facility. The facility placed signs at the exit doors from the secured unit alerting visitors and staff to not allow anyone they do not know off the secured unit. The SRI was closed on [DATE] and was unsubstantiated. Review of a nursing progress note dated [DATE] revealed a maintenance staff member arrived at the facility on [DATE] at approximately 9:30 P.M. to check the function of the door alarms. Review of a maintenance door lock and alarm operations test revealed all exit doors and alarms were tested in the facility on [DATE] with no concerns identified. Review of a physician order dated [DATE] revealed a WanderGuard was placed on Resident #10's right ankle with instructions for staff to check placement, function, and skin integrity every shift. Review of Resident #10's elopement care plan revealed an intervention was added on [DATE] to include the use of a WanderGuard. Review of the [DATE] Medication Administration Record (MAR) revealed Resident #10's WanderGuard placement, function, and skin integrity were monitored every shift as ordered with no concerns identified. Review of a nursing progress note dated [DATE] revealed Resident #10 was alert to self, walked independently, and was exit seeking throughout the day. Resident #10 was pleasantly confused and easily redirected. Resident #10 continued every 15-minute observations and was accounted for the entire shift. Review of a nursing progress note dated [DATE] revealed Resident #10 was observed opening the east emergency exit door on the unit. The door alarm sounded, Resident #10 closed the door, and Resident #10 did not exit the facility. Resident #10 was encouraged not to tamper with the emergency exit doors and was redirected to his room without further incident. Resident #10's WanderGuard remained in place. Review of a nursing progress note dated [DATE] revealed Resident #10 was exit seeking throughout the shift but was easily redirected. Review of a nursing progress note dated [DATE] revealed Resident #10 opened the east emergency exit door and was fully dressed in a coat and had luggage. Resident #10 immediately closed the door once the alarm sounded. Resident #10's WanderGuard remained in place on his right ankle, and he was easily redirected. Review of a nursing progress note dated [DATE] revealed Resident #10 showed signs of agitation related to his WanderGuard and indicated he was going to cut it off. Resident #10 was encouraged not to tamper with the WanderGuard and educated that it was for his safety. Resident #10 was easily redirected and the WanderGuard remained in place to the right ankle. Interview on [DATE] at 8:33 A.M. with the Administrator revealed he was notified on [DATE] at approximately 8:30 A.M. of Resident #10's elopement from the facility. The Administrator stated the facility initiated a search and contacted the local police who found Resident #10 in the community. Resident #10 returned to the facility unharmed on [DATE] at approximately 9:00 P.M. The Administrator stated he was not sure of the exact location where Resident #10 was found, but that he was unaccounted for in the facility for approximately 40 minutes. The Administrator verified he initiated an investigation and opened an SRI. Through the investigation it was discovered a frequent visitor to the secured unit engaged in conversation with Resident #10 on [DATE]. The Administrator stated the visitor comes almost daily to visit Resident #23 and was given the code to the secured unit because of the frequency of his visitations and the time he usually visited was after work between 7:30 P.M. and 8:00 P.M. The visitor admitted to putting in the code to the secured doors and the main lobby exit door while walking and talking with Resident #10. The Administrator stated the visitor had no idea who Resident #10 was and mistook him for another visitor. The Administrator stated the visitor was educated about not letting people he did not know off the secured unit and signs were placed on the door indicating staff and visitors should not allow anyone they did not know out of the secured unit. The Administrator stated they closed the investigation and Resident #10 had no further elopements. A telephone interview was completed on [DATE] at 9:33 A.M. with STNA #353, who verified she was working on the secured unit on [DATE] when Resident #10 eloped. STNA #353 stated she last saw Resident #10 standing at the nurses' station around 8:00 P.M. and the nurse was administering his medications. STNA #353 stated she went into another resident's room to perform care and came out around 8:20 P.M. and did not see Resident #10. STNA #353 stated she checked Resident #10's bedroom and the entire unit but could not locate him. STNA #353 reported there were no alarms sounding at that time and there were no doors or windows open. STNA #353 stated she informed the nurse she could not find Resident #10 and they alerted the other facility staff and began a search. STNA #353 stated the nurse left the facility in her car and drove around looking for Resident #10 and she stayed on the unit with the residents. STNA #353 stated Resident #10 returned to the secured unit with the nurse and was not injured, in pain, or in distress. STNA #353 stated Resident #10 was dressed appropriately with shoes, a sweatshirt, and blue jeans. STNA #353 did not know where Resident #10 was found, and reported he was placed on every 15-minute observations and the nurse put a WanderGuard on him. STNA #353 verified there was a visitor on the unit prior to Resident #10's elopement who she identified as the visitor who visited Resident #23 frequently. STNA #353 stated she did not see Resident #10, or the visitor leave the unit so she could not say how they left the unit. A telephone interview was completed on [DATE] at 9:45 A.M. with LPN #332 who verified she was the nurse working on the secured unit on [DATE] when Resident #10 eloped. LPN #332 stated she started her shift on [DATE] at 7:00 P.M. and verified STNA #353 was the only other staff member working the secured unit at that time. LPN #332 stated [DATE] was the first time she had any interaction with Resident #10 and stated around 8:00 P.M. he was given his medications and he took them without issues. LPN #332 stated Resident #10 was one of the first residents she gave medications to that evening, so she continued with her medication administration to the rest of the residents on the secured unit. LPN #332 stated he was in and out of resident rooms giving them their medications when around 8:20 P.M., STNA #353 approached her and stated she could not locate Resident #10. LPN #332 stated she and STNA #353 did a search of the secured unit and could not find Resident #10, and no door alarms were sounding, and all doors and windows were closed. LPN #332 stated she informed the other staff in the building, called the director of nursing, and called emergency services to report a missing person. LPN #332 stated other staff members were looking inside the facility and outside the facility grounds, so she got into her car and drove the surrounding streets to look for Resident #10. LPN #332 stated she stopped at a nearby gas station and the attendant indicated they did not see anyone walking by, so she continued to the next gas station. LPN #332 stated at that time she received a call from emergency services who indicated they received a report of an elderly man walking on the road. The local police had Resident #10 and were not willing to take him to the facility but could meet LPN #332 in a parking lot to receive Resident #10. LPN #10 stated she was not familiar with the area and could not remember the exact location where she picked Resident #10 up from the police. LPN #332 could only remember it was the parking lot of a business but had no other information. LPN #332 stated Resident #10 was free from injuries, expressed no pain, was properly dressed, and was not in distress when she picked him up. Resident #10 returned to the facility without incident, and she received an order for a WanderGuard and every 15-minute checks for 24 hours. LPN #332 stated a maintenance staff member came to the facility on [DATE] to check all the doors and windows and found no concerns. LPN #332 stated she did not see how Resident #10 left the secured unit, but verified a visitor was on the unit visiting Resident #23 around the time Resident #10 was missing. Interview on [DATE] at 10:09 A.M. with Resident #82 confirmed she saw two older males walking past her room on [DATE] and one of them had a suitcase. Resident #82 stated the two men were talking and they were heading toward the exit doors in the main lobby. Resident #82 stated she did not recognize either male and did not hear any door alarms or commotion at that time. Resident #82 stated it was not until the facility started to look in resident rooms for Resident #10 that she realized one of the men she saw walking in the hallway was Resident #10. Resident #82 stated, later in the night on [DATE], she saw the man with the suitcase in the hallway again with staff and realized at that time it was the resident the facility was looking for. Interview on [DATE] at 10:46 A.M. with Maintenance Director (MD) #342 stated as part of the facility's routine testing and maintenance, all exit doors are tested for operation of locking mechanisms and alarms weekly. MD #342 stated there were no issues with any of the exit door alarms or locks during his previous monthly checks. MD #342 verified he was contacted on [DATE] around 8:50 P.M. by the Administrator to come to the facility to check and test the exit doors in the facility because a resident eloped. MD #342 stated he arrived at the facility on [DATE] at approximately 9:15 P.M. and began checking exit door locks and alarms and found no concerns. MD #342 stated all doors were locking, releasing, and alarming appropriately with no evidence any of the doors were tampered with. MD #342 reported he also checked every window on the secured unit to ensure there were no issues with them, and verified all windows and screens were in place with no evidence of anyone exiting through a window. Observation on [DATE] at 10:58 A.M. with MD #342 revealed upon entrance to the secured unit, the unit was configured in an L shape with the north hallway directly ahead and the east hall directly to the right and a nurses' station located in the elbow of the L. There were no alarms sounding upon entrance to the secured unit. MD #342 first tested the secured doors from inside the secured unit, and when tested , an audible alarm sounded, and did not open or stop alarming until a code was inputted into the keypad. MD #342 then tested the emergency exit door at the end of the north hall. The door alarmed once pressure was applied and remained locked while continuing to alarm for 15 seconds at which time the door opened but continued to alarm. MD #342 closed the door and inputted the code on the keypad to silence the alarm and re-engage the lock. MD #342 then stopped in the activity room on the north hall and duplicated how he checked the windows on [DATE]. MD #342 opened the window in the activity room which slid horizontally from right to left but only opened approximately five inches. MD #342 then proceeded past the nurses' station toward the dining room where the door was tested that lead to an enclosed courtyard with a tall vinyl fence with a gait on the north side of the exterior of the building, completing the perimeter on the west, east, and south side. MD #342 tested the door and it alarmed, remained locked, and released in 15 seconds while continuing to alarm with no issues. MD #342 again demonstrated the testing of a window in the dining room and, just as before, the window only opened approximately five inches. The last door tested was the emergency exit door on the east hall of the secured unit. The east emergency exit was equipped with a window and the facility parking lot and public street could be viewed from that location. MD #342 tested the east emergency exit door and when pressure was applied, the door began alarming and remained locked for 15 seconds. After 15 seconds, the door locks released, and the door opened while the alarm continued to sound. MD #342 inputted a code into the keycode to silence the door alarm and re-engage the locking mechanism. All doors and locks tested on the secured unit were working appropriately during all observations. At this time, three staff members were observed through the window of the east emergency exit door and they were standing by the public street, one of which was the Administrator on a cellular telephone. At approximately 11:00 A.M. on [DATE], this surveyor remained on the secured unit and approached Resident #10's bedroom in hopes to interview the resident. Observation inside Resident #10's bedroom at that time revealed Resident #10 was not in his room. Upon exit from Resident #10's bedroom, LPN Unit Manager #398 was observed with concerned eyes and a reddened face and was walking quickly to the nurses' station. Interview on [DATE] at 11:03 A.M. with LPN Unit Manager #398 revealed Resident #10 was unaccounted for and the facility was initiating a missing person alert. Observation on [DATE] at approximately 11:03 A.M. revealed facility staff began head counts of residents on the secured unit to ensure no other residents were missing. Observation of Resident #10's bedroom on [DATE] between 11:05 A.M. and 11:10 A.M. revealed the exterior window was closed and the screen was in place. Resident #10's WanderGuard was nowhere to be found. Interview on [DATE] at 11:12 A.M. with Activities Staff #362 revealed she was assisting with the head count on the secured unit and Resident #10 was not located. Activities Staff #362 stated the last time she saw Resident #10 was approximately 9:30 A.M. at the nurses' station. Interview on [DATE] at 11:14 A.M. with the Administrator revealed Resident #10 got out of the facility, flagged down a car on the street, and got in. The Administrator stated the local fire department had Resident #10 and was bringing him back to the facility. Interview on [DATE] at 11:17 A.M. with Admission Assistant #356 stated she was not on the unit when Resident #10 eloped and was only assisting with monitoring the residents on the secured unit during the facility search. Admissions Assistant #356 verified she did not know of Resident #10's whereabouts. Observation on [DATE] at 11:20 A.M. revealed Resident #10 walking in the hallway toward the secured care unit with staff members. Resident #10 was appropriately dressed, was wearing shoes, and had a plastic grocery bag in his hand. Resident #10 was ambulating independently, was talking with staff in a pleasant manner, and was free from any apparent distress or pain. Once Resident #10 walked through the entrance of the secured unit, the door alarm began alarming, indicating the WanderGuard was in place. The facility staff escorted Resident #10 to his bedroom on the secured unit at that time. Interview on [DATE] at 11:21 A.M. with the Administrator revealed the person who picked Resident #10 up from the street was in the facility and could be interviewed at that time. This surveyor informed the Administrator it was necessary to remain with Resident #10 to ensure Resident #10's safety, but to inquire with the person about contact information and details surrounding the incident. Observation on [DATE] at 11:22 A.M. revealed Resident #10 sitting in his reclining chair in his bedroom. Resident #10 remained pleasant and was free from distress, pain, and apparent injuries. Further observation with Therapy Director #333 verified Resident #10 had a WanderGuard on his right ankle. Observation on [DATE] at 11:23 A.M. revealed Regional MDS Coordinator #416 assessed Resident #10's physical body and asked general questions about his health. Resident #10 was observed to have no injuries, no pain, no range of motion concerns, and was in no distress. At 11:24 A.M., Regional MDS Coordinator #416 confirmed Resident #10 had no abnormal findings. At 11:25 A.M., LPN #343 entered Resident #10's bedroom to obtain his vital signs with no abnormal findings noted. Interview on [DATE] at 11:25 A.M. with Resident #10 stated he was ready to go home, so he went out of his condominium (condo), went out to the street, and hitch-hiked. Resident #10 motioned by placing his thumb in the air and moving his arm and hand up and down when mentioning hitch-hiking. Resident #10 was asked twice how he was able to get out of the facility and Resident #10 kept replying he did not understand the question. Interview on [DATE] at 11:39 A.M. with the Administrator revealed he obtained the contact information for the person that picked Resident #10 up from the road. The Administrator stated the person was a neighbor of the facility and lived approximately four houses north of the facility. The Administrator stated the neighbor told him he saw an elderly man outside his house and could tell he was confused, so he picked him up in his vehicle. A telephone interview was completed on [DATE] at 11:42 A.M. with Neighbor #415 who verified he picked Resident #10 up from the public street on [DATE]. Neighbor #415 stated he could not remember exact times, but he was at his house, which was located on the same side of the road as the facility approximately three to four houses to the north. Neighbor #415 stated he could see a well-dressed elderly man that he did not recognize on the opposite side of the road putting his thumb in the air and trying to hitch-hike. Neighbor #415 stated it was raining out and cars kept going past Resident #10 and not stopping, so he got up, put his shoes on, got in his car, and drove to see if Resident #10 needed assistance. Neighbor #415 stated when he stopped and talked to Resident #10, he asked where he was heading, and Resident #10 gave the name of the city the facility was located. Neighbor #415 responded that if Resident #10 kept walking in the direction he was heading, he would end up in the state to the north, that boarded the state the facility was located in. Neighbor #415 stated he then let Resident #10 into his vehicle and asked him what part of the town Resident #10 was heading to, in which Resident #10 only stated North End. Neighbor #415 stated at that time, he could tell R[TRUNCATED]

Based on medical record review, observation, staff and resident interview, review of a facility-reported incident (FRI), review of an employee written statement, and review of a facility policy the facility failed to prevent staff to resident physical abuse which resulted in actual harm when a resident was forced onto his bed which caused bruising and psychosocial distress. This affected one (#1) of three residents reviewed for abuse. The census was 84. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had short and long term memory problems. Review of a nursing progress note dated 07/22/18 revealed Resident #1 displayed aggressive behaviors toward staff and other residents, grabbing at them, was argumentative, and difficult to redirect. Review of an FRI dated 07/22/18 revealed the facility was alerted to an incident involving Resident #1 and a Registered Nurse (RN) supervisor. The FRI revealed the nurse on the secured unit called the RN supervisor to assist in re-directing Resident #1. Another resident approached Resident #1 and to avoid an altercation, the RN supervisor hugged Resident #1, picked him up, and laid him down in his bed in his room. The staff continued to monitor Resident #1, an assessment was completed with no findings, and the social worker interviewed Resident #1 who expressed no concerns. The facility unsubstantiated abuse. Review of a nursing progress note dated 07/22/18 revealed a nurse was told of the alleged abuse on the secured unit and was asked to perform an assessment of Resident #1. During the assessment, the nurse noted several small bruises to Resident #1's bilateral upper extremities that were not present on 07/20/18 when Resident #1 had fallen and his skin was assessed by the same nurse. Review of a hand written statement dated 07/22/18 completed by STNA #20 revealed RN Supervisor #50 picked Resident #1 up from behind, lifted him off his feet, and slammed Resident #1 onto the bed. STNA #20 wrote Resident #1 was screaming, crying, shaking, and visibly upset. Interview on 07/31/18 at 9:50 A.M. with Licensed Practical Nurse (LPN) #10 stated she was not in the facility when the incident occurred but was asked to perform an assessment of Resident #1's skin on 07/22/18. LPN #10 verified Resident #1 had bruises on his arms that were not present the last time she worked with him, and LPN #10 verified she did not know where the bruises came from. LPN #10 stated on 07/22/18 she asked Resident #1 about the incident. Per LPN #10, Resident #1 told her a tall man threw him on the bed, yelled at him, and he was scared. LPN #10 stated Resident #1 kept repeating he did not do anything wrong and he seemed scared and apprehensive. Interview on 07/31/18 at 10:04 A.M. with Resident #1, with LPN #10 present, revealed he no longer had recollection of the incident when questioned. Observation of Resident #1's arms with LPN #10 at this time revealed bruises on both arms which LPN #10 identified were present on 07/22/18 during her assessment, but were not present after Resident #1's fall on 07/20/18. Interview on 07/31/18 at 2:22 P.M. with State tested Nurses Aide (STNA) #20 stated she was working on the secured unit with Resident #1 when the incident occurred on 07/22/18. STNA #20 stated Resident #1 was agitated and the nurse on the secured unit was trying to make him lay down and was getting mad when Resident #1 would not lay down. STNA #20 stated the nurse went and got the supervisor working that night (RN Supervisor #50) and confronted Resident #1 stating he was not going to be have Resident #1 up all night. RN Supervisor #50 bear hugged Resident #1 lifting him off his feet and was heading toward Resident #1's bedroom. STNA #20 stated she followed RN Supervisor #50 into the room, continually telling him he did not have to handle the situation like he was doing and trying to get him to stop. STNA #20 stated once in the room RN Supervisor #50 slammed Resident #1 down hard onto his bed, told him to lay there and not get up, and slammed the bedroom door behind him. STNA #20 stated Resident #1 was shaking and crying so she stayed with him. STNA #20 stated she worked the next night and Resident #1 would not come out of his room, he would just open his door to peek into the hallway. STNA #20 stated Resident #1 would not let staff do anything for him, was complaining of back pain, and was walking with a limp. STNA #20 verified only herself, the nurse, RN Supervisor #50, and another STNA were on the unit when the incident occurred, and verified only herself and RN Supervisor #50 were in the bedroom when Resident #1 was slammed onto the bed. STNA #20 verified she gave a written statement to the Administrator. Interview on 07/31/18 at 2:42 P.M. with STNA #30 stated she was not present when the incident occurred, but was on the secured unit shortly after it happened. STNA #30 stated she went to the secured unit because she heard what happened and stated when she saw Resident #1 he was shaking and crying in his room. STNA #30 stated she told a nurse the incident had to be reported immediately as abuse. Telephone interviews were attempted on 07/31/18 with RN Supervisor #50 at 10:46 A.M., 11:44 A.M., and 2:04 P.M.; to the nurse working the secured unit during the incident at 10:55 A.M., 12:47 P.M., and 2:08 P.M., and the other STNA working during the incident at 10:54 A.M., 11:46 A.M., 1:00 P.M., and 2:07 P.M. with no answer received. Interview on 07/31/18 at 2:51 P.M. with Human Resource Director #1 verified RN Supervisor #50 and the nurse working the secured unit the night of the incident no longer worked for the facility. Review of a policy titled, Abuse Prohibition, revised 07/01/18, revealed the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This deficiency substantiates Complaint Number OH 325.