Every finding on record at Eastbrook Healthcare Center

Based on observation and interviews, the facility failed to maintain resident rooms in a safe and sanitary condition. This affected 14 residents (#1, #3, #36, #39, #52, #60, #63, #64, #65, #72, #84, #94, #100 and #101) out of 24 residents reviewed for environment. The facility census was 103.Findings include:Interview on 01/12/26 at 9:39 A.M. with Resident #72 revealed his shared bathroom toilet for Rooms #112 and #114 had been plugged up and unusable since 01/10/25 for two days. Resident #72 stated he notified nursing of the issue on 01/10/26 and was informed they would notify maintenance and place a work order. The nurses provided the residents (#36, #39, #72 and #101) who shared the bathroom with urinals; however, there was no place to empty the urinals since the toilet was broken. So, they were told to use the communal bathroom out on the floor, but Resident #72 complained there was no toilet paper in the bathroom. Observation at the time of the interview of the shared bathroom revealed the toilet appeared plugged up and had old urine and feces inside the toilet. Interview with the Director of Nursing (DON) on 01/12/26 at 10:00 A.M. revealed she was unaware of the problem and verified there was no work order placed on 01/10/25. Observation on 01/12/26 at 10:35 A.M. of Resident #60's and #94's room revealed red and brown stains on both residents' privacy curtains. Resident #94's fall mat was stained and had various debris on it. Crushed chocolate candies were scattered all over the floor. Heavy dust build-up was underneath the air conditioner unit. The wall between the bathroom and the sink had numerous stains of what appeared to be blood and feces. The bathroom had an empty hanger and various pieces of trash on the ground with brown stains on the wall behind the toilet. The floor was very sticky. Interview at the time of the observation with Housekeeping Director (HD) #573 confirmed the findings. Observation on 01/12/26 at 10:50 A.M. of Resident #1's and #64's room revealed dust build-up on the portable fan and a sticky floor. Resident #64 had tracheostomy tubing, a cookie wrapper, alcohol pads, gloves, a napkin, and numerous crumbs around and underneath his bed. Numerous stains and splatters were on the wall between the sink and the bathroom. Resident #1 had numerous food crumbs, wipes and a dirty urinal on the floor. Interview at the time of the observation with HD #573 confirmed the findings. Observation on 01/12/26 at 11:06 A.M. of Resident #65's room revealed the floor was sticky and there were two gloves on the ground underneath the floor air vents. Interview at the time of the observation with the DON confirmed the findings. Observation on 01/12/26 at 11:09 A.M. of the second-floor shower room located near room [ROOM NUMBER] revealed the floor was dirty, and tissue paper was on the floor. There was an estimated three-inch stain of what appeared to be feces on the top inside of the toilet. Interview at the time of the observation with the Administrator confirmed the findings. Observation on 01/12/26 at 11:18 A.M. of Resident #100's room revealed a banana on the floor with numerous foam cups and plastic food containers around room. There was cluttered items on the floor. Interview at the time of the observation with Resident #100 revealed he had asked staff numerous times to clean up the room and assist with arranging items, so he was able to reach them. Interview at the time of the observation with Licensed Practical Nurse (LPN) #528 confirmed the findings. Observation on 01/12/26 at 12:05 P.M. of Resident #63's room revealed numerous items of trash on the floor including a pillowcase, a pillow, a bowl, a napkin, numerous crumbs and an incontinence brief. The mini refrigerator in the room had visible dust build-up. Interview at the time of the observation with the Assistant Director of Nursing (ADON) #596 confirmed the findings. Observation on 01/12/26 at 4:18 P.M. of Resident #3's and #84's room revealed visible dust build-up and splatter along the floor vents and wall by Resident #3's bed. Resident #3 had various shoes, incontinent briefs and wedges behind the bed on the floor. Interview at the time of the observation with Housekeeper #507 confirmed the findings. Observation on 01/12/26 at 4:46 P.M. of Resident #52's room revealed numerous stains, splatter and a napkin on the wall by the bed. Interview at the time of the observation with Certified Nursing Assistant (CNA) #577 confirmed the findings. Observation on 01/15/26 at 10:19 A.M. of the first-floor shower and bathroom located across from room [ROOM NUMBER] revealed dirty footprints and two toilet paper rolls on the floor. The toilet had dried urine splatter on the seat. There was a used disposable razor on the sink, shaved hair clippings in the sink, and the facet seal was dirty and brown. The floor around the toilet had brown debris and stains. The non-skid strips across from the toilet were coming unattached from the floor. The floor vents were visibly dusty. The vent on ceiling had thick dust build-up. The shower had the appearance of mold in the corner, orange build-up along the tile grout, and soap build-up on the soap dispenser. Interview at the time of the observation with Housekeeper #525 confirmed the findings. Observation on 01/15/26 at 10:32 A.M. of the second-floor shower and bathroom revealed a one inch by one-inch dried stain which appeared to be feces on the toilet seat. Interview at the time of the observation with DON confirmed the findings. Observation on 01/15/26 at 10:36 A.M. of the findings in the first-floor shower and bathroom with DON confirmed the above findings. Observation on 01/15/26 at 11:01 A.M. with HD #573 of the entry way for room [ROOM NUMBER] revealed the vinyl flooring was cracked, raised up above floor and had a hole in it. Interview at the time of the observation with HD #573 confirmed the findings. Review of facility policy labeled, Quality of Life - Homelike Environment, revised May 2017, revealed residents were provided with a safe, clean, comfortable and homelike environment, and encouraged to use their personal belongings to the extent possible,. The facility staff and management maximized to the extent possible the characteristics of the facility that reflected a personalized, homelike setting. This included a clean and orderly environment. This deficiency represents non-compliance investigated under Complaint Number 2570903.

Based on observation, record review and interview the facility failed to provide restorative services to prevent a decline of the residents' functional abilities in the facility. This affected three residents (#10, #14 and #54) out of four residents reviewed for rehabilitation services. The facility census was 103.Findings include:1. A review of Resident #14's clinical record revealed an admission date of 06/11/26 with diagnoses including diabetes mellitus type two, high blood pressure and cholesterol, centrilobular emphysema, segmental and somatic dysfunction of the sacral region, myalgia, pulmonary fibrosis, adult failure to thrive, gastroesophageal reflux disease, dementia with agitation, dysphagia (trouble swallowing), tachycardia, depression and pain. Resident #14 had medical conditions including muscle weakness, abnormal gait and mobility and other signs and symptoms of cognitive functions and awareness, and long-term drug therapy. A review of Resident #14's plan of care revealed no restorative services to prevent a decline in his functional ability to balance during walking and transitions. A review of Resident #14's Restorative assessment dated [DATE] indicated Resident #14 was unsteady when moving from seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and surface to surface transfers between the bed and chair/wheelchair. Resident #14 used a wheelchair for mobility. Resident #14 needed limited assistance of one staff member for transfers, walking, dressing, toilet use, personal hygiene, and bathing. The assessment indicated Resident #14 was currently receiving occupational and physical therapy services. An interview with Resident #14 on 01/12/26 at 11:00 A.M. revealed Resident #14 was not receiving therapy services to increase his strength for his ability to independently perform his activities of daily living needs. An interview with Therapy Director of Rehabilitation (DOR) #520 on 01/13/25 at 4:10 P.M. revealed Resident #14 received physical therapy services with an evaluation completed on 01/11/25 and the first physical therapy session was scheduled on 01/13/25. DOR #520 stated the facility did not provide restorative therapy services. DOR #520 stated the Director of Nursing (DON) informed her the facility did not provide restorative therapy to maintain the residents' functional abilities. DOR #520 stated that when a resident had a decline in activities of daily living, therapy would evaluate the resident to determine their need for therapy services. DOR #520 stated the facility would routinely recertify a resident for therapy services when they exhibited a decline in their functional abilities and physical/occupational therapy did not provide recommendations for restorative services because the facility did have a restorative therapy system in place. DOR #520 agreed that the residents who had therapy services were at risk for declining after their therapy services were discontinued because there was no restorative services implemented after discontinuation of the therapy services. DOR #520 stated the facility would have the physician order an evaluation for the need for therapy services when a resident had a decline in their functional abilities. An interview with DON on 01/15/26 at 10:00 A.M. revealed the facility did not offer restorative services to prevent a functional decline in a resident's ability to perform activities of daily living. DON stated the facility provided quarterly restorative assessments and when a resident had a decline in their functional abilities, the resident was referred to therapy for an evaluation to provide therapy services. DON stated the facility did not have a policy and procedure for restorative care in the facility. DON verified the above findings at the time of the interview. An interview with Certified Nursing Assistant (CNA) #577 on 01/15/26 at 10:18 A.M. revealed the residents were not provided with routine restorative therapy services. If a resident required range of motion exercises, occupational and physical therapy services were provided to address range of motion needs. 2. A review of Resident #10's clinical record revealed an admission date of 05/11/23 with diagnoses including dementia, kidney failure, anemia, malnutrition, high blood pressure and cholesterol, depression, stroke, arteriovenous malformation of the digestive system, dysphagia, altered mental status, alcohol abuse, diabetes mellitus type two, peripheral vascular disease, nicotine dependence, high potassium level, insomnia, metabolic encephalopathy, hemiplegia and hemiparesis, melena, liver disease, gastroesophageal hemorrhage, and high magnesium level. A review of Resident #10's care plan initiated on 01/13/24 indicated a self-care deficit related to stroke, cognitive communication deficits, impaired mobility and weakness. The goal of the care plan was to maintain current ability with activities of daily living through the next review. There were no interventions to address this goal. Interventions included the amount of assistance Resident #10 needed to perform activities of daily living and to refer to therapy to evaluate and treat as needed. An interview with Resident #10 on 01/13/25 at 7:54 A.M. revealed Resident #10 stated he was unsure if he was receiving exercises for his contracted right hand or other exercises to assist him with maintaining his current level of function to perform his activities of daily living. An observation of Resident #10 revealed his right hand was contracted. An interview with DOR #520 on 01/13/25 at 4:19 P.M. revealed there was no restorative program recommended to address Resident #10's contracted right hand because the facility did not offer restorative services to the residents. An interview with DON on 01/15/26 at 10:00 A.M. revealed the facility did not offer restorative services to prevent a functional decline in a resident's ability to perform activities of daily living. DON stated the facility provided quarterly restorative assessments and when a resident had a decline in their functional abilities, the resident was referred to therapy for an evaluation to provide therapy services. DON stated the facility did not have a policy and procedure for restorative care in the facility. DON verified the above findings at the time of the interview. 3. A review of Resident #54's clinical record revealed an admission date of 04/16/25 with diagnoses including nontraumatic cerebral hemorrhage, hemiplegia and hemiparesis, dysphagia, facial weakness, dysarthria (a motor speech disorder caused by muscle weakness, paralysis, or poor coordination due to brain or nerve damage), post-traumatic stress disorder, restlessness, agitation, high cholesterol and blood pressure, contracted left hand, and high potassium.Resident #54's care plan initiated on 04/19/25 indicated a self-care deficit related to failure to thrive, stroke with left sided paralysis, facial weakness with speech dysfunction and communication deficit, contracture of left hand, restlessness, agitation and chairbound. A review of Resident #54's care plan revealed no interventions to address the left-hand contracture or other restorative interventions to prevent further decline in his functional ability. Interventions on the plan of care included assisting with activities of daily living as needed and report improvement or decline in resident's participation with activities of daily living, assess functional level and refer to therapy/Registered Nurses and/or physician orders. There were no interventions to address the left-hand contracture, range of motion or exercises to prevent loss of functional ability.An observation of Resident #54 on 01/13/25 at 1:30 P.M. revealed Resident #54 was unable to answer questions regarding his care in the facility. Resident 54 had a contracted left hand with the fingers clenched tightly in his left palm.An interview with DOR #520 on 01/13/25 at 4:23 P.M. revealed Resident #54 developed a wound on his left palm due to his contracted fingernails digging into his palm causing a wound. The wound had healed and now therapy could work on his range of motion for his left-hand contracture to assist in loosening up the left-hand contracture to prevent wound development.An interview with DON on 01/14/25 at 7:42 A.M. revealed Resident #54 did not have restorative exercises to address his left-hand contracture and if he had a decline in his functional ability, the facility would have therapy evaluate him for physical and/or occupational therapy to address his specific decline in his functional ability. DON verified the above findings and agreed the facility did not have a restorative therapy system in place to prevent a decline in a residents' functional ability.An interview with CNA #577 on 01/15/26 at 10:18 A.M. stated the residents should have range of motion exercises performed by the aides but the residents do not routinely receive range of motion services because therapy performs the range of motion exercises.

Based on interview and record review the facility failed ensure there was accurate documentation. This affected two residents (#31 and #42) out of 24 medical records reviewed for accuracy of medical records. The facility census was 103. Findings include: 1. Review of medical record for Resident #42 revealed an admission date of 05/23/24 and his diagnoses included morbid obesity, diabetes with diabetic neuropathy, chronic kidney disease, and chronic obstructive pulmonary disease (COPD). Review of care plan dated 05/24/24 revealed Resident #42 had potential for hypoglycemia and/or hyperglycemia related to diabetes. Interventions included checking glucose levels, administering insulin and monitoring labs as ordered.Review of care plan dated 05/24/24 revealed Resident #42 had a nutritional problem related to morbid obesity, history of binge eating, congestive heart failure (CHF), and excessive consumption of highly processed snacks and beverages. Interventions included administering medication as ordered, monitoring and documenting side effects and effectiveness, monitoring weights and providing and serving diet as ordered. Review of September 2025 Medication Administration Record (MAR) revealed Resident #42 had an order for Mounjaro (an injectable medication used to treat diabetes and obesity) subcutaneous (SQ) solution auto-injector 2.5 milligrams (mg) per 0.5 milliliter (ml), inject one application SQ in the afternoon every Wednesday for diabetes. The MAR indicated on 09/17/25 to see the nursing notes as it was not administered. Review of nursing note dated 09/17/25 at 6:12 P.M. revealed Resident #42's Mounjaro was not given as it was reordered. There was no documentation Primary Care Physician (PCP) #900 was notified regarding Resident #42 missing his dose and Resident #42 did not receive the medication until the next time that it was scheduled on 09/24/25. Review of November 2025 MAR revealed Resident #42 had an order for Mounjaro SQ solution auto-injector 2.5 mg per 0.5 ml, inject one application SQ in the afternoon every Thursday for diabetes. The MAR was blank on 11/06/25. Review of nursing notes dated 11/01/25 to 12/31/25 for Resident #42 revealed no documentation PCP #900 was notified regarding Resident #42 not receiving his Mounjaro on 11/06/25 and 12/11/25. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was cognitively intact. Review of Physician Progress Note dated 11/10/25 at 8:11 A.M. and completed by PCP #900 revealed Resident #42 had the following diagnoses: morbid obesity, diabetes, and COPD. He recommended to continue Mounjaro for diabetes and morbid obesity. Review of December 2025 MAR revealed Resident #42 had an order for Mounjaro SQ solution auto-injector 2.5 mg per 0.5 ml, inject one application SQ in the afternoon every Thursday for diabetes. The MAR was blank on 12/11/25. Interview on 01/12/26 at 9:40 A.M. and 01/15/26 at 8:43 A.M. with Resident #42 revealed he was supposed to receive Mounjaro once a week mainly to assist him in weight loss. He revealed at times he did not receive this medication but could not remember details of when he did not or how often. Interview on 01/14/26 at 2:22 P.M. with Director of Nursing (DON) verified on Resident #42's MAR it indicated on 09/17/25 his Mounjaro was not given as it was not available, and on 11/06/25 and 12/11/25 the MAR was blank. She verified there was nothing in the nursing notes regarding the physician being notified that the medication was not given. She revealed she felt the medication possibly was given but the nurse did not document it. 2. Review of medical record for Resident #31 revealed an admission date of 09/11/25 and diagnoses included paraplegia, hypertension and neuromuscular dysfunction of the bladder. Review of care plan dated 10/01/25 revealed under resident care Resident #31 required catheter care per policy, always keep catheter bag below level of bladder, and keep catheter bag always covered. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had intact cognition and had an indwelling catheter (a flexible tube inserted into the bladder for continuous urine drainage). He was dependent on staff assistance with toileting hygiene. Review of Treatment Administration Record (TAR) for December 2025 and January 2026 revealed there was no documentation catheter care was completed for Resident #31. Review of task bar from 12/14/26 to 01/14/26 revealed there was no order and/or documentation Resident #31's catheter care was completed. Review of January 2026 physician orders revealed Resident #31 had a urinary indwelling catheter to continuous drainage and there were no orders for catheter care. Interview on 01/12/26 at 10:10 A.M. with Resident #31 revealed he was unsure how often staff provided catheter care as it was something he did not keep track of. Review of Kardex for Resident #31 dated 01/14/26 revealed staff were to complete catheter care per policy and after each incontinent episode of bowel. There was no frequency identified regarding catheter care. Interview on 01/14/26 at 1:30 P.M. with the DON verified there was no physician order for catheter care or evidence of documentation that catheter care was completed. She revealed she felt it was completed every shift but that it was not documented. She verified there should have been a physician order for catheter care to be completed every shift and that staff should have documented the completion. Review of facility policy labeled, Administering Medications dated April 2019 revealed medications were to be administered in a safe and timely manner as prescribed. If the drug was withheld, refused or given at a time other than scheduled the nurse administering the medication shall initial and circle the MAR space provided. The nurse administering the medication initialed the MAR after giving the medication. Review of facility policy labeled, Catheter Care dated September 2024 revealed the purpose of the policy was to prevent catheter-associated urinary tract infections. There was nothing in the policy regarding documenting the completion of catheter care and/or how often catheter care should be completed. This deficiency represents non-compliance investigated under Complaint Number 2585985 and Complaint Number 2560614.

Based on observation and interview, the facility failed to post the most recent survey results readily accessible to residents and family members. This had the potential to affect all 103 residents residing in the facility. Findings include: Observation on 01/15/26 at 10:34 A.M. of the public survey binder located on the bottom shelf of a table by the facility entrance door with no signage related to binder or its access. The last survey included in the binder was dated 01/27/22. There were no recent surveys conducted after 01/27/22 contained within the survey binder. Interview on 01/15/26 at 11:00 A.M. with the Administrator verified the most recent survey results were not included in the survey binder making it readily accessible to residents and family members.

Based on observation, review of the facility's contract with therapy services, resident interview, and staff interview, the facility failed to administer the facility in a manner to maintain therapy equipment in proper working order. This affected one resident (#51) and had the potential to affect all 91 residents in the facility. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including encounter for other orthopedic aftercare, person injured in unspecified motor-vehicle, colostomy status and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/03/24, revealed Resident #51 had moderate cognitive impairment, was dependent on staff for bed/chair to chair transfers, and required partial/mod assist for bed mobility. On 01/22/25 at 7:48 A.M., an interview with Resident #51 stated the therapy gym did not have the equipment they needed and he was told by staff to just hold onto the sink and pivot while attempting to stand. On 01/22/25 at 8:33 A.M., an observation of the facility's therapy gym revealed there was an ultrasound and tens unit (electrotherapy device) on a shelf and there was a set of balance bars (parallel bars used to help people stay balanced while standing or walking) in the corner surrounded by walkers, rollators, canes, and other equipment, making the balance bars inaccessible to residents. On 01/22/25 at 8:36 A.M., an interview with Certified Occupational Therapy Assistant (COTA) #814 stated the facility did not have much therapy equipment and the ultrasound and tens unit were used for pain management but they had been unable to use them because the facility refused to pay for routine maintenance and calibration. COTA #814 also stated the balance bars could not be used because they were not secured to anything and unsafe in their current state. COTA #814 revealed they had to be super creative when providing therapy because they did not have the equipment they need. On 01/22/25 at 8:49 A.M., an interview with Rehabilitation Director #815 confirmed the ultrasound and tens unit had not been used since at least July 2024 because they needed serviced. She stated the therapy staff were contracted and the facility was responsible for maintaining therapy equipment. Rehabilitation Director #815 also confirmed therapy staff were unable to use the balance bars in the therapy gym because they were not secure and verified Resident #51 had to use a sink to support himself while standing up. Rehabilitation Director #815 revealed therapy gave the faciliy a list of needs within the last month and has not received a response yet. On 01/22/25 at 9:56 A.M., an interview with the Administrator verified the ultrasound and tens unit was due for maintenance in August 2024 and maintenance had not yet been completed. Administrator revealed they haven't had anyone with orders for the ultrasound and Tens unit since August 2024, indicating there was not hurry to get it serviced. On 01/22/25 at 10:35 A.M., an interview with Occupational Therapist (OT) #816 stated they did need to use the ultrasound and tens unit for some residents (she was unable to specify who those residents were). On 01/23/25 at approximately 1:45 P.M., during the exit conference, the Administrator was adamant that although the therapy equipment was in the therapy gym at the facility, the facility was not required to keep the equipment in proper working order because it was not being used. The Administrator insisted the equipment was not used and did not need to be maintained, despite therapy staff stating they would use this equipment if it were in proper working order. Review of the facility's contract with therapy services, dated 07/01/24, revealed it was the facility's responsibility to provide, at its sole expense, all supplies and equipment necessary to provide services and the facility would keep such equipment in good order and repair. This deficiency represents non-compliance investigated under Complaint Number OH00161622 and OH00160645.

Based on interview, record review, facility investigation review, and facility policy review the facility failed to ensure Resident #73 was transferred safely resulting in a fall. This affected one resident (#73) of three residents reviewed for accidents. Facility census was 83. Findings include: Review of Resident #73's medical record revealed an admitted [DATE] with diagnoses included but not limited to systolic congestive heart failure, acute respiratory failure, acute kidney failure, and artificial opening of urinary tract status and need for assistance with personal care. Review of the care plan dated 05/10/19 revealed Resident #73 had an ADL self-care performance deficit related to activity intolerance and impaired balance. Interventions included toileting dependent with assist of two persons and mechanical lift with two person assist for transfers. Review of Resident #73's quarterly Minimum Data Set assessment dated [DATE] revealed the resident required substantial/maximal assistance with toileting hygiene and was dependent on staff for mobility. Review of the progress noted dated 06/14/24 at 4:49 P.M. authored by Licensed Practical Nurse (LPN) # 223 revealed she was notified by State tested Nurse Aide (STNA) #305 regarding Resident #73 fell out of bed while being provided care with one assist for peri care. LPN #223 did an assessment, notifications, and started neurological (neuro) checks. LPN #223 and STNA #305 lifted resident back to bed with two-staff assistance without mechanical lift. Review of the investigation report dated 06/14/24 revealed Resident #73 received care by one staff and fell out of bed. LPN #223 assessed Resident #73, and she was lifted from floor mat back into bed with two staff assist manually. Resident #73 sustained no injuries or complaints of pain. Interview on 08/19/24 at 11:06 A.M. with Nurse Practitioner (NP) #326 revealed she was notified of the fall and reported the STNA #305 was new and was only using one assist for care and there should have been two assisting with peri care/toileting. Interview on 08/19/24 at 11:53 A.M. with LPN #223 revealed STNA #305 reported Resident #73 had fallen out of bed during peri care/toileting. LPN #223 reported she believed Resident #73 was a two person assist for peri care/toileting. Interview on 08/19/24 at 12:39 P.M. with LPN #212 revealed Resident #73 was a two person assist for peri care/toileting. Interview on 08/19/24 at 12:41 P.M. with STNA #297 revealed Resident #73 was a two person assist for peri care/toileting. Interview on 08/19/24 at 12:49 P.M. with STNA #305 revealed at the time of Resident #73's fall, the resident was supposed to be a two person assist for peri care and he only had himself assist because he didn't check the Kardex to see what assistance was required. STNA #305 reported he received education after the incident to include she was two person assist with peri care. Interview on 08/20/24 at 7:30 A.M. with the Director of Nursing (DON) confirmed Resident #73 had a fall during peri care with only one staff present, and Resident #73 required two staff per the care plan and Kardex. Review of the facility policy, Falls and Fall Risk, Managing, revised March 2018, revealed staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with history of falls. This deficiency represents non-compliance investigated under Complaint Number OH00156029.

Based on observation and interview, the facility failed to ensure medications were administered with an error rate of less than 5%. A total of two errors out of 29 opportunities observed resulting in a 6.9% medication error rate. This affected two resident (#36 and #73) out of four observed for medication administration. Findings include: 1. Review of Resident #36's medical records revealed an admitted [DATE]. Diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed resident had intact cognition. Review of physician orders for 07/07/23, revealed resident was ordered Aspirin 81 milligram (mg) chewable to give one tablet by mouth (PO) in the morning. Observation of medication administration on 08/15/24 at 8:29 A.M. with Licensed Practical Nurse (LPN) #266 for Resident #36 revealed the LPN administered Aspirin 81 mg enteric coated (EC), not chewable. Interview on 08/15/24 at 10:08 A.M. with LPN #266 verified she gave the wrong medication. LPN #266 reported she didn't look to see it was Aspirin 81 mg chewable and administered Aspirin 81 mg EC. 2. Review of Resident #73's medical records revealed an admitted [DATE]. Diagnosis included but not limited to systolic congestive heart failure, acute respiratory failure, acute kidney failure, artificial opening of urinary tract status and need for assistance with personal care. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed resident had intact cognition. Review of physician orders for 12/29/23 revealed resident was ordered Senna 8.6 mg give 50 mg PO (by mouth), one tablet, two times a day for constipation. Observation of medication administration on 08/15/24 at 8:01 A.M. with LPN #249 for Resident #73 revealed LPN administered Senna 8.6 mg, one tablet PO. Interview on 08/15/24 at 10:13 A.M. with LPN #249 verified she gave incorrect medication. LPN #249 verified it should have been Senna 8.6-50 mg 1 tablet PO. Interview on 08/15/24 at 12:30 P.M. with Regional [NAME] President of Clinical Services (RVPCS) # 329 verified the wrong medication was administered and education provided to the nurse. Review of facility policy, Administering Mediations, revised April 2019, revealed medications are administered in accordance with prescriber orders and the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route of administration before giving the medication. This deficiency represents non-compliance investigation Complaint Number OH00155885.

Based on observations, resident interview, staff interview, and facility policy review, the facility failed to ensure food served was palatable for all residents. This affected four residents (#45, #47, #50, and #62) of five residents observed for food palatability and had the potential to affect all residents receiving food from the facility. The facility census was 90. Findings include: Observations on 07/19/24 from 12:25 P.M. to 12:54 P.M. revealed six total pre-prepared plates were sent up from the kitchen to the second-floor dining room; four with a hot dog and French fries and two with grilled cheese and French fries. The plates were not covered in warming containers; they were covered in plastic wrap and sat on an open-air cart until they were delivered to the resident's hallway. Interview with Registered Dietitian #204 and Culinary Manager #120 on 07/19/24 at 1:05 P.M. confirmed the pre-prepared plates were left on the open-air cart from the time it left the kitchen at 12:25 P.M., until the time the carts were taken to the hallways to be served. They confirmed the pre-prepared plates did not have a warming base or top on them; they only had plastic wrap to keep them covered. Interview with Resident #47 on 07/19/24 at 1:10 P.M. revealed he ate his hot dog but confirmed that it was not warm. He would have preferred it to be much warmer than it was. Observation on 07/19/24 at 1:15 P.M. revealed Resident #45 was not in her room, but her plate of food (hot dog and French fries) was delivered, waiting for her to return. The temperature of her food was taken, and the hot dog was 91 degrees Fahrenheit (F), and the French fries were 100 degrees F. The temperatures were taken and confirmed by Registered Dietitian #204. Interview with Resident #62 on 07/19/24 at 2:05 P.M. revealed she asked the aide to take her plate back (hot dog and French fries) because it was cold when she got back from dialysis. Interview with Resident #50 on 07/19/24 at 2:47 P.M. revealed her grilled cheese was very cold. She asked if there could be anything done to make the food warmer when she gets it. Review of the facility Food Preparation and Service policy, dated April 2019, revealed food and nutrition service employees prepare and serve food in a manner that complies with safe food handling practices. The danger zone for food temperatures is between 41 and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. Palatability of food determines appropriate temperature at bedside and tableside food. Generally, hot food is palatable between 100 and 120 degrees F or greater, and cold food is palatable between 50 degrees and 45 degrees F or less. This deficiency represents non-compliance investigated under Master Complaint Number OH00155188.

Based on observation, interview and facility policy review, the facility failed to ensure food items were appropriately labeled, dated and contained. This had the potential to affect 85 residents receiving meals from the kitchen as three residents (#41, #71 and #77) were ordered nothing-by-mouth (NPO). The facility census was 88. Findings include: Observation of the kitchen on 05/05/24 starting at 9:15 A.M. with Cook #116 revealed the following: In the beverage cooler, there were four desserts in styrofoam bowls with lids that lacked labels or dates. In the walk-in cooler, a case of bacon slices was open to air with no other covering and there was a pan of fried chicken in a hotel pan uncovered and open to air. There was a bag of lettuce that was not re-sealed, a pack of sliced cheese and a bag of shredded cheese and all lacked labels and dates. In the dry storage room, there was a sanitizer pail and the bin of sugar was open to air. Interviews with Cook #116 verified the findings at the time of observation. Cook #116 indicated food items should be covered, labeled and dated before placed in the coolers. Cook #116 was not sure why there was a sanitizer pail in the dry storage room. Review of the undated facility policy, Food Storage, revealed food items should be stored, thawed and prepared in accordance with good sanitary practice. All products should be dated upon receipt, when open and when prepared. Remember to cover, label and date. Review of a diet list as of 05/05/24 revealed three residents (#41, #71 and #77) were NPO.

Based on interview, record review and facility policy review, the facility failed to provide spend-down letters for each month residents were approaching or over the resource limit. This affected two residents (#11 and #16) of five residents reviewed for resident funds. The facility census was 88. Findings include: 1. Review of Resident #11's medical record revealed an admitted [DATE] and diagnoses including paranoid schizophrenia, violent behavior, unspecified psychosis, impulse disorder, anxiety and hypertension. Review of a social service progress note dated 03/27/24 revealed the Business Office Manager (BOM) informed Resident #11's guardian that Resident #11 was in jeopardy of losing Medicaid due to an abundance of funds. Review of Resident #11's quarterly funds statement from 01/01/24 to 03/31/24 revealed an ending balance of $1832.49 on 01/31/24, an ending balance of $1872.59 on 02/29/24 and an ending balance of $1912.69 on 03/31/24. Review of attached documentation revealed a spend-down letter dated 03/27/24. No other spend-down letters were available for review. Interview on 05/06/24 at 10:52 A.M. with BOM #218 revealed she provided a spend-down letter when residents had a balance of $1800.00 or more every quarter with the quarterly financial statements. BOM #218 confirmed she did not have spend-down letters for January 2024 and February 2024 for Resident #11 during the interview. 2. Review of Resident #16's medical record revealed an admitted [DATE] and diagnoses including bipolar disorder, anxiety disorder, hypertension, dementia without behavioral disturbance and chronic hepatitis C. Review of Resident #16's quarterly funds statement from 01/01/24 to 03/31/24 revealed an ending balance of $1808.61 on 01/31/24, an ending balance of $1838.70 on 02/29/24 and an ending balance of $1868.79 on 03/31/24. Review of attached documentation revealed a spend-down letter dated 03/29/24. No other spend-down letters were available for review. Interview on 05/06/24 at 10:52 A.M. with BOM #218 revealed she provided a spend-down letter when residents had a balance of $1800.00 or more every quarter with the quarterly financial statements. BOM #218 confirmed she did not have spend-down letters for January 2024 and February 2024 for Resident #16 during the interview. Review of the facility policy, Accounting and Records of Residents Funds, revised April 2017 revealed a representative of the business office would inform the resident if the balance in his/her personal funds account reached $200.00 less than the resident's supplemental security income (SSI) resource limit and that if the amount in the account reached the SSI resource limit for one person, the resident could lose eligibility for Medicaid or SSI.

Based on record review and staff interview, the facility failed to accurately code comprehensive assessments for two residents (#54 and #88) of 24 residents reviewed for assessments. The facility census was 88. Findings Include: 1. Medical record review revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following skin grafts to bilateral feet for burns, diabetes, stroke, end stage renal disease dependent on dialysis, and high blood pressure. Review of the physician's orders dated 02/13/24 revealed an order for oxycodone (an opioid pain medication) 5 milligrams (mg) orally every six hours as needed for pain. Review of the admission comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #88 was cognitively intact, received scheduled and as needed pain medication, and received non-medication alternatives for pain. On a scale of zero to ten with zero indicating no pain and ten indicating severe pain, the resident rated his pain level as a five. The pain occasionally interfered with therapy activities, daily activities, and sleep. The medications Resident #88 received during the assessment period included insulin, an anticoagulant, and a diuretic. The resident received no opioids during the assessment period per the assessment. Review of the progress notes for Resident #88 revealed on 02/12/24 Licensed Practical Nurse (LPN) #151 was performing the resident's dressing change to his feet which caused severe pain for the resident. LPN #151 administered oxycodone 5 mg orally for pain, waited 30 minutes, then resumed the dressing changed. Interview with MDS Coordinator #222 on 05/06/24 at 3:55 P.M. confirmed the Admission MDS assessment was incorrectly coded under Section N, Medications, and should have marked Resident #88 received opioids during the assessment period. 2. Review of the MDS discharge assessment for Resident #88, dated 02/15/24, revealed the resident was discharged to the hospital on 02/15/24. Review of the progress notes dated 02/15/24 revealed Resident #88 was discharged against medical advice and arranged for a ride home. Interview with MDS Coordinator #222 on 05/06/24 at 3:55 P.M. confirmed the discharge assessment as being transferred to the hospital was coded incorrectly. 38522 3. Review of Resident #54's medical record revealed an admitted [DATE] and diagnoses including vascular dementia without behavioral disturbance, adult failure to thrive, hyperlipidemia, chronic kidney disease and hypertension. Review of an annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 was cognitively impaired. The assessment indicated that no falls had occurred since the prior assessment. Review of a fall report dated 09/19/23 revealed Resident #54 fell on [DATE] at 8:00 P.M. with no injuries noted. Interview on 05/06/24 at 3:54 P.M. with MDS Registered Nurse (RN) #222 revealed Resident #54 had a fall on 09/19/23. MDS RN #222 stated the annual MDS assessment dated [DATE] was coded to reflect Resident #54 having no falls, when in fact he did have a fall and verified the assessment was coded incorrectly.

Based on observation, interview, medical record review, and policy review, the facility failed to ensure a medication error rate of less than five percent (%). Six medication errors occurred within 31 observed opportunities for error resulting in an error rate of 19.35% . This affected three residents (Residents # 241, #41, and #58) of nine residents observed during medication administration. The facility census was 88. Findings include: 1. Review of the medical record for Resident #241 revealed an admitted [DATE] with diagnoses including sepsis due to other specified staphylococcus, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, depression, dependence on renal dialysis, and anemia. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 04/27/24 revealed Resident #241 had intact cognition. Further review of the MDS revealed Resident #241 had no insulin-related order changes and had received an insulin injection seven of the seven days during the look-back period. Review of the physician orders revealed an order dated 04/22/24 for nystatin mouth/throat suspension, 100,000 units per milliliter (ml), five ml by mouth every six hours with instructions for the resident to swish and then swallow the nystatin. Review of the physician orders further revealed an order dated 04/20/24 for Humulin N KwikPen 100 unit/ml, four units subcutaneously before meals and at bedtime for type two diabetes mellitus. Observation on 05/06/24 at 12:13 P.M. of Resident #241's medication administration by licensed practical nurse (LPN) #140 revealed Resident #241 took the nystatin suspension and was instructed to swish but not swallow the medication. LPN#140 then placed a plastic cup under Resident #241's mouth and instructed him to spit the nystatin into the cup. Further observation Resident #241's medication administration revealed LPN #241 dialed the Humalog N KwikPen to the ordered dose of four units, carried the pen and injection supplies into the resident's room, applied the needle at the bedside, and injected the insulin subcutaneously into the back of Resident #241's left upper arm before first priming the needle. Interview on 05/06/24 at 12:15 P.M. with LPN #140 confirmed she administered the Humalog KwikPen to Resident #241 without first priming the needle. She further confirmed it was her typical practice to dial the dose knob to the ordered dose, take the injection pen into the residents' rooms, apply the needle to the injection pen at the bedside, and administer the insulin without first priming the needle and re-dialing the dose knob to the ordered insulin dose. Another interview with LPN #140 on 05/06/24 at 12:58 P.M. confirmed she instructed Resident #241 to spit and not swallow the nystatin and confirmed the written order contained instructions to swish and swallow the nystatin. Review of the policy titled Administering Medications, revised April 2019 revealed medications were to be administered in accordance with prescriber orders and the staff administering the ordered medications should check the label three times to verify the administration rights, which included the right method of administration. Review of the Instructions for Use Humulin (R)N KwikPen(R) revealed the injection needle must be primed prior to each injection. The instructions further revealed once the new needle is placed, the dose knob should be turned to two units and then depressed until a 0 is seen in the dose window and insulin could be seen at the tip of the needle before resetting the dose knob to the ordered dose. 2. Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including unspecified dementia, late onset Alzheimer's disease, psychotic disorder with delusions, restlessness and agitation, hypertension, type two diabetes mellitus, moderate protein-calorie malnutrition, and encounter for fitting and adjustment of gastrointestinal appliance and device. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 02/18/24 revealed Resident #41 had severely impaired cognition and had a feeding tube. Review of the care plan dated 02/08/24 revealed Resident #41 had the potential for an alteration in comfort secondary to deconditioning and decreased mobility. Interventions included anticipating Resident #41's need for pain relief, responding immediately to complaints of pain, and reviewing pain medication dosing schedules and pain interventions for effectiveness. Review of the physician orders revealed an order dated 04/22/24 for Resident #41 to receive acetaminophen 1,000 milligrams (mg) through her percutaneous endoscopic gastrostomy (PEG) tube (a tube that is surgically placed into the stomach for nutrition, hydration, and medication) three times a day for pain. Review of the physician orders revealed no additional instructions related to water flushes with medications. Observation on 05/06/24 at 12:50 P.M. of licensed practical nurse (LPN) #143 administering acetaminophen to Resident #41 revealed LPN #143 crushed the 1,000 mg of acetaminophen, mixed the granule with water in a plastic cup, withdrew the water mixture from the cup, paused the tube feeding, attached the syringe with the water and medication onto the port of the PEG tube, pushed the medication through the tubing by depressing the plunger of the syringe, then reconnected and restarted the tube feeding. At the time of the medication administration, no flush was observed before of after the medication administration and the plastic cup used to mix the acetaminophen still contained a moderate amount of white medication granules settled at the bottom of the cup with a small amount of cloudy water. Interview on 05/06/24 at 12:50 P.M. with LPN #143 at the time the medication administration observation, once she resumed the tube feeding, confirmed she was finished with the administration of the ordered acetaminophen, restarted the tube feeding without flushing the PEG tube, and then confirmed there was left over medication settled on the bottom of the cup that was not given to Resident #41 at the time of the medication administration. Review of the policy titled Administering Medications, revised April 2019 revealed medications were to be administered in accordance with prescriber orders. Review of the policy titled Administering Medications through an Enteral Tube revised in November 2018 revealed if the tube feeding was running at the time medication was to be administered, staff were to stop the feeding, flush with at least 15 milliliters (ml) of warm purified water, unless a different amount or fluid was prescribed for flushing, administer the diluted medication into the syringe (without the plunger) by gravity flow, flush the tube with 15 ml of warm purified water, clamp the tubing, remove syringe, and then restart the feeding. 32650 3. Observation of medication administration on 05/07/24 at 8:45 A.M. for Resident #58 revealed Licensed Practical Nurse (LPN) #155 administering Miralax (a medication used to prevent constipation) 17 grams (gm) mixed in four ounces of water, Eliquis (an anticoagulant) 5 milligrams (mg), a multi-vitamin, omeprazole (used to treat gastric reflux) 20 mg, and Colace (a medication used to prevent constipation) 100 mg. All medications were given orally. Review of Resident #58's May 2024 recapitulation of physician's orders revealed an order dated 08/29/23 for Breo Ellipta Aerosol Powder Breath (an inhaler used to treat asthma or chronic obstructive pulmonary disease) 200-25 micrograms (mcg) one puff every morning. Rinse mouth thoroughly and spit, and orders dated 07/11/22 for magnesium 100 mg administer two tablets every morning, and Flonase nasal spray (a medication used to treat environmental allergies) 50 mcg/AT one spray in each nostril. Review of the Medication Administration Record dated 05/07/14 revealed the Breo Ellipta inhaler, Flonase nasal spray and magnesium were not signed off by LPN #155 as being administered. Interview with LPN #155 on 05/07/24 at 1:30 P.M. regarding the omitted medications revealed the magnesium was not available, she thought she administered the Flonase nasal spray and she did not remember if she administered the Breo Ellipta inhaler. The Director of Nursing (DON) was present during the interview.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of Emergency Department notes, review of facility investigative information, review of facility elopement and missing resident policy and procedures and interviews, the facility failed to provide adequate supervision to prevent Resident #92, who had cognitive impairment, wandering behaviors and diagnoses of schizophrenia and dementia, from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 08/18/23 at approximately 8:30 P.M. when Resident #92 walked through the secured third-floor nursing unit back hallway door leading to a stairwell without staff knowledge; the door alarm sounded and was turned off by Agency Licensed Practical Nurse (LPN) #210 who failed to check to make sure all the residents residing on the secured third-floor nursing unit were on the unit and failed to notify other staff members the alarm sounded and was turned off. Resident #92 proceeded to walk down the stairs to the secured second-floor nursing unit back entrance which led to the outside. Resident #92 walked outside, the door alarm sounded, and he walked out of the facility into the parking lot. STNA #278 heard the second-floor door alarm sound and went to check the door, she saw a man walking in the parking lot, but did not think it was a facility resident and did not go outside to further investigate who the man was. Resident #92 was found by railroad tracks (approximately a quarter mile from the facility, after he experienced a fall without loss of consciousness. Resident #92 was noted to have abrasions to his left elbow and forearm and was transported to the local hospital Emergency Department on 08/18/23 around 11:30 P.M. This affected one resident (#92) of three residents reviewed for elopement. On 10/10/23 at 3:29 P.M. the Administrator, [NAME] President of Operations #209 and [NAME] President of Clinical Services #211 were notified Immediate Jeopardy began on 08/18/23 at approximately 8:30 P.M. when Resident #92 opened two facility secured doors (alarms sounded for both doors), walked out of the facility and was found by railroad tracks around 11:00 P.M. after he experienced a fall. Staff were unaware the resident had eloped from the facility at the time of the incident. The Immediate Jeopardy was removed and corrected on 08/19/23 when the facility implemented the following corrective actions: A resident head count was completed on 8/18/2023 at 11:00 P.M. by facility staff. On 08/18/23 Resident #92 was evaluated in the Emergency Department and no medical treatment was warranted. The resident returned to the facility on [DATE] at 5:31 P.M. and was placed on one-on-one (staff) supervision until being discharged from the facility on 08/31/23. Within two hours of notification that Resident #92 was missing from the facility, the Administrator physically verified and visualized that all door alarms, mag locks, secure care system, window guards, and window stops were all in functioning order so no other residents were at risk for elopement. A route cause analysis was completed on 8/19/2023 by the interdisciplinary team. The interdisciplinary team identified the root cause was Agency LPN #210 deactivated sounding door alarm to the D floor stairwell (secured third-floor nursing unit) without identifying the reason why the door was alarming. Agency LPN #210's shift ended on 08/18/23 at 11:00 P.M. The agency nurse was placed on a do not return (DNR) list following this shift. Facility staff, including agency staff, nursing, activities, therapy, laundry, housekeeping, admissions, maintenance, and business office were educated on the proper response to facility door alarms and initial resident search expectations when door alarms were activated. The Administrator or Designee educated all staff on missing resident policy and procedure for responding to the door alarm by 8/19/2023. Beginning 08/19/23, the Administrator or Designee completed elopement drills on each shift for seven days and with a plan to continue to complete elopement drills monthly for four months. The Administrator or Designee had agency staff review facility policies including elopement, missing resident procedure and the process for what to do when an alarm was activated. The education would be reviewed at the front desk or prior to entering the clinical area. The front desk was monitored by staff around the clock by 08/19/2023 to ensure all staff reviewed. On 08/19/23 the Director of Nursing or Designee completed elopement risk assessments for all facility residents to ensure appropriate precautions and interventions were put in place. The Director of Nursing or Designee reviewed all residents care plans who residents who were identified as high risk for elopement and revised as needed by 8/19/2023. The facility residents identified as high risk for elopement plans of care were reviewed and revised as needed by the Director of Nursing or designee by 8/19/2023. Director of Nursing or Designee reviewed the elopement book and updated all Resident identification (photos, name, address, phone, etcetera) information by 8/19/2023. The Director of Nursing or Designee posted visual signs at the front, rear exit door alerting residents, families, and friends to notify staff when a resident is leaving the facility and need to sign out at the nurse's station by 8/19/2023. The facility Administrator or Designee reviewed the Elopement Prevention-missing person policy and noted it would be updated as needed by 8/19/2023. The VP (vice president) of Operations and VP of Clinical services reviewed the Abuse Prohibition policy by 8/19/2023. The Administrator or Designee educated all facility staff on the Abuse Prohibition Policy by 8/19/2023. The Administrator educated all facility staff on responding to any alarms in the building promptly and to do a visual resident observation if a resident exhibited exit seeking behavior or expressed a desire to leave LOA (leave of absence)/AMA (against medical advice) by 8/19/2023. The Administrator or Designee completed education on the sign in, sign out procedure to residents and responsible party by 8/20/2023. The Administrator/designee communicated with family and visitors concerning the purpose, use of alarmed exit doors, and risk for residents leaving by 8/20/2023. The Administrator notified all resident representatives via broadcast message, educating them on the facility's process for unplanned LOA and personal outing by 8/20/2023. The facility interdisciplinary team (IDT) conducted T Ad Hoc Quality Assessment Performance Improvement (QAPI) meeting to discuss the elopement incident and review the facility plan of correction by 08/21/2023. Beginning 08/19/23 the facility began auditing elopement policy/review for current and agency staff. Audits consisted of three facility staff members and three agency staff members weekly for two weeks, two facility staff members and two agency staff members weekly for two weeks and one facility staff member weekly and one agency staff member for two weeks. Elopement drills would be audited every shift for seven days and then monthly times four weeks. Updates to the elopement book would be audited weekly for four weeks. All identified areas would be submitted to the Quality Assurance committee for additional analysis, review, and implementation of corrective actions, in-services, or modified policies and procedures. Findings include: Review of Resident #92's closed medical record revealed an admitted [DATE] with diagnoses including schizophrenia, delusional disorder, diffuse traumatic brain injury without loss of consciousness, dementia, and epilepsy. Resident #92 was discharged from the facility on 08/31/23. Review of Resident #92's care plan dated 05/13/23 included Resident #92 was an elopement risk, wanderer related to history of attempts to leave facility unattended, impaired cognition, impaired safety awareness, new environment, traumatic brain injury (TBI), delusions and agitation. The goal developed with a target date of 08/20/23 indicated Resident #92 would not leave the facility unattended and Resident #92's safety would be maintained (through the review date). Interventions included to assess Resident #92's fall risk, identify pattern of wandering, (was wandering purposeful, aimless, or escapist, was resident looking for something, does wandering indicate the need for more exercise) and intervene as appropriate. On 07/18/23 the plan of care was updated to included safety checks every 15 minutes. initiated 07/18/23. Review of Resident #92's physician's orders revealed an order, dated 07/17/23 for every 15-minute checks for wandering. Review of Resident #92's Elopement Evaluation dated 07/13/23 revealed Resident #92 was at risk of elopement. Review of Resident #92's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had severe cognitive impairment. The assessment revealed Resident #92 required supervision and a one-person (staff) physical assist for bed mobility, transfers, and locomotion on and off the unit. Resident #92 was not steady walking, but able to stabilize without staff assistance. Review of a nurse practitioner progress note, dated 08/11/23 included Resident #92 was still wandering. Further review revealed Resident #92 required a secure memory unit for safety due to TBI and bipolar disorder (psychiatry following in-house). Continue with meds (medications) and monitor. Review of a hospital emergency department note, dated 08/18/23 at 10:51 P.M. revealed Resident #92 arrived to the local hospital Emergency Department via ambulance and Emergency Medical Services (EMS) and was admitted due to a fall. Resident #92 told the Emergency Department staff he got lost on his walk and tripped over a rock and fell backwards. Resident #92 was found by train the tracks. Resident #92 stated he hit his head but denied loss of consciousness. Review of a cat scan (CT) of the head, without contrast dated 08/19/23 at 2:38 A.M. revealed Resident #92 had an unwitnessed fall with head strike and findings included no acute intracranial hemorrhage or mass effect. Review of Resident #92's medical record/progress notes revealed no written documentation related to an actual elopement on 08/18/23. Review of Resident #92's progress notes dated 08/19/23 at 6:30 A.M. revealed the local hospital Emergency Department was contacted for an update on Resident #92. The notes included Resident #92 was being discharged and was awaiting transportation. The notes did not document why Resident #92 was transported to the local hospital Emergency Department. Review of Resident #92's Elopement Evaluation dated 08/19/23 revealed Resident #92 was at risk for elopement. Review of a facility investigation included a staff interview, dated 08/19/23 from Licensed Practical Nurse (LPN) #210 who revealed she was the nurse assigned to the secured third-floor memory unit (on 08/18/23) when Resident #92 eloped from the facility. LPN #210 stated she was completing medication administration for the residents and heard the back stairwell alarm sound. LPN #210 turned the door alarm off. LPN #210 stated the State tested Nursing Assistant (STNA) was in a resident room providing resident care. LPN #210 stated she did not look for any residents and stated she did not tell the STNA about the alarm. Review of a facility investigation included a staff interview, dated 08/19/23 from STNA #204 who was assigned to the secured third-floor memory unit (on 08/18/23) when Resident #92 eloped from the facility. STNA #204 stated Resident #92 asked about a shower, and she told him she could help him with a shower. STNA #92 revealed the nurse left the unit and STNA #204 was redirecting another resident from trying to leave the unit. LPN #210 never told STNA #204 anything about the alarm. STNA #204 stated she did not know Resident #92 was missing or off the unit until around 10:30 P.M. to 10:45 P.M. when she could not find Resident #92 to help him into bed and immediately notified LPN #210 and Supervisor #265. A staff statement, dated 08/19/23 from Supervisor #265 revealed she was told Resident #92 was missing (on 08/18/23) at 11:15 P.M. Supervisor #265 stated LPN #210 never told her she heard an alarm going off. A search was immediately initiated for Resident #92. Supervisor #265 stated she was notified by local hospital staff that Resident #92 was in the Emergency Department. A staff statement, dated 08/19/23 revealed STNA #278 was assigned to the back hallway of the second-floor nursing unit when Resident #92 eloped from the facility. STNA #278 stated she heard an alarm sounding around 8:30 P.M. for the door leading outside to the back parking lot. STNA #278 checked the door, looked outside, and saw a man walking out of the parking lot. STNA #278 indicated she did not realize it was Resident #92 because people who were not residents in the facility always stood in the parking lot or lay in the grass. Review of Resident #92's Weekly Skin assessment dated [DATE] at 10:37 P.M. revealed a new area was found. The new area was an abrasion of the left outer forearm, in-house acquired on 08/18/23. Resident #92's abrasion measured a length of 1.0 centimeter (cm), width of 1.0 cm and depth was not applicable. The area had a scab covering it and no drainage or swelling was noted. The assessment stated soap and water were used to cleanse the area and there was no dressing. Resident #92's physician and responsible party were notified. Review of Resident #92's physician's orders dated 08/20/23 at 12:52 A.M. revealed an order to cleanse left elbow and forearm abrasions with soap and water and leave open to air, every shift for wound care. Review of an interdisciplinary team (IDT) care conference note dated 08/20/23 at 2:00 P.M. revealed the note was a late entry and on 08/18/20 at 8:30 P.M. Resident #92 exited the facility without informing staff. Resident #92 was wearing a t-shirt, shorts, blue jacket and footwear and the weather was approximately 68 degrees Fahrenheit, partly cloudy. Night rounds on 08/18/23 at 11:00 P.M. revealed Resident #92 was not in his room and a search was initiated. While the facility was being searched a call was received from Resident #92's sister stating the resident was in the Emergency Department for evaluation due to a fall while out of the building. The Administrator and Director of Nursing were notified on 08/18/23 at 11:15 P.M. and Resident #92's physician was notified by the Director of Nursing upon arrival to the facility. Resident head count revealed all other residents were accounted for, door alarm system testing completed by the Administrator revealed alarms were functioning per manufacturer's specifications. Windows were assessed by the Administrator and no issues were identified. Resident #92 returned to the facility on [DATE] via ambulance. 08/19/23. The Director of Nursing interviewed Resident #92 to determine purpose for leaving the facility and Resident #92 stated I was going to work. No psychosocial or emotional distress noted at the time of the assessment. The facility provided information from a public records request as part of their investigation. The record (requested by the facility on 08/21/23) included Resident #92 was picked up in the vicinity of a local road by railroad tracks and brought to the local hospital on 08/18/23 at approximately 11:00 P.M. Interview on 10/10/23 at 1:55 P.M. with [NAME] President of Clinical Services (VPCS) #211 verified Resident #92 eloped from the facility on 08/18/23. VPCS #211 stated staff were interviewed about when they last saw Resident #92 and when door alarms were heard. VPCS #211 indicated she was not in the facility at the time of the elopement but from the interviews it was determined Resident #92 was last seen on 08/18/23 at approximately 8:30 P.M. VPCS #211 stated Resident #92's sister called the facility regarding Resident #92's elopement around 10:30 P.M. to 11:00 P.M. which was about the same time Resident #92 was found to be missing (by staff). VPCS #211 stated Resident #92 resided on the third-floor secured nursing unit and residents did not wear wander guards. VPCS #211 revealed a code was needed to exit two stairwells which could be used to enter and exit the third-floor secured nursing unit. VPCS #211 indicated there was an elevator which was used to enter and exit the third-floor secured nursing unit, and a code was needed to use the elevator. VPCS #211 stated both stairwells had a 15-second egress and would alarm immediately and open after 15 seconds if an attempt was made to open the door without a code. VPCS #211 stated Licensed Practical Nurse (LPN) #210 was an agency nurse working on the secured third-floor nursing unit on 08/18/23 when Resident #92 eloped from the facility. VPCS #211 stated LPN #210 heard a door alarm and turned it off without notifying anyone. VPCS #211 stated she did not know why LPN #210 did not tell anyone or initiate a resident head count when she heard the alarm. VPCS #211 stated Resident #92 walked down a flight of stairs from the third-floor secured nursing unit back entry to the second floor back entry which also had an alarm and opened after 15-seconds to the outside at ground level. VPCS #211 stated the second-floor entrance door alarmed, and opened after 15 seconds, and Resident #92 walked out the second floor back entrance to the outside. VPCS #211 revealed an aide heard the alarm and turned off the alarm without realizing Resident #92 left the facility via the second-floor entrance. VPCS #211 stated the aide saw someone standing in the parking lot but did not realize the person was Resident #92. Interview on 10/11/23 at 12:36 P.M. of State tested Nursing Assistant (STNA) #204 revealed 08/18/23 was the first time she worked on the secured memory unit. STNA #204 stated during the day shift on 08/18/23 she was assigned to a different nursing unit, and stayed after her regular shift ended at 7:00 P.M. to work on the secured nursing unit because the secured memory unit needed coverage from 7:00 P.M. until 11:00 P.M. STNA #204 stated she did not know the residents on the secured nursing unit and an agency nurse she did not know was also assigned to the secured memory care unit. STNA #204 stated the agency nurse did not give her a thorough report regarding which residents were elopement risks. STNA #204 stated she was completing documentation on a resident who was a fall risk, and the agency nurse left the unit for a break. STNA #204 stated the nurse came back from her break, used the back entrance of the secured nursing unit, and did not mention an alarm was sounding when she came back. STNA #204 stated she discovered Resident #92 was missing around 10:30 P.M. and could not remember the time she last saw Resident #92. STNA #204 indicated after Resident #92 was found to be missing the agency nurse told her when she came back from her break the door for the rear entrance of the secured nursing unit was alarming and she turned the alarm off. STNA #204 stated the agency nurse told her she did not think a resident eloped when the door was alarming and that was why she did not say anything. STNA #204 stated she completed rounds on the residents she was assigned to every two hours and did not remember Resident #92 seeking to leave the unit. STNA #204 revealed while they were searching for Resident #92 someone from the hospital emergency department called the facility and told them Resident #92 was being evaluated at the hospital. Review of the facility undated policy titled Missing Resident revealed the purpose was to ensure missing residents were located quickly. A search of all rooms in the facility would be done if a resident was thought to be missing. Assign two personnel to check the area immediately outside the facility. Personnel should go around the facility in opposite directions. When they meet, they should return inside for reassignment. Review of the facility undated policy titled Elopement Prevention revealed it was the goal of the facility to provide a safe environment for all residents while using the least restrictive measures possible. Elopement occurred when a resident left the premises or safe area without authorization and, or necessary supervision to do so. A resident who left a safe area might be at risk of heat or cold exposure, dehydration, and, or other medical complications, drowning, or being struck by a motor vehicle. Residents would be assessed upon admission, quarterly, and with a significant change in condition using the facility designated assessment form to determine whether the resident was at risk for elopement. Once the risk assessment was completed, the IDT (interdisciplinary team) would review the assessment and make the determination if the resident should be identified at risk for wandering and, or elopement. The IDT would document their decision accordingly on the format provided and proceed with determining interventions to keep the resident safe. This deficiency represents non-compliance investigated under Complaint Number OH00146796.

Based on staff interview, review of personnel files and review of the facility abuse prevention policy and procedure, the facility failed to implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property This had the potential to affect all 91 residents residing in the facility. Findings include: Review of a list of faciliy new hires since 06/06/23 revealed 40 non State tested Nursing Assistants (STNA) and non licensed nurses were hired. Review of the personnel files for Licensed Practical Nurse (LPN) #217 and LPN #313 revealed no evidence they were screened using the State of Ohio Nurse Aide Registry. Interview with the Administrator on 10/17/23 between 11:30 A.M. and 11:45 A.M. revealed he was checking all staff against the nurse aide registry but there was no documented evidence of when the check was completed and what staff the check was completed for. Interview on 10/17/23 at 11:58 A.M. with Human Resources Director #207 revealed he was new to the position in the last 45 to 50 days. He confirmed he was not checking new hires against the nurse aide registry unless they were an STNA. He was unaware that all new hires should be checked against the nurse aide registry. Review of the undated facility policy entitled Abuse, Neglect, Exploration, and Misappropriation of Resident's Property and Injuries of Unknown Sources revealed the facility would screen individuals prior to hiring in order to prevent the employment of individuals with convictions or prior history of resident abuse, neglect or mistreatment.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #15, #26, #49 and #50 were supervised while they were smoking and failed to ensure Resident #15 was wearing a smoking apron while smoking. This affected four residents (#15, #26, #49 and #50) reviewed for smoking safety and had the potential to affect all 33 residents (Resident's #1, #2, #5, #6, #8, #9, #11, #13, #14, #15, #18, #23, #25, #26, #33, #36, #43, #49, #50, #54, #56, #58, #59, #61, #62, #64, #67, #74, #75, #80, #87, #89, #95) who smoked in the facility. The facility census was 91. Findings include: 1. Review of Resident #15's medical record revealed an admitted [DATE] and diagnoses included necrotizing fasciitis, acquired absence of left leg above the knee, type two diabetes mellitus without complications, arthritis due to other bacteria left hip and arthritis due to other bacteria right wrist. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 required extensive assistance of one staff member for locomotion off the unit and personal hygiene. Resident #15 had upper extremity impairment on one side and lower extremity impairment on one side. Resident #15 used a wheelchair. Review of Resident #15's Smoking Safety assessment dated [DATE] included Resident #15 had cognitive loss, a visual deficit, and dexterity problems. Resident #15's plan of care was used to assure resident was safe while smoking. Resident #15 needed a smoking apron and supervision while smoking. Review of Resident #15's care plan dated 09/16/23 included Resident #15 was a cigarette smoker by personal choice. Resident #15 would not suffer an injury from unsafe smoking practices through the next review date. Interventions included to supervise and provide assistance as needed. Observation on 10/10/23 at 4:24 P.M. of Resident #15 revealed the resident was outside in a secured area smoking with other residents Resident's #15 was not wearing a smoking apron. Observation revealed there was no staff member supervising the residents while they smoked. Observation on 10/10/23 at 4:26 P.M. revealed Activities Aide (AA) #333 walked out of the facility and into the outside secured area. When asked if Resident #15 should be supervised while they smoked AA #333 said these residents do not need supervision while they smoked. Interview on 10/11/23 at 4:04 P.M. with the Director of Nursing (DON) revealed she expected residents to be supervised by staff while they were smoking. Interview on 10/12/23 at 2:40 P.M. with Administrator revealed today was the first day smoking break assignments were scheduled through workforce management software. The Administrator stated before 10/12/23 the activities and nursing departments covered smoke breaks. The Administrator indicated activities covered afternoon smoke breaks and nursing would cover the rest of the smoke breaks. The Administrator stated staff who smoked would usually volunteer to cover smoke breaks. Interview on 10/12/23 at 3:14 P.M. of Activities Director (AD) #305 revealed activities covered the 12:00 P.M. and 2:00 P.M. smoke breaks and nursing covered the other smoke break times. AD #305 stated if nursing was unable to cover a smoke break then they would step in and supervise the smoke break. AD #305 stated the nursing department covered the 4:00 P.M. smoke break. 2. Review of Resident #26's medical record revealed an admitted [DATE] and diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, anxiety disorder and need for assistance with personal care. Review of Resident #26's care plan dated 08/14/23 included Resident #26 was a cigarette smoker by personal choice. Resident #26 would not suffer injury from unsafe smoking practices through next review date. Interventions included to supervise and provide assistance as needed. Review of Resident #26's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #26 had severe cognitive impairment. Resident #26 required supervision of one staff member for locomotion on and off the unit. Resident #26 used a wheelchair. Observation on 10/10/23 at 4:24 P.M. of Resident #26 revealed the resident was outside in a secured area smoking with other residents. Observation revealed there was no staff member supervising the residents while they smoked. Observation on 10/10/23 at 4:26 P.M. revealed AA #333 walked out of the facility and into the outside secured area. When asked if Resident #26 should be supervised while they smoked AA #333 said these residents do not need supervision while they smoked. Interview on 10/11/23 at 4:04 P.M. with DON revealed she expected residents to be supervised by staff while they were smoking. Interview on 10/12/23 at 2:40 P.M. with Administrator revealed today was the first day smoking break assignments were scheduled through workforce management software. The Administrator stated before 10/12/23 the activities and nursing departments covered smoke breaks. The Administrator indicated activities covered afternoon smoke breaks and nursing would cover the rest of the smoke breaks. The Administrator stated staff who smoked would usually volunteer to cover smoke breaks. Interview on 10/12/23 at 3:14 P.M. of AD #305 revealed activities covered the 12:00 P.M. and 2:00 P.M. smoke breaks and nursing covered the other smoke break times. AD #305 stated if nursing was unable to cover a smoke break then they would step in and supervise the smoke break. AD #305 stated the nursing department covered the 4:00 P.M. smoke break. 3. Review of Resident #49's medical record revealed an admitted [DATE] and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, ataxia (impaired coordination) following cerebral infarction, and muscle weakness. Review of Resident #49's Quarterly MDS 3.0 assessment dated [DATE] included Resident #49 had moderate cognitive impairment. Resident #49 required supervision of one staff member for locomotion on the unit and limited assistance of one staff member for locomotion off the unit. Resident #49 had upper and lower extremity impairment on one side. Resident #49 used a wheelchair. Review of Resident #49's care plan dated 09/16/23 included Resident #49 was a cigarette smoker by personal choice. Resident #49 would not smoke without supervision through the next review date. Resident #49 would not suffer injury from unsafe smoking practices through next review date. Interventions included to supervise and provide assistance as needed. Review of Resident #49's Smoking Safety assessment dated [DATE] included Resident #49 did not have cognitive loss, and had a visual deficit. Resident #49's plan of care was used to assure Resident #49 was safe while smoking. Resident #49 required supervision while smoking. Observation on 10/10/23 at 4:24 P.M. of Resident #49 revealed the resident was outside in a secured area smoking with other residents. Observation revealed there was no staff member supervising the residents while they smoked. Observation on 10/10/23 at 4:26 P.M. revealed AA #333 walked out of the facility and into the outside secured area. When asked if Resident #49 should be supervised while they smoked AA #333 said these residents do not need supervision while they smoked. Interview on 10/11/23 at 4:04 P.M. with the DON revealed she expected residents to be supervised by staff while they were smoking. Interview on 10/12/23 at 2:40 P.M. with Administrator revealed today was the first day smoking break assignments were scheduled through workforce management software. The Administrator stated before 10/12/23 the activities and nursing departments covered smoke breaks. The Administrator indicated activities covered afternoon smoke breaks and nursing would cover the rest of the smoke breaks. The Administrator stated staff who smoked would usually volunteer to cover smoke breaks. Interview on 10/12/23 at 3:14 P.M. with AD #305 revealed activities covered the 12:00 P.M. and 2:00 P.M. smoke breaks and nursing covered the other smoke break times. AD #305 stated if nursing was unable to cover a smoke break then they would step in and supervise the smoke break. AD #305 stated the nursing department covered the 4:00 P.M. smoke break. 4. Review of Resident #50's medical record revealed an admitted [DATE] and diagnoses included muscle weakness, delusional disorders, and presence of right artificial hip joint. Review of Resident #50's care plan dated 03/14/23 included Resident #50 was a cigarette smoker by personal choice. Resident #50 would not smoke without supervision through the next review date. Resident #50 would not suffer injury from unsafe smoking practices through next review date. Interventions included to supervise and provide assistance as needed. Review of Resident #50's Annual MDS 3.0 assessment dated [DATE] revealed Resident #50 had severe cognitive impairment. Resident #50 required supervision of one staff member for locomotion on and off the unit. Resident #50 had lower extremity impairment on one side. Resident #50 used a wheelchair. Review of Resident #50's Smoking Safety assessment dated [DATE] included Resident #50 had cognitive loss. Resident #50's plan of care was used to assure Resident #50 was safe while smoking. Resident #50 required supervision while smoking. Observation on 10/10/23 at 4:24 P.M. of Resident #50 revealed the resident was outside in a secured area smoking with other residents. Observation revealed there was no staff member supervising the residents while they smoked. Observation on 10/10/23 at 4:26 P.M. revealed AA #333 walked out of the facility and into the outside secured area. When asked if Resident #50 should be supervised while they smoked AA #333 said these residents do not need supervision while they smoked. Interview on 10/11/23 at 4:04 P.M. with the DON revealed she expected residents to be supervised by staff while they were smoking. Interview on 10/12/23 at 2:40 P.M. with Administrator revealed today was the first day smoking break assignments were scheduled through workforce management software. The Administrator stated before 10/12/23 the activities and nursing departments covered smoke breaks. The Administrator indicated activities covered afternoon smoke breaks and nursing would cover the rest of the smoke breaks. The Administrator stated staff who smoked would usually volunteer to cover smoke breaks. Interview on 10/12/23 at 3:14 P.M. with AD #305 revealed activities covered the 12:00 P.M. and 2:00 P.M. smoke breaks and nursing covered the other smoke break times. AD #305 stated if nursing was unable to cover a smoke break then they would step in and supervise the smoke break. AD #305 stated the nursing department covered the 4:00 P.M. smoke break. Review of a list of residents who smoke revealed Resident's #1, #2, #5, #6, #8, #9, #11, #13, #14, #15, #18, #23, #25, #26, #33, #36, #43, #49, #50, #54, #56, #58, #59, #61, #62, #64, #67, #74, #75, #80, #87, #89, #95 smoked. Review of the facility policy titled Resident Smoking Policy undated included staff would supervise all smoking sessions to ensure safety regulations were met. This deficiency represents non-compliance investigated under Complaint Number OH00147268.

Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #67's right knee skin impairment was accurately documented to include wound type in the medical record. This affected one resident (Resident #67) out of three residents reviewed for wounds. The facility census was 91. Findings include: Review of Resident #67's medical record revealed an admitted [DATE] and diagnoses included immersion foot, left foot (an injury caused by cold exposure to tissue not resulting in freezing), schizophrenia and type two diabetes mellitus without complications. Review of Resident #67's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 required supervision of one staff member for bed mobility, limited assistance of one staff member for transfers and locomotion off the unit, and Resident #67 was not steady but able to stabilize without staff assistance for walking. Resident #67 used a wheelchair and a walker. Review of Resident #67's Guardianship record dated 07/18/23 included Resident #67 was mentally impaired and had moderate mental retardation, developmental disabilities. The record further stated Resident #67 had mild schizophrenia. Resident #67 had difficulty with decision making and required repetition for learning. Review of Resident #67's Smoking Injury report dated 08/21/23 at 10:23 A.M. included while staff was providing care Resident #67 was observed with an intact blister to the right knee and measured length 2.8 centimeters (cm), width of 2.8 cm and depth was not applicable. Resident #67 reported he might have burned himself while smoking but was unsure. Resident #67 was alert and oriented to person, and confused to place, time, and situation. Resident #67 was unable to provide detail. Resident #67 was ambulatory with an assistive device and staff assist. Resident #67 locomotion with a wheelchair. No witnesses were found to the incident. Smoking assessment completed on 08/23/23 and smoking apron was initiated due to Resident #67's statement of being unsure if area was a burn from a cigarette. Based on review of Resident #67's room, wheelchair, walker, bed, diet, and foods on the menu, coffee consumption, clothing, modalities that would cause trauma during therapy sessions, it was determined that the non-pressure area was consistent with sleeping in the wheelchair. Would encourage Resident #67 not to sleep in wheelchair for prolonged periods of time. The documentation did not specify how the wheelchair caused the blister to Resident #67's right knee. Review of Resident #67's Wound Evaluation and Management Summary dated 08/28/23 included non-pressure wound of the right knee and etiology was undetermined, unknown was resolved. Anatomic location of previously existing wound examined today, epthelialized and resolved and follow up only as needed. Review of Resident #67's Wound Evaluation and Management Summary dated 09/04/23 included burn wound of the right knee, full thickness and etiology was burn and duration was greater than seven days. The objective was to maintain healing phase, cigarette burn. Measurements were length 2.0 cm, width 2.0 cm, and depth was 0.2 cm. A light serrous exudate was noted, granulation tissue was 60 percent. Dressing treatment plan was xeroform gauze, apply once daily for 30 days, and gauze border dressing, apply once daily for 30 days. Review of Resident #67's Wound Evaluation and Management Summary dated 09/25/23 included burn wound of right knee, full thickness and etiology was burn and duration was greater than 27 days. Measurements were length 0.8 cm, width 1.3 cm, and depth was 0.2 cm. Light serrous exudate was noted, and slough was 20 percent and granulation tissue was 80 percent. Further review revealed surgical excisional debridement procedure and the indication for the procedure was to remove necrotic tissue and establish the margins of viable tissue. The wound was cleansed with normal saline. A curette was used to surgically excise devitalized tissue including slough, biofilm, and non-viable muscle level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure the non-viable tissue in the wound bed decreased from 20 percent to 0 percent. Dressing treatment plan xeroform gauze, three times per week and gauze border dressing, three times per week. Review of Resident #67's Wound Evaluation and Management Summary dated 10/02/23 included burn wound of the right knee was resolved on 10/02/23. Anatomic location of previously existing wound was examined, epithelialized and resolved. Follow up only as needed. Review of the facility list of Resident's with Wounds dated 10/01/23 through 10/07/23 included Resident #67 had a right knee burn which was greater than 33 days and was now resolved. Interview on 10/12/23 at 12:03 P.M. of Registered Nurse/ Unit Manager (RN/UM) #200 revealed Resident #67 had a blister on his right knee. When he was asked how he got the blister Resident #67 stated he thought he burned himself while smoking. RN/UM #200 stated this made sense because of the location of the wound. RN/UM #200 stated Resident #67 was supervised while smoking, but not required to wear a smoking apron. RN/UM #200 stated the blister was observed during Resident #67's therapy appointment. Observation on 10/12/23 at 1:03 P.M. of Resident #67's right knee with Licensed Practical Nurse (LPN) #217 revealed the top of Resident #67's right knee had a pink area about the size of a fifty-cent piece, the area was not open and had no drainage. Resident #67 stated he burned himself on his right knee while he was smoking. Resident #67 stated the cigarette burned his right knee through his pants and he fell from his chair. Resident #67 stated he was outside smoking when the cigarette burn occurred and there were no other residents or staff with him. Interview on 10/12/23 at 1:25 P.M. of LPN #217 revealed she sometimes supervised smoking breaks. LPN #217 stated she was not aware Resident #67 had a burn on his leg. Interview on 10/12/23 at 4:27 P.M. of [NAME] President of Operations (VPO) #209 revealed it was speculation that Resident #67's right knee blister was caused from a burn. VPO #209 stated the area was too large to be a burn from a cigarette and was not consistent with a cigarette burn. VPO #209 did not state what caused the right knee blister. Review of Resident #67's Wound Physician (WP) #206's note revised on 10/24/23 at 1:37 P.M. for the date of service 08/21/23. The note stated Resident #67's right knee blister was classified as undetermined, unknown etiology to further investigate the cause. After further investigation it was determined that this was an injury from the wheel chair and resolved on 08/28/23. Inadvertently WP #206 forgot to change the etiology to trauma, injury prior to resolving the wound on 08/28/23. Resident #67's right knee wound opened up again and was evaluated on 09/04/23 and labeled as a burn wound due to miscommunication. In reality the wound opened up due to Resident #67 picking on the old site. Etiology was trauma, injury and was self-inflicted. WP #206 did not state how the wheelchair caused the blister. Review of Resident #67's Registered Nurse/Unit Manager (RN/UM) #200 statement written on 10/24/23 revealed she documented Resident #67's right knee wound as a blistered area. Resident #67 stated he might have burned himself but was unsure. RN/UM #200 wrote her clinical judgement did not lead her to believe it was a cigarette wound due to the size of the wound. RN/UM #200 stated the size of the wound did not correlate with Resident #67 burning himself with a cigarette. RN/UM #200 did not state what caused the right knee blister. This deficiency represents non-compliance investigated under Complaint Number OH00147268 and OH00146796.

Based on observation, interview, record review, and facility policy review the facility did not ensure insulin was dated after it was opened and/or failed to ensure the insulin was labeled with the resident's name after it was pulled from the contingency box. This affected three residents (#44, #45 and #59) out of nine residents who had orders for insulin on the C North medication cart. This had the potential to affect 20 residents (#6, #9, #14, #16, #27, #29, #30, #32, #35, #44, #45, #47, #50, #52, #55, #59, #60, #74, #80, and #85) who had orders for insulin at the facility. Findings included: 1. Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease, and heart failure. Review of the August 2023 physician orders revealed Resident #44's orders included: Novolog FlexPen 100 units per milliliter (ml) inject 35 units subcutaneously (SQ) before meals and Ozempic pen-injector 2 milligram (mg) per 1.5 ml inject 0.25 mg SQ every seven days in the morning. Observation on 08/18/23 at 9:06 A.M. revealed Licensed Practical Nurse (LPN) #602 opened a new Novolog insulin FlexPen and administered Resident #44's 35 units SQ to his right upper arm per his order. She placed the new insulin FlexPen back into the medication cart without labeling with the date that she had opened. Observation of the C North medication cart with LPN #602 on 08/18/23 at 10:06 A.M. revealed Resident #44's Novolog continued to be not dated. Observation revealed there was an opened Ozempic insulin pen that was undated as to when it was opened and without a name to who the insulin pen belonged to. Interview on 08/18/23 at 10:06 P.M. with LPN #602 verified she had forgot to date the Novolog insulin for Resident #44 when she opened it. She also verified the Ozempic insulin pen was unlabeled with name of resident and/ or date when opened. She revealed she did not know who the Ozempic pen belonged to. Interview on 08/18/23 at 10:08 A.M. with the Director of Nursing (DON) as she walked by the C North medication cart verified the Ozempic pen was unlabeled as there was no identification of a resident's name on the pen and/ or a date of when the pen was opened. She revealed the pen was pulled from the contingency box and should have been labeled with the resident name and dated when opened. Interview on 08/18/23 at 2:31 P.M. with the DON verified the Ozempic pen belonged to Resident #44. 2. Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia and diabetes. Review of the August 2023 physician orders revealed Resident #59 had a physician order for Novolog FlexPen 100 units per ml inject per sliding scale SQ. Observation on 08/18/23 at 9:25 A.M. revealed LPN #602 administered Resident #59's Novolog insulin 10 units to her left upper arm per her sliding scale. The insulin pen was not dated as to when it was opened. Interview on 08/18/23 at 9:34 A.M. with LPN #602 verified that the insulin pen was not dated as to when it was opened and that she had not checked the pen prior to administering Resident #59 her insulin. 3. Review of medical record for Resident #45 revealed an admitted [DATE] with diagnoses including diabetes and hypertension. Review of the August 2023 physician orders revealed Resident #45 had an order for Humalog Kwik pen solution 100 units per ml per sliding scale. Observation of the C North medication cart with LPN #602 on 08/18/23 at 10:06 A.M. revealed there was a Humalog insulin vial approximately one fourth full of a date as opened as 08/01/23 but the vial did not have a resident's name on the vial. Interview on 08/18/23 at 10:06 P.M. with LPN #602 verified the Humalog vial did not have a resident's name on it to identify who the insulin belonged to. Interview on 08/18/23 at 10:08 A.M. with the DON as she walked by the C North medication cart verified the Humalog vial was pulled from the contingency box and was not labeled properly with a resident's name of who the insulin belonged to. Interview on 08/18/23 at 2:31 P.M. with the DON verified the Humalog belonged to Resident #45 as they had pulled the insulin from the contingency box for him. Review of the facility policy labeled, Administering Medications, dated April 2019, revealed medications were to be administered in a safe and timely manner. The policy revealed the expiration date on the medication was checked prior to administering and when opening a multi-dose container, the date opened was to be recorded on the container. The policy revealed insulin pens containing multiple doses of insulin were for single-resident use only. The policy revealed insulin pens were clearly labeled with the resident's name or other identifying information prior to administering the insulin. This deficiency represents non-compliance investigated under Complaint Number OH00144529.

Based on interview and record review, the facility failed to prevent an event of physical abuse at the facility. This affected one resident (Resident #84) out of five residents reviewed for abuse prohibition. The total census was 88. Findings include: Record review of a self-reported incident (SRI) revealed physical abuse was alleged on 09/16/22 involving Resident #84. Resident #84 alleged that STNA (state-tested nursing aide) #701 threw a soda bottle at him. Review of the facility investigation revealed STNA #701 denied the allegation. A typed witness statement from Resident #84 stated the STNA took his breakfast tray before he was done with it. The STNA said it was empty, Resident #84 called him a liar, and STNA #701 flicked a soda in Resident #84's face. A typed witness statement from Resident #64 (Resident #84's roommate) stated that Resident #84 wanted to keep his food when the staff member took it away, and Resident #84 cursed at the staff and staff flicked soda on Resident #84. Review of the police investigation narrative revealed Resident #84 said he was struck in the face by a soda bottle thrown by STNA #701, and Resident #64 said he saw the event happen. The facility unsubstantiated the allegation. Interview with Resident #84 on 10/18/22 at 9:48 A.M. revealed he recalled the above event and said STNA #701 threw a bottle at him like a baseball pitcher after he called STNA #701 a liar for removing his untouched breakfast tray and claiming it was empty. Resident #84 was able to deflect some force of the throw by raising his arm, but was still struck in the face and soda splashed onto his eyes. He had no pain at the time except a burning sensation in his eyes from the soda. Interview with Resident #64 on 10/18/22 at 3:36 P.M. revealed he recalled the event identified in the SRI. He said he saw STNA #701 throw a soda bottle at Resident #84 and hit his face. Interview with the Administrator on 10/19/22 at 10:13 A.M. reviewed the above findings. He was involved with the investigation for the SRI and said they could not substantiate because it was one person's word against another. He said the investigation did not identify Resident #64 saw the event, only that he heard it. STNA #701's employment was terminated following the event. Record review of Resident #84 revealed he was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His minimum data set assessment dated [DATE] revealed he had mild or no cognitive impairment. A skin assessment following the alleged abuse event revealed no evidence of new injury. His care plan included a history of making false accusations against staff members and making inappropriate comments. Record review of Resident #64 revealed he was admitted to the facility 09/23/21 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His minimum data set assessment dated [DATE] revealed he had mild or no cognitive impairment. His care plan revealed no mention of any history of false accusations against staff members. This citation was a result of incidental findings during the investigaiton of Complaint Number OH 659.

Based on record review and interview, the facility failed to ensure ordered blood tests were done for Resident #74. This affected one of three residents reviewed for laboratory services. The total census was 88. Findings include: Record review of Resident #74 revealed he was admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had an order dated 03/24/22 for a complete blood count (CBC), magnesium (mag), and basic metabolic panel (BMP) lab tests to be done weekly. He had no lab results present in his paper chart, and the only blood lab posted in his computer charting was a complete metabolic panel and CBC dated 06/03/22. Interview with Licensed Practical Nurse (LPN) #401 on 10/18/22 at 11:29 A.M. confirmed the above findings. Following surveyor intervention, the facility contacted Resident #74's nurse practitioner and clarified the labs were to be drawn monthly. This deficiency resulted from an incidental finding during the investigation of Complaint Number OH 910.

Based on observation, interview, and record review, the facility failed to ensure call light systems were in place and functioning in each resident room. This affected two (Resident #64 and #84) of five residents reviewed for call light response. The total census was 88. Findings include: Observation on 10/18/22 at 11:09 A.M. revealed the call light plug and push-buttons for Resident #64 and #84's room were disconnected from the wall and sitting on a chair near the foot of the bed. Interview with Resident #84 at this time revealed it occurred some time yesterday morning. He did not know how it happened, and did not receive any alternate means of calling for help (such as a physical bell) from facility staff. Interview with Licensed Practical Nurse (LPN) #203 on 10/18/22 at 11:32 A.M. confirmed the above observation. She was the direct-care nurse for the above two residents at the time of the observation and was not aware the call light had been disconnected. Observation on 10/18/22 at 3:35 P.M. revealed the call light in Resident #64 and Resident #84's room was still on the chair, and there was still no call light plugged into the wall. Resident #84 was asleep at this time. Interview with LPN #203 on 10/18/22 at 3:44 P.M. confirmed the call light in the room was still disconnected. She said she had not yet contacted anyone to fix it and was not sure how. An unidentified STNA entered the interview at this time and said she would page maintenance for assistance. Interview with the Administrator on 10/18/22 at 3:57 P.M. reviewed the above findings. Following surveyor intervention, the facility promptly connected the unplugged call light and found it to be functional. Record review of Resident #84 and Resident #64 revealed no documentation indicating they were incapable of using a call light or that it would be appropriate to be removed. This deficiency substantiates Complaint Number OH 910.

Based on observation, interview, record and policy review, the facility failed to monitor and consistently implement treatment to Resident #26's avoidable pressure ulcer. This resulted in actual harm when an in-house acquired pressure ulcer to the coccyx declined to a Stage 4 pressure ulcer with recommendation for surgical debridement and [CONDITION(S)]. In addition, the facility failed to consistently provide treatment to Resident #92's pressure ulcers. This affected two, Resident #26 and Resident #92 of three residents with pressure ulcers reviewed. The facility census was 91. Findings include: 1. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She required the extensive assistance of two plus staff for bed mobility, total dependence of two plus staff for transfers, total assistance of one person for toilet use and extensive assistance of one person for personal hygiene. She was occasionally incontinent of bladder and frequently incontinent of bowel. She had occasional pain at a level two out of ten. She had a fall and fracture prior to admission. She was identified at risk for pressure ulcers but had none upon admission. Review of the plan of care revised 08/23/22 indicated Resident #26 had been non-compliant with turning and repositioning. The interventions included to invite her to activities that encourage physical activity to promote mobility, monitor for immobility, provide supportive care, assistance with mobility and refer to therapy as ordered. The initial skin plan of care was initiated on 07/13/22 and revised on 08/23/22 indicating she had an unstageable pressure ulcer to the sacrum. The interventions included to avoid scratching and keeping hands and body parts from excessive moisture, keep fingernails short, educate family on causative factors and measures to prevent skin injury, encourage good nutrition and hydration, follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 07/21/22 at 7:32 A.M. indicated she had moisture associated skin damage to proximal end of gluteal folds. The nurse practitioner was notified and ordered a barrier cream twice daily and as needed. On 08/10/22 at 12:45 P.M. Resident #26 was moved to the second floor. She was complaining of pain and foul odor was coming from her buttocks. A skin assessment was performed and observed an area to the coccyx of about 2.5 cm (centimeters) in length and 5 cm across. It was noted the measurement could be off due to the resident unable to remain still. The area was cleansed with normal saline, hydra gauze was applied, covered with foam dressing, and giving Tylenol for discomfort that rated a seven out of ten. The nurse manager was notified of the skin issue. Review of the progress note dated 08/14/22 at 7:35 P.M. the nurse practitioner noted she complained of worsening sore to her coccyx and to consult the wound care team. On 08/24/22 at 2:50 P.M. the nurse was informed the resident had a new pressure area. However, this was charted in error. The pressure ulcer was identified as a Stage 4 slough and maceration pink deep wound bed, some granulation tissue, moderate amount of drainage serosanguineous and no odor. The wound measured 2.5 cm wide by 3 cm long by 1.5 cm deep. The nurse practitioner was notified of the changes and a new order to cleanse with normal saline, pack with alginate ensuring the edges were covered and cover with boarder foam three times weekly and start [MEDICATION(S)] (an opioid analgesic) 30 minutes prior to wound care and as needed. The son was notified of the changes in the wound and an air mattress put into place. Review of the July 2022 treatment administration record (TAR) revealed she was ordered wound care to the coccyx two times daily beginning on 07/23/22. The TAR had blanks for day shift on 07/27/22 and 07/28/22. A code 9 was documented for night shift on 07/23/22, 07/24/22, 07/29/22 and 07/31/22. According to the chart code a 9 meant other to see progress notes. Review of the progress notes lacked corresponding notes on 07/23, /22 07/24/22 and 07/29/22 as identified on the TAR. The nurse practitioner noted on 07/31/22 at 9:04 P.M. the resident complained of worsening sore on her coccyx. Review of the August 2022 TAR revealed blanks on day shift on 08/01/22, 08/13/22 and 08/19/22 and night shift on 08/08/22, 08/09/22 and 08/13/22. Interview with Unit Coordinator #126 on 08/30/22 at 8:44 A.M. reported she was newly hired and placed in charge of wound care. She thought Resident #26's wound started prior to admission but declined during her stay. She reported she initiated an air mattress, pain control, a treatment change, and nutritional supplements to aid in the healing of the wound. Interview with and observation of Resident #26 on 08/30/22 at 9:00 A.M. revealed her wincing in pain. She stated she was sitting on her sore and it hurt. Interview with the Director of Nursing (DON), Unit Coordinator #126 and the Assistant Director of Nursing (ADON) on 08/30/22 at 11:44 A.M. revealed upon admission she was provided a barrier cream. They verified the pressure ulcer started as moisture associated skin damage that declined into a pressure ulcer. They verified there was no documented evidence the pressure ulcer was monitored between 08/10/22 and 08/24/22. They attributed some of the decline to her contracting COVID 19 and decreased mobility. They verified the blanks on the TAR; and there should have been corresponding progress notes to address why a treatment was not provided and the TAR coded a 9. Interview with Unit Coordinator #126 on 09/07/22 at 11:12 A.M. regarding the pressure ulcer revealed Resident #26 was medicated for pain prior to the dressing change. She indicated the wound had a foul odor and a lot of drainage. Wound Physician #300 assessed the wound on 09/02/22 and was going to admit Resident #26 to the hospital for surgical debridement. She indicated the Wound Physician was going to notify her regarding a time for the procedure. Interview with Resident #26 on 09/07/22 at 11:15 A.M. revealed she was in pain and indicated she wished the facility would have addressed the wound when she first complained to the staff. Wound care was observed for Resident #26 on 09/07/22 at 11:18 A.M. Unit Coordinator #126 set up her supplies on the bedside table. After washing her hands and putting on clean gloves Unit Coordinator #126 and State tested Nurse Aids (STNA) #139 removed the resident's brief. The dressing was intact to Resident #26's coccyx. The brief had a large amount of serosanguinous drainage which had seeped out from under the resident's dressing onto the brief. Unit Coordinator #126 removed the dressing along with the gauze packing inserted into the wound. A large amount of serosanguinous drainage was present on the soiled dressing. Resident #26 moaned several times during the packing removal. The wound had tunnelling and a foul odor present. Unit Coordinator #126 cleansed the wound with normal saline soaked gauze then dried it with gauze. She then soaked a roll of gauze with normal saline and packed the wound with it. A foam dressing was then placed over wound with Unit Coordinator #126 ensuring the dressing adhered to the skin and did not cover the rectum. Review of the wound progress note date 09/02/22 from Wound Physician #300 revealed Resident #26's wound had significant necrotic tissue and moderate associated fecal contamination. Wound Physician #300's recommendation was to perform a [CONDITION(S)] (a surgical intervention where an opening is made into the bowel and fecal matter would then drain into a [CONDITION(S)] bag) and surgical debridement. 2. Review of the medical record revealed Resident #92 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission comprehensive assessment dated [DATE] indicated he was cognitively intact. He displayed no symptoms of [CONDITION(S)] or behaviors. It was very important for him to choose the clothes he wore but somewhat important to choose between a tub, shower, bed, or sponge bath. He required the extensive assistance of two plus staff for bed mobility, transfers, toilet use and personal hygiene. He had one Stage 3 and one Stage 4 pressure ulcer and one unstageable pressure ulcer. Review of the skin integrity care plan initiated on 07/11/22 indicated the interventions were to avoid scratching and keep hands and body parts from excessive moisture, keep fingernails shirt, educate the resident on causative factors and measures to prevent skin injury, encourage good nutrition and hydration to promote healthier skin, head to toe assessment performed on shower days and report any changes with skin integrity. Review of the July 2022 TAR revealed he had treatments to his right stump, left hip and sacrum pressure ulcers. There were blanks on the following days for each treatment 07/08/22, 07/14/22, 07/26/22, 07/27/22 and 07/29/22. Review of the August 2022 TAR revealed blanks on 08/02/22, 08/09/22, 08/13/22 and 08/14/22. The number 7 was marked for 08/12/22. Interview with the DON on 08/30/22 at 11:44 A.M. verified 7 was the code for sleeping. Review of the undated pressure ulcer prevention and risk identification policy and procedure indicated residents would be assessed weekly for four weeks upon admission, quarterly and with significant change thereafter. Preventive measures would be implemented based upon the residents' assessed needs. If a new skin area was identified the nurse would initiate a skin/grid measurement flow record that would be updated every seven days until the area was resolved. This deficiency substantiates Compliant Number OH 086 Complaint Number OH 218.

Based on observation, medical record review, interviews with facility staff, review of facility policy, and review of American Heart Association guidelines, the facility failed to ensure a 911 call was immediately placed for Emergency Medical Services (EMS) when Resident #92 was found in his bed unresponsive and without vital signs. Cardiopulmonary Resuscitation (CPR) was initiated, but a 911 call for Emergency Medical Services (EMS) was not placed until 5:39 A.M., 39 minutes after Resident #92 was found unresponsive. The EMS crew arrived at 5:47 A.M. and at 5:54 A.M. Resident #92 was pronounced dead on arrival. This affected one resident (Resident #92) of three residents reviewed for CPR. On [DATE] at 4:51 P.M. the Administrator and Vice President/Administrator/Registered Nurse (VP/Administrator/RN) #684 were notified Immediate Jeopardy began on [DATE] at 5:00 A.M. when the facility failed to call 911 for 39 minutes after Resident #92 was discovered unresponsive and without vital signs in his bed. Licensed Practical Nurse (LPN) #673 entered the room at 5:00 A.M. and observed Resident #92 in his bed unresponsive and without vital signs. LPN #673 called out for Respiratory Therapist (RT) #633 to assist her. RT #633 ran to Resident #92's room and CPR was initiated. There was no indication a back board was used for CPR. LPN #673 did not activate Resident #92's call light, did not retrieve the Automated External Defibrillator (AED) or crash cart, or yell out for other staff to come to the room to assist her. State tested Nursing Assistant (STNA) #650 observed RT #633 running into Resident #92's room, did not see a call light on, did not hear calls for help, and did not enter Resident #92's room to see if there was a problem. CPR was initiated but a 911 call was not immediately placed for EMS services. LPN #673 did not call 911 until 5:39 A.M., 39 minutes after Resident #92 was found unresponsive. The EMS crew arrived at 5:47 A.M. and at 5:54 A.M. Resident #92 was pronounced dead on arrival, with observations of rigor mortis around his mouth and jaw, pupils were dilated and he was non-responsive. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · Beginning [DATE] all resident code statuses have been reviewed for all residents by Director of Nursing (DON) for auditing purposes. · On [DATE] and [DATE], five STNA's and one RN completed a CPR certification class by Certified CPR Instructor. · On [DATE], starting at 5:30 P.M., two mock code drills were completed on separate floors of the facility. One on B floor at 5:30 P.M., and one on C floor at 6:00 P.M. The Summary of Mock Code indicated all elements of the mock code were demonstrated and executed. Mock code drill conducted by DON and Administrator. · On [DATE], education provided to all facility nursing staff by DON on Codes policy and procedure, including calling 911 and what to do if you're alone and have to initiate CPR. All nurses not in the facility were educated via phone. All agency staff educated prior to working at the facility. Facility staff educated: 5 RN's, 5 LPN's and 13 STNA's. · On [DATE], Human Resources Director (HRD) #640 and the Administrator audited current nursing staff for CPR certification and any uncertified nurses were removed from the schedule until certification is obtained. · On [DATE], a mock code drill conducted by DON and Administrator on night shift at 6:00 A.M. · Mock code [NAME] to be completed three times a week for four weeks with random mock code drill thereafter to be completed by DON or designee. · All real codes will be reviewed by the DON to ensure code ran accordingly. Education to follow as needed and mock code [NAME] increased if needed by DON or designee. · HRD #640 or designee will verify CPR certification upon hire and audit HR files weekly for four weeks, and randomly thereafter to ensure certifications are current. · Results of audits will be reviewed in Monthly QAA meeting. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of Resident #92's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #92's Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident was cognitively intact. Resident #92 was totally dependent on and required the assistance of two staff for bed mobility, transfers, toilet use, and personal hygiene. Review of Resident #92's care plan included the resident had chosen Full Code measures and CPR would be initiated during cardiac/pulmonary arrest. The care plan included resident choices would be honored through the next review date on [DATE]. Interventions revealed to initiate 911, provide full resuscitative measures and verify resident choice quarterly. Review of Resident #92's progress notes written on [DATE] at 7:47 A.M. revealed LPN #673 entered Resident #92's room at 5:00 A.M. and found him unresponsive. LPN #673 immediately called Respiratory Therapist (RT) #633 for assistance, 911 was called (time not specified) and compressions started. CPR was continued until the ambulance arrived. There was no indication a back board was used. The note stated CPR was unsuccessful and Resident #92 was pronounced dead at 5:45 A.M. The family and Administrator were notified, and Resident #92's physician and nurse practitioner were unable to be contacted. Review of Resident #92's EMS Patient Care Report revealed on [DATE] at 5:39 A.M. a call was received for a Cardiac/Respiratory Arrest. The EMS crew was dispatched and arrived on scene at 5:47 A.M., was at the patient at 5:51 A.M., and the outcome was Resident #92 was dead on arrival. Further review of the report revealed Resident #92 was found unresponsive, pulseless, apneic, laying supine with a staff member performing CPR. Resident #92 was last seen approximately 3:00 A.M. when he was suctioned. Staff stated they checked on Resident #92 at approximately 5:40 A.M. and the resident would not respond. Staff stated Resident #92 was found in cardiac arrest, CPR was started, and 911 was called. Resident #92 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A heart monitor was placed, and asystole (no heartbeat) was confirmed, skin was pale, cool, and dry, onset of rigor mortis around mouth and jaw, pupils were dilated and non-reactive. Resident #92 was pronounced dead on arrival at 5:54 A.M. and left in the care of the nursing home staff. Review of Respiratory Therapist's (RT) #633 statement written on [DATE] revealed Resident #92 activated his call light at 3:45 A.M. because he wanted to be suctioned, then went back to sleep. The statement revealed at 5:00 A.M. LPN #673 had RT #633 come to Resident #92's room because she felt something was wrong. Resident #92 had no pulse, the nurse left the room to call 911 (time not specified), and RT #633 assembled the oxygen equipment and began to manually administer oxygen to the resident until the paramedics arrived at around 5:40 A.M. Review of LPN #673's statement undated, stated at 3:00 A.M. Resident #92 asked for pain medication, was told it was too soon for him to receive it, and she would give it to him between 5:00 A.M. and 6:00 A.M. The statement included LPN #673 entered Resident #92's room at 5:00 A.M. and the resident was unresponsive. RT #633 was called to help, 911 was called (time not specified), and CPR was initiated and continued until the ambulance arrived. CPR was unsuccessful and Resident #92's mother was notified. There was no indication a back board was used for CPR. Review of Resident #92's Code Blue Bedside Documentation for [DATE] included CPR was initiated at 5:05 A.M. by LPN #673 and RT #633, the arrest was unwitnessed, the time of the 911 call was not recorded, absence of vital signs was recorded at 5:00 A.M. and 5:05 A.M., CPR was ongoing, and no pulse established. RT #633 administered oxygen via an Ambu (self-inflating bag) bag through Resident #92's [CONDITION(S)]. The documentation revealed EMS arrived at 5:40 A.M. and the code was called by EMS/emergency room physician at approximately 6:00 A.M. The time of death was not recorded, and Resident #92's physician and family were notified. Observation on [DATE] at 12:00 P.M. of the nursing unit Resident #92 resided on, revealed Resident #92's room was directly across from the nurse's station, only a few steps away. An AED was located in a clear case attached to the wall inside the nurse's station. A crash cart was located to the right of Resident #92's room along the side of the hall. Interview on [DATE] at 3:42 P.M. with LPN #673 revealed Resident #92 asked her for pain medication around 3:00 A.M., it was too early for him to receive pain medication, and she told him she would give him his pain medication at 5:00 A.M. LPN #673 stated at 5:00 A.M. she entered Resident #92's room to give the pain medication, noticed his color was off, shook him, called his name but he did not respond. LPN #673 stated she called out for RT #633 to assist her because she knew RT #633 was close to Resident #92's room. LPN #673 stated CPR was initiated when RT #633 entered the room, and 911 was called (time not specified) when RT #633 was bagging (administering oxygen through his [CONDITION(S)]) the resident. Interview on [DATE] at 7:30 A.M. and 12:39 P.M. with LPN #673 revealed she was sure she entered Resident #92's room at 5:00 A.M. because she started her med pass at 5:00 A.M., and she made sure he was the first resident to have medications administered because she knew he wanted pain medication. LPN #673 stated CPR was initiated, continued for 45 minutes, and it was around 5:30 A.M. to 5:45 A.M. when 911 was called. LPN #673 stated we worked on him awhile before 911 was called. LPN #673 stated there was another nurse assigned to the nursing unit, but she left work early and was not available to help. LPN #673 stated she did not activate the call light and did not bring the AED and crash cart to the room. LPN #673 stated she panicked and did not call for the STNA to assist her. LPN #673 stated the STNA's were on the other hall providing resident care and would not be able to help. LPN #673 stated she and RT #633 took turns providing chest compressions until EMS arrived. There was no indication a back board was used during the chest compressions. Interview on [DATE] at 6:12 P.M. with RT #633 revealed she was sure it was 5:00 A.M. when LPN #673 called her to assist in Resident #92's room because she wore a watch and looked at the time. RT #633 stated the time was 5:00 A.M., that was the time she started her rounds, and she was getting ready to start her rounds when she was called into Resident #92's room. RT #633 stated when she entered Resident #92's room, he was unresponsive, and CPR was started. Interview on [DATE] at 2:45 P.M. with STNA #650 revealed on [DATE] she was working on the nursing unit Resident #92 resided on, but his room was not part of her assignment. STNA #650 stated she did not hear LPN #673 scream for RT #633 to help her in Resident #92's room, but she saw RT #633 running into the room. STNA #650 stated she did not know if RT #633 saw her, but RT #633 did not say anything was wrong or call out for help. STNA #650 stated she did not know anything was wrong and did not go in Resident #92's room to see if RT #633 needed assistance. STNA #650 stated she continued providing care for the residents on her assignment. Interview on [DATE] at 2:32 P.M. with the Administrator and the DON revealed although there were no identified problems with how the code was conducted on [DATE] an education on cardiac/respiratory arrest was conducted on [DATE]. The Administrator and DON stated they were not aware a 911 call was not placed for 39 minutes after Resident #92 was found unresponsive on [DATE] at 5:00 A.M. Review of the facility Cardiopulmonary Resuscitation (CPR) certifications revealed the facility was unable to provide evidence LPN #673 (involved in Resident #92's cardiac/respiratory arrest) was certified in CPR. Review of the facility Cardiopulmonary Resuscitation (CPR) certifications revealed Registered Nurse (RN) #630, and Licensed Practical Nurse's (LPN) #647 and #676 had online certification only and did not have hands-on skills assessment as part of their certification. Review of the facility Cardiopulmonary Resuscitation (CPR) certifications revealed the facility was unable to provide evidence LPN #608 was certified in CPR. Interview on [DATE] at 8:40 A.M. with Human Resources Director (HRD) #640 revealed it was the nurse's responsibility to make sure their CPR certification was renewed. HRD #640 stated she was new to the facility in ,d+[DATE] and had a lot of things to catch up on. HRD #640 stated when nurses were hired, she asked for their CPR certification card to make a copy of it for their file, but she was not always able to get it because the nurse's said they had a hard time getting the card from their CPR instructor. HRD #640 stated from now on she would make sure CPR certifications were up to date. HRD #640 stated LPN #673 was newly hired in ,d+[DATE] but her employee file did not contain evidence of CPR certification. Interview on [DATE] at 12:00 P.M. with the DON and Administrator confirmed RN #630 and LPN's #647 and #676 had online CPR certification only and did not have hands-on skills assessment. The DON and Administrator confirmed there was no evidence of CPR certification for LPN's #608 and #673. Review of a facility in-service titled, Mock Code Blue Survey, dated [DATE] and [DATE] included steps to assess resident, check scene, call 911, check pulse, crash cart, AED, chest compressions, and notify nursing management and the Administrator. The code checklist included crash cart obtained, 911 called, AED used, and backboard utilized. Review of the facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation, revised, ,d+[DATE], included Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. The policy further included if an individual was found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest was likely, begin CPR and instruct a staff member to activate the emergency response system and call 911, verify or instruct a staff member to verify the DNR or code status of the individual, and initiate the basic life support (BLS) sequence of events. Review of American Heart Association guidelines, dated [DATE], included Part 5: Adult Basic Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Basic Life Support (BLS) was the foundation for saving lives following cardiac arrest. Fundamental aspects of BLS include immediate recognition of sudden cardiac arrest (SCA) and activation of the emergency response system, early cardiopulmonary resuscitation, and rapid defibrillation with an AED. The guidelines included a core set of actions provides a universal strategy for achieving successful resuscitation. These actions were termed links in the chain of survival. For adults they include, immediate recognition of cardiac arrest and activation of the emergency response system, early CPR that emphasizes chest compressions, rapid defibrillation if indicated, effective advanced life support, and integrated post-cardiac arrest care. This deficiency substantiates Complaint Number OH 661.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure appropriate care and services were provided for one resident (Resident #37) to prevent a deep tissue injury to the left plantar foot. Actual harm occurred when care planned interventions were not implemented, physician orders were not followed, and a pressure injury to Resident #37's foot was not treated or documented before it was identified as an unstageable deep tissue injury. This affected one resident (Resident #37) out of three residents reviewed for pressure injury. Findings include: Review of Resident #37's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's care plan, dated 06/21/21, revealed the resident had actual impairment to skin integrity related to Stage 3 decubitus ulcer of left calcaneous, and Resident #37 would maintain or develop clean and intact skin through the review date of 09/19/21. Interventions included to encourage Resident #37 to comply with turning side to side and document non-compliance, head to toe skin assessments to be performed weekly on shower days by the nurse, and document and report new areas to the physician, wound nurse, and dietician, notify physician of any redness, and observe for skin injury on shower days and while performing care. Review of Resident #37's physician orders on 07/13/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Document skin assessments and shower refusals with progress notes. Review of Resident #37's Braden Scale Assessment for Predicting Pressure Sore Risk, dated 08/05/21, revealed resident was at a moderate risk for developing pressure ulcer injury. The assessment included Resident #37 was bedfast and confined to his bed, was completely immobile and did not make even slight changes in body or extremity position without assistance. Resident #37 required moderate to maximum assistance in moving, and complete lifting without sliding against sheets was impossible. The assessment revealed Resident #37 frequently slid down in bed or chair, requiring frequent repositioning with maximum assistance. [CONDITION(S)], contractures, or agitation led to almost constant friction. Review of Resident #37's Minimum Data Set (MDS) 3.0 assessment, dated 08/19/21, revealed the resident had moderate cognitive impairment. The assessment revealed Resident #37 required extensive assistance of two staff for bed mobility and transfers, was at risk for developing a pressure ulcer injury, and had one or more unhealed pressure ulcers. Review of Resident #37's wound round notes on 08/04/21, 08/12/21, 08/17/21, 08/26/21 revealed the resident had a Stage 3 decubitus pressure ulcer of left calcaneous (heel). Resident #37's feet were noted to be wrapped and padded and elevated by pillow. The notes included a plan to keep heels elevated off of the bed with foam padding and pillows (the plan was highlighted in big, bold, black letters). Review of Resident #37's physician orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders to elevate the resident's heels. Review of Resident #37's left heel wound round assessment, dated 08/26/21, revealed daily dressing changes were recommended. The medical record contained no evidence the daily dressing change recommendation was addressed. Observation on 09/09/21 at 10:16 A.M. of Resident #37 revealed the resident's heels were elevated by a pillow but not by foam padding. Observation of Wound Physician Assistant (PA) #688 and DON completing Resident #37's left foot dressing for Stage 3 decubitus ulcer of left calcaneous revealed the dressing being changed was dated 09/02/21. Removal of the dressing revealed a Stage 3 decubitus ulcer of left calcaneous and a new deep tissue injury of left plantar foot (sole of foot). The left plantar foot was deep purple in color, black around the edge and did not blanche. Wound PA #688 measured the injury and length was 3 cm, width 1.5 cm, depth unable to be measured. Review of Resident #37's Treatment Administration Record (TAR) revealed a left heel dressing change was not documented as completed on 09/03/21 or 09/06/21. It was documented the dressing change was completed on 09/08/21, however observation revealed the dressing was not changed since 09/02/21. Review of Resident #37's medical record from 06/21/21 through 09/09/21 did not reveal documentation Resident #37's heels were elevated or evidence of a deep tissue injury to the left plantar foot. Review of Resident #37's assessments from 08/10/21 through 09/09/21 revealed a weekly skin assessment on 08/10/21 and no further weekly skin assessments were documented. Review of Resident #37's progress notes from 08/20/21 through 09/09/21 did not reveal Resident #37 declined to be turned side to side, declined showers, or declined weekly skin assessments. Review of Resident #37's Wound Round documentation by Wound Physician Assistant (PA) #688 on 08/04/21, 08/12/21, 08/17/21 and 08/26/21 did not reveal documentation of a deep tissue injury of left plantar foot. Review of Resident #37's wound round documentation on 09/02/21 did not reveal documentation of a deep tissue injury to the left plantar foot. Review of Resident #37's Wound Round documentation on 09/09/21 revealed the resident has a pressure induced deep tissue injury of left plantar foot. The measurements were length 3 centimeters (cm), width 1.5 cm, and depth was unable to be determined. The documentation revealed skin was deep purple, non-blanchable, no surrounding redness or swelling and no break in skin. Review of Resident #37's left heel wound round assessment, dated 09/09/21, revealed daily dressing changes were recommended. The medical record contained no evidence the daily dressing change recommendation was addressed. Interview on 09/22/21 at 9:42 A.M. with the Director of Nursing (DON) revealed Wound Nurse (WN) #632 managed all resident wounds, including documentation and communications with the physician. The DON did not know why the dressing changes were recommended daily. The DON stated WN #632 resigned on 09/09/21 and since her resignation the DON was managing the wounds. The DON stated her observations of Resident #37's wound did not reveal dressing changes should be done daily, three times a week were sufficient, but she would investigate the progress notes recommending daily changes. Interview on 09/09/21 at 10:16 A.M. with Wound PA #688 revealed the deep tissue injury to Resident #37's left plantar foot was not there two weeks ago when she did wound rounds. Wound PA #688 stated she did not do wound rounds on 09/02/21 and the last wound rounds were 08/26/21. Wound PA #688 was standing near the foot of the bed, patted the footboard and stated Resident #37's deep tissue injury of the left plantar foot was caused by the pressure of his foot against the footboard. Interview on 09/09/21 at 10:16 A.M. with the DON confirmed the dressing on Resident #37's left foot was dated 09/02/21. Interview on 09/09/21 at 3:45 P.M. with State tested Nursing Assistant (STNA) #683 revealed she worked second shift and was usually assigned to the nursing unit Resident #37 resided on. STNA #683 stated Resident #37 tended to slide down in bed with his feet pressing against the footboard, she did not like to see him in that position and would pull him up in bed when she noticed it. STNA #683 stated this happened often. STNA #683 stated Resident #37 had dressings on his feet, the nurse did the dressing changes, and she could not see his feet when she assisted him with his care. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 04/2018 included the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s).

Based on observations, staff interviews, review of the medical record, hospital record, and the facility elopement and neglect policies, the facility failed to ensure adequate supervision to prevent one cognitively impaired resident (Resident #47) exiting out a third story window in an attempt to elope from a secured unit. This resulted in Immediate Jeopardy on 11/18/20 at 1:10 P.M. when Resident #47 climbed out of a third-floor window without staff knowledge. The likelihood of serious harm, injury, or death occurred when Resident #47 unscrewed and removed the metal [MEDICATION NAME] from the window, climbed out and fell to the asphalt pavement below. Resident #47 was seen passing by the window of the [MEDICAL TREATMENT] center by [MEDICAL TREATMENT] Technician (DT) #213 as he fell . Actual harm occurred when Resident #47 required emergent transfer to the hospital where he was diagnosed with [REDACTED]. The blood accumulates in the space between the inner lining of the abdominal wall and internal abdominal organs). This affected one of three residents residing on the third floor who were identified as being at risk for elopement (Residents #45, #47 and #59). The facility census 82. On 11/25/20 at 4:43 P.M. the facility Administrator was notified Immediate Jeopardy began on 11/18/20 at 1:10 P.M. when Resident #47, who was at risk for elopement and had exit seeking behaviors, fell from a third-floor window located on the secured care unit landing on the asphalt pavement below. Resident #47 required emergent transfer to the local hospital by Emergency Medical Services (EMS) and was subsequently admitted for treatment of [REDACTED]. The Immediate Jeopardy was removed on 11/23/20 when the facility implemented the following corrective actions: · On 11/18/20 at 1:15 P.M, the window which Resident #47 exited was secured by placing four screws into the window by Plant Operations Manager (POM) #201. · On 11/18/20 by 2:15 P.M., four screws were placed in each window on the D-floor (third floor secured unit) securing both windows to the window frame making all windows inoperable. This was completed by POM #201. · On 11/18/20 at 3:00 P.M., the facility began conducting elopement drills. Drills were conducted on 11/18/20 at 3:00 P.M. by the Administrator; on 11/19/20 at 6:35 A.M. by Social Services Manager #214 and Regional Admissions Coordinator #236; on 11/19/20 at 2:30 P.M. by the Administrator, and on 11/23/20 at 7:00 A.M. by Social Service Manager #214. Staff were observed for response time to the alarm, identifying who sounded the alarm and searching premises. Once all steps had been taken and/or an elopement was ruled out, an All Clear was called. Based on observation staff were re-educated as needed. Elopement drills will be conducted weekly for three months then monthly. Review of staff sign in sheets revealed by 11/23/20, twenty-six of 45 facility staff (RNs, Licensed Practical Nurses (LPNs) and State tested Nurse Aides (STNAs)) had participated in an elopement drill. · On 11/18/20 at 3:30 P.M., the facility began educating staff on elopement policies and procedures, including elopement prevention, emergency door codes and walkie talkie use. The education was provided on 11/18/20 at 3:30 P.M. by the Vice President of Operations; on 11/19/20 at 11:00 A.M. by Director of Marketing #237, and on 11/20/20 at 7:00 A.M. by Minimum Data Set (MDS) Coordinator #230. Any employees that were not educated will complete the education with Human Resource Manager #233 or designee prior to starting their shift. Review of the elopement education sign is sheets revealed on 11/23/20, thirty-eight of 45 facility staff (RNs, LPNs, and STNAs) had received the education. All new facility staff will be provided with a list door codes upon hire. Policies and procedures regarding the door alarms will be reviewed with all new hires during orientation by Human Resource Manager #233. · On 11/18/20 at 3:30 P.M., the Vice President of Operations completed an audit of the D-floor windows and verified all windows were screwed shut with four screws and all windows were inoperable and safe. · On 11/18/20 by 6:30 P.M., POM #201 placed a 21-inch metal window stop in every window on the D-floor and secured them with four screws (two(NAME)head and two Hex head). The four previously placed screws that secured the window to the frame of the window were left in place, so there were four screws in each window and a 21-inch metal window stop with four screws. · On 11/18/20 at 6:30 P.M., the Vice President of Operations and Administrator completed an audit of the D-floor windows and verified that each window had four screws and a 21-inch metal window stop with four screws securing it to the frame of the window. A daily window audit will continue by the Vice President of Operations, Administrator or designee for one month. The audits will then move to three times a week. · On 11/18/20 at 7:00 P.M., a window audit was started every hour to verify each window was secure. The staff assigned to the D-floor completed the audits. The one-hour window audits continued for 72 hours. · On 11/19/20 from 10:35 A.M. through 11:06 A.M., Social Services Manager #214 interviewed all residents on the D-floor ( Residents #10, #22, #25, #38, #45, #46 #52, #57, #58, #59, #65, #69, #79 and #81) to assess for possible home going exit seeking behaviors or frustrations with being on a secure unit. No residents interviewed were seeking to leave the facility. · On 11/19/20 at 11:00 A.M. and 11/20/20 at 7:00 A.M., Abuse, Neglect and Misappropriation education was conducted by MDS Coordinator #230 and the Director of Marketing. Any employees that did not attend the education, where educated over the phone before their next shift. If the employee was unable to be reached, a voicemail was left for the employee to complete the education with Human Resource Manager #233 or designee prior to starting their shift. · On 11/19/20 from 1:19 P.M. through 3:41 P.M., an elopement risk assessment was completed by Registered Nurse (RN) #203 and RN #216 for all residents on the D-floor ( #10, #22, #25, #38, #45, #46 #52, #57, #58, #59, #65, #69, #79 and #81). All the residents were assessed to be at low risk. Each week all new admissions will be audited by the Director of Nursing (DON), the Assistant Director of Nursing (ADON) or the Unit Managers to ensure an Elopement/Exit seeking risk assessment has been completed and a plan of care developed if the resident was identified at high risk. · All staffing agencies are informed of the facility's policies prior to any employees being sent to the facility. On the first day an employee from a staffing agency arrives they are given a packet of mandatory in-services, door codes, and login information. They must sign they have received the packet and education related to the contents of the packet. Policies and procedures regarding the door alarms will be reviewed with agency staff prior to the start of their shift by Human Resource Manager #233 or designee. · Interviews on 11/24/20 from 6:41 A.M through 12:40 P.M., on 11/25/20 from 11:20 A.M. through 1:12:55 P.M., on 11/30/20 from 7:55 A.M. through 2:20 P.M., and 12/02/20 from 11:03 A.M. through 1:32 P.M. revealed staff from all three shifts (RN #203, LPN #211, STNA #205, STNA #210, RN #216, STNA #234 and LPN #235) had received training and were knowledgeable on elopement procedures, elopements prevention, door codes, walkie talkie use and abuse and neglect. · On 11/25/20 at 9:36 A.M., observation revealed each window on the D-floor, including the room where Resident #47 exited had a 21-inch bar in the base of the window with four separate screws attaching the bar to the window frame. All windows were screwed shut. · On 11/27/20 (no time), The Quality Assurance Performance Improvement (QAPI) committee, which included the medical director and all department heads, met and reviewed the incident involving Resident #47 falling from the window. The committee reviewed the responsive actions taken including education conducted, drills conducted and audits which had been completed. The QAPI committee will review all future findings including ongoing education, elopement drills and audits to ensure ongoing compliance and ensure immediate corrective action taken if necessary. Although the Immediate Jeopardy was removed on 11/23/20, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine further action if required. Findings Include: Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47's care plan dated 08/03/20 revealed Resident #47 was an elopement risk/wanderer related to dementia. The resident wandered aimlessly. Interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book; identify pattern of wandering and intervene as appropriate; observe for fatigue and weight loss; provide structured activities. The care plan indicated Resident #47 resided on a secured unit. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #47 required supervision for transfers, walking and locomotion; had delusions and wandered, and the Brief Interview of Mental Status (BIMS) score of seven indicated Resident #47 had severe cognitive impairment. Review of the Elopement Risk Assessment completed 10/01/20 revealed Resident #47 was at high risk for elopement. Review of the progress notes revealed on 10/01/20 at 6:30 P.M. Resident #47 went to the exit doors saying he was going to leave to go pay his bills; on 10/06/20 at 7:45 A.M. Resident #47 was agitated and tried to get on elevator with staff; on 10/06/20 at 12:42 P.M. Resident #47 told the nurse he needed to go to the drugstore to get his money and was not easily redirected. Review of the progress noted dated 11/18/20 at 1:10 P.M. revealed Resident #47 climbed out of a third-floor window without staff knowledge and fell to the asphalt below. The resident was transported to the hospital. Review of the hospital records revealed Resident #47 sustained a pelvic fracture, bladder wall injury and hemoperitoneum on 11/18/20 as result of the fall. Interview on 11/24/20 at 12:40 P.M. with LPN #211 revealed she was the nurse on duty when Resident #47 climbed out the window; however, LPN #221 was not present on the third floor when Resident #47 went out the window. LPN #221 observed Resident #47 in the dining area earlier in the day and he appeared to be calm with no signs of exit seeking. When LPN #221 left the floor for approximately 10 minutes to go to the administrator's office, she heard a Code Silver on her walkie talkie and saw staff running outside. When she got outside, she observed Resident #47 on the ground. Nurse Practitioner (NP) #212, who was present at the facility, assessed Resident #47 and he was awake, alert and oriented. LPN #221 said Resident #47 was able to recall what had happened. He said he unscrewed the bolt on the window, was able to get the window opened and he fell out. LPN #211 said EMS was called and Resident #47 was sent to the hospital for evaluation. Interview on 11/25/20 at 11:20 A.M. with STNA #210 revealed Resident #47 had been having a good day and was joking with the staff while sitting in the dining room. STNA #210 explained Resident #47 could be exit seeking in that he would say he was going shopping or looking for his wife. To her knowledge, Resident #47 had never pulled at the window or played with the [MEDICATION NAME] on the window prior to 11/18/20. STNA #210 saw Resident #47 walk from the dining room to his room right before lunch trays came up. There was another STNA and orientees (Certified Nurse Assistant #209 and orientee STNA #238) working on the floor in addition to STNA #210. The STNAs were passing trays when they heard an announcement on the walkie talkie and saw the housekeeper running down the hall. STNA #210 ran to Resident #47's room and saw the window was wide open. Interview on 12/02/20 at 12:10 P.M. with NP #212 revealed on 11/18/20 around 1:15 P.M. she was arriving at the facility and saw people running toward a body on the ground. She jumped out of her car and ran over. Resident #47 was on the asphalt under the [MEDICAL TREATMENT] center window. Resident #47 was on his left side with a window screen underneath him. He was complaining of left leg pain. The third-story window was entirely open. NP #212 observed maintenance at the window trying to figure out what had happened and how. Resident #47 initially said he had fallen out the window. Resident #47 had a small red suitcase with him and when questioned he said he was trying to go home. During the 25-minute wait for EMS to arrive Resident #47 changed his story several times. Resident #47 said the [MEDICATION NAME] and screw were in the drawer in his room. NP #212 said she did not know how Resident #47 was able to remove the screw from the metal [MEDICATION NAME] and open the window because his cognitive skills to reason something like that were not there. NP #212 revealed Resident #47 was mildly exit seeking, in that he would say he wanted to go home. NP #212 stated during the last few weeks, Resident #47 had not expressed any exit seeking behaviors Interview on 12/02/20 at 1:26 P.M. with DT #213 revealed on 11/18/20 at about 1:10 P.M. she saw someone drop past her window of the [MEDICAL TREATMENT] center. She could not look, but immediately notified the nurses in the [MEDICAL TREATMENT] department who looked out the window and saw a resident on the ground. They notified the nursing home and ran outside to check on the resident. Review of the facility's undated Elopement Prevention policy and procedure revealed it was the facility's policy to ensure that a resident's environment remained as free from accidents hazards as was possible. Further, it was the goal of the facility to provide a safe environment for all residents while using the least restrictive measures possible. The policy indicated unsafe wandering or elopement was defined as random or repetitive locomotion. The movement could be goal directed or could be non-goal directed or aimless. Non-goal-directed wandering required a response in a manner that addressed both safety issues and evaluation to identify root cause to the degree possible. Under Procedure the policy indicated staff were to promptly report any resident who tried to leave the premises to the charge nurse. This information would be placed in the clinical record and notification to the DON immediately when exit seeking behaviors continued or increased to determine need and plan for increased supervision. Review of the facility's undated Abuse, Neglect, Exploitation and Misappropriation of Resident's Property and Injuries of Unknown Sources revealed the following key components: screening of potential new hires; training of employees; prevention; identification of possible incidents or allegations which need investigation; investigation of incidents and allegations; protection of residents during investigations; reporting of incidents, investigations and the facility response to the results of their investigations. This deficiency substantiates Complaint Number OH 515 and OH 483.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, review of the medical record and the facility elopement and neglect policy, the facility failed to provide appropriate supervision of one cognitively impaired resident, to prevent elopement from the secure unit. This resulted in Immediate Jeopardy on 10/01/20 at approximately 11:00 A.M. when Resident #51 eloped from the facility from the secure unit without staff knowledge. The likelihood of serious harm or injury occurred when Resident #51 removed a window and proceeded onto the roof and attempted to descend the building via the drainpipe. Resident #51 was seen passing by the window of the [MEDICAL TREATMENT] area by [MEDICAL TREATMENT] Registered Nurse (RN) #113 as she fell to the ground. Serious harm occurred when Resident #51 sustained a fracture of right calcaneus sequela (ankle area), fracture shaft of right fibula, displaced fracture of navicular right foot and a subarachnoid bleed. This affected one (Resident #51) of three residents reviewed for elopement. This had the potential to affect five (Residents #21, #51, #52, #62 and #68) who were at risk for elopement residents who resided on the secure unit on 10/01/20. The facility census on 10/01/20 was 99. The facility census at the time of the survey was 98. On 10/27/20 at 4:07 P.M. the facility Administrator was notified of a situation of Immediate Jeopardy which began on 10/01/20 when Resident #51 who was at risk for elopement and had exit seeking behaviors, exited the facility unattended from the secured care unit without staff knowledge. The Immediate Jeopardy was removed and corrected on 10/03/20 when the facility implemented the following corrective action: · On 10/01/20 at approximately 11:10 A.M. all department heads were called to the administrator's office. They were informed that all windows and doors needed checked. At 11:15 A.M., Human Resource Director #106 and Dietary Manager #115 checked rooms 101 to 119. Therapy Director #116, Minimum Data Set (MDS) Nurse #117, and Business Office Manager #118 checked rooms 201 to 240. Activities Director #119 and Housekeeping Supervisor #102 checked rooms 301 to 314. · On 10/01/20 at 12:00 P.M., Plant Operations Supervisor (POS) #101, purchased the items needed to modify the windows. The window modifications started on 10/01/20 at 2:00 P.M. On 10/01/20, the D-floor window modifications were completed at 3:08 P.M. On 10/01/20, the C-floor window modifications were completed at 4:16 P.M. On 10/01/20, the B-floor window modifications were completed at 5:05 P.M. The plastic window [MEDICATION NAME] were replaced with steel window [MEDICATION NAME] and a steel restrictive plate was added to all windows. At 6:20 P.M. the Administrator and Vice President of Operations #120 verified all windows had been retrofitted and all windows were secured. They verified all doors had functioning alarms and all windows only opened four inches, had a metal [MEDICATION NAME] in place, and the window was secured with a steel restrictor plate to prevent the window from being removed from the track. · On 10/01/20 at 1:00 P.M., Director of Nursing (DON) #110 started the elopement risk assessments on Residents #8, #11, #21, #25, #50, #51, #52, #62, #63, #66, #67, #68, #74, #78, #89, #93, and #97 and was completed on 10/01/2020 at 5:36 P.M. No changes noted from the previous elopement risk assessments performed on the above noted residents. Therefore, no revision in their plan of care was needed. · On 10/01/20 at approximately 2:00 P.M. Assistant Director of Nursing (ADON) #121 started the education for elopement prevention, missing resident, and emergency codes to all staff present in the building at that time. · On 10/02/20 at approximately 6:00 A.M., DON #110 continued with the education to all staff that were present in the building at that time and she completed it on 10/02/20 at 6:00 P.M. · An elopement drill was conducted by POS #101 for all staff on 10/02/20, 10/09/20 and 10/28/20. Elopement drills will be conducted by POS #101 or designee once a month for the next 90 days. · Completed staff education and drills: 10/2/20, DON on 11:00 P.M. to 7:00 A.M. and 7:00 A.M. to 3:00 P.M. shift; 10/09/20, POS #101 and DON on 7:00 A.M. to 3:00 P.M. shift; 10/28/20, DON, POS #101, and ADON #121 on 3:00 P.M. to 11:00 P.M. shift · On 10/08/20 at 5:00 P.M. Resident #51 returned from her hospital stay and her safety and medical needs were reassessed by Licensed Practical Nurse (LPN) #122 and her plan of care was revised and updated by the DON. Resident #51 was placed on 1:1 supervision until she was discharged home under the supervision of her family and home health services on 10/27/20. · All new residents upon admission, readmission, quarterly, and as needed, are assessed with [REDACTED]. · All new employees are educated the Human Resources Manager (HR) #106 on the facility's elopement and abuse policy upon hire. · All staff will be educated annually and as needed on the facility's elopement and abuse policy by Plant Operations Manager #101 and/or the DON. · All new staff/agency staff are given a list of all the door codes upon hire. It is gone over with all new hires during their orientation by HR Manager #106 and all agency staff receive it on their first day at the start of their shift by HR Manager #106 or designee. · A walkie talkie was on the unit at the time of the incident. We have assigned a walkie to each individual working on the secured unit. We will also monitor weekly for three months that the walkie talkie is charged and functioning properly. · A current phone list with the extension all landlines located in the building and employee phone numbers are located at each nursing station next to the telephone. · Door Audits will be completed weekly for 30 days and twice a month for 30 days by the plant operations supervisor or designee and validated by the facility administrator or designee. All findings will be reported to the QAPI committee. Door audits were performed and validated on: 10/07/20, 10/14/20, 10/19/20, and 10/28/20 · Window Audits will be completed weekly for 30 days and twice a month for 30 days by the plant operations supervisor or designee and validated by the facility administrator or designee. All findings will be reported to the QAPI committee. Window audits were performed and validated on: 10/01/20, 10/07/20, 10/14/20, 10/21/20, and 10/28/20 · Negative findings, if any, will be addressed immediately to the administrator and reported to the QAPI committee, which includes the medical director and all the department heads. Findings include: Record review revealed Resident #51 was admitted to the facility 09/25/20 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 had a Brief Interview of Mental Status (BIMS) score of one, indicating severe cognitive impairment and required limited assistance with one to ambulate. The resident wandered daily. Review of the nurse's documentation dated 10/01/20 at 12:24 P.M. revealed the DON was notified by Ohio Certified [MEDICAL TREATMENT] Technician (OCDT) #111 that Resident #51 was found outside on the ground. It appeared she exited through a window. Interview on 10/26/20 at 5:26 P.M. with OCDT #111 revealed on 10/01/20 she heard a thump, and RN #113 stated she thought someone fell off the roof. OCDT #111 went outside to see if Resident #51 was okay. Resident #51's fingers and arm were bloody. OCDT #111 assisted Resident #51 back into the building. Resident #51 was transferred to the hospital on [DATE] and was diagnosed with [REDACTED]. Review of the facility incident report dated 10/01/20 completed by the DON revealed Resident #51 was observed on the ground by OCDT #111. It appeared the resident exited the secured unit window. Review of the schedule for the secured unit dated 10/01/20 revealed two State tested Nursing Assistants (STNA) and one nurse were scheduled on the unit. Interview with STNA #100 on 10/27/20 at 12:25 P.M. revealed she worked by herself on the secured unit on 10/01/20 because STNA #104 was pulled to a different floor. At the time of the elopement, RN #103 was downstairs in the human resources office. STNA #100 could not recall the time on 10/01/20 (prior to the elopement) when Resident #51 took the window off the tracks over the black plastic [MEDICATION NAME]. When Resident #51 took the window off the tracks the first time, STNA #100 asked Housekeeping Supervisor #102 to get maintenance to secure the window. STNA #100 stayed with Resident #51 and redirected her to the dining room with the other residents. After redirecting Resident #51 to the dining room, a call light went off, so she answered the call light. She stated she left the door cracked while giving care to the other resident and observed Resident #51 walk past the door in the direction of her room. STNA #100 completed the care for the other resident, and then she went to check on Resident #51. Resident #51 was standing near the window attempting to remove it again. STNA #100 left the secure unit unattended and went to the maintenance office, which was located down the hall behind two sets of locked doors, to get someone to secure the window. STNA #100 exited the secure unit but was unable to get back into the locked unit because she did not have the code. STNA #100 began banging on the door, and the DON opened the door and informed STNA #100 that Resident #51 had jumped from the window. The DON had gone to the secure unit because she was informed of Resident #51's elopement. Interview on 10/27/20 at 11:44 A.M. with Housekeeping Supervisor #102 revealed on 10/01/20, STNA #100 asked him to get Maintenance Director #101 because Resident #51 took the window off the tracks. STNA #100 informed him she put the window back on the tracks and redirected the resident to the dining room. He stated he informed Maintenance Director #101 that the window needed to be secure. Maintenance Director #101 stated she would fix the window. Housekeeping Supervisor #102 stated he proceeded to do rounds. After Housekeeping Supervisor #102 did rounds, he saw the Assistant Director of Nursing (ADON) #121 and the code went over the walkie talkies for all department heads to report to the Administrator's office. Interview on 10/27/20 at 1:54 P.M. with Maintenance Director #101 revealed she put the window back on the track. There was one aide on the floor, and she was with Resident #51 so Maintenance Director #101 went to her office to get a drill and screw to secure the window. She stated she was off the unit gathering supplies from 10:30 A.M. to 10:45 A.M. While she was gathering her supplies to secure the window, the announcement went over the walkie talkies for all department heads to go to the Administrator's office. She stated after the incident, all windows were secured with a metal [MEDICATION NAME] (instead of the plastic [MEDICATION NAME]), and a bracket was installed so no window could be pulled of track. She stated she was given a directive to have all windows secured prior to leaving for the night. Interview on 10/26/20 at 4:29 P.M. with the DON revealed Resident #51 got out of the window and she was alerted. Prior to the elopement, Resident #51 was exit seeking, so Resident #51 was transferred from the first floor to the secure unit on 09/30/20. After the elopement, the DON did an incident report, investigated, reassessed all residents for elopement, checked all windows and secured them, in-serviced everybody and put Resident #51 on one on one supervision when she returned from the hospital. Interview on 10/28/20 at 10:21 A.M. with Certified Nursing Assistant (CNA) #104 revealed she was scheduled for the secure unit on 10/01/20. She was only on the secure unit for approximately one hour before she was instructed to go to a different unit by the nurse, stating it was a direct order from the Administrator because they were short-staffed. CNA #104 stated prior to Resident #51's elopement, there were one to two aides scheduled on the secure unit. Interview on 10/28/20 at 11:53 A.M. with Human Resource Director (HR) #106 revealed on 10/01/20, RN #107 came to her office and stated that she did not want to work on the secure unit. She wasn't sure what time RN #107 was in the office but believes she was in the office for approximately seven minutes. Then the alert came over the walkie-talkies that all department heads report to the Administrator's office immediately due to the elopement of Resident #51. The Administrator and DON put the department heads in teams to check all the windows and doors. Phone interview on 10/28/20 at 1:04 P.M. with RN #107 revealed she was scheduled to work on 10/01/20 but did not have an assignment, so she went to the secure unit. There were two aides to start the shift, and they pulled one aide at 8:00 A.M. to another unit because they were short-staffed. RN #107 stated she completed the morning medication pass and resident checks, and then she went to HR #106. She stated she was in HR #106's office from approximately 10:30 A.M. to 10:45 A.M. She stated Resident #51 was looking out the window all morning, but most of the residents on that unit look out the windows. RN #107 stated while she was in HR #106's office the walkie talkies went off alerting staff of the elopement. Review of the admission assessment dated [DATE] revealed Resident #51 was readmitted to the facility with a right fibula fracture and 1:1 supervision. Resident #51 was discharged home under the supervision of her family and home health services on 10/27/20. Review of the undated facility policy titled, Elopement Prevention, revealed it is the goal to provide a safe environment for all residents while using the least restrictive measures possible. This deficiency substantiates Complaint Number OH 535.

Based on record review and interview, the facility failed to ensure one resident (Resident 13) was free from significant medication errors. This affected one of three residents whose medication administration records were reviewed. Actual Harm occurred to Resident #13 when the facility failed to administer physician ordered medication for the treatment of [REDACTED]. Findings Include: Record review for Resident #13 revealed an admission date of [DATE] with a primary [DIAGNOSES REDACTED]. Other pertinent [DIAGNOSES REDACTED]. The minimum data set 3.0 (MDS), dated [DATE] revealed a brief interview for mental status (BIMS) was conducted and Resident #13 scored a 15 which indicated a cognitively intact resident. Review of the nursing notes reflected the nursing staff had contacted the pharmacy to have medications delivered to the facility on [DATE] at 10:59 A.M These medications would not arrive for another three to four hours according to the note written at 10:59 A.M. Review of the physician orders [REDACTED].#13 revealed the following had been active on 10/27/17 and the resulting nurse documentation for the medications. Insulin [MEDICATION NAME] (long acting insulin) 30 units for diabetes was to have been administered on 10/26/17 at 9:00 P.M. and the facility was not able to evidence the administration of this medication on the medication administration record. The facility failed to evidence the administration of insulin [MEDICATION NAME] 20 units on 10/27/17 at the scheduled time of 9:00 A.M. [MEDICATION NAME] (anti-convulsant medication used in the treatment of [REDACTED].M., 2:00 P.M. and 9:00 P.M. The facility failed to evidence two administration opportunities on 10/26/17 at 9:00 P. M. and on 10/27/17 at 6:00 A.M. The physician had ordered for Resident #13 to have his blood sugars checked four times a day and the resident was to receive a dose of insulin based on the level of glucose in the resident's blood. These checks were to be done before meals and at bedtime. The facility failed to evidence a blood glucose check with resulting values on 10/26/17 at 9:00 P.M. and 10/27/17 at 7:30 A.M. The next documented nursing note stated on 10/27/17 at 12:41 P.M. Resident #13 was observed outside in a wheel chair, slumped over and unresponsive. Resident #13 was foaming at the mouth, had heavy breathing and his body was jerking. [MEDICAL CONDITION] interventions were initiated by the staff. The nurse practitioner was notified and Resident #13 was to be transferred to the hospital per the new order obtained. The notes stated no physical injury was sustained at the time of the transfer with the emergency medical transport service. Review of the hospital emergency room report revealed a documented admission of [MEDICAL CONDITION] with aggressive behavior. The laboratory values obtained from blood samples on admission to the hospital revealed an elevated blood glucose level of 581 milligrams per deciliter (mg/Dl), normal range was listed as 74-99 mg/Dl. An interview with the Administrator and the Director of Nursing (DON) on 11/13/17 at 8:10 A.M. verified the facility had missed two doses of anti-[MEDICAL CONDITION] medications and verified the failure to monitor blood glucose levels and administer insulin. An interview with Licensed Practical Nurse (LPN) #102, who was working the day shift on 10/27/17, verified she had not administered the morning medications as ordered and was in the process of obtaining the medications with communication between the nurse and the pharmacy. At the time of arrival of the medications for Resident #13 on 10/27/17 around the lunch hour, Resident #13 was having a [MEDICAL CONDITION] and transferred to the hospital. In an interview with the Corporate Manager #105 on 11/13/17 at 1:35 P.M. these findings were verified. This deficiency substantiates Complaint Number OH 511 and Complaint Number OH 427.