Every finding on record at Embassy of Cambridge

Based on staff interviews, record review, and hospital record review, the facility failed to send a resident to the hospital for evaluation after the medical provider recommendation. This affected one resident (#4) of four residents reviewed for change in condition. The facility census was 61. Findings include:Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including non-ST elevation myocardial infarction (NSTEMI), asthma, and chronic obstructive pulmonary disease (COPD). Review of a care plan dated 07/24/26 revealed Resident #4 was at risk for complications and signs/symptoms related to diagnosis of anemia. The goal was to remain free of signs or symptoms of complications related to anemia through the review date of 10/22/26. Interventions included but were not limited to administer medications as ordered and observe for side effects and effectiveness; encourage intake of foods high in iron and vitamin C; obtain lab work and diagnostic work as ordered; offer foods high in iron when available; report to provider signs/symptoms as follows: pallor, increased fatigue, dizziness, syncope, headache, palpitations, weakness, or shortness of breath. Review of a care plan dated 07/24/26 revealed Resident #4 had the potential for bleeding or hemorrhage related to the use of anticoagulant medication or the use of medications that have blood-thinning effects. The goal was to be free from abnormal reactions to anticoagulant use. Interventions included but were not limited to observe for signs of bleeding, black tarry stools, bruising, hematuria, headaches, nosebleeds and report to provider; protect from falls/injury as much as possible; give medications as prescribed; and identify conditions or medications that could inhibit or enhance anticoagulant actions such as ASA, thyroid medications, antacids, barbiturates, and alcohol and report to provider. Review of a minimum data set (MDS) dated [DATE] revealed Resident #4 was dependent on staff for transfers. Review of a nursing note dated 07/28/26 at 9:03 A.M. by Licensed Practical Nurse (LPN) #180 revealed Resident #4 went very pale and got lightheaded during a transfer to her wheelchair. Resident #4's vitals were obtained (the note did not indicate what the vital signs were) and the resident was assisted back to bed. The color came back to resident's face. Review of an e-Interact Change in Condition assessment dated [DATE] at 9:49 A.M. revealed Resident #4 had a change in condition related to abnormal vital signs including a blood pressure of 99/64 and respirations of 30 breaths per minute. The medical provider was contacted on 07/28/26 at 9:00 A.M. and gave the recommendation to transfer Resident #4 to the emergency department (ED). Resident #4's husband was notified at 9:00 A.M. as well. Review of a nursing note dated 07/28/26 at 11:00 A.M. by LPN #180 revealed Resident #4's husband arrived to the facility and her husband requested the resident be sent to the ED for evaluation. The squad was contacted for transport. Review of a nursing note dated 07/28/26 at 11:17 A.M. by LPN #180 revealed the squad arrived to transport Resident #4 to the hospital and the ED was contacted for report. Review of a nursing note dated 07/28/26 at 5:29 P.M. by LPN #180 revealed Resident #4 was being transferred to a tertiary care facility. Review of a hospital note dated 07/28/26 revealed Resident #4 presented to the ED with complaint of weakness, hypotension, dizziness while standing, decreased appetite, decreased urine output, and generally not feeling well. Resident #4's labs all came back and showed no infections but her white blood cell count was high. Resident #4 was fecal occult positive. Resident #4 would need transferred to a higher level of care facility related to recent stent placement. Interview on 08/19/26 at 12:35 P.M. with LPN #180 revealed on 07/28/26, therapy was working with Resident #4 and Certified Nursing Assistant (CNA) #164 went in to assist and when Resident #4 stood, she got really pale and acted like she was going to pass out so they put her back in the wheelchair and obtained her vital signs which were abnormal. LPN #180 stated Resident #4's family was called by Registered Nurse (RN) #170 so she did not know what notifications or conversations were had with the family. Resident #4's husband came in and he wanted her sent to the hospital and the provider was notified. LPN #180 stated at that point, Resident #4 was responding like normal again. LPN #180 confirmed in the nursing note at 9:03 A.M., she did not include information regarding notification of Resident #4's family or medical provider. LPN #180 confirmed in the change in condition assessment, it stated the medical provider was notified at 9:00 A.M. and wanted Resident #4 sent out the hospital. LPN #180 stated the conversation with the medical provider was to wait for the husband's decision regarding the hospital but confirmed the assessment did not read that way and she forgot to put the order in to go to the hospital. LPN #180 stated if she thought the resident's condition was urgent, she would have sent her out right away. LPN #180 stated once the resident was back in bed, she was talking, her color came back and she was drinking fluids. LPN #180 stated the aide kept checking on the resident and clarified Resident #4's husband was at the facility for approximately 30 minutes before requesting she be sent out (to the hospital). Interview on 08/19/26 at 1:18 P.M. with RN #170, the Assistant Director of Nursing, revealed while reviewing Resident #4's nursing notes and change in condition assessment, it read as if the resident was not sent out to the hospital when the medical provider recommendation was made at 9:00 A.M. until 11:00 A.M. when the resident's husband requested she go to the ED. RN #170 stated Resident #4 had no changes, was stable, and they should have charted she did not want to be sent out. RN #170 stated she was called into Resident #4's room because the resident got weak while trying to stand with therapy. LPN #180 then checked the vital signs, she wasn't having any pain, had weakness, and she could not recall if Resident #4 had stated whether or not she wanted to go to the hospital. RN #170 stated the resident was not used to sitting up a lot but she did not have changes in speech. RN #170 stated LPN #180 made all the calls to notify the medical provider and she (RN #170) made the call to the resident's husband and let him know about the incident and the resident was fine now. RN #170 stated she did not relay the physician's recommendation to go to the hospital at that time because she was not aware of it as LPN #180 had made the phone call to the medical provider. RN #170 stated she would not have left Resident #4 in her room had she been unstable. RN #170 stated LPN #180 probably should have called the medical provider to let him know the resident's husband was on the way to see the resident before making a decision to send her to the hospital. Interview on 08/19/26 at 2:46 P.M. with CNA #164 revealed she was at the nurses station while therapy was in Resident #4's room and the call light came on so she responded and therapy asked to help stand Resident #4. As soon as Resident #4 stood, she was dizzy, really weak, and had to be sat back down. CNA #164 stated she called out for the nurse who was in another resident's room so RN #170 came over, completed vital signs, and CNA #164 stated she observed Resident #4 to be pale and her body was limp. CNA #164 stated she did continue to check on Resident #4 after the incident and to ensure she was comfortable. CNA #164 stated the resident's husband came but it took about 30-40 minutes, then he sat with her for about 30 minutes before deciding he wanted her sent to the ED. Interview on 08/19/26 at 2:45 P.M. with the Director of Nursing (DON) confirmed how the medical record read was a delay in treatment, but stated she did not believe the record to be accurate since there was no physician's order for transfer to the ED. The DON also provided information related to Resident #4's previous hospital stay where her white blood cells were elevated prior to admission to the facility and had also been trending down instead of going up. The DON provided labs completed at the hospital on [DATE] all indicating Resident #4 was negative for any type of infection. This deficiency represents non-compliance investigated under Complaint Number 3159890.

Based on record review and interview, the facility failed to ensure accurate and complete medical records when documentation was not completed each shift for activities of daily living (ADLs). This affected one resident (#4) of four residents reviewed for activities of daily living. The facility census was 61. Findings include:Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including non-ST elevation myocardial infarction (NSTEMI), asthma, and chronic obstructive pulmonary disease (COPD). Review of a minimum data set (MDS) dated [DATE] revealed Resident #4 was dependent on staff for bed mobility and transfers. Review of bed mobility and repositioning task documentation revealed Resident #4 had missing documentation for dayshift on 07/25/26, dayshift on 07/26/26, and nightshift on 07/27/26. Review of transfer task documentation revealed Resident #4 had missing documentation for dayshift on 07/25/26, dayshift on 07/26/26, and nightshift on 07/27/26. Interview on 08/19/26 at 2:45 P.M. with the Director of Nursing (DON) confirmed missing documentation for ADL documentation. This deficiency represents non-compliance investigated under Complaint Number 3159890.

Based on observation, interview, and policy review, the facility failed to ensure the ice machine was maintained in a sanitary condition. This had the potential to affect 61 of 61 residents who receive ice from the facility. The facility census was 70. Findings include:Observation and interview on 02/23/26 at approximately 3:10 P.M. with Licensed Practical Nurse (LPN) #107 revealed a clean utility room which contained an ice machine. The ice machine had white steaks of buildup down the sides of it and a brown streak down the front. When opened, the upper wall of the machine was noted to have a black mold-like substance. LPN #107 looked inside the ice machine to confirm the observation and said, oh yeah, that's mold. Interview on 02/23/26 at 3:20 P.M. with the Administrator confirmed there was a black substance in the ice machine. When asked if she thought residents should consume ice from the machine, the Administrator stated, No. Review of a sanitation log completed by Maintenance Director (MD) #120 revealed he had marked the inspection of the ice machine and sanitation as completed twice a month since 05/31/25. Review of a manual for the ice machine revealed it should be cleaned and sanitized every six months for efficient operation. If more frequent cleaning was needed, a consult company should be contacted to test the water and recommend appropriate water treatment. The sanitizer procedure would be used to remove algae or slime, using the sanitizing solution and a sponge or cloth, sanitize the following areas: side walls, base (area above water trough), water distribution tube, water pump, inch thickness probe and water level probe and bin or dispenser. The rinse all areas with clear water.This deficiency represents incidental findings of non-compliance investigated under Complaint Number 2713371.

Based on observations of the facility, staff interview, and policy review, the facility failed to maintain a safe, clean, homelike environment. This affected four residents (#4, #5, #13, and #14) of seven residents reviewed for environment and had the potential to affect 35 residents on the north unit. The facility census was 70. Findings include:1.Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including type II diabetes and hypertension. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including thyrotoxicosis and muscle weakness. Initial tour of the facility was completed on 02/23/26 between 9:20 A.M. and 9:37 A.M. and revealed there were splatters on the walls on the north unit which were brown in color. Interview with Residents #4 and #5 on 02/23/26 at 12:15 P.M. revealed they felt the facility was not very well taken care of and it was dirty. Observation and interview on 02/23/26 at 4:25 P.M. with Licensed Practical Nurse (LPN) #107 confirmed there was a floor tile in the hallway which had broken in half with the broken half missing and there were baseboards coming loose. A tour with Administrator and Director of Nursing (DON) were completed on 02/24/26 from 10:00 A.M. to 10:20 A.M. and revealed there were missing floorboards, loose floorboards, splatters on the wall, three vents with rust, and missing half of a floor tile which could be a tripping hazard. 2.Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including epilepsy and hypo-osmolality and hyponatremia. Record review revealed Resident #14 admitted to the facility on [DATE] with diagnoses including schizoaffective disorder and type II diabetes. Observation on 02/23/26 at 3:45 P.M. revealed Resident #13 and #14 were roommates. Observation on their room revealed Resident #14's footboard had trim on the left side which had come off and she had tried to tape it back on but the tape did not hold so there was a gap between the trim and footboard of approximately two inches, the grout around the toilet was dirty and brown, the toilet moved, and the sharps container was overflowing. Interview on 02/23/26 at 4:00 P.M. with Certified Nursing Assistant (CNA) #123 confirmed the trim and footboard had about a two-inch gap, the grout around the toilet was brown and the sharps container was overflowing. Interview on 02/23/26 at 4:15 P.M. with LPN #107 confirmed trim and footboard had about a two-inch gap, the grout around the toilet was brown and the sharps container was overflowing. Additionally, she confirmed the toilet moved. Review of a policy titled Safe and Homelike Environment dated 06/01/24 revealed in accordance with resident rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. This deficiency represents non-compliance investigated under Complaint Number 2713371.

Based on observation, interview, and policy review, the facility failed to maintain a sanitary laundry room. This had the potential to affect 68 of 68 residents who have their laundry done at the facility. The facility census was 70. Findings include:Observation and interview on 02/23/26 at approximately 3:05 P.M. with Licensed Practical Nurse (LPN) #107 revealed the laundry room had two separate areas- one for the dirty side with the washers, and one for the clean side with the dryers. On the side with the washers, observations revealed there were two washes with one non-functional. There were 11 barrels of dirty clothing and linens in the room with one red hazardous bag on the floor. Eight of the barrels were not covered, had linens not bagged, and were over-flowing. There was a leak noted from the washer and only a small walking path from the washer to the door leading to the clean laundry area. LPN #107 stated the laundry room was cause for concern related to infection control. Observation on 02/23/26 at 4:31 P.M. revealed the laundry room now had 12 full barrels. Interview on 02/24/26 at 6:30 A.M. with Laundry Aide (LA) #115 revealed there were now 15 barrels of laundry, four were outside the laundry room in the hallway with one barrel without a lid, the additional barrels were in the laundry room and eight did not have a lid, had unbagged clothing and linens, and were overflowing. LA #115 stated second shift was let go so nightshift aides were supposed to help with laundry which is not always possible because they are busy too. LA #115 stated she is able to get eight loads of laundry done during her shift. LA #115 stated she gets so many complaints about the laundry because it is so backed up due to having to focus on linens and supplies for care needs instead of personal items. LA #115 confirmed there was a red hazardous bag and stated it had been placed on top of a laundry basket so both the bag and basket items would have to be bleached. LA #115 stated she is not ever made aware of what type of infection the red bags indicate so everything gets bleached, even personal items which can get ruined. Review of a policy titled Infection Prevention and Control Program dated 01/07/25 revealed soiled linen should be collected at the bedside and placed in a linen bag, then the bag should be closed securely and placed in the soiled utility room. Soiled linen should not be kept in the resident's room or bathroom. Environmental services staff should not handle soiled linens if it is not properly bagged. Observation and interview on 02/23/26 at approximately 3:10 P.M. with Licensed Practical Nurse (LPN) #107 revealed a clean utility room which contained an ice machine. The ice machine had white steaks of buildup down the sides of it and a brown streak down the front. When opened, the upper wall of the machine was noted to have a black mold-like substance. LPN #107 looked inside the ice machine to confirm the observation and said, oh yeah, that's mold. Interview on 02/23/26 at 3:20 P.M. with the Administrator confirmed there was a black substance in the ice machine. When asked if she thought residents should consume ice from the machine, the Administrator stated, No. Review of a sanitation log completed by Maintenance Director (MD) #120 revealed he had marked the inspection of the ice machine and sanitation as completed twice a month since 05/31/25. Review of a manual for the ice machine revealed it should be cleaned and sanitized every six months for efficient operation. If more frequent cleaning was needed, a consult company should be contacted to test the water and recommend appropriate water treatment. The sanitizer procedure would be used to remove algae or slime, using the sanitizing solution and a sponge or cloth, sanitize the following areas: side walls, base (area above water trough), water distribution tube, water pump, inch thickness probe and water level probe and bin or dispenser. The rinse all areas with clear water.This deficiency represents incidental findings of non-compliance investigated under Complaint Number 2713371.

4. Review of Resident #69's medical record revealed he was admitted to the facility 05/23/25 with diagnoses including malignant neoplasm of lower third ossiphageous, severe protein calorie malnutrition, malignant neoplasm of the brain, cardiomyopathy, heart failure, depression, constipation, gastroesophageal reflux, chronic pain, cardiac defibrillator, and hypertension. Review of Resident #69's minimum data set (MDS) completed 05/28/25 revealed a brief interview for mental status score of 15 indicating no cognitive impairment. Review of Resident #69's smoking assessment completed on 5/23/25 and revealed the resident was a smoker, had no cognitive loss impairing their ability to smoke safely, the resident had no visual deficit, the resident smokes two to five times per day during the morning, afternoon, evenings, and nights. Question of can the resident light his own cigarette not applicable (N/A) was marked on the smoking assessment. Findings of the smoking assessment completed 05/23/25 for Resident #69 revealed he required adaptive equipment while smoking such as supervision. Resident smoking status determined by smoking assessment and facility assessment revealed he requires supervised smoking. Review of Resident #69's record revealed a progress note completed 06/01/25 stating Resident just came in from smoking, daughter states she lives down the street and doesn't mind coming up with him out to smoke. Ambulatory with one assist, medicated with morphine. Review of Resident #69's care plan completed 05/23/25 revealed the resident was at risk for alteration in skin integrity due to prolonged sun exposure while smoking. Review of Resident #69's care plan completed 05/23/25 revealed Resident #69 has potential for safety hazard or injury related to smoking. Resident #69 is able to smoke with supervision by staff or family. Goals include the resident will continue to follow facility smoking policy. Interventions include while smoking resident will have direct supervision by staff or family members. Interview on 07/01/25 at 8:11 A.M. with certified nurses' aide (CNA) #112 confirmed Resident #69 is a smoker. They state he smoked daily; about every three hours Resident #69 goes out to smoke. Observation on 06/30/25 at 12:50 P.M. revealed Resident #69 down the street at a nearby apartment complex under no supervision smoking a cigarette. Interview with Director of Nursing (DON), Administrator, and Regional Director #214 on 07/01/25 at 9:43 A.M. and 2:00 P.M. confirmed Residents #21 and #53 have lost their independent smoking privileges because of violations of the smoking policy by keeping smoking materials in their rooms. She also confirmed Resident #66 has been a supervised smoker since admission and Resident #69 is a supervised smoker because he was admitted to the facility after the new smoking policy was enacted that required all residents to be supervised smoking. They confirmed they keep resident smoking materials, who are supervised smokers, at the nurses desk, and they can retrieve them when it's smoking time. They confirmed if a resident is deemed safe to go on a leave of absence independently, they are able to take their smoking materials and go to the front of the facility property to smoke by themselves. They confirmed the smoking assessment doesn't differentiate between the smoking abilities/safety of the resident smoking, and the resident's refusal of not following the rules regarding keeping smoking materials in their room. Their policy is they do not want a resident who does not follow the rules of smoking or that is not safe to be a smoker, to smoke on property and potentially harm other residents. But, when asked why the above residents are permitted to leave property independently and smoke, if they are deemed supervised smokers. There was no adequate answer provided, other than they are trying to keep all the residents in the facility safe. Review of facility Smoking Policy, (undated), revealed the employee responsible at the time of the supervised smoke time is the only one to have smoking materials. There was nothing within the policy to dictate the procedures or responsibilities for those residents deemed to be supervised smokers, but choose to go on a leave of absence off facility property to independently smoke. Based on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure a safe smoking environment. This affected four residents (#21, #53, #66, and #69) of four residents reviewed for smoking safety. The census was 70. Findings Include: 1. Observations on 06/30/25 at approximately 9:30 A.M. revealed Resident #21 was given his smoking materials by facility nursing staff, and he went to the front of the building to smoke independently. He had his lighter and smoking materials in his hands with no staff going with him to the front of the building, and to the sidewalk, which is considered off property for smoking. Record review revealed Resident #21 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disorder (COPD), idiopathic progressive neuropathy, alcoholic liver disease, type II diabetes, anemia, morbid obesity, and hypertension. Review of his minimum data set (MDS) assessment, dates 06/12/25, revealed he was cognitively intact. Review of Resident #21's smoking assessment, dated 03/11/25, revealed he was deemed to be an independent smoker. Review of Resident #21's smoking assessment, dated 05/23/25, revealed he was deemed to need supervision for smoking. The justification for making him a supervised smoker was he did not follow the facility policy of not keeping smoking materials in his room. Review of Resident #21's care plan, dated 06/29/23, revealed he was able to smoke without supervision of staff or family. Review of Resident #21 care plan, dated 06/29/25, revealed he was deemed to be a supervised smoker. But, according to his smoking assessment, he was deemed to be a supervised smoker on 05/23/25. Interview with Resident #21 on 06/30/25 at 8:45 A.M. revealed he was very upset and disappointed he was not deemed to be an independent smoker any more, simply because he had loose tobacco and rolling papers in his room. He confirmed he was able to get his smoking materials from nursing staff, and then wheel himself out to the sidewalk to smoke by himself. He didn't understand how he was allowed to do that by himself, but not smoke in the facility designated smoking area independently. 2. Observation on 06/30/25 at 2:15 P.M. revealed Resident #53 receiving her smoking materials from nursing staff, and going outside independently to smoke. She had her smoking materials in her hands with no staff going with her to the front of the building, and to the sidewalk, which was considered off property for smoking. Record review revealed Resident #53 was admitted to the facility on [DATE]. Her diagnoses were radiculopathy, dysphagia, hemiplegia, type 1 diabetes, spinal stenosis, congestive heart failure, vitamin D deficiency, dorsalgia, depression, post traumatic stress disorder, hypertension, sleep apnea, polyneuropathy, hyperlipidemia, osteoarthritis, panic disorder, obesity, and allergic rhinitis. Review of her MDS assessment, dated 04/20/25, revealed she was cognitively intact. Review of Resident #53's smoking assessment, dated 04/17/25, revealed she was deemed to be an independent smoker. Review of Resident #53's smoking assessment, dated 05/23/25, revealed she was deemed to need supervision for smoking. The justification for making her a supervised smoker was she was not following the facility policy of not keeping smoking materials in her room. Review of Resident #53's care plan, dated 05/27/24, revealed she was deemed to be an independent smoker. Review of Resident #53's care plan, dated 06/30/25, revealed she was deemed to be a supervised smoker. But, according to her smoking assessment, she was deemed to be a supervised smoker on 05/23/25. Interview with Resident #53 on 06/29/25 at 11:25 A.M. revealed she went from unsupervised smoking to supervised smoking because the facility found a vape in her room. She doesn't feel it's fair to be deemed a supervised smoker for only having a vape in her room. She stated she can get her smoking materials and go to the front sidewalk by herself, but she has to sign out at the nurse's desk. She doesn't understand why she has to go to the front side walk, where there is no shade from the sun, by herself, but she can't do that in the facility's designated smoking area. 3. Observation on 07/01/25 at 12:20 P.M. revealed Resident #66 getting his smoking materials from nursing staff, and going independently to the front side walk to smoke. He had no staff or supervision with him. Record review revealed Resident #66 was admitted to the facility on [DATE]. His diagnoses were quadriplegia, type II diabetes, muscle weakness, need for assistance with personal care, intraspinal abscess and granuloma, hypokalemia, constipation, peripheral vascular disease, bipolar disorder, hyperlipidemia, and long QT syndrome. Review of his MDS assessment, dated 06/12/25, revealed he was cognitively intact. Review of Resident #66 smoking assessment, dated 03/07/25, revealed he was deemed to need supervision for smoking. Review of Resident #66 care plan, dated 06/30/25, revealed he was deemed to be a supervised smoker. Prior to 06/30/25, he did not have a care plan related to smoking.

Based on observation, interview, and record review the facility failed to implement interventions for a missing glasses lens and provide timely vision services for a resident. This affected one resident (#69) of two residents investigated for communication and sensory concerns. The census was 70. Findings include: Review of Resident #69's medical record revealed the resident was admitted to the facility 05/23/25 with diagnoses including malignant neoplasm of lower third ossiphageous, severe protein calorie malnutrition, malignant neoplasm of the brain, cardiomyopathy, heart failure, depression, constipation, gastroesophageal reflux, chronic pain, cardiac defibrillator, and hypertension Review of Resident #69's minimum data set (MDS) completed 05/28/25 revealed a brief interview for mental status score of 15 indicating no cognitive impairment. Section B of the MDS revealed Resident #69 used corrective lenses. Review of Resident #69 care plan completed 05/23/25 revealed the resident was at risk for visual decline related to wearing eyeglasses. Interventions included to arrange eye appointments if increased visual deficits are noted, encourage residents to wear glasses. Interview with Resident #69 on 06/29/25 at 9:04 A.M. revealed the resident was wearing prescription glasses with no lens in the right side of the glasses. Resident #69 stated the lens had been missing since he was at home, before he arrived to the facility. He stated he called his doctor before his admission, and it was going to be $200 out of pocket to fix them, and he couldn't pay that. Interview on 07/01/25 at 9:17 A.M. with Resident # 69 revealed his glasses have been missing from the lens since before he arrived to the facility. He stated he had told a few people about it but can't specifically recall who. He stated if anyone had seen him while wearing his glasses, they can see the lens is broken. Interview on 07/01/25 at 9:40 A.M. with the Administrator revealed she spoke with Resident #69 and he stated the glasses had been broken since before he got here. Interview on 07/01/25 at 9:41 A.M. with the Assistant Director of Nursing (ADON) revealed she recalled Resident #69 right glasses lens was missing upon admission. Review of Resident #69's record revealed a signed consent to be seen by 360 Care on 6/12/25. 360 Care consent form stated vision services may include items such as eye health exams, vision test, eyeglass dispensing. 360 Care form stated any service not covered by insurance can be covered through the offset process. Review of Resident #69's record revealed an order dated 05/23/25 ordered by the facility medical director that stated Resident #69 was ok to use the facility ancillary services such as psychiatrist, psychologist, social service, ophthalmologist, dentist, vision, hearing, podiatrist, certified nurse practitioner, and wound services. Review of Resident #69's record including progress notes, uploaded documents, and orders revealed no documentation the facility had reached out to 360 Care to provide services for Resident #69 regarding his broken eye lens to his prescription glasses.

Based on review of the medical record and interview, the facility failed to provide care without causing a skin tear for Resident #67. This affected one resident (#67) of three residents reviewed for skin conditions. The facility census was 70. Findings include: Record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including morbid obesity and muscle weakness. Review of an MDS dated [DATE] revealed Resident #67's cognition remained intact, he had no behaviors, and had moisture associated skin damage (MASD). Review of a care plan dated 04/02/25 revealed Resident #67 was at risk for potential alteration to skin integrity and required protective/preventative skin care maintenance related to bladder and bowel incontinence and decreased mobility with a goal to have no new skin issues through the next review. Review of a nursing note dated 04/09/25 at 11:19 A.M. by Registered Nurse (RN) #115 revealed the wound nurse practitioner visited Resident #67 due to an open area to left side abdominal fold area. Resident #67's wife was present and stated it occurred during care when a staff member pulled up resident's pants too quickly/far. A new treatment was ordered. Review of a Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #67 had a new skin area related to trauma in left side fold which was acquired on 04/08/25. The area was 0.2 centimeters (cm) by 0.8 cm by 0.1 cm with scant drainage. Interview on 06/29/25 at 3:26 P.M. with Resident #67 revealed his skin had been growing back under his abdominal fold after having yeast and an aide came in to clean him up, lifted his stomach too quickly and tore the skin. Interview on 07/01/25 at 9:48 A.M. with Certified Nursing Assistant (CNA) #132 revealed Resident #67 had reported to her another aide was cleaning him up and tore his new skin on his stomach fold so she reported it to the nurse. She could not recall which nurse. Interview on 07/01/25 at 2:39 P.M. with DON confirmed nursing note stated a skin tear was caused by an aide lifting Resident #67's stomach too fast/far.

Based on record review and interview the facility failed to acquire post dialysis vital signs as ordered for one resident(#55). This had the potential to affect one resident (#55) of one resident on dialysis in the facility. The census was 70. Findings include: Record review revealed Resident #55 was admitted to the facility 9/13/23 with diagnoses including Stage 4 chronic kidney disease (CKD), kidney transplant, convulsions, hypothyroidism, hyperlipidemia, dependence on renal, benign prostatic hyperplasia, intellectual disabilities, polycystic kidneys, cardiomyopathy, hypertension, iron deficiency, cardiac arrhythmia, arthritis, mitral valve prolapse, and gastro esophageal reflux disease. Review of Resident #55's Minimum Data Set (MDS) completed 03/25/25 revealed a brief interview for mental status (BIMS) score of 10. The MDS revealed Resident 55 was receiving dialysis. Review of Resident #55 care plan revealed Resident #55 was at risk for impaired fluid volume and electrolyte imbalance related to impaired renal function, end stage renal disease (ESRD), and renal failure. Interventions included taking vital signs as ordered. Record review revealed an order for Resident #55 to go to dialysis every Monday, Wednesday, and Friday. Record review revealed an order placed 05/23/25 at 6:00 A.M. to obtain vital signs (VS) after returning from dialysis one time a day every Monday, Wednesday, and Friday. Review of medication administration records (MAR), treatment administration records (TAR), and vital sign flow sheet revealed the resident had no documentation of vital signs being completed after returning from dialysis on 05/23/25, 05/28/25, 06/20/25, and 06/27/25 as ordered. Interview on 07/01/25 at 4:15 P.M. with the Director of Nursing (DON) confirmed VS should be completed on Resident #55 after return from dialysis and on the dates of 05/23/25, 05/28/25, 06/20/25, and 06/27/25 VS were not completed post-dialysis.

Based on review of the medical record and interview, the facility failed to ensure a resident had a thorough medication regimen review completed by the pharmacist. This affected one resident (#39) of five residents reviewed for medication review. The facility census was 70. Findings include: 1. Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression and anxiety disorder. Review of a care plan dated 10/13/24 revealed Resident #39 was at risk for potential adverse side effects of psychotropic drug use with a goal to use the lowest therapeutic dose for control of symptoms through the review period. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #39's cognition was severely impaired and she had no behaviors. Review of a nursing note dated 06/17/25 at 9:20 A.M. by Licensed Practical Nurse (LPN) #210 revealed a new order was received from hospice to increase Xanax from 0.5 milligrams (mg) to 1 mg twice a day scheduled, then every 4 hours as needed. Hospice had contacted and updated Resident #39's husband. Review of an order dated 06/17/25 revealed Resident #39 was to receive Xanax oral tablet 0.5 mg give 1 mg by mouth every four hours as needed for anxiety for 90 days per hospice. An additional order dated 06/17/25 revealed Resident #39 would receive Xanax 0.5 mg tablet give 1 mg by mouth one time a day for anxiety/aggression. An order dated 06/17/25 for Xanax 0.5 mg tablet give 1 mg by mouth at bedtime for anxiety and an order dated 06/17/25 for Alprazolam (Xanax) tablet 1 mg give 1 tablet by mouth in the evening for anxiety with dinner. Review of a controlled drug log dated 06/18/25 revealed Resident #39 received Lorazepam 1 mg from the pharmacy with instructions to administer 1 tablet by mouth two times a day (morning and bedtime) and 1 tablet by mouth every four hours as needed for anxiety. Resident #39 received one dose of unordered Lorazepam on 06/18/25, two doses on 06/19/25, one dose on 06/20/25, one dose on 06/21/25, one dose on 06/22/25, two doses on 06/23/25, and one dose on 06/24/25. Review of a pharmacy packing slip dated 06/17/25 revealed Resident #39 received a prescription containing 60 Lorazepam tablets 1 mg dose. Review of a Pharmacist Medication Regimen Review assessment dated [DATE] revealed the pharmacist completed a medication review for Resident #39 and had no recommendations. Review of Resident #39's medication administration record (MAR) for June 2025 revealed there was no documentation of Resident #39 receiving Lorazepam. Interview on 06/30/25 at 1:07 P.M. with Director of Nursing (DON) revealed hospice had updated Resident #39's Xanax order because her family was concerned she was not getting enough sleep so they were trying to accommodate the family. Interview on 07/01/25 at 8:15 A.M. with DON confirmed the controlled substance log shows medications were not given as ordered and she had additional information regarding this time period due to a medication error that occurred when hospice mistakenly sent a script for Ativan (Lorazepam) instead of Xanax. Interview on 07/01/25 at 9:57 A.M. with Hospice Representative #313 revealed she works in the office and pushes orders from the physician to the nurses out in the field. HR #313 stated Resident #39's orders have always been for Xanax and the current order was for Xanax 1 mg scheduled three times daily dated 06/24/25. HR #313 revealed Resident #39 has never had an order for Ativan, but it was possible the physician sent the wrong medication for her due to a lot of medication changes. HR #313 stated if the facility received orders from hospice to adjust the Xanax but received a shipment of Ativan it would be their responsibility to identify the issue and contact hospice for clarification. Interview on 07/01/25 at 11:56 A.M. with Pharmacist #322 revealed when she completes the medication regimen review, she goes into the electronic system to review orders and most of the time she looks at them. Pharmacist #322 stated she assumes the medication sent to the facility is what is on the orders. Pharmacist #322 stated she does narcotic count audits, but she looks at the sheets to make sure the count is correct, and they are filling out the log correctly and numbers match. Pharmacist #322 stated it would have been hard for her to catch the medication error.

Based on observation, interview, and record review the facility failed to ensure medication error rate was less than five percent. There were a total of 36 medication opportunities observed with two medication errors resulting in a 5.55% medication error rate. This affected one resident (#4) of three residents observed for medication administration. The census was 70. Findings include: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including hypertension, chronic kidney disease stage four, schizoaffective disorder, diastolic congestive heart failure, epilepsy, congenital absence of extremities, hyperlipidemia, hypothyroidism, chronic obstructive pulmonary disease, convulsions, drug induced dyskinesia, gastroesophageal reflux disease, arteriosclerotic heart disease, constipation, insomnia, failure to thrive, anemia. Record review of Resident #4's minimum data set (MDS) assessment completed 06/03/25 revealed a brief mental status (BIMS) score of 14. Observation of medication pass on 06/29/25 at 9:30 A.M. with Licensed Practical Nurse (LPN) #173 of medication administration to Resident #4 revealed LPN #173 prepared Rufinamide 400 milligrams (mg) 4 tablets for 1600 mg, Folic Acid 1 mg, Cimetidine 400 mg, Loratadine 10 mg, Multivitamin 1 tablet, Metoprolol 25 mg half a pill , Aspirin 81 mg, Lasix 20 mg, Levetiracetam 1000 mg, Levothyroxine 125 micrograms (mcg), Lisinopril 10 mg, Epidiolex 6.6 milliliters (ML) to be administered. Observation revealed Valbenazine 40 mg and Albuterol inhalation were marked as completed on the medication administration record (MAR). LPN #173 signed the MAR prior to medications being administered. LPN #173 verified observation of medication cup contained 14.5 pills, LPN #173 closed the computer screen out and grabbed the medication cup and began walking to Resident #4's room. Interview on 06/29/25 at 9:37 A.M. with LPN #173 revealed that when asked where the Valbenazine tablet was, LPN #173 stated it wasn't in the pre- packed pill package. When asked where the Albuterol was, LPN #173 stated it was in the cup, LPN #173 stated the Albuterol was a pill in the cup. LPN #173 proceeded to look at Resident #4's record and read that Albuterol was to be given as inhalation through inhaler, LPN #173 confirmed the Valbenazine was in its own medication bottle and not in the prepacked pill pack. LPN #173 confirmed she had not administered Albuterol and Valbenazine at that time. Review of Resident #4's orders revealed Resident #4 was to receive Ipratropium-Albuterol solution 0.5-2.5 (3) mg/3 ml 3 ML inhale orally, Rufinamide 400 milligrams (mg) 4 tablets for 1600 mg, Folic Acid 1 mg, Cimetidine 400 mg, Loratadine 10 mg, Multivitamin 1 tablet, Metoprolol 25 mg half a pill , Aspirin 81 mg, Lasix 20 mg, Levetiracetam 1000 mg, Levothyroxine 125 micrograms (mcg), Lisinopril 10 mg, Epidiolex 6.6 milliliters (ML) at the time of medication administration. Review of facility policy Medication Administration dated and revised 08/22/22 revealed review of the MAR to identify medication to be administered, administered medication as ordered in accordance with manufactures recommendations, and sign MAR after administration of medications.

Based on record review and interview, the facility failed to ensure accurate documentation in the medical record for treatments for a resident. This affected one resident (#1) of 25 residents reviewed for documentation. The facility census was 70. Findings include: Review of the medical record for Resident #1 revealed an admission date of 10/11/17 with diagnoses including diabetes mellitus, heart failure and dementia. Review of the physician's orders for Resident #1 revealed she had orders for [NAME] hose, on in the morning and off at night dated 01/15/25; Miconazole Powder (antifungal), apply under breasts and abdominal folds topically every shift for redness/excoriation, apply to the crease of the buttocks and groin dated 05/13/22; Lac Hydrin External Cream 12%, apply to bilateral lower extremities/feet topically every night shift for diabetes mellitus dated 05/23/25; and Voltaren Arthritis Pain External Gel 1%, apply to shoulders topically one time a day for pain use 2 grams to the upper extremities and 4 grams to the lower extremities dated 06/11/25. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2025 for Resident #1 revealed treatments were not documented completed as ordered for the [NAME] hose on 06/06/25 and 06/08/25; Miconazole Powder on dayshift on 06/02/25, 06/05/25, 06/13/25, 06/20/25, 06/25/25, 06/27/25 and 06/29/25 and at night on 06/06/25 and 06/08/25; Lac Hydrin on 06/06/25 and 06/08/25; and Voltaren on 06/13/25, 06/19/25, 06/20/25, 06/25/25, 06/27/25 and 06/29/25. Interview on 07/01/25 at 12:37 P.M. with the Director of Nursing (DON) verified the missing documentation on the TAR on the dates listed above for Resident #1. Review of the facility policy titled, Medication Administration, dated 08/22/22, revealed staff were to sign the MAR after medications were administered.

Based on observation and interview, the facility failed to ensure an ice machine was clean and sanitary. This had the potential to affect all residents residing in the facility. The census was 76. Findings include: Observation on 3/19/25 at 12:35 P.M. with Dietary [NAME] # 100 revealed brownish-black, mold-like appearing areas located on the white plastic shield inside of the facility's ice machine. The exterior of the ice machine appeared to have water stains, fingerprints, and dust-like debris. The ice machine was located outside of the kitchen, in a dining room/common area. Interview on 03/19/25 at 12:36 P.M. with Dietary [NAME] #100 confirmed there was brownish-black, mold-like appearing areas located on the white plastic shield located inside of the ice machine, and stated she was unaware of a cleaning schedule or cleaning log for the ice machine. Interview and observation on 03/19/25 at 12:40 P.M. with the Administrator confirmed there was brownish-black, mold-like appearing areas located on the white plastic shield inside of the ice machine and the exterior of the ice machine did not appear to be clean. The Administrator stated the ice machine would be taken out of commission until it was cleaned and sanitized. This deficiency demonstrates non-compliance investigated under Master Complaint Number OH00163676 and Complaint Numbers OH00163596 and OH00162928.

Based on record review, review of personal inventory sheets, review of grievance/concern logs, review of email correspondence between a resident representative and the facility, interviews, and policy review, the facility failed to ensure resident representative reports of missing personal items were addressed in a timely manner. This affected one (Resident #2) of three residents reviewed for missing personal items. Findings include: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, post-traumatic stress disorder, anxiety disorder, age-related macular degeneration, and bilateral hearing loss. Review of Resident #2's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty in hearing and her speech was clear. She was able to make herself understood and was usually able to understand others. Her cognition was on the high end of being moderately impaired. She was not known to reject care or display any behaviors. On 12/04/24 at 11:27 A.M., an interview with Resident #2's representative revealed she reported to the facility that the resident was missing personal items that included a white/maroon colored fleece blanket and a gray t-shirt that was 2X in size. She stated she reported the items missing to the facility's Social Service Director (SSD) about three weeks ago. She also stated she had sent an email to the facility's management team about the missing personal items, but had not heard anything back yet. She claimed the items were still missing and had not been replaced or reimbursed. She provided a copy of the email that she had sent to the facility regarding the resident's missing items. Review of the email correspondence from Resident #2's representative to the facility staff revealed the representative sent an email to the facility's Admissions Director, Administrator, Director of Nursing (DON), Social Service Director (SSD), and the Business Office Manager on 10/02/24 at 2:42 P.M. The email indicated she had attached a scan of her Amazon clothing orders for the resident in order to try to keep track of what she had and what was missing. She had to visit the laundry area the night before because the resident only had two tops hanging in her closet and another in the laundry basket that the family brought in so they could do her laundry. They had two signs hanging in the resident's room to let the staff know that the family was doing the resident's laundry. The family opted to do her laundry because they did not want her clothing to be worn out prematurely due to the heat of the water used by the facility and the dryers they used. The scanned Amazon clothing order list indicated a short sleeve nightgown that was aqua-green and a size XX-large was missing. There was also a women's plus size V-neck rolled short sleeve casual soft Summer t-shirt medium gray and 2 XL in size that was indicated to be missing. Review of an email correspondence from the facility's DON to Resident #2's representative dated 10/02/24 at 2:50 P.M. revealed the DON acknowledged receiving the email and thanked the representative for sending the email to allow them to address some of the issues she was having. The DON indicated the facility's Administrator was out of the building on that date, but she would make sure her concerns were addressed with their team. The email correspondence further showed Resident #2's representative responded to the DON's email on 10/02/24 at 2:54 P.M. thanking her for the response and she told the DON an all points bulletin (APB) on the missing clothing probably wouldn't hurt either. Review of Resident #2's personal belongings inventory sheets revealed an inventory of the resident's personal belongings was obtained upon her admission to the facility on [DATE] and again on 07/23/24. The inventory sheet for 07/23/24 revealed the resident was known to have in her possession a three stretch t-shirts size 2X, with one of the three being [NAME] gray in color. There was no indication that a white and maroon colored fleece blanket was part of the resident's belongings. The resident personal belongings inventory sheet for 07/23/24 was signed by both the resident's representative and a facility nurse indicating they had read and acknowledged that was an accurate listing of her belongings. Review of the facility's grievance/concern log for the past three months revealed there was no documentation to indicate there had been any reports of missing personal items pertaining to Resident #2 during the past three months. Missing items were included on the logs for other residents. On 12/04/24 at 3:10 P.M., an interview with Resident #2 revealed she has had issues with some of her personal items coming up missing. She was not sure exactly what was missing and indicated her daughter had been handling that. On 12/05/24 at 10:38 A.M., an interview with Certified Nursing Assistant (CNA) #125 revealed she was aware of Resident #2 having a white/maroon colored fleece blanket while in the facility. She stated it was usually draped across the foot of her bed. She was not sure if the resident had the blanket in her possession as she did not recall still seeing it across her bed. She was aware there was a gray t-shirt that was reported as being missing, but she believed it was found on another resident and returned to the resident. On 12/05/24 at 11:44 A.M., an interview with CNA #133 revealed she recalled a couple of weeks ago one of Resident #2's shirts was found on another resident. She stated they saw the other male resident wearing it, but noticed it just did not look right on him. It looked like a woman's shirt as it had a V-neck and the short sleeves were rolled at the end. They took it off the other resident and found it had Resident #2's name on it. They placed it in the resident's laundry basket so the family could take it home and wash it. She reported she believed that t-shirt was teal in color and was not a gray one. She was not aware of a gray t-shirt being missing or anything about a white and maroon fleece blanket. Personal inventory sheets were completed on paper and were to be done upon a resident's admission. They gave them to the nurse's after they were completed. She denied inventory sheets would be updated after the resident's admission even if things were brought in by the family later. On 12/05/24 at 2:04 P.M., an interview with SSD #200 revealed she had been the facility's SSD for the past two years. She was aware of their being reports of missing personal items for Resident #2. She stated it was a [NAME] gray t-shirt and a maroon/white swirl pattern blanket that was reported missing. The daughter had sent her a photo of the blanket and she was told what else was missing and had passed it on to management. She reported everyone was made aware to include the Administrator, DON, and laundry staff. She checked her phone and verified the reports of the missing clothing was received on 11/18/24. She indicated she received a phone call from the daughter about 10 minutes before getting the photo sent to her to let her know about the missing items. She was asked what she did when a resident or family reported it missing. She stated she usually passed the information along and it got put on the grievance/concern log. She was not sure if she had put it on there, or if someone else did. She stated she was in the middle of a few things when that call was received. She did not hear anything back from the resident's daughter and just quite frankly forgot everything about it. She was given a copy of the grievance/concern log and verified there were no reports of missing items indicated for Resident #2 on 10/02/24, when the initial email was sent about missing items or on 11/18/24, when she was called again about the missing items. On 12/05/24 at 2:45 P.M., an interview with the facility's Administrator revealed she had a soft file on concerns they had received from Resident #2's family. She confirmed there had been reports of missing personal items to include a blanket and a gray colored t-shirt. She acknowledged the missing items had not been logged onto their grievance/ concern log where missing items were recorded. She did not have a missing item report for the missing blanket or shirt. She confirmed an email was received from the resident's daughter about the missing items, but they did not have any evidence she had a blanket in her possession that fit that description. She indicated the staff documented items present upon admission on a personal inventory list, but it was the responsibility of the family to complete a personal inventory list for any additional items brought in after their admission. She confirmed a personal belongings inventory sheet dated 07/23/24 did show the resident was known to have a gray t-shirt that was 2X in size. She reported it was the facility's corporate policy that they were not responsible for lost items, especially if the resident's family was doing their laundry. She claimed the resident's daughter did not want them to mark the resident's name in her clothing, since it was their intent to launder her clothing. She acknowledged the facility would be responsible for keeping the resident's personal belongings inventory sheet updated and was responsible for replacing missing items the resident was known to have while in the facility. She acknowledged the facility staff were still sending the resident's clothing to their laundry room to be processed at times when it had been made known that the family would do that. On 12/05/24 at 4:05 P.M., an observation noted the Administrator and the DON to enter the room of Resident #2 to discuss her missing personal items. The Administrator informed the resident the facility would be replacing her lost items for her. On 12/05/24 at 4:12 P.M., a follow up interview with the Administrator revealed she had talked to the corporate office and it was decided that they would go ahead and replace the resident's missing personal items. Review of the facility's policy from Embassy Healthcare on Concerns/ Grievances revealed it was the policy of the facility and in accordance with 483.10 (f) (1) Grievances, the facility would honor the resident's right to voice concerns and/or grievances without discrimination or reprisal. Such concerns and/or grievances would include, but was not limited to, treatment which had been furnished or not furnished. Other forms of grievances could include management of funds, lost items, and/or violation of rights. The SSD would coordinate the facility system for collecting concerns and tracking concerns for timely and appropriate response. Social services would instruct facility staff to submit to the SSD that all concerns received would be investigated within 72 hours following receipt of the concern. Within seven days following the receipt of the concern, the facility would inform the complainant with the results of the investigation. The resident/ family concern form was to be completed when a resident and/or family member had a concern that must be addressed by the facility. The form should be used to document specific concerns and in the event of missing items brought forth by the resident and/or family. When the concern was related to missing items, complete the missing items form. Time frames for resolution would remain the same as above. Concerns submitted to the SSD would be presented to the Administrator as soon as the form was completed. The administrator/designee would forward the concern form to the appropriate management representative. Social services would maintain a concern log in order to track concerns and/or missing items. This deficiency represents non-compliance investigated under Complaint Number OH00160107 and is an example of continued non-compliance from the survey 11/22/24.

Based on record review, and interviews the facility failed to ensure a resident, who was dependent on staff for personal care, received appropriate incontinence products needed for proper incontinence care and was assisted up in her chair daily as per her normal routine. This affected one (Resident #2) of three residents reviewed for incontinence care. Findings include: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), obstructive and reflux uropathy, post traumatic stress disorder, gastrostomy status, macular degeneration, and bilateral hearing loss. Review of Resident #2's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty with her hearing and clear speech. She was able to make herself understood and was usually able to understand others. Her cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12 (a score of 13-15 was being cognitively intact). She was not known to display any behaviors nor was she known to reject any care. She was dependent on staff for transfers and toilet use. She was coded as always being incontinent of her bladder and bowel. Review of Resident #2's care plans revealed she had a care plan in place for needing assistance for activities of daily living (ADL's) related to cognitive impairment and immobility. The care plan was initiated on 07/02/24. The goal was for the resident to continue to participate in ADLs as able and have no decline in ADLs through next review and for her to be clean, odor-free and appropriately dressed on a daily basis. The interventions included her being a mechanical lift x2 (two staff) for transfers. She required the assist of two for toileting hygiene and for chair to bed transfers. Review of Resident #2's physician's orders revealed the resident went under the care and services of hospice for the diagnosis of COPD on 10/11/24. An order was received for the resident to have the use of an indwelling urinary catheter beginning on 11/22/24. Review of Resident #2's point of care response history for bed to chair and chair to bed transfers for the past 30 days (11/08/24 to 12/07/24) revealed there was a two day period in which the resident was not indicated to have been transferred from her bed to her chair. On 11/21/24 and again on 11/22/24, the nursing assistants documented that activity did not occur. On 12/04/24 at 11:27 A.M., an interview with Resident #2's daughter revealed the facility had issues with supplies more often than she cared to recall. She reported there had been an issue with not having the proper size incontinent brief the resident needed to wear and she was made to wear ones that were too small for her. The resident was a 3 X in incontinent brief sizes and the facility staff had to use medium sized briefs on her. It resulted in her leaking or being saturated through her clothing due to the incontinent brief not being a proper fit. That had been an issue as recent as two weeks ago, but had also happened in the past sometime between 06/26/24 (when she was admitted ) and 10/03/24 (when she finished working with therapy at the completion of her 100 days of skilled services). On 12/04/24 at 3:10 P.M., an interview with Resident #2 revealed there had been problems with the facility not having the proper size of incontinent briefs for her resulting in her having to wear smaller ones that did not properly fit. She claimed there had been a time in the past when she was in therapy and was wearing a smaller sized brief. She recalled being incontinent and making a mess, which was embarrassing to her. On 12/02/24 at 3:50 P.M., an interview with Central Supply Employee #250 revealed she was the employee that used to be responsible for ordering supplies. She had been in central supply since July 2023, but did not start being in charge of ordering supplies until January 2024. The facility decided they would start having the corporate office order supplies in October or November of 2024. They only did that for a month or so before they began having issues with the availability of supplies sometime in November 2024. On 12/05/24 at 10:38 A.M., an interview with Certified Nursing Assistant (CNA) #125 revealed Resident #2 did require the use of incontinent briefs. She used to be incontinent of her bladder, but now had the use of a catheter and was only incontinent of her bowels now. The resident needed a size 3 brief. There was a three day time span in which they were out of size 3 briefs. They had to use pull ups or use a blue brief under Resident #2 and another blue brief down the front of her. She reported they were constantly telling the DON, Assistant Director of Nursing (ADON), the unit manager, and the nurses that they were out and would be told they were working on it. She could not recall if that was prior to Resident #2 being under hospice's care or if it was after that. She stated the messes were massive and they were unable to get Resident #2 up out of bed due to that. She used to be up daily, but during that time when they did not have the appropriate size brief, they had to leave her in bed. The family of the resident was mad at them. She denied the management team offered to go to the store to purchase any of the briefs they needed, while they were waiting for them to be delivered. There was a time three to four weeks ago they had no briefs at all. Everyone was wearing pull ups during that time. On 12/05/24 at 11:44 A.M., an interview with CNA #133 revealed Resident #2 had her indwelling urinary catheter for about a month now. They continued to check her for bowel incontinence though. She confirmed the facility definitely had issues with supplies. It happened a lot when they were out of incontinent briefs. The problem with not having incontinent briefs was about two weeks ago or at least within the last month. She reported they were completely out of briefs and only had a few pull ups, if any at all. Pull ups were very limited as well. She reported Resident #2 wore size 3 briefs. She then recalled there was a time they were using the two blue briefs for Resident #2. One was placed under her and another was placed up the front of her. She confirmed that resulted in them having to leave the resident in bed, so she did not have any accidents in her chair. She thought the supply issue was a communication problem. Before they would tell the nurses when they needed something. The nurses would in turn pass it on to the facility's prior DON. Now they tell the new DON or the unit manager. Central Supply Employee #250 used to handle the ordering of supplies, but had been taken off of it. She was not sure who took over after that. This deficiency represents non-compliance investigated under Complaint Number OH00160107.

Based on record review, observation, and interviews the facility failed to ensure administrative staff maintained sufficient supplies to adequately care for the residents residing in the facility. This affected one (Resident #2) of three residents reviewed for incontinence and enteral tube feedings. Findings include: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), obstructive and reflux uropathy, post traumatic stress disorder, gastrostomy status, macular degeneration, and bilateral hearing loss. Review of Resident #2's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty with her hearing and clear speech. She was able to make herself understood and was usually able to understand others. Her cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12 (a score of 13-15 was being cognitively intact). She was not known to display any behaviors nor was she known to reject any care. She was dependent on staff for transfers and toilet use. She was coded as always being incontinent of her bladder and bowel. She was indicated to have a feeding tube that was providing 51% or more of her nutritional intake. Review of Resident #2's physician's orders revealed she was placed under the care and services of hospice on 10/11/24 for the diagnosis of COPD. She also had an order to receive Isosource 1.5 cal at 55 milliliters (ml)/ hour x 10 hours from 6:00 P.M. until 4:00 A.M. every night. The order was in place between 11/01/24 and 11/25/24. She received a second order for her to receive Jevity 1.5 cal at 55 ml/ hour per peg tube via pump to be ran over 10 hours from 6:00 P.M. to 4:00 A.M. every night. That order was in place from 11/26/24 until 12/04/24. She received a third order on 12/04/24 to resume the first order and for the resident to receive Isosource 1.5 cal at a rate of 55 ml/ hour per peg tube via pump to be ran for 10 hours between 6:00 P.M. and 4:00 A.M. Her orders also reflected she was placed under the care and services of hospice on 10/11/24 for the diagnosis of COPD. She had an indwelling urinary catheter placed on 11/22/24. Review of Resident #2's medication administration record (MAR's) for November 2024 revealed the resident did receive Isosource 1.5 cal at 55 ml/ hour between 6:00 P.M. to 4:00 A.M. every night from 11/01/24 through 11/25/24. She was then given Jevity 1.5 cal at 55 ml/ hour every night between the hours of 6:00 P.M. to 4:00 A.M. from 11/26/24 through 11/30/24. Review of Resident #2's MAR's for December 2024 revealed the resident continued to receive Jevity 1.5 cal at 55 ml/ hour nightly between the hours of 6:00 P.M. to 4:00 A.M. from 12/01/24 through 12/03/24. The MAR then reflected she was changed back to Isosource 1.5 cal at 55 ml/ hour between the hours of 6:00 P.M. to 4:00 A.M. beginning the evening of 12/04/24. Review of Resident #2's progress notes revealed a nurse's note dated 11/22/24 at 5:21 P.M. that indicated the nurse had spoke with the certified nurse practitioner and received an approval to change the resident's Isosource to Jevity if needed. Another progress note dated 11/22/24 at 5:30 P.M. revealed the approval to supplement Isosource with Jevity 1.5 call was due to the Isosource being on back order. Another nurse's note dated 12/03/24 at 8:00 P.M. revealed the nurse spoke with the nurse practitioner and the resident's daughter regarding an order change back to Isosource related to it's availability. On 12/04/24 between 8:54 A.M. and 9:41 A.M., an observation of Resident #2 noted her to be lying in bed in a supine position with the head of her bed up. The resident had her eyes closed with oxygen on per nasal cannula and in no apparent distress. She was noted to have a couple of rolls of toilet paper sitting on the top of the nightstand next to her bed. She did not have a box of facial tissues in her room at the time the observation was made. She had an indwelling urinary catheter draining to gravity drain. She was covered with a blanket and it was not visible if she was wearing any type of incontinent product. On 12/04/24 at 11:27 A.M., an interview with Resident #2's daughter revealed they have had issues with supplies more often than she cared to recall. She confirmed the resident had to have her enteral tube feeding changed to another type due to supply problems. She has also had issues with not having the proper size incontinent brief to wear and was made to wear ones that were too small for her. She stated the resident was a 3 X in incontinent brief sizes and the facility staff had to use medium sized briefs on her. It resulted in her leaking or being saturated through her clothing due to the incontinent brief not being a proper fit. That had been an issue as recent as two weeks ago, but had also happened in the past sometime between 06/26/24 when she was admitted and 10/03/24, when she finished working with therapy at the completion of her 100 days of skilled services. There had also been a problem with the facility not having facial tissues for the residents. She had found a couple rolls of toilet paper on the resident's nightstand in place of a box of tissues that the resident liked to have on hand. The resident used them to tuck in the front of her shirt collar to help when she drooled or dribbled when taking drinks. She blamed the supply issue to a particular employee that was in charge of ordering supplies. She stated she did not know what the issue was, but the employee evidently did not understand how much they needed to order to be able to meet the demands of the residents they were taking care of. On 12/04/24 at 3:10 P.M., an interview with Resident #2 revealed there had been times where she has ran out of facial tissues and the facility did not have any to give her. She was not too concerned about it and was usually able to get them if she really needed them. Her daughter had brought her in some when the facility did not have any. She also confirmed there had been problems with the facility not having the proper size of incontinent briefs for her resulting in the facility staff putting smaller ones on her that did not properly fit. She claimed there had been a time in the past in which she was in therapy and was wearing a smaller sized brief. She recalled being incontinent of her bowels and making a mess, which was embarrassing to her. She denied any recent issues with not having the proper size of incontinent briefs, but they were now being supplied through hospice. On 12/02/24 at 3:50 P.M., an interview with Central Supply Employee #250 revealed she was the employee that used to be responsible for ordering supplies. She had been in central supply since July 2023, but did not start being in charge of ordering supplies until January 2024. The facility started having the corporate office order supplies in October or November of 2024. They only did that for a month or so, before they began having issues with the availability of supplies sometime in November 2024. She placed orders every Monday and Wednesday for deliveries on Tuesdays and Thursdays. When the corporate office took over ordering supplies, they wanted to place orders every couple of weeks. The first order the corporate office placed in November did not come until 11/20/24. They were in need of briefs as their supply was running low. She was not made aware the staff were using smaller size briefs on residents, due to not having the proper size they needed. They got a hold of the corporate office when supplies were low and fast tracked an order. They placed an order on 11/20/24 and got it the next day. They (facility's management staff) told the corporate office, after that happened, that they would go back to having her (Central Supply Employee #250) order the supplies. She denied any issues with not having facial tissues available. When she was in charge of supplies, she would check daily Monday through Friday to see what they had on hand and put out supplies as needed. The corporate office did not have anyone on site to check supplies like she did. She was asked to place a case of briefs in Resident #2's room about two or four weeks ago. The facility used to supply her with briefs, but believed hospice was doing that now since she was under their care. She was not aware of any problems with enteral tube feeding solutions not being available. She was aware that some had been changed to Jevity from Isosource, but thought that was due to the corporate office wanting them to use up the Jevity they had on hand. She was not sure exactly what Resident #2 currently had ordered in regards to her tube feeding. She stated she would have to get with the nurse to see what they were actually using (1000 ml closed bags or the 250 ml cartons) to get her the 550 ml she received nightly. She used a running inventory list to keep track of what supplies they had on hand before, when she handled the ordering of supplies. When the corporate office took over ordering supplies, she handed that all over to them. She stated since she took over the ordering of the supplies on 12/01/24, she would start a running inventory again. On 12/04/24 at 4:52 P.M., an interview with LPN #100 revealed the facility has had some issues with ordering supplies when the corporate office took over. When they were low on supplies, they were required to put it in the dashboard. She stated she felt, by the time they let them know and when they received it, they were usually out. She stated it was a lot better when Central Supply Employee #250 was in charge of ordering supplies. Facial tissues not being available for resident use had been an issue a couple weeks ago. They had some, but were getting low the last time she saw them. She was not sure if they ran completely out. She confirmed Resident #2's daughter did tell her they had to bring facial tissues in for the resident due to her not having any. She recalled that was two or three weeks ago and she was informed of that over the phone during shift change. She shared that information with the night shift nurse. She denied she actually checked to see if they had any tissues or not. The night shift nurse was aware of them having some in the medication room and was to take the resident some back. They were using the 1000 ml closed bags of Isosource 1.5 cal for Resident #2. She denied they had any 250 ml cartons of Isosource 1.5 cal on the South unit and she did not think they had any on the North unit. She reported the other resident that had Isosource bolus feedings on the South unit may have had some in the medication cart. She called the nurse practitioner and got the okay to switch to Jevity 1.5 cal that they had on hand, in the event that they ran out of Isosource before the shipment was received. She stated they were interchangeable and just made by a different company. She was not aware of there being any problems with incontinent briefs. Hospice had been providing briefs to Resident #2 since she had been under their care and services since October 2024. On 12/05/24 at 10:38 A.M., an interview with Certified Nursing Assistant (CNA) #125 revealed Resident #2 did require the use of incontinent briefs. She used to be incontinent of her bladder, but now had the use of a catheter and was only incontinent of her bowels now. The resident needed a size 3 brief. There had been an issue in the past in which the facility ran out of size 3 briefs. She stated it was a supply issue and they had since changed suppliers. Since the facility's new Director of Nursing (DON) took over, they were not having as much of an issue with that anymore. There was a three day time span in which they were out of size 3 briefs and that was after the new DON was there. They had to use pull ups or use a blue brief under Resident #2 and another blue brief down the front of her. She reported they were constantly telling the DON, Assistant Director of Nursing (ADON), the unit manager, and the nurses that they were out and would be told they were working on it. She could not recall if that was prior to Resident #2 being under hospice's care or if it was after that. She reported that problem occurred before the resident had her indwelling urinary catheter placed. She stated the messes were massive and they were unable to get Resident #2 up out of bed due to that. She used to be up daily, but during that time when they did not have the appropriate size brief, they had to leave her in bed. The family of the resident was mad at them. She felt they were threw them under the bus because the family was told it would be taken care of it and blamed the aides for the lack of care provided. She denied the management team offered to go to the store to purchase any of the briefs they needed, while they were waiting for them to be delivered. She denied they had ever went to the store to purchase anything they were out of. They just got the facial tissues in and had been out of those for quite a while. There was a two week period she worked in which tissues were not available. The facility just recently opened a CNA closet for supplies to be readily available. When they were out of tissues, it was before the CNA supply closet was created. They checked five different areas in which they might have been stored in, but were not able to find any. They were not able to find any during that two week period. She reported they have had issues with incontinent briefs not being available that was more than just with the size 3's. There was a time three to four weeks ago they had no briefs at all. Everyone was wearing pull ups during that time. The corporate office took over ordering supplies when there had been previous issues with supplies not being available. She felt it only got worse after corporate took that over. That was when they were told they were getting new suppliers. They (corporate office) were not on-site to see what they had and what was needed. She felt there was a communication issue as to why supplies were not readily available. It would get passed on to management, but did not make it's way to the corporate level to order. It had been getting better after they changed things back to the way they were. Central Supply Employee #250 had things set up prior to the corporate office taking over. It was getting back to how it was before. It was not drastic when Central Supply Employee #250 was in charge of supplies before. Shipments were usually received the following day and they did not completely run out of things. Supplies at that time were just getting low. On 12/05/24 at 11:44 A.M., an interview with CNA #133 revealed Resident #2 had her indwelling urinary catheter for about a month now. They continued to check her for bowel incontinence though. She confirmed the facility definitely had issues with supplies. It happened a lot when they were out of incontinent briefs, cups, lids, straws etc. They have had issues with facial tissues as well not being available. The problem with not having incontinent briefs was about two weeks ago or at least within the last month. They were completely out of briefs and only had a few pull ups, if any at all. Pull ups were very limited. She reported Resident #2 wore size 3 briefs. Since hospice has cared for her, she has had the incontinence briefs she needed. She believed the issue they had with that might have happened after Resident #2 was getting hers through hospice. The issue had been since the facility's new DON started there, but she could not recall how long that had been. She recalled there was a time they were using two blue briefs for Resident #2 putting one under her and the other up the front of her. She confirmed that resulted in them having to leave the resident in bed, so she did not have any accidents in her chair. She also confirmed they had been completely out of facial tissues during that same time period (two to four weeks ago). She recalled one former resident that was in need of some, but they looked everywhere and could not find any. She had heard a nurse talk about not having enough supplies and made the comment that it was embarrassing that they did not even have enough supplies on hand to take care of the residents. She thought the supply issue was a communication problem. Before, they would tell the nurses when they needed something. The nurses would in turn pass it on to the facility's prior DON. Now they tell the new DON or the unit manager. Central Supply Employee #250 used to handle the ordering of supplies, but had been taken off of it. She was not sure who took over after that. This deficiency represents non-compliance investigated under Complaint Number OH00160107.

Based on medical record review, interview, and policy review the facility failed to implement an effective pain management program, including the administration of scheduled and as needed opioid medication for Resident #7. Actual Harm occurred on 11/09/24, when Resident #7, who was identified with chronic pain and a new onset of acute pain related to a fall resulting in a fractured sternum, did not receive her scheduled or as needed Percocet (narcotic pain medication) as requested, resulting in uncontrolled pain that affected the resident's ability to participate in activities of daily living and required the administration of a one-time emergent dose of Percocet to re-gain control of the resident's pain. This affected one resident (#7) of five residents reviewed for pain. Findings included: Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including chronic pain, diabetes, osteoarthritis, carpal tunnel, cervicalgia, muscle spasm, and chest pain. Review of Resident #7's pain care of plan, initiated on 05/10/21 and revised 04/16/24, revealed the resident had pain related to peripheral neuropathy, peripheral vascular disease, osteoporosis, gastric reflux disease, muscle spasms, cardiac disease, restless leg syndrome, bilateral knee and rib pain, and carpal tunnel release. Interventions included encourage to request pain medication before pain becomes severe, offer analgesics per physician order, and attempt non-pharmacological intervention prior to administering medications. Review of the October 2024 physician's orders revealed an order (dated 07/24/24) for the narcotic pain medication, Percocet 5/325 milligrams (mg) one tablet twice daily for chronic pain. Review of Resident #7's annual Minimum Date Set (MDS) assessment dated [DATE] revealed the resident had taken scheduled and as needed pain medication. The assessment noted the resident's pain had rarely or not at all affected activities of daily living. The resident's pain, at its worst on a scale of 0-10 and in the last five days, been a three (on a 0-10 scale with 0 meaning no pain and 10 being the worst pain ever) during the assessment period. Review of Resident #7's progress note dated 10/23/24 at 2:32 A.M., revealed a Certified Nursing Assistant (CNA) reported to the nurse that the resident fell in (her) bathroom. The resident was sitting on her bed when the nurse walked in. Noted a moderately raised bump to the crown of the head. Tender to touch. Resident reported neck, shoulders and top of chest feeling sore from being jolted. Resident explained that she fell asleep on the toilet and woke up when she fell forward and hit her head on the sink. Resident explained that she got herself back to bed before ringing her call light. Review of Resident #7's progress note dated 10/26/24 at 11:48 A.M., revealed the resident approached the nurse and reported she was hurting in her back, chest and she reported something was wrong and wanted a computed tomography (CT) scan. The resident was transferred to the emergency room . Review of Resident #7's progress note dated 10/26/24 at 3:55 P.M., revealed the resident returned to the facility via cot accompanied by paramedics. Resident received a final diagnosis of a closed fracture of the sternum (breastbone) resulting from her fall that occurred on 10/23/24. New order received for Percocet Oral Tablet 5-325 mg one tablet by mouth every eight hours as needed for pain for 30 days. The resident received as needed (PRN) pain medication and stated that it was effective. Review of Resident #7's progress note dated 11/04/24 at 4:11 P.M., revealed the resident denied worsening pain or discomfort associated with (her) sternum fracture at this time. Review of Resident #7's provider note dated 11/08/24 revealed the resident was seen for a follow up on chronic conditions including pain and chronic obstructive pulmonary disease. The note revealed the resident's pain was controlled with Percocet, Tylenol, Voltaren gel, and muscle rub. The note also reflected the resident's pain was exacerbated due to a recent fall and sternal fracture. The resident started Percocet 5/325 twice daily on 07/28/24 and Percocet 5/325 mg every eight hours as needed for 30 days on 10/26/24 for better control which had been helpful. Further review of the provider note revealed the resident was seen today in her room and reported her chronic pain continued to be exacerbated due to the recent fall and sternal fracture. The resident reported the addition of as needed Percocet has been helpful at bringing her pain to a tolerable level. No noted adverse effect of additional pain medication availability. Resident reported it was difficult to take a deep breath due to the pain associated with it (the sternal fracture). Review of Resident #7's undated Percocet control sheet revealed on 11/09/24 Registered Nurse (RN) #700 (a contracted agency staff nurse) had signed out Percocet 5/325 mg at 7:11 A.M., 11:00 A.M., and 12:00 P.M. (each time a narcotic is removed from the double locked narcotic drawer, the number assigned to the pill removed from the bubble pack is documented on the narcotic control sheet in order to quickly identify the number of narcotics contained in that bubble packet are remaining according to the narcotic control sheet and account for removed doses of the narcotic medication). Review of Resident #7's orders and Medication Administration Records (MAR) dated 11/2024 revealed the resident was ordered Percocet 5/325 mg one tablet by mouth twice daily upon rise (6:00 A.M. to 10:00 A.M.) and bedtime (6:00 P.M. to 10 P.M) and as needed every eight hours for pain. RN #700 documented she administered the rise dose of Percocet 5/325 mg on 11/09/24. There was no documented evidence on the MAR that the as needed Percocet was administered on 11/09/24 (the 11:00 A.M. or the 12:00 P.M. doses as signed out on the Percocet Control Sheet). Further review of the medical record revealed there also was no evidence a pain assessment (numerical pain rating or location of the resident's pain) was completed at the time the prn doses of Percocet were documented on the narcotic sheet. Review of the MAR and Percocet Control Sheet revealed a one-time dose of Percocet 5/325 mg was administered on 11/09/24 at 3:08 P.M for pain assessed to be rated a 10 out of 10. However, review of Resident #7's progress notes revealed no documentation the resident was having increased pain on 11/09/24 resulting in the one-time order of Percocet 5/325 mg. Interview on 11/12/24 at 9:00 A.M. and 10:02 A.M. with Resident #7 revealed she didn't get several of her scheduled morning medications on Saturday 11/09/24 which included a scheduled pain pill. The resident reported she recently had a fall and fractured her sternum. The resident stated on the morning of 11/09/24 she waited and waited for her morning medication. Finally, RN #700 arrived at her room and put the medication cart right in front of her door. The nurse left the cart in front of her door but never gave her any medications. The resident reported she used her good arm and pushed the medication cart out of the way so she could exit her room. Resident #7 asked the nurse for her meds and RN #700 responded No, I'm going up the hall. Resident #7 followed the nurse up the hall and requested her morning medications. The resident stated RN #700 gave her medication, however there was no Percocet in the medication cup. The resident reported she could not get out of bed most of the day and could not participate in activities because the pain in her sternum was so severe. Interview on 11/13/24 at 1:56 P.M., with Regional Support Nurse (RSN) #116 confirmed Resident #7 did not get her pain medication on 11/09/24 resulting in increased pain requiring a one-time order for Percocet 5/325 mg to be administered (because RN #700 had documented on the narcotic sheet she had removed three Percocet from the narcotic drawer for Resident #7 but did not document the administration of two of the doses). RSN #116 verified the facility had confirmed Resident #7 had not received her scheduled medication, resulting in a pain rating of 10/10 and the physician had to order a one-time dose since too many doses had already been signed out for Resident #7. Interview on 11/13/24 at 2:35 P.M., with Licensed Practical Nurse (LPN) #600 revealed she had worked dayshift on 11/09/24 and Resident #7, who is alert and oriented and knowledgeable about her medications, reported she didn't receive any pain medications on 11/09/24 (it was after 2:00 P.M. this date) and her pain was not controlled due to not receiving medications for pain, especially with a sternum fracture. The LPN verified the resident's physician had to be contacted for a one-time dose of Percocet for the resident's pain. Review of the facility's policy titled Pain Management dated 08/22/22 revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility would use a pain assessment tool, which was appropriate for the resident cognitive status, to assist in consistent assessment of the resident's pain. This deficiency represents non-compliance investigated under Master Complaint Number OH00159408 and Complaint Number OH00159399.

Based on medical record review, review of the facility concern log, review of a facility soft file, interviews, and policy review the facility failed to ensure timely and appropriate efforts were implemented to achieve resolution regarding Ombudsman, resident representatives, and/or resident concerns. This had the potential to affect all 72 residents residing in the facility. Finding included: 1. Review of the facility's soft file related to the Ombudsman's concerns revealed on 09/05/24 at 3:00 P.M., the Ombudsman had visited, and she was here two weeks ago and had the same issues she had this day. Today's concerns include a resident was still not getting bologna sandwiches at bedtime, grilled cheese sandwiches and potatoes were burnt, call lights not being answered timely (worse on weekends), residents not getting what they asked for with meals, food over cooked, always available items not always available, and sheets not being changed on shower days. There was no documented evidence who attended the meeting. A meeting was held on 10/15/24 that included handwritten notes that Agency staff were not setting up meal trays, residents not getting milk, concern with changing linens, and call lights. There was no documented evidence who attended the meeting. An additional handwritten note with the Ombudsman's concerns dated 10/31/24 revealed they would like to meet the Director of Nursing (DON). There were concerns with Resident #68 that included receiving assistance with meal trays, not getting supplements, and barrier cream not always available. On Saturday (date not provided) residents didn't have new cups of ice water. Staff told residents they didn't have cups. No fruity pebbles, burnt food, linens not changed on shower days, call lights take 1/2 to one hour to be answered, issues with Direct TV channels, Resident #4 was uncomfortable about talking about politics with a staff member. It was not documented who attended the meeting. Interview on 11/05/24 at 8:25 A.M., with the Ombudsman revealed on 10/15/24 she had requested a meeting with Corporate Staff due to resident concerns (fresh water, bed linens, call lights, dietary concerns, medication administration, Hoyer lift education, etc.) she has reported to the facility staff (Administrator and previous DON, whom now is the Assistant Director of Nursing) and are not being addressed. The Ombudsman reported she tried reaching out to the new Director of Nursing (DON) however she has not been able to talk with her because she was either busy or in a meeting. The residents were still voicing concerns with not receiving fresh water, bed linens, dietary concerns, etc. as of today. The Ombudsman was having another care conference today with the facility due to Resident #68's family concerns from 09/17/24, that still have not been addressed to the family's or her satisfaction. She had requested Corporate Staff to attend this meeting as well. The facility was not addressing resident concerns she has reported over the last few months. 2. Review of Resident #68's care conference note in the electronic medical record dated 09/17/24 revealed concerns (meal tray preferences, boost time frames, medication, and staffing issues) were reviewed with the daughter, social worker, nursing administration, Administrator, and Ombudsman. Review of the facility's soft file dated 09/17/24 revealed handwritten notes with a list of concerns including needs fed at all meals, if daughter not here, sometimes takes 30 plus minutes, if she eats less than 50% she gets a boost, always gets peanut butter and jelly (PBJ) sandwich with all meals, doesn't' like lemonade or OJ, never gets water on meal trays, doesn't' get hot tea, weekends no help with meals and eating, make sure aides notice thing on trays if missing, issues with constipation lately, making sure medication given daily, laid in bed for four days straight, needs twenty minutes to sit on bedside to have bowel movement, fresh new cups, floating heels daily, repositioning needs every two hours, missing two shirt protectors, therapy not updating, prune juice daily, hair washed once weekly, Hoyer lift training/education, and go to church on Sunday. There was an additional note that was labeled Ombudsman that indicated no improvement with ice water. Review of Resident #68's care conference note in the electronic medical record dated 11/05/24 revealed concerns reviewed included PBJ with all meals, audits to be done for ice water, up and down schedule, ancillary services, staffing, and boost instead of boost breeze. There was a handwritten note to add a peanut butter and jelly sandwich (PBJ) to all meals, ice water, up and down schedule, ancillary services, boost, and night managers. Review of the facility's soft file dated 11/05/24 revealed handwritten notes with a list of concerns including boost administration, magic cups not being substituted with mighty shakes, barrier cream availability, break down on heels, repositioning, education on Hoyer lift, call lights on chair and bed, not getting fresh cups and water, not getting help with meals, PBJ, still getting Lemonade, staffing issues, and ensure staff do bed baths instead of waiting on hospice. Interview on 11/05/24 at 8:25 A.M., with the Ombudsman revealed she had another care conference set up today for Resident #68 at 2:00 P.M. and had requested corporate staff to attend due to previous concerns from 09/17/24 involving Resident #68 and other resident concerns from 10/15/24 have not been addressed. The family had documentation and photos to support concerns. The resident needs assistance with meals and the family came in and the resident's meal tray was sitting next to her. The resident was supposed to have a supplement four times a day and it still wasn't being administered, the facility doesn't have barrier cream for the resident and all the residents had to share one tube of barrier cream. The nurse would give staff a medication cup with a small amount of barrier cream in it. The resident's daughter had photos of medication left on her beside table, and concerns medication not administered per orders. There were concerns of lack of communication with staff. The facility was to put a communication book together for the agency staff to know the resident's routines and likes but it was never done. The facility just put a turn schedule in the closet. The dietary staff were not reading the meal tickets and kept giving the resident lemonade when it's on her dislikes on the meal tickets. The family have concerns with ice water not being given. The family were told the facility was out of foam cups and the Administrator reported they had some, but agency staff don't know where they were at. Resident #68's daughter reported there were no cups this weekend after staff were supposed to be educated on where to find the cups. Resident #68s' family had concerns with improper use of the Hoyer lift and where afraid staff were going to break the resident's (recliner) chair. In the September meeting the Administrator was supposed to educate staff on the Hoyer lift but education was not provided. and said she thought the concern was staff was not washing the resident's hair. Even after having meetings nothing gets resolved. Interview on 11/06/24 at 1:30 P.M., with Resident #68's daughter revealed she had a care conference 09/17/24, with the facility and again yesterday (11/05/24) and discussed the same concerns she had in September. The daughter reported she wasn't asking for much but felt like giving up and just going with it because it was a losing battle, and it could be worse. The family member shared text messages and photos from 07/26/24 to present between the Administrator, the DON (who is now the Assistant Director of Nursing), and herself. The messages included photos of pain patches that had not been changed for three days, pills found on the floor and bed in the resident's room, etc. The family showed pictures of meal tray not in reach, call light not in reach, fluids not in reach, heel boots not in-place, heels not elevated, alternative meals not provided per request, etc. The family also had meal tickets with notes they had kept supporting photos. The facility keeps sending Lemonade on her meal trays even though her meal ticket said no lemonade, the meal ticket indicated to provide water with each meal and the resident doesn't get it. Resident #68 doesn't' get fresh ice water, supplements as ordered, assistance with meals, nor does staff transfer her safely in a Hoyer lift, and she was afraid they were going to break the resident's recliner chair. Interview on 11/06/24 at 3:17 A.M., with Corporate Nurse (CN) #116 confirmed the facility had a general meeting in October with the Ombudsman to discuss general concerns. The facility had a meeting with Resident #68's daughter and the Ombudsman and had discussed concerns including assistance with meals, supplements, barrier cream, heel boots, call light, request to be up in chair, staff training on Hoyer lift, changing clothes, new chair, PBJ sandwich with each meal, ground meat, staff education on reading meal tickets, and having more staff on weekends. CN #116 reported the facility doesn't document every concern in the medical record and there should have been concern forms completed, however the general meeting in October with the Ombudsman was not documented on a concern form. She had educated Resident #68's family to report concerns in real time when the incidents occur to help the facility identify the problem. Some of the resolutions to the family's concerns were to administer boost four ounces seven times a day with meals and med pass. The facility ordered barrier cream that can be kept in the resident's room. Before it was a zinc product and could not be kept in the room. They are going to have two call lights one for the bed and one for the chair to help detect movement since the resident can't use the call light. Staff would be educated to provide care even if hospice was coming, staff would be trained on the Hoyer lift, a new broda chair for comfort was ordered by hospice, and staff would get the resident up more and during times the family requested. The order for the ground meat was corrected due to it was put in for a one-time order, the resident's meal ticket was updated, dietary would be educated, and the facility was going to add a weekend manager and/or late-night manager. Interview on 11/07/24 at 12:35 P.M., with the Director of Nursing (DON) revealed the facility was currently working on audits for supplements, unattended medications, meal preferences, ice water, and changing bed linens after a shower. Interview on 11/12/24 at 11:09 A.M., with Resident #68's daughter revealed the concerns addressed in September and on 11/05/24 were still not addressed. The daughter provided photos that the heel boots nor was the resident's feet elevated while she was in bed over the weekend. The photos showed the boots sitting in the chair near the bed. The resident still didn't have barrier cream. The staff finally broke her mom's recliner due to not using the Hoyer correctly. The daughter demonstrated that one staff stands behind the recliner and leans over of the back of the recliner and grabs the Hoyer lift pad and pulls the resident back and lets her slide down the back of the recliner. The daughter reported the weight of the staff member leaning over the back of the recliner and resident's weight on the back of recliner back snapped the bars on the back of the recliner. The resident didn't get supplements twice over the weekend while she was visiting. During the last care conference on 11/05/24 her mom was to get seven small cups of boost (four times a day with her Tylenol and with each meal). She didn't' get fresh water on Saturday. The cup still had Friday's date and the same smiling face someone had drawn on the cup. The daughter shared a photo of the resident call light hanging off the bed over the weekend when she arrived. They still haven't brought the second call light for the recliner/chair as discussed in the meeting on 11/05/24. On Thursday she was left up six hours and was not checked and changed and she had confirmed that with one of aides. She has another care conference set up on 11/19/24 to follow up on concerns. Interview on 11/13/23 at 12:15 P.M., with the DON revealed she could not find any staff education regarding assisting residents with meals, whoever she provided education on 11/11/24 (after surveyor observed concern with resident not receiving assistance with lunch meal). The DON confirmed Resident #68 medication administration record had missing documentation that the supplements was administered. The maintenance director added a second call light in Resident #68's room today. There was no documented evidence staff were educated on the Hoyer lift and the staff did break the recliner over the weekend and the facility will replace the recline. The DON reported she was not aware staff were not implementing heel boots or elevating heels and would start audits. 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including but not limited to lymphedema, diabetes, neuropathy, depression, anxiety, and insomnia. Review of the facility's concern log and report dated 10/31/24 revealed Resident #4 reported to the Ombudsman that Agency Certified Nursing Assistant (CNA) #545 was engaging in a political view conversation and the resident had asked him to stop the conversation during care. The CNA had also stretched the resident's leg too far during care. The Assistant Director of Nursing (ADON) #153 spoke to CNA #545 and he recalled having a conversation months ago about politics but be thought they were just having fun because how blown up it all was now. The ADON educated the CNA not to provide care or engage with the resident and to assign another staff to his room assignment and education was provided to the CNA on 10/31/24 and 11/01/24 to avoid offensive conversations particularly religion/politics. There was no evidence the concern regarding the resident's leg being stretched was addressed. Review of Resident #4's progress notes dated 09/07/24 to 11/07/24 revealed no evidence of any incident involving Resident #4's and CNA #545 was documented. Interview on 11/05/24 at 7:07 A.M., 11/06/24 at 7:42 A.M., and 11/13/24 at 7:30 A.M., with Resident #4 revealed an Agency CNA (CNA #545) did not treat him with respect and dignity recently and the facility permits the Agency CNA to work. The resident reported CNA #545 was providing care to him and was making comments about his music and saying the singers were witches, Satan, and belonged to cults. He made inappropriate comments about a singer. Then he started on him about voting for (a said presidential candidate). Resident #4 reported he kept telling CNA #545 he didn't want to discuss politics, and the staff member kept on and on and asking him if he was (a said presidential candidate) and told him he better not vote for (a said presidential candidate). CNA #545 then pulled his leg up to wash under it which was a very uncomfortable position for the resident and caused him pain the rest of the day. He has never had anyone left his leg to wash under it. Staff usually have him roll to his side to wash the back side of his body. The resident had reported his concerns to the Ombudsman and the ADON came and spoke to him. He told the ADON he preferred that CNA #545 not provide care to him anymore and the ADON kept asking if the facility hired CNA #545 full time, would he permit the CNA to provide care to him. The resident reported the ADON kept asking him the same question and he kept telling her No, he didn't want the CNA to provide care to him. Resident #4 reported he felt CNA #545 had mentally abused him related to the politics and music comments and physically abused him for raising his leg in a position that caused him increased pain. The facility didn't address his concern regarding the CNA lifting his leg. The ADON was just concerned about what would happen if they hired the CNA full-time, according to Resident #4. Interview on 11/05/24 at 8:25 A.M. with the Ombudsman revealed Resident #4 was upset and had reported concerns to her regarding CNA #545 discussing politics and music views. She had reported the concern to the Administrator and was told the Agency CNA would not be returning to the facility. Interview on 11/12/24 at 4:23 P.M., via email with the Director of Nursing (DON) revealed Resident #4 reported his concern to the ombudsman on 10/31/24 indicating issues with CNA #545 were not acute. The resident was assessed on 10/30/24 by the ADON and wound doctor and verbalized zero complaints of pain/discomfort at that time. The CNA provided a statement and education was provided on 11/01/24 and assignment changes per request. The ADON reassessed the resident on 11/06/24 with the wound doctor. An allegation of abuse was reported on 11/06/24 and a self-reported investigation (SRI) submitted, and investigation begun. Interview on 11/18/24 at 8:42 A.M., with the DON revealed the facility had completed the Abuse investigation and determined the allegation was not abuse. The resident had perceived it as a respect and dignity issue. Review of the facility's policy titled Customer Service undated revealed every person in the facility deserves to be always treated with respect and dignity. No matter Who they were before they were here, once they come through our door, they are our resident or guest, and every staff person will treat them with respect. Always treat our residents as you would want them to treat you. Know each person's preference about care and ask them how they would like it done. Treat each person as an adult no matter what their cognitive function level is. All residents are entitled to self-choice-speak to the resident respectfully, explaining care as needed and giving the resident the chance to respond and to refuse. Be as gentle as possible-a resident may have pain, pain on movement, stiffness, fragile skin, etc. that was not apparent to you. Review of the facility's policy titled Resident Rights dated 06/01/24 revealed the resident had a right to be treated with respect and dignity. This deficiency represents non-compliance investigated under Master Complaint Number OH00159408 and Complaint Number OH00159399.

Based on personnel file review, review of the facility Bureau of Criminal Identification (BCI) log, review of employee time sheets, interview, and policy review the facility failed to ensure staff were not permitted to work in a direct care capacity with a disqualifying offense. This had the potential to affect all 72 residents residing in the facility. Findings included: An anonymous concern made on 11/12/24 revealed the Administrator employed staff with criminal backgrounds (felony). This concern was investigated as part of the onsite complaint survey. Review of Certified Nursing Assistant (CNA) #702's application dated 08/12/24 revealed CNA #702 had checked yes to having been convicted or pled guilty to a crime. The CNA documented on the application she had a felony on 07/07/24 in (location) county. The CNA's at the facility work history included she worked as an CNA in a skilled nursing facility from 12/23/23 until 07/03/24. Review of the facility BCI log dated 04/17/24 to 11/11/24 revealed CNA #702 was hired on 08/13/24 and the BCI was submitted on 08/13/24. There was no documented evidence when the BCI report was received, however the background check was documented as being completed on 08/29/24. The log noted the employee was not hired using the personal character standards. The log further noted the employee was terminated for a disqualifying offense that required termination. Review of CNA #702's time sheet revealed the employee worked (providing direct resident care) on 09/08/24 from 6:00 A.M. to 6:15 P.M. and on 09/09/24 from 5:45 A.M. to 3:00 P.M. (after BCI results were completed and the employee was determined to have a disqualifying offense that required termination). Interview on 11/18/24 at 4:42 P.M., with the Administrator confirmed the BCI log did not indicate when the facility received the BCI results, however the log indicated the check was completed on 08/29/24. The facility was unable to provide written evidence as to when the results were actually received. The Administrator confirmed CNA #702 worked on 09/08/24 and 09/09/24 after the BCI was completed on 08/29/24 with a disqualifying offense that required termination. The Administrator also verified CNA #702 documented on her application she had been convicted of or plead guilty to a felony on 07/07/24. Review of the facility's policy titled Background Screening Investigation dated 11/2015 revealed the facility conducts employment background screening checks, references, and criminal conviction investigation checks on direct access employees. Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual had been convicted of abuse, neglect, mistreatment of individuals, or theft of property, the applicant would not be employed and/or would be terminated from employment. This deficiency represents non-compliance investigated under Complaint Number OH00159408.

Based on review of concern log, review of food committee meeting minutes, observation, interviews, and policy review the facility failed to ensure dietary staff were competent to carry out functions of food delivery. This had the potential to affect all 72 residents, except Resident #51, whom the facility identified as nothing by mouth (NPO). Findings included: Review of the concern log dated 09/06/24 to 10/31/24 revealed 10 concerns were reported regarding food preferences and receiving food items per order. Review of food committee meeting minutes dated 10/02/24 revealed the kitchen was running out of wheat bread and they needed more snacks and more of a variety. Interview on 11/05/24 at 7:07 A.M. and 11/06/24 at 7:42 A.M. with Resident #4 revealed the food was not much better since the last time the kitchen was surveyed in September and received citations. One day he didn't even receive a meal tray. The facility uses the excuse the truck didn't come and that was why they were running out of food, but he heard it was because of the budget, and they can only order so much, and it was not enough for all the residents. Review of the breakfast menu for 11/05/24 revealed cream of rice, sausage patty, and apple muffin. Interview on 11/05/24 at 7:21 A.M. and 2:22 P.M. with an anonymous staff member #800 revealed the food was burnt, dietary was not following menus, meals are late almost every day, they run out of food, not providing the correct fluid textures and portion sizes, or the correct adaptive equipment ordered. The staff member provided photos showing small portion sizes, which a resident only got a meatball sandwich and slaw, and the meal ticket said no slaw. Another photo provided was of a former resident meal tray that received pureed, and she was supposed to be on a regular diet. Observation on 11/05/24 at 7:37 A.M. of breakfast meal revealed the residents were to receive a cream of rice, apple muffin and sausage patty, however there was no muffins or sausage patty. [NAME] #200 reported there was no more sausage patties and only the residents in the dining room and northeast received sausage patties and everyone else received bacon. The cook reported the apple cake was made in place of the apple muffin. The pureed and mechanical soft diets received sausage gravy because she didn't have sausage for them. Resident #71 was to receive fruit loops three days a week, however the facility didn't have fruit loops so [NAME] #200 replaced them with cornflakes. Interview on 11/05/24 at 8:25 A.M. with the Ombudsman revealed residents have voiced concerns with not receiving diets as ordered, mealtimes, not receiving requested items, residents not receiving assistance with meals Interview on 11/05/24 at 1:52 with Licensed Practical Nurse (LPN) #115 revealed some days meal trays are received late and the kitchen does run out of the main food items frequently. Interview on 11/05/24 at 2:14 P.M., with LPN #114 revealed meals were not delivered timely all the time and residents have voiced concerns they were not getting food items they ordered. Interview on 11/05/24 at 2:40 P.M., with anonymous staff member #801 revealed meals were late a lot of the time. The kitchen was running out of food and coffee. Interview on 11/06/24 at 10:18 A.M., with Resident #2 revealed meals were hit and miss. The facility was still running out of food items. Interview on 11/06/24 at 11:18 A.M., with Resident #66 revealed the food was no better than when the facility received kitchen citations in September 2024. The meal times still vary and were too far apart and the food was still awful. Interview on 11/06/24 at 11:30 A.M., with Resident #71 confirmed she didn't get her fruit loops yesterday. The resident reported she doesn't like corn flakes because they are difficult for her to swallow sometimes when they get soft, but she ate them yesterday anyway. Interview on 11/06/24 at 12:00 P.M., with Resident #56 revealed she doesn't' always get food items she orders, and the mealtimes vary. Interview on 11/06/24 at 9:34 A.M., with the Assistant Director of Nursing (ADON) #153 revealed occasional meals were late and she has heard occasional food items were not available, however it has improved. Interview on 11/07/24 at 6:24 A.M. with Certified Nursing Aide (CNA) #150 revealed last night meal trays were late and didn't come out until 6:30 P.M. The mealtimes vary and residents have complained they are not getting food items they ordered. Interview on 11/07/23 at 6:30 A.M., with CNA #117 revealed mealtimes vary and run late frequently. Interview on 11/07/24 at 7:36 A.M., with Resident #31 revealed the kitchen frequently runs out of food. She usually orders tomato soup and peanut butter and jelly sandwiches. The eggs are usually raw and smell like raw eggs and it makes her sick to her stomach to smell. Interview on 11/07/24 at 8:14 A.M. with Dietary Manger #201 revealed she had just started on 10/01/24 and the left side of the oven has not been working properly and the staff had not been using it. The right-side seal was not working properly; however, the oven was still functional. The DM reported she looked in the freezer and found sausage patties, but the staff never looked or called her on 11/05/24 or she would been able to tell them where it was since she put the delivery away. She was not aware the staff used sausage gravy for the pureed and mechanical soft diets on 11/05/24. The DM confirmed trays were late last night 11/06/24 because they were trying to get the apples up to temp. The DM reported she had just provided education on 10/28/24 regarding mealtimes, food temperatures, reading meal tickets, adaptive equipment, and stocking (supplies). Review of mealtimes undated revealed the dining room on north was 7:00 A.M., 12:00 P.M., and 5:00 P.M. Northeast Hall was 7:15 A.M., 12:15 P.M., 5:15 P.M., Northwest Hall 7:25 A.M., 12:25 P.M. and 5:25 P.M. Southwest Hall 7:40 A.M., 12:40 P.M., and 5:40 P.M., and Southeast 7:50 A.M., 12:50 P.M., and 5:50 P.M. Observation on 11/06/24 at 8:30 A.M. revealed the breakfast trays had just arrived at Southwest Hall. Observation confirmed with DON at 8:30 A.M. on 11/06/24. The DON confirmed the mealtime sheet indicated 7:40 A.M. for breakfast. Interview on 11/07/24 at 1:30 P.M., with Resident #68's daughter revealed she requires assistance with meals and she doesn't get it. The daughter reported you never know what time meals will arrive. Sometimes lunch will come at 12:30 P.M. and sometimes it may be 1:30 P.M. Sunday dinner didn't come to 7:30 P.M., and her mom was usually in bed by that time. Her mom has trouble swallowing food and she was to have ground meats and doesn't always receive ground meats. The kitchen sends lemonade even though the meal ticket states no lemonade. They are to send water and tea on the tray and she rarely receives water on her tray. The daughter had notes on meal tickets that she shared with the surveyor. On 10/24/24 they were having a cold sandwich, and her mom doesn't like cold sandwiches, so they ordered grilled cheese, tomato soup, and cottage cheese, which was on the meal ticket, however she never received it. This deficiency represents non-compliance investigated under Complaint Number OH00159399.

Based on medical record review, review of hospital records, staff interview, and policy review, the facility failed to ensure fall interventions were implemented and residents were provided the appropriate level of assistance to prevent falls. This affected one (Resident #27) of six residents reviewed for accidents. The facility census was 68. Actual Harm occurred on 04/29/24 at approximately 4:30 A.M. when Resident #27, who was assessed to have severely impaired cognition, required physical assistance of one staff member for lower body dressing and was identified as a high fall risk, fell after having been instructed by staff (while in the shower room with the resident) to stand up and remove his pants, without staff assistance on a wet floor. Resident #27 sustained a displaced, comminuted (broken into several pieces) fracture of the left radius (one of the two large bones of the forearm) and a displaced fracture of the right ulna styloid process (small bony projection at the end of the ulna bone that maintains wrist stability and facilitates wrist movements). Findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia with agitation, bipolar disorder, anxiety disorder, cognitive communication deficit, alcohol abuse with encephalopathy, cerebral atherosclerosis, and contracture of the left ankle. Review of the Care Plan, last reviewed 03/20/24, revealed Resident #27 was at risk for falls related to alcohol induced dementia, neuropathies, cognitive communication deficit, confusion, shuffling gait, poor communication/comprehension, unawareness of safety needs, medication use, and wandering with interventions which included ensuring the call light was always within reach and wearing non-skid footwear while out of bed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/09/24, revealed the resident had severely impaired cognition, with no behaviors or rejection of care. The assessment further revealed the resident required moderate/partial physical assistance for lower body dressing and putting on/taking off footwear; and was dependent for showers and baths. The assessment indicated the resident had impairment, on one side of a lower extremity, and his mobility device was a wheelchair. Review of the Fall Risk Assessment, dated 04/02/24, revealed Resident #27 was determined to be a high fall risk. Review of a nursing progress note (authored by Licensed Practical Nurse (LPN) #205), dated 04/29/24 at 4:30 A.M., revealed while State-tested Nursing Assistant (STNA) #132 was getting the shower ready, Resident #27 stood up quickly to take his pants off, lost his balance, and landed on his left wrist/arm. The fall was witnessed. Resident #27 denied pain and stated he just fell over. Review of the Incident Report and Fall Investigation, dated 04/29/24 at 4:30 A.M., revealed the incident location was the shower. While the STNA was getting the shower ready, Resident #27 stood up quickly to take his pants off and lost balance, landing on his left wrist/arm. The fall was witnessed with no head injury noted. The resident was assessed, and a darkened area was noted to the left wrist. The family and physician were notified. A mobile x-ray of the left wrist and shoulder was ordered by the physician. The incident report indicated at the time of the fall, the resident was alert and oriented to person only; the predisposing psychological factors were confusion and impaired memory; and the predisposing environmental factors were a wet floor and non-skid socks not being in place. Review of the Post-Fall Investigation form, dated 04/29/24, revealed Resident #27 fell on [DATE] at 4:30 A.M. The investigation form was completed by LPN #205 and the Director of Nursing (DON). The section on the form titled Care Plan Interventions in Place was blank. The new interventions listed for Resident #27 were an x-ray of the left upper extremity, and for the STNA to have the shower room ready. The bottom section of the form, which was completed by the DON, indicated with check marks that the intervention was appropriate and documented in the care plan. Review of a nursing progress note (authored by the DON), dated 04/29/24 at 8:20 A.M., revealed the interdisciplinary team (IDT) met and reviewed Resident #27's fall on 04/29/24 at 4:30 A.M. in the shower room. While STNA #132 was getting the shower ready, the resident stood up quickly to take his pants off and lost balance, landing on his left wrist/arm. The fall was witnessed with no head injury. The resident denied pain and stated he just fell over. Vital signs were obtained, and a skin assessment revealed a darkened area to the left wrist. The resident denied pain. A mobile x-ray was ordered of the left wrist. The post fall intervention put into place was for the STNA to have the shower ready for the resident prior to taking the resident into the shower room and the STNA was to assist the resident with removing his clothes. Review of the Emergency Department Provider Notes, dated 04/29/24 at 11:45 A.M., revealed Resident #27 presented after an outpatient x-ray obtained at his nursing facility indicated a left wrist fracture. The resident, who has a history of dementia, stated he did not remember when he sustained the injury. The resident complained of tenderness and pain to the left wrist. The musculoskeletal examination revealed significant edema, subacute ecchymosis, and tenderness to palpation without active or passive range of motion testing performed. The x-ray impression was an impacted intra-articular distal radius fracture with comminution and mild dorsal angulation resulting in posttraumatic ulnar positive variance and a small displaced ulnar styloid process fracture. X-rays were discussed and reviewed with orthopedic surgery who recommended splint placement and close follow-up at their office. A fiberglass splint was placed. Review of STNA #132's Witness Statement, dated 04/29/24, revealed she was in the southeast shower room with Resident #27 when he fell . STNA #132 stated Resident #27 was usually a partial/moderate assist with footwear but required supervision for upper and lower dressing. The STNA stated I told him to go ahead and stand up to get his pants off. After the resident stood up, he lost his balance and fell over, falling on his left side. STNA #27 stated the resident hit his wrist fairly hard, but he didn't hit his head. STNA #132 went to the hallway and yelled for the nurse. LPN #205 came and assessed the resident. The resident stated his wrist pain was a five out of 10 (zero was no pain and ten was the worst pain possible). Review of an in-service, dated 04/29/24, revealed the topic: STNA to have shower room set-up and ready for the resident prior to taking the resident to the shower room. The in-service was signed by 11 nursing staff members. Review of a Nurse Practitioner (NP) progress note, dated 05/01/24 and untimed, revealed a follow-up visit with Resident #27 for an acute left wrist fracture and previously identified neck mass. The assessment indicated Resident #27 had a fracture at wrist/and or hand level with the plan for surgical intervention with an open reduction and internal fixation (ORIF) or closed reduction with casting on 05/07/24. Resident #27 reported some mild pain in his left wrist. The resident fell on [DATE] in the shower with immediate pain that was progressive to the left wrist. Interview on 05/14/24 at 3:23 P.M. with the DON confirmed the fall investigation determined STNA #132 was getting the shower room ready when Resident #27 stood up and sustained a fall. The DON verified the investigation determined the predisposing factors were a wet floor, non-skid socks not in place, as well as the resident's confusion and his impaired memory. The DON confirmed following the incident, the intervention initiated was for staff to have the shower room ready prior to taking a resident into the shower room. The DON further confirmed some staff received an in-service on this topic. Interview on 05/14/24 at 4:34 P.M. with STNA #132 revealed prior to Resident #27's fall, she walked with him to the shower room. STNA #132 stated normally she will turn the shower on to have the water already running before bringing the resident into the shower room. STNA #132 stated she did not turn on the water ahead of time and prior to bringing the resident from his room because she had given two other showers that night and she was afraid the water would get too hot. STNA #132 stated, I turned around to turn the water on to let it heat up and I told him to pull his pants off. When I turned around, I saw that he was falling backwards, he fell on his side and tried to catch himself. STNA #132 revealed that she went to the shower room door and called for the nurse to come and help. Resident #27 complained that his wrist was hurting. The STNA stated when LPN #205 came to assess the resident, he was already completely undressed, and was not wearing non-skid socks. STNA #132 stated the resident's wrist was beginning to swell and he complained that it felt stiff. Interview on 05/15/24 at 7:40 A.M. with the DON confirmed STNA #132 should have had the shower room ready before bringing Resident #27 into the shower room. The DON confirmed STNA #132 should have assisted Resident #27 with removing his pants, and Resident #27 should have been wearing his non-skid socks. Interview on 05/15/24 at 8:17 A.M. with STNA #113 revealed Resident #27 required physical assistance from staff for lower body dressing and undressing. Interview on 05/20/24 at 8:10 A.M. with the DON revealed on Friday evening, 05/17/24, STNA #132 came to her and stated that in fact, Resident #27 had been wearing non-skid socks, the shower room floor was not wet, and she was facing the resident when he was removing his pants. The DON confirmed STNA #132's new statement had changed from her post-fall witness statement and did not reflect the information documented in the facility's fall investigation. Interview on 05/20/24 at 9:38 A.M. with STNA #114 verified Resident #27's call light was not within reach, and she would place it on his bedrail. Interview on 05/20/24 at 11:28 A.M. with the DON confirmed a care planed fall intervention for Resident #27 was for the call light to be within reach. During a second interview on 05/20/24 at 9:52 A.M., STNA #132 stated on Friday evening, 05/17/24, she spoke with the DON about Resident #27's fall. STNA #132 stated prior to Resident #27's fall, the floor was not wet, and the resident was wearing non-skid socks. When asked by the state surveyor why her second interview was inconsistent and differed from her first interview regarding Resident #27's fall, STNA #132 stated the whole incident had made her nervous and about 30 minutes prior to her first interview with the state surveyor, the DON called her and spoke to her about the incident. STNA #132 stated at the time of her first interview, nothing was fresh in my mind, but once I read my statement, it refreshed my memory, and it wasn't that I lied in my first statement. STNA #132 stated she walked with the resident from his room into the shower room. While the resident started to remove his shirt, she placed a bath blanket on a floral chair and then told the resident to sit down. The resident sat down in the chair and then she told him to remove his pants. Next, the resident then stood up to remove his pants. STNA #132 stated prior to the fall, she was standing in front of Resident #27 when he started stumbling. The resident was able to regain his balance and then removed his pants. The resident started stumbling again and lost his balance and fell to the side and hit his wrist. STNA #132 stated, I completely remember being with him. I didn't think to have him sit back down when he started stumbling, I felt bad. I felt terrible. STNA #132 further stated that following the fall and assessment by LPN #205, Resident #27 did complain of wrist pain, however, she proceeded to give him his shower. Following the shower, she dressed him and walked him back to his room. STNA #132 stated she was not told of any new fall intervention after the fall and did not receive an in-service regarding the incident. Interview on 05/20/24 at 11:56 A.M. with LPN #205 revealed STNA #132 activated the shower room's call light and he responded. LPN #205 observed the resident sitting on the floor beside a white shower chair and the resident was naked. LPN #205 stated he did not see any non-skid socks and assumed the resident had not been wearing any, which is why he indicated this in his nursing progress note following the fall; however, following a subsequent conversation with STNA #132 on Friday evening, 05/17/24, she told him that Resident #27 had been wearing his non-skid socks prior to the fall. LPN #205 stated following Resident #27's fall, he observed the shower room's floor to be wet (as documented in his nursing progress note), and the room was hot and steamy. LPN #205 stated the immediate fall intervention initiated was to make sure the shower room floors were dry before taking a resident into the shower room and for Resident #27 to be assisted by two staff members for showers. Review of the facility policy titled, Fall Prevention Program, dated 07/19/23, revealed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Fall interventions may include call light and frequently used items to be within reach and to encourage residents to wear shoes or slippers with non-slip soles when ambulating. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care, interventions will be monitored for effectiveness.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of the facility incident log, review of a facility investigation, review of the facility elopement policy and interview, the facility failed to provide adequate supervision to Resident #58, who had a developmental disability, exhibited severe cognitive impairment (with a Brief Interview for Mental Status score of four), had exit seeking behaviors and required the use of a wander guard device (a special bracelet to alert staff when a resident exits the facility), to prevent the resident from exiting the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death on [DATE] at 4:30 P.M. when Resident #58 was unable to be located inside or outside on facility property. On [DATE] at 4:38 P.M. a passerby notified the facility that a possible resident was seen walking near the baseball diamonds at the city park, approximately one mile from the facility. Social Services Director #46 and Admissions Assistant #134 drove to the city park and identified the possible resident to be Resident #58. The resident had walked approximately one mile from the facility using either a walking path not directly visible to the community, crossed a creek using a foot bridge and arrived at the city park without assistance from staff or walked an alternate route with no sidewalks on the street, crossed a bridge and walked uphill to arrive at the destination. The resident returned to the facility with staff at 4:50 P.M. This affected one resident (#58) of three residents reviewed for wandering and elopement. The facility census was 74. On [DATE] at 3:05 P.M. the Administrator, Director of Nursing (DON), and the Regional Nurse Consultant (RNC) #290 were notified Immediate Jeopardy began on [DATE] at 4:30 P.M. when Resident #58 was unable to be located inside the facility or outside on facility property and had exited the building without staff knowledge despite interventions to keep the resident safe from wandering and leaving the facility unsupervised. The Immediate Jeopardy was removed and subsequently corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 4:38 P.M. a headcount was completed by the Director of Nursing (DON) and 74 of 75 residents were observed in the facility. (The in-house census on [DATE] was 75) On [DATE] at 4:45 P.M. the DON audited the elopement binder to ensure current pictures and pertinent information was included in the binder. Pertinent resident information contained in the binder included resident weight, height, race, eye color, nicknames, last known address, and emergency contact. No concerns were identified. Beginning on [DATE] at 4:45 P.M. and continuing through [DATE] at 5:05 P.M. staff education was conducted by the DON and included education on the facility elopement policy and procedure, facility abuse policy and procedure and not giving door codes out to residents, families, or visitors. The education was provided to 102 of 103 facility staff. The facility implemented a plan for any staff not educated during this time to be educated prior to their next scheduled shift. The facility implemented a plan for all new hires to be educated on the facility elopement policy by the DON/designee during facility orientation. On [DATE] beginning at 4:50 P.M. Resident #58 was placed on 1 on 1 (1:1) supervision by the DON/designee. Resident #58 remained on 1:1 supervision through the on-site complaint investigation. A head-to-toe assessment of the resident was also completed following his return and neurological checks were initiated with no abnormal findings. At 6:00 P.M. Designated Social Services #46 completed a Brief Interview for Mental Status which resulted in a score of four out of 15, indicating the resident had severe cognitive impairment. On [DATE] at 5:05 P.M. the DON checked seven total residents (Resident #58, #41, #40, #75, #32, #59 and #24) with wander guard bracelets to ensure placement, function, and expiration dates were appropriate with no adverse findings. On [DATE] at 5:15 P.M. the Maintenance Director and Administrator checked all outgoing doors to ensure they were all functioning properly with no concerns noted. This check included testing of 15 second or less egress, function of wander management system to include alarming when appropriate; when checking doors, the wander guard was held in the staff's hand, walked up to door, the door locked, and staff were unable to open using visitor code due to wander guard being within range. When the door was open and the wander guard fob then came in range, the door alarmed as it should. On [DATE] at 5:20 P.M. the Maintenance Director #166 changed all door codes and ensured the doors were all functioning properly with no concerns. On [DATE] at 5:23 P.M. the DON and Administrator notified Medical Director #300 and Nurse Practitioner (NP) #302, via phone, of the incident and no new orders were given. On [DATE] at 5:30 P.M. the DON and Administrator collected written statements from staff in the building during the incident. Statements from staff included Licensed Practical Nurse (LPN) #114, State tested Nursing Assistant (STNA) #28, STNA #36, STNA #152, Physical Therapy #236, RN #246, Director of Nursing, Administrator, Assistant DON #86, Social Services (SS) #46, Human Resources Assistant #134, Admissions #62, LPN #146, LPN #32, STNA #20, STNA #82, Laundry #54, Dietary #150 and Dietary #174. On [DATE] at 5:45 P.M. the DON and Administrator contacted frequent visitors to get their statements if applicable. Frequent visitors #400, #401, and #402 were interviewed by phone to add to the investigation. On [DATE] at 7:00 P.M. the DON posted bright colored signage at the front doors to remind/educate staff and/or visitors to not allow anyone out of the facility when they enter/leave the facility. (Signage was already at the front door but on white paper) On [DATE] at 7:19 P.M. the DON sent a CareFeed message (a system of being able to send out text messages and emails per family's preference) to all families to educate them on proper protocol when entering/leaving the facility and ensuring they do not allow anyone out when the door is open for entrance/exit. On [DATE] at 10:30 P.M. the DON verified all orders for wander guards were entered correctly for Resident #58, #41, #40, #75, #32, #59 and #24 with no concerns identified. On [DATE] at 11:00 P.M. the DON reviewed all residents for elopement risk. No new residents identified at risk for elopement. On [DATE] at 11:30 P.M. the DON reviewed the treatment record of each resident with a wander guard, Resident #58, #41, #40, #75, #32, #59 and #24 to ensure the nurses were documenting the wander guards were in place and functioning properly. On [DATE] at 8:00 A.M. Regional Maintenance Director #292 arrived to inspect the doors to ensure functionality with no concerns. This inspection included testing of 15 second or less egress, function of wander management system to include alarming when appropriate. When checking doors, the wander guard fob was held in staff's hand, the staff walked up to the door, the door locked, and staff was unable to open the door (using the visitor code) due to wander guard being within range. When the door was open and the wander guard came within range, the door alarmed as it should. On [DATE] at 11:45 A.M. the Administrator and DON conducted an elopement drill for first shift. On [DATE] at 1:13 P.M. the facility conducted an ad hoc (not planned) Quality Assurance Performance Improvement (QAPI) meeting with Medical Director #300, the Administrator, DON, Regional Director of Operations (RDO) #296, Assistant Director of Nursing (ADON) #86, Admissions Assistant #62 and Maintenance #166. A Root Cause Analysis was completed with the following systemic analysis reviewed which included the root cause of the incident being Resident #58 stating he had followed a lady out the doors. A visitor was determined to have the staff code to the door with corrective action being education to all families to not let others follow them out of the facility and education to all staff on elopement policy and not giving out the staff door codes to visitors, completed on [DATE]. On-going monitoring is needed with corrective action being establish on-going door audits for review at Quality Assurance and Performance Improvement meetings with initial audits on [DATE] and ongoing for four weeks. Visitors letting others out behind them with corrective action being new bright colored signage to alert them not to let others out behind them was posted on the front doors on [DATE]. Staff door codes were given out to others with corrective action being door codes were changed by maintenance and completed on [DATE]. On [DATE] at 1:45 P.M. Minimum Data Set (MDS) Nurse #24 reviewed the care plans for all 75 residents with no changes made. On [DATE] at 3:30 P.M. the Administrator and DON conducted an elopement drill for the second shift. On [DATE] at 11:30 P.M. the Administrator and DON conducted an elopement drill for third shift. Beginning on [DATE], the Administrator/designee implemented a plan to audit exit doors to ensure correct alarm conditions weekly for four weeks. This audit included testing of 15 second or less egress, function of wander management system to include alarming when appropriate using a wander guard fob to check the doors. When checking the doors, the wander guard will be held in the staff's hand while walking up to the door; verify the door is locked and the staff is unable to open the door using the visitor code due to the wander guard being within range. When the door is open and the wander guard then comes within range, the door will alarm. The Regional Maintenance Director/designee would also continue to audit functionality of doors and alarm system five days a week for four weeks (this was currently in place but would continue for four additional weeks, beginning [DATE]). This audit included testing of 15 second or less egress, function of wander management system to include alarming when appropriate. When checking the doors, a wander guard was held in the staff's hand, the staff walked up to door, the door locked and was unable to open using the visitor code due to the wander guard being within range. When the door opens and a wander guard then comes in range, the door alarms. Beginning on [DATE], the facility implemented a plan for the Administrator/designee to check placement and function of wander guards weekly for four weeks. All audits would be brought to the monthly QAPI meeting with the next meeting scheduled for [DATE]. Findings Include: Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including encephalopathy, type two diabetes mellitus, unspecified intellectual disabilities, and depression. Review of the admission progress note authored by Licensed Practical Nurse (LPN) #76 on [DATE] at 8:40 P.M. revealed Resident #58 arrived at the facility via ambulance service from the hospital with diagnoses of unspecified encephalopathy. Resident #58 was independent with a steady gait while ambulating. Review of the admission Embassy Wander/Elopement Assessment authored by Licensed Practical Nurse (LPN) #76 dated [DATE] revealed Resident #58 was at low risk for elopement with a score of three. A score of five or higher reflected a high risk for elopement. Review of the baseline care plan for Resident #58 dated [DATE] revealed Resident #58 required limited assistance from staff, was ambulatory, and was low risk for elopement. Review of the Admission Assessment Section D: Neurological authored by LPN #76 dated [DATE] at 11:45 P.M. revealed Resident #58 was alert to self and place, had impaired cognition, and had clear verbal communication. Review of the physician orders dated [DATE] at 10:13 A.M. revealed Medical Director #300 ordered a wander guard to the (resident's) left ankle. The order indicated to check function/placement every shift. Review of the Embassy Wander/Elopement Assessment authored by the Director of Nursing (DON) dated [DATE] at 10:15 A.M. revealed Resident #58's elopement score increased to four (a score of five or higher reflected a high risk for elopement) due to Resident #58's verbalization of wanting to leave the facility. There was no corresponding progress note or further documentation regarding the resident's expression of wanting to leave the facility resulting in the application of a wander guard bracelet at this time. Review of the Treatment Administration Record (TAR) for February 2024 revealed Resident #58's wander guard was applied on [DATE] and the first entry for monitoring was documented on [DATE] during night shift. Review of a progress note for Resident #58 dated [DATE] at 4:30 P.M. and authored by the DON revealed, during mealtime the resident was unable to be located. Code [NAME] initiated. Resident located and brought back into the facility. No injuries noted. Denies pain. Range of Motion (ROM) within normal limits (WNL) to all extremities. Neuro checks initiated. Wander guard left ankle in place and functioning to left ankle. CNPs (not identified) notified. Head to toe assessment completed with no skin issues noted. Placed on one on one at this time. Review of the facility incident logs for February 2024 and [DATE] revealed on [DATE] a wandering incident occurred involving Resident #58. There were no other wandering/elopement incidents documented on the incident log during this timeframe. Review of the facility's completed investigation initiated on [DATE] included the following staff statements: A written statement completed by LPN #114 on [DATE] revealed Around 4:30 P.M. I noticed the resident was not in the dining room (DR)/table for meal. Sent STNAs/staff to get the resident (R) when they didn't find him in his room; I instructed staff to search facility and notified Admin/DON during search. Nurse Practitioner (NP) (unidentified) also made aware. Last time I seen R was in DR/table eating a snack. Checked FSBS (fingerstick blood sugar) at 3:35 P.M. read 245. (Normal blood sugar level is between ,d+[DATE]). A written statement completed by STNA #152 on [DATE] at 5:01 P.M. revealed, I saw R on Northwest (NW) hallway walking up and down the hall. He spent most of the day at the nurses' station and sitting at a table in the dining room. I saw him between 2:00 P.M. and 3:00 P.M. on NW hallway walking. A written statement completed by SS #46 on [DATE] at 5:03 P.M. revealed, Alerted by the DON via phone at 4:46 P.M. that R was not found in the building. SS and the Admission Assistant were enroute to the facility (they had been out searching for Resident #58), spotted R walking on 8th street. R name was called out the window and he stopped and stated hey. SS tells him it's time to go home, he gets into SS vehicle and is returned to the facility. A written statement by Admission Assistant (AA) #134 on [DATE] at 5:04 P.M. revealed, Alerted to Resident missing by the DON at 4:46 P.M. SS and AA were on the way to the facility, spotted R walking on 8th street. SS yelled R name out the window and he stopped and said hey. SS told him it's time to go home, he got into the car and returned to the facility. A written statement completed by STNA #36 on [DATE] at 5:41 P.M. revealed, I saw R in the north dining room, sitting at the table. He spent most of the day in the dining room and at the nurses' station. Around 3:00 P.M. I last saw him in the dining room on North. At 4:30 P.M. my nurse asked me to get him from his room. He was not there. I alerted my nurse, she had me check the south dining room. I then called my DON at 4:35 P.M. to alert her that he was unable to be found, she told me and the nurse to start checking each hallway. At 10:13 A.M. my nurse and I placed the wander guard on his left ankle. Review of a Root Cause Analysis completed on [DATE], during the special QAPI meeting, revealed a systemic analysis and root cause of the incident included Resident #58 stated he had followed a lady out the doors. A visitor had the staff code to the door. This resulted in the door alarm being deactivated and not sounding when the resident exited. Observation on [DATE] at 10:00 A.M. revealed Resident #58 was participating in activities with an (unidentified) staff member sitting with Resident #58 providing one on one monitoring. There was a wander guard bracelet observed to Resident #58's left ankle. Interview on [DATE] at 10:25 A.M. with the DON revealed on the morning of [DATE] Resident #58 had walked to the front door with his case manager. Resident #58 had started to verbalize the desire to leave the facility and at approximately 10:15 A.M. Medical Director #300 was notified, and an order was received for a wander guard. LPN #114 and STNA #36 assisted in placing the wander guard on Resident #58's left ankle. The DON confirmed at 4:35 P.M. she had been notified that Resident #58 was not in the facility and the elopement protocols had been implemented. At approximately 4:38 P.M. a passerby had observed Resident #58 walking along Eighth Street near the city baseball diamonds. At 4:46 P.M. the DON notified SS #46 and AA #134, who were out searching for Resident #58 via a car, and were enroute back to the facility, of the location of Resident #58 on Eighth Street. At 4:50 P.M. Resident #58 was returned to the facility by SS #46 and AA #134. The DON revealed when Resident #58 was questioned about how he left the facility, he had pointed to the front door and stated, I followed a lady out. Interview on [DATE] at 10:45 A.M. with STNA #36 revealed she and LPN #114 had placed a wander guard on Resident #58 on [DATE] at approximately 10:15 A.M. STNA #36 stated she was the staff member who observed Resident #58 not being in his room at 4:30 P.M. and participated in searching for Resident #58. STNA #36 stated there were no alarms sounding in the facility before Resident #58 was identified as missing. Interview on [DATE] at 10:50 A.M. with STNA #152, scheduled to work on the North hallway, revealed Resident #58 was observed on the Northwest hallway ambulating up and down the hallway between 2:00 P.M. and 3:00 P.M. on [DATE]. STNA #152 stated she had not heard Resident #58 say he wanted to leave the facility. Interview on [DATE] at 11:01 A.M. with LPN #114 revealed she was Resident #58's nurse and on [DATE] at approximately 10:15 A.M. she had placed the wander guard on Resident #58's left ankle due to his verbalizations of wanting to the leave the facility. LPN #114 stated she last saw him in his room on [DATE] at 3:35 P.M. during the evening meal blood sugar check. At 4:30 P.M. LPN #114 realized Resident #58 was not in the dining room for the evening meal and requested STNA #36 go to Resident #58's room and encourage him to come up to the dining room. LPN #114 stated STNA #36 came back to the dining room and reported Resident #58 was not in his room. LPN #114 initiated the facility's elopement protocols and notified the DON. LPN #114 stated the door alarm never sounded during the afternoon of [DATE]. On [DATE] at 11: 14 A.M. interview with STNA #82 revealed Resident #58 was observed standing around the nurses' desk, located across from the front door, for most of the day on [DATE]. STNA #82 stated she did not hear Resident #58 wanting to leave the facility and there were no alarms sounding during the afternoon of [DATE] at the time Resident #58 would have left the facility. Interview on [DATE] at 2:37 P.M. with the Administrator revealed Resident #58 had been admitted to the facility on [DATE] and was at a low risk for elopement. On the morning of [DATE] Resident #58's case manager visited. At the end of the visit, Resident #58 walked the case manager to the door, which leads to the entrance lobby. At 10:15 A.M. the Resident #58 was verbalizing the desire to leave the facility. Licensed Practical Nurse #114 and STNA #36 placed a wander guard bracelet on Resident #58's left ankle at that time. At 3:35 P.M. LPN #114 had been to Resident #58's room to conduct a blood sugar test prior to the supper meal. At 4:30 P.M. LPN #114 noticed Resident #58 was not in the dining room for the supper meal and requested STNA #36 go check on Resident #58 in his room. STNA # 36 reported Resident #58 was not in his room and elopement protocols were initiated. At 4:38 P.M. a passerby contacted the DON that a resident (Resident #58) was seen by the baseball diamonds approximately one mile from the facility. At 4:50 P.M. Resident #58 was returned to the facility by Social Services (SS) #46 and AA #134. When the DON asked Resident #58 how he left the facility, as he pointed at the front door leading out to the front lobby, he stated, I followed a lady out the door. The facility does not maintain a visitor log and the visitor the resident potentially followed out of the building could not be determined during the on-site investigation. Interview on [DATE] at 3:15 P.M. with SS #46 revealed SS #46 and AA #134 were returning to the facility from searching for Resident #58 (by car) when she was alerted by the DON Resident #58 was not found in the facility. The DON reported Resident #58 was seen by a passerby at the city baseball diamonds at the city park. SS #46 drove to the area and spotted Resident #58 walking along the street. Resident #58's name was called, and he responded to SS #46 when told it was time to go home. Resident #58 then got into the vehicle and was returned to the facility at 4:50 P.M. Observation on [DATE] at 4:30 P.M. revealed two potential routes which Resident #58 could have taken when he left the facility. Route one included a walking path not directly visible to the community where he would have crossed a creek using a foot bridge and arrived near the city baseball diamonds. This route was approximately 1.2 miles from the facility. Route two, would have required Resident #58 to have walked along the street with no sidewalks, turned onto Eighth Street, crossed a bridge, and continued up a hill and across the ridge to arrive at the city baseball diamonds. This route was approximately 2.3 miles from the facility. On [DATE] at 8:10 A.M. interview with the DON verified there were likely two possible routes the resident may have taken when he eloped from the facility. One route had a walking path and foot bridge and the other followed paved roads. The DON was unaware which route the resident took after he left the facility unsupervised and without staff knowledge. Interview on [DATE] at 9:15 A.M. with Regional Maintenance #292 revealed the door code, which the visitors would use, would unlock the door for exiting off the unit (known as the visitors' code). The alarm would immediately sound if a resident with a wander guard in place were to come within four to five feet of the opened door. The door must manually be reset to stop the alarm from sounding. The staff have another code which would override the system allowing for an escorted resident to be taken out the door without the alarm sounding. (This code is referred to as the staff code). During the investigation, attempts were made to contact Medical Director #300 via phone call and voice mail; however, no return call was provided. During the investigation, attempts were made to contact Case Manager #500 via phone call and voice mail; however, no return call was provided. Interview on [DATE] at 11:11 A.M. with the Administrator revealed the staff code should never be given out to family members or residents. The code was only to be known by the administrator, the facility staff, regional maintenance, and the transport staff. The codes were reset (the code is changed) by either the Administrator or the facility maintenance when staff terminate their employment or when a resident knows the code. Interview on [DATE] at 9:53 A.M. with RF Technologies (Code Alert) Technician (RFT) #310 revealed the two bypass codes (the staff code and visitor code) on the door alarm must be different so the system will be activated when a wander guard fob (magnetic part of the wander guard that sets off the alarms when the fob nears the system) is within four to five feet of the antennas located at the door. The frequency of resetting the codes is made by the facility and their preference. RFT #310 stated, The only way a resident with a wander guard would be able to leave through an opened door is if the staff code had been entered to by-pass the system. When the visitor code is used and the door is opened, the alarm should have sounded immediately when the wander guard came into range of the antennas, which would be four to five feet from the door. Review of the facility's policy titled, Elopements and Wandering Residents revised date [DATE] revealed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. This deficiency represents non-compliance investigated under Complaint Number OH00151916.

Based on closed medical record review, policy review, and interview, the facility failed to timely identify a change in condition and failed to address and manage complaints of pain following a fall with injury for Resident #8 that occurred on 09/18/23. Actual Harm occurred on 09/22/23 when Resident #8, who was assessed to have severe cognitive impairment, was observed by staff moaning in pain while being turned and repositioned during personal care. The staff failed to notify the resident's nurse of her signs/symptoms of pain and failed to pursue pain relief for the resident. On 09/23/23 the resident was sent to the emergency room for further evaluation and was found to have an obvious deformity of the right leg and diagnostic imaging revealed thoracic, rib, sacral, and hip fractures. The resident was transferred to a trauma center. This affected one (Resident #8) of three residents reviewed for pain. Findings include: Review of Resident #8's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease, history of malignant neoplasm of the breast, muscle weakness, and history of falling. The resident was discharged from the facility following hospitalization on [DATE]. Review of the plan of care, dated 12/21/22, revealed Resident #8 had impaired expressive or receptive communication and was rarely understood. Interventions included for staff to anticipate the residents needs if resident was unable to communicate needs. Review of the plan of care, dated 12/22/22, revealed the resident has the risk for pain/discomfort. Interventions included complete pain assessment, observe characteristics of pain (location, duration, quality) and observe for pain every shift. Review of the plan of care, dated 12/23/22, revealed the resident was at risk for falls related to impaired cognition, poor safety awareness, wandering, and ambulating without her walker at times. Interventions included to maintain bed in lowest position when occupied, non-skid footwear, non-skid strips in front of recliner, call light to be within reach, and therapies as indicated. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment, dated 09/07/23, revealed the resident had severely impaired cognition and wandering behavior. The assessment indicated the resident walked in her room and corridor independently. The resident required limited, one-person physical assistance for dressing, personal hygiene, and toileting. There were no falls since admission on the prior assessment. Review of a nursing progress note, dated 09/08/23 at 6:55 A.M., revealed Resident #8 was found on the floor. The resident was assessed, and no injuries were noted. An investigation noted the resident was attempting to ambulate without assistance. On 09/10/23 at 11:24 P.M. the resident was assessed to have non-verbal signs/symptoms of pain related to the fall. The resident was grabbing at her middle/lower back and grimacing. The provider was notified, and new orders were received for a Lidocaine patch, a cold compress, and x-rays of the thoracic and lumbar spine. The resident also received Tylenol for pain on 09/13/23 and 09/18/23. Review of the lumbar and thoracic x-rays, dated 09/11/23, revealed the findings for the thoracic spine x-ray indicated an age-indeterminate wedge deformity as above. Computerized tomography (CT) or magnetic resonance imaging (MRI) was recommended in the setting of point tenderness or trauma. The findings for the lumbosacral spine x-ray indicated no acute osseous abnormality. Review of the nurse practitioner progress note, dated 09/15/23, revealed the resident was examined for follow-up for fall and review of x-ray. The resident was assessed to be at her baseline level of confusion. Palpation of the spine did not elicit any pain from the resident and there was no facial grimacing or behaviors during the assessment. There was no point tenderness. The resident was ambulating without issue. The plan was to continue the Lidocaine patch and Tylenol as needed (PRN). The resident was essentially non-verbal and her adult failure to thrive was stable. Review of a nursing progress note, dated 09/18/23 at 9:00 P.M., revealed the nurse was summoned to the resident's room where the resident was found to be lying on the floor, in the middle of the room. The resident denied injury but was unable to tell the nurse if she had fallen. The resident was assessed to have full range of motion (ROM) and the neurological check was within normal limits at this time. The resident was last observed in her bed prior to being found on the floor. The Nurse Practitioner and family were notified. Review of the Incident Report, dated 09/18/23, revealed Resident #8 was lying face down on her belly, in the middle of her room when she was found by STNAs. The resident appeared to have no injuries and a ROM of all extremities was performed. Vital signs and neurological checks were performed per facility policy. The resident was helped off of the floor by two STNAs and walked back to bed. The resident was not sure how she fell . The resident was oriented to person only and was ambulating without assistance. Review of the nurse practitioner progress note, dated 09/19/23, revealed the resident was lying in bed and appeared comfortable. The resident had stable adult failure to thrive. The resident was alert but confused, and her mood was flat and withdrawn. The resident's past medical history included failure to thrive. The nurse practitioner note documented the resident's thoracic/lumbar/sacral assessment revealed no palpable deformity or signs of pain. Review of the nurse progress note dated 09/22/23 at 12:47 P.M. revealed the resident's bowel sounds were assessed due to no documented bowel movement. (The resident had) active bowel sounds. The resident does not show any sign of pain to the abdomen. Abdomen is flat/soft. There was no additional information related to the resident's previous fall and/or pain. Review of the nurse progress note dated 09/22/23 at 1:10 P.M. revealed the resident had no complaints at this time. An additional note at 4:51 P.M. revealed the resident's diet was downgraded to a puree diet and magic cup supplement orders put into place. There was no additional information related to the resident's previous fall and/or pain. Review of Physician #400's progress note, dated 09/23/23, revealed a fall was reported last week, (09/08/23), without injury. Per the nurse practitioner's progress notes, the resident had another fall on 09/18/23 and had been bed bound since and no longer responded verbally. The resident had decreased oral intake and previously would be slow to respond, but would respond appropriately at times. During the physician's examination on 09/23/23, Resident #8 was lying in bed and appeared to be in significant discomfort. The resident had a right hip deformity which was not tender to touch and there was no palpable spine deformity. The resident was immediately sent to the ER for evaluation at this time. Review of the nurse progress note dated 09/23/23 at 4:12 P.M. revealed the physician was in to do rounds and ordered the resident to be sent to the emergency room for evaluation and due to complaints of pain and decline. Review of the nurse progress note dated 09/23/23 at 4:20 P.M. revealed the resident had functional decline (worsening function and/or mobility) and pain (uncontrolled). The doctor was in and evaluated patient and ordered to send to the emergency room (ER) for evaluation and treatment. Review of the nurse progress note dated 09/23/23 at 4:26 P.M. revealed this nurse spoke with a nurse in the emergency room about the resident and this nurse verified the resident walked and talked as the ER nurse stated she and the ER physician don't think she (the resident) had for a very long time. This nurse reassured the ER nurse that patient does in fact do both but does have confusion and disorientation. Lab results, last dose of antibiotic, x-ray results and fall information reviewed. The ER nurse stated she still did not believe this nurse and thinks we are talking about two different patients and verified patient name again which I stated yes, we are talking about the same patient and the ER nurse states she would let the ER physician know. Review of the September 2023 Treatment Administration Record (TAR) revealed to monitor for and document pain. Document pain level and non-pharmacological interventions. Is the pain program effective: yes or no. Further review revealed no directive to monitor the resident for non-verbal signs and/or symptoms of pain or what those signs and/or symptoms would be. From 09/18/23 through 09/23/23 the every shift (day and night) pain monitoring indicated a pain level of 0. The staff were directed to assess the resident twice a day for pain. However, the assessment/documentation did not indicate if the resident was receiving care during the assessment or the time the assessment was completed. Review of a hospital report, dated 09/23/23, revealed per the nursing home, Resident #8 had a fall five days ago. At that time, she was evaluated by a physician and deemed medically cleared. Today, the resident was re-evaluated by a physician at the local nursing home and was noted to be in severe pain. The resident is nonverbal and unable to provide detailed history. The resident was sent to the ER for further evaluation. At the time of evaluation, the resident was noted to be lethargic, cachectic, and appeared to be in distress due to pain symptoms. The resident did have an obvious deformity of the right leg. Diagnostic work-up findings are concerning for acute kidney failure, electrolyte imbalance, acute appearing, nondisplaced fractures involving left, transverse processes of T9, T10, and T11; minimally displaced fracture involving left 10 th rib head; acute, nondisplaced fracture involving the lower sacrum; and right intertrochanteric hip fracture with moderate displacement. The resident was transferred to a trauma center. Review of the hospital records from the trauma center, dated 09/23/23, revealed the resident would be undergoing surgical repair of the right hip fracture after medical stabilization. During interview on 09/26/23 at 2:29 P.M., Licensed Practical Nurse (LPN) #102 revealed she was never told by the STNA staff of Resident #8 crying out or moaning in pain during personal care prior to the resident being transferred to the hospital. Interview on 09/26/23 at 3:15 P.M. with State tested Nursing Assistant (STNA) #100 revealed Resident #8 did not moan during personal care until after the second fall that occurred on 09/18/23. STNA #100 stated she provided care to the resident on 09/22/23 and 09/23/23 and she recalled the resident was moaning (in pain) when she repositioned the resident onto her side during personal care. The STNA stated she did not report this to the nursing staff because she thought that the nurses knew and because she was told the resident did not sustain injuries during her falls and her x-rays were negative. STNA #100 stated on 09/23/23, Physician #400 was in the room talking to the other resident (the resident's roommate) when he heard Resident #8 scream during personal care. STNA #100 stated the physician came over and examined the resident and immediately sent her to ER. During interview on 09/26/23 at 3:47 P.M. interview with LPN #104 revealed she was working during the second fall. The STNA came and got her and said the resident was found on her belly in the middle of the room. The staff rolled her over slowly. The LPN stated she checked the resident's shoulders, elbows and there was no bruising on her fingers, knees or hips. The resident denied pain and the resident wasn't grimacing. The staff sat her up and two STNAs stood her up and walked her and laid her in bed and placed a fall mat (on the floor). The nurse stated she assessed the resident again and the resident said she had no pain. The resident stayed in bed the rest of the shift. Further interview revealed LPN #104 cared for the resident once or twice after the fall and a decline was noticed. The resident wouldn't swallow her medications and the staff crushed the medications. During shift report, they said that she had been declining and after the second fall, not wanting to take her medications or get out of bed. Interview on 09/26/23 at 4:24 P.M. with STNA #103 confirmed Resident #8 was moaning and appeared to be in pain during personal care on 09/22/23 and 09/23/23. STNA #103 could not remember if she reported this to the nurse. During interview on 09/27/23 at 8:33 A.M., Nurse Practitioner (NP) #401 revealed she was notified of both of Resident #8's falls. NP #401 revealed on 09/15/23, she and NP #402 examined Resident #8's spine and palpated her hips. The NP revealed they considered ordering a CT scan, but the resident was standing and bearing weight, and they didn't feel a CT scan was warranted. A medication review was completed to determine why the resident was falling and did a reduction of Remeron because often a lower dose of Remeron would stimulate the appetite. NP #401 revealed Resident #8 had been pacing and ambulating frequently after the first fall. The resident had a urinary tract infection (UTI) and was started on an antibiotic. NP #401 stated during examination on 09/19/23, Resident #8 was resting without complaint and there was nothing that gave her suspicion there was an injury. NP #401 stated she did not feel there was a change of condition following the second fall. NP #401 stated that she did not recall being notified of Resident #8 moaning or exhibiting pain during personal care and that she would expect to be notified of a resident exhibiting symptoms of pain. Interview on 09/27/23 at 9:35 A.M. with Resident #7 revealed she was Resident #8's roommate and on the night of the fall (on 09/18/23), witnessed the resident get out of bed, walk into the middle of the room, and fall on her stomach. Resident #7 stated Resident #8 did not hit her head. Resident #7 stated she called for help and staff came in and checked the resident and then put her back into bed. During interview on 09/27/23 at 10:45 A.M., the Director of Nursing (DON) stated STNA #100 and STNA #101 should have immediately reported Resident #8's signs of symptoms of pain during personal care on 09/22/23 to the nursing staff for further assessment/follow up care. Review of the facility policy titled, Notification of Changes, dated 10/01/22, revealed the facility must inform the resident, consult with the resident's physician and /or notify the resident's family member when there is a change requiring such notification. Circumstances requiring notification include accidents that result in injury with the potential to require physician intervention; a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. This deficiency represents non-compliance investigated under Master Complaint Number OH00146825 and Complaint Number OH00146737

Based on medical record review, review of hospital records, review of the facility policy and procedures related to change of condition, diagnostic testing services, culture and sensitivity lab results, and physical assessment and interviews with staff and Resident #65's family, the facility failed to provide timely and adequate care and treatment for Resident #65 who exhibited acute changes in condition with resident/family requests for hospitalization . This resulted in Immediate Jeopardy with serious life-threatening harm beginning on 12/23/22 when Resident #65, who was symptomatic of a C-Diff infection was not tested for the infection as ordered by the physician, properly treated or transferred to the hospital until 01/02/23 where he was admitted for nine days for treatment of C-Diff, colitis due to Clostridial Difficile, bilateral effusion, urinary tract infection, acute on chronic renal failure, elevated troponin, and adult failure to thrive. The Immediate Jeopardy continued 01/24/23 when Resident #65 experienced a second acute change/decline in condition and the resident, and his family requested the resident be transferred to the emergency room for evaluation and treatment. Registered Nurse (RN) #39 denied the resident's request to be transferred, failed to identify the significant change in condition, and failed to notify the resident's physician resulting in a delay in treatment until Resident #65's eventual transfer to the hospital (four hours after the change in condition and request by the resident) where he required aggressive critical care treatment including intravenous (IV) insulin push and drip, IV fluids, BiPap (respiratory care) and vasopressor medication and was transferred to the intensive care unit (ICU) for continuous monitoring and treatment of septic shock, diabetic ketoacidosis (DKA), acute respiratory failure related to COVID-19, hyperglycemia (blood sugar greater than 700) acute on chronic renal failure and dyspnea. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified related to the facility's failure to appropriately and timely treat Resident #56's post surgical right wrist infection. Actual Harm occurred to Resident #56 on 01/07/23 when the facility was notified of the final culture results identifying a right wrist surgical wound infection and the facility failed to notify the resident's physician of the results thereby delaying treatment of the surgical wound for two days resulting in worsening of the infection requiring hospitalization and treatment with IV antibiotics. This affected two residents (#65 and #56) of three residents reviewed for change in condition. The facility census was 74. On 02/02/23 at 4:34 P.M., the Director of Nursing (DON), Regional Director of Clinical Operations #55, and Assistant Director of Nursing (Registered Nurse (RN)) #59, were notified Immediate Jeopardy began on 12/23/22 when the facility failed to timely identify and provide medical treatment to Resident #65 following an acute change in his medical condition resulting in a nine-day hospitalization . Following the resident's return, on 01/24/23 Resident #65 exhibited nausea and vomiting and requested to be transferred to the emergency room , however, RN #39 declined to send the resident and did not notify the physician. Resident #65 was sent to the hospital four hours after he requested additional evaluation and treatment at the hospital where he was admitted to the intensive care unit. The Immediate Jeopardy was removed on 02/06/23 when the facility implemented the following corrective actions: On 02/02/23 at 4:07 P.M. Medical Director (MD) #56 was notified by the Director of Nursing (DON)/designee Resident #65 stool cultures were not obtained on 12/23/22 and 12/30/22 which contributed to the resident's hospitalization . In addition, MD #56 was notified Registered Nurse (RN) #39 had not afforded Resident #65 the right to timely transfer to the emergency roiagnom on [DATE] and 01/24/23 per the resident/family request. MD #65 was also notified of the facility's plan of correction and agreed with the plan moving forward. On 02/02/23 (no time identified)- the facility identified that all 72 residents had the potential to be affected by labs not being completed timely, physical assessment not being completed and notification of change to physician not being completed. On 02/02/23 at 5:41 P.M. Regional Director of Clinical Operations #55 reviewed the facility notification of change and culture and sensitivity lab results policies with no changes made. On 02/02/23 at 5:45 P.M. RN #3, RN #43 and LPN #60 completed physical assessments for all 72 residents to identify any changes in condition and notification was made to the physician of any noted changes. On 02/02/23 at 6:00 P.M. Regional Director of Clinical Operations #55 reviewed resident discharges to the hospital from 12/23/22 to 02/02/23 for proper communication/notification. On 02/02/23 at 6:40 P.M. the DON educated RN #39 on following policies for changes in condition, lab procedures and resident/family requests. On 02/02/23 at 6:40 P.M. the DON was educated by Regional Director of Clinical Operations #55 to review the facility 24-hour report and Order Listing report identifying any changes of conditions with notifications that need completed and following up on all labs ordered to ensure they were completed timely. On 02/02/23 at 8:30 P.M. the DON and ADON #59 reviewed all labs ordered from 12/23/22 to 02/02/23 to ensure labs were obtained. As a result of the review, laboratory testing that had not been completed was identified. Laboratory testing for Resident #41, Resident #43, Resident #38, and Resident #65 were obtained as needed following the audit/review. On 02/02/23 at 9:05 P.M. Resident #65 was readmitted to the facility. A head-to-toe assessment (including vital signs), skin observation, oral assessment, neurological assessment, respiratory assessment, cardiovascular assessment, GI/GU assessment, pain assessment, mobility and psychosocial assessment were completed by Registered Nurse (RN) #57. Beginning on 02/02/23 the DON/designee provided staff education via in person and/or via telephone related to notification of changes, performing an assessment, and obtaining labs as ordered. The facility identified ten RN's and nine LPN's were educated. Seven (7) staff members did not receive the education (RN #5, LPN #19, LPN #21, RN #26, RN #30, RN #31, and RN #42) and are not permitted to work a shift until education had been completed by the DON/designee. Beginning on 02/02/23 (no time identified) the DON/designee implemented a plan for new hire licensed nurses to be educated on notification of changes, obtaining labs as ordered and performing an assessment. Beginning on 02/03/23 (no time identified) the facility implemented a plan for the DON/designee to audit the 24-hour report daily and Order Listing report to monitor for change in resident condition, labs ordered, and notification daily for two weeks, then three times a week for two weeks. This would monitor to ensure labs ordered were being completed timely and changes with residents included notifications completed timely. The facility identified changes in condition could include the following: Accidents Resulting in injury. Potential to require physician intervention. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: Life-threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment. This may include: New treatment. Discontinuation of current treatment due to: Adverse consequences. Acute condition. Exacerbation of a chronic condition. A transfer or discharge of the resident from the facility. A change of room or roommate assignment. A change in resident rights. Beginning on 02/03/23 (no time identified) the facility implemented a plan for the DON/designee to complete chart audits on three (3) residents randomly weekly for four weeks to ensure labs ordered were completed timely, notification was completed and assessments for residents were properly documented with notifications of change completed if applicable. On 02/06/23 from 9:10 A.M. and 9:17 A.M. interviews with LPN #2, LPN #38, LPN #60, and RN #59 revealed the staff could not recall the education they were provided on 02/02/23. LPN #2 reported she was educated on elopements and change of condition was all she could recall. LPN #38 reported she was educated on elopements and couldn't think of anything else. LPN #60 reported she was educated on elopements and transfers. She could not recall being educated on notification of change or laboratory testing. RN #59 reported she could not recall what she was educated about and asked LPN #2 and #60 if they could recall. On 02/06/23 at 12:35 P.M. interview with the DON and Regional Director of Clinical Operations #55 verified all licensed nurse staff were not knowledgeable on the education they were supposed to have received on 02/02/23. Based on the staff's lack of knowledge, Regional Director of Clinical Operation #55 indicated additional re-education would be completed on this date. On 02/06/23 from 3:46 P.M. to 3:48 P.M. interview with RN #59, RN #61, LPN 38, and LPN #60 revealed they were acknowledgeable on notification of changes, laboratory testing, and physical assessments. Beginning on 02/09/23 the facility identified all audits would be brought to the facility Quality Assessment Performance Improvement (QAPI) meeting and reviewed beginning with a meeting scheduled for 02/09/23. Although the Immediate Jeopardy was removed on 02/06/23, the facility remained out of compliance at Severity Level 3 (actual harm that is not Immediate Jeopardy) due to the identified deficiency for Resident #56 and as the facility was in the process of implementing their corrective action plan and monitoring related to the Immediate Jeopardy findings. Findings Include: 1. Review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute osteomyelitis in left ankle and foot, gastric reflux disease, heart failure dysphagia, anxiety, type two diabetes, and benign prostatic hyperplasia. Review of Resident #65's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 which reflected moderate cognitive impairment (score 8-12 moderate; score 13-15 intact cognition). The assessment also reflected the resident was always incontinent of bowel. Record review revealed a plan of care, initiated 11/14/22 related to bowel and bladder incontinence. The care plan did not include any interventions related to monitoring the resident's bowel function, identification of changes or physician notification. A second plan of care, initiated 11/19/22 revealed the resident was at risk for hyperglycemia. Interventions included to be alert for signs/symptoms of hyperglycemia including increased lack of appetite, fatigue, abdominal cramps, nausea/vomiting, and blood glucose greater than 200. Interventions included laboratory testing as ordered. Review of a Nurse Practitioner (NP) note, dated 12/23/22 revealed staff requested the resident be seen for frequent loose stools for several days and occasional nausea and poor appetite. The resident denied diarrhea and vomiting, however had loose stools. The NP provided new orders for stool cultures and the medication Questran (bile acid sequestrant) as needed and noted to continue Zofran medication for nausea. Review of the nursing progress notes for this time period revealed no additional assessment, monitoring or notation identifying or addressing these symptoms the resident was having at that time. Record review revealed no evidence the stool culture ordered on 12/23/22 was obtained by the facility. Review of Resident #65's nursing progress notes dated 12/23/22 to 01/01/23 revealed Resident #65 was alert, but had impaired decision making, normal breathing, and was incontinent of bowel and bladder. The progress notes failed to contain any additional follow up or evidence of monitoring related to the NP note dated 12/23/22. Review of a progress note from Physician #56, dated 12/31/22 revealed the resident's daughter had requested the resident be seen due to the resident having diarrhea and weakness. New orders for laboratory testing, including a complete blood count (CBC), complete metabolic profile (CMP) and the stool culture was already ordered (12/30/22). Record review revealed no evidence the stool culture ordered on 12/30/22 was obtained by the facility. The next nursing progress note (following the physician note on 12/31/22), dated 01/02/23 at 8:00 P.M. and authored by RN #39 revealed Resident #65 complained of persistent nausea and had emesis times two. RN #39 documented the resident was given medication for nausea with not much relief. Resident #65's wife and daughter were at the bedside and insisted the resident be sent to the emergency room for an evaluation for nausea and vomiting. The progress note indicated Resident #65's vital signs were within normal limits. The resident's blood sugar was elevated at 408 milligrams per deciliter (mg/dL) and a COVID-19 swab was negative. A nursing progress note, dated 01/02/23 at 9:15 P.M. and authored by RN #39 revealed the nurse made the physician on-call service aware of Resident #65's nausea and vomiting that occurred on this date. The physician on-call service gave orders to start the mediation, Protonix (a medication to reduce stomach acid) 40 milligrams (mg) twice daily, a kidney ureter bladder (KUB) x-ray, and noted if the family insisted to send Resident #65 to the emergency room . A nursing progress note dated 01/02/23 at 9:20 P.M. and authored by RN #39 revealed Resident #65's family wanted the resident sent to the emergency room . On 01/02/23 at 9:45 P.M. transportation arrived to take the resident to the emergency room . Review of Resident #65 hospital note, dated 01/02/23 revealed the resident was admitted to the hospital with C-Diff, colitis due to Clostridial Difficile, bilateral effusion, urinary tract infection (UTI), acute on chronic renal failure, elevated troponin, and adult failure to thrive. Following treatment, the resident was readmitted to the facility on [DATE]. Review of nursing progress notes dated 01/12/23 to 01/23/23 revealed Resident #65 continued to have loose stools and swelling in the right abdomen that would come and go. NP #65 was aware and ordered ultrasound on 01/13/23. On 01/15/23 at 4:50 P.M., the abdomen ultrasound was completed at the facility. Review of the abdominal ultrasound, dated 01/15/23 revealed the resident had 2.2 centimeter (cm) by 2.3 cm area suspicious for hernia in the right lower quadrant. Review of a nursing progress note dated 01/24/23 at 7:00 P.M. and authored by RN #39 revealed Resident #65's wife stated the resident had some emesis. The resident's wife wanted the resident sent to the emergency room . The note revealed RN #39 administered the medication Zofran, assessed the resident's lungs (which were clear) and documented will continue to monitor. There was no documented evidence the RN assessed the resident's vital signs, including temperature, blood pressure, pulse, or oxygen saturation at that time. In addition, record review revealed no evidence the physician or on call services were notified of Resident #65's family request to send the resident to the emergency room for evaluation and treatment or Resident #65's emesis. There was no documented evidence RN#39 assessed Resident #65 after 7:00 P.M. Review of a nursing progress note dated 01/24/23 at 11:05 P.M. and authored by LPN #52 revealed she was called to Resident #65's room by the State tested Nursing Assistant (STNA). Resident #65 was vomiting, shaky, stated he had chills and was assessed to have adventitious lung sounds with rhonchi in his upper lobes. The resident was assessed to have an elevated temperature of 99.5 degrees Fahrenheit and requested to go to the emergency room for evaluation. The resident's wife was called at this time and stated she wanted the resident transferred to the hospital for evaluation. The emergency squad was called for transport, and report was called to the hospital. Resident #65's wife was at the facility when the resident left. Review of Resident #65's hospital notes, dated 01/24/23 revealed the resident was seen in the emergency room at 11:55 P.M., was unstable and required constant supervision by the physician for 45 minutes. The resident was placed on a BiPap (respiratory machine) secondary to respiratory distress. The resident's blood glucose/sugar level was greater than 700 (hyperglycemic) requiring an IV insulin push followed by an insulin drip. The resident required four liters of normal saline (fluids) due to being in septic shock with depressed renal perfusion as well as hypovolemia from nausea and vomiting and poor intakes. The resident was transferred to ICU for close observation and aggressive management as mentioned. The resident's admitting diagnoses were diabetic ketoacidosis (DKA), acute respiratory failure due to COVID-19, hyperglycemia, acute and chronic renal failure, dyspnea, acute confusion, and severe sepsis. On 01/30/23 at 9:41 A.M., interview with Resident # 65's wife and daughter revealed they had concerns with the resident's care and treatment at the facility. Resident #65's family requested the DON and ADON (RN) #59 be present for the interview. Resident #65's family members reported they had requested Resident #65 be transferred to the emergency room twice and both times RN #39 refused to send the resident. Both times RN #39 told Resident #65 and family the resident just needed something for nausea. Per Resident #65's family, the first incident was on 01/02/23, however RN #39 eventually called the on-call provider, and the provider gave permission to send the resident to the emergency room if the family insisted, but indicated they were told the provider just wanted to try something stronger for the resident's nausea. Resident #65's family insisted the resident be sent to the emergency room and RN #39 did make the arrangements. The hospital told Resident #65's family it was a good thing they got him there when they did because he (Resident #65) was almost dead due to his body being filled with infection. Resident #65's family also indicated the resident was ordered stool testing for C-Diff prior to being sent to the hospital and it was never completed. The family was told the first specimen was lost and the second was still in the refrigerator and was never sent. Resident #65's family reported a second incident with RN #39 occurred on 01/24/23. RN #39 refused to send Resident #65 to the emergency room upon resident/family request. The resident's wife reported she knew the resident was in bad shape when he asked to go to the emergency room . This time, RN #39 did not call the physician. The resident deteriorated and was sent to the emergency room a few hours later by another nurse who took over the resident's care at 10:00 P.M. When Resident #65 was admitted to the hospital on 01/24/23, the family revealed he was diagnosed with COVID-19, a bowel infection, dehydration, and C-Diff. Resident #65 remained in the hospital as of 01/30/23 at 9;41 A.M. (the date and time of this interview). On 01/31/23 at 1:26 P.M. interview with STNA #50 revealed on 01/24/23 Resident #65 was fine during the day and then at dinner time he refused his dinner and had vomited. Resident #65's wife reported the resident had consumed water and milk and it caused him to be sick. Resident #65's wife had voiced concerns to STNA #50 that RN #39 refused to let her husband go to the emergency room . During the interview, STNA #50 reported there was an incident prior to 01/24/23 when Resident #65 was exhibiting signs and symptoms of C-Diff and he was not placed in isolation until he returned from the hospital (on 01/11/23). Resident #65 had orders for stool cultures, however they were never sent to the laboratory for testing. Per STNA #50, there had been complaints the on-call (physician) services don't want to send residents to the emergency room . On 01/31/23 at 3:17 P.M. interview with STNA #40 revealed Resident #65's family had voiced concerns regarding RN #39 refusing to send Resident #65 to the hospital after the family had demanded he be sent to the hospital. Resident #65's family reported there were two incidents RN #39 refused to send the resident out upon request of the family and resident. STNA #40 reported she was the one who had reported the resident was having loose stools to the nurse. The STNA revealed Resident #65 was quiet and sleeping a lot which was a change of condition for him. At first Resident #65's stools were just loose then they were more frequent and had an odor. The STNA indicated there were two stool samples collected for Resident #65, however the samples were never sent to the laboratory for testing. On 01/31/23 at 5:57 P.M. interview with RN #39 revealed she could not remember much about Resident #65's first hospitalization on [DATE]. RN #39 thought maybe Resident #65's family wanted to have the resident sent out, but stated she was passing medications at that time. Per RN #39, she did call the nurse practitioner (NP) and indicated the NP wanted to treat Resident #65 in-house, but stated if the family really wanted the resident sent out then she (RN #39) could do so. Per RN #39, on 01/24/23, she only worked 6:00 P.M. to 10:00 P.M., that night. The aides came to her and reported she was needed in Resident #65's room. The resident had vomited and was nauseated. RN #39 recalled she had offered Resident #65 Zofran for the nausea. She listened to the resident's lungs, and they were fine. RN #39 touched the resident's head and said she didn't think he was running a fever. RN #39 reported she doesn't think she checked the resident's temperature at that time with a thermometer. Per RN #39, Resident #65's wife wanted the resident sent to the hospital and RN #39 told her there was no reason to send him and to let the Zofran work. Resident #65's wife also wanted a chest x-ray; RN #39 told the resident's wife there was no need for a chest x-ray. Resident #65's wife told RN #39 If it turns into pneumonia, it is back on you. RN #39 checked the resident's blood sugar and gave him his scheduled insulin. RN #39 did not contact the physician regarding Resident #65's condition and gave report of the incident to LPN #52 at 10:00 P.M., when the LPN took over her shift. On 01/31/23 at 6:30 P.M. interview with LPN #52 revealed she had worked beginning on 01/24/23 at 10:00 P.M. and during report, RN #39 noted Resident #65 had vomited once and she checked his lung sounds and was monitoring him. RN #39 had reported the family wanted the resident sent out (to the hospital), but she (RN #39) did not send Resident #65 out and wanted to know LPN #52's opinion on what she should have done. LPN #52 told RN #39 she would have sent Resident #65 out to the hospital if the family requested. Shortly after report, staff reported to LPN #52 that Resident #65 had vomited again. Per LPN #52, upon her assessment, Resident #65's lungs were raspy, and he was chilled. LPN #52 used her nursing judgement and sent Resident #65 to the hospital. Resident #65's wife had voiced concerns she had requested the resident be sent out earlier and the nurse (RN #39) refused to send him. Per LPN #52, Resident #65 now had a fever and she thought he had aspirated on his vomit causing his lungs to be raspy. LPN #52 knew with Resident #65's history of sepsis and comorbidities she needed to get him sent out to the hospital fast. LPN #52 confirmed she did not check Resident #65's blood sugar or call the physician to approve Resident #65's transfer to the hospital. On 02/02/23 at 9:30 A.M. interview with the DON and Regional Director of Clinical Operations #55 verified Resident #65's stool cultures were not obtained per order on 12/23/22 or 12/30/22 and Resident #65 was hospitalized from 01/02/23 to 01/11/23 for diagnosis and treatment of C-Diff. In addition, an interview on 02/06/23 at 1:20 P.M. with Regional Director of Clinical Operations #55 verified Resident #65's laboratory testing ordered on 12/31/22 had not been obtained as ordered. Review of the facility policy titled Notification of Changes dated 10/01/22 revealed the facility would promptly inform the resident, consult the resident's physician; and notify, consistent with his or her authority, the resident's representative when there was a change requiring notification. The facility is required to inform the residents of his/her rights upon admission and during the resident's stay. Review of the facility policy titled Diagnostic Testing Services dated 10/01/22 revealed the facility would provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. The facility would maintain a schedule of diagnostic tests in accordance with the physician orders. No diagnostic test will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialist orders in accordance with State law to include scope of practice law. Qualified nursing personnel will receive and review the diagnostic teste reports and communicate the results to the ordering physician within 24 hours of receipt unless that report results fall outside the clinical reference ranges and require immediate attention at which time the physician would be notified upon receipt. Documentation of the test results, date/time of Physician notification would be maintained in the resident's clinical records. Review of the facility undated policy titled Culture and Sensitivity Lab Results revealed culture and sensitivity refers to laboratory testing of various specimens for the identification of pathogens and the susceptibility of those pathogens to treatment with antibiotics. Laboratory testing shall be in accordance with providers orders and current standards of practice. Specimens for culture and sensitivity testing shall be collected and transported in accordance with facility and laboratory policies for collection and transport. Review of the facility undated policy titled Validation Checklist Physical Assessment revealed the purpose of the checklist was to ensure the individual performing the physical assessment of the resident was doing so in accordance with current standards of practice. Assess all organ systems, verbalize which findings are abnormal and which ones require immediate physician notification. Notify physician, where applicable, and document findings appropriately. 2. Review of the medical record for Resident #56 revealed an original admitted [DATE] and re-admitted [DATE]. Diagnoses included acute pain related to trauma, laceration of the spleen, fractured shaft of right femur, open [NAME] fracture, fracture distal end of right radius, multiple rib fractures, and low back pain. Review of nursing progress note dated 01/04/23 at 12:49 P.M., revealed Resident #56 reported that her right wrist had a different pain to it. Upon observation of the right wrist, the pin site was red in color, swollen, and scant amount of yellow drainage noted. Resident stated that she doesn't receive pain medication in the middle of the night but once she wakes up her pain was out of control. The Nurse Practitioner (NP) #65 was notified of the residents' concerns and orders were given for the resident to receive scheduled Oxycodone 5 milligrams (mg) every hour, culture of pin site, apply ice to right wrist every two hours and as needed. Culture was collected at this time. Review of nursing progress note dated 01/05/23 at 10:23 A.M., revealed the wound culture was picked up by the lab. Further review of nursing progress notes dated 01/05/23 to 01/10/23 revealed no evidence of assessment of the right wrist wound, however on 01/09/23 the resident was ordered Augmentin Oral Tablet 875-125 MG (Amoxicillin & Pot Clavulanate) give 1 tablet by mouth two times a day for wound infection for seven days. On 01/11/23 the nursing note indicated the nurse was summoned to Resident #56's room. The resident was holding her right wrist in the air and stated that she was concerned about her wrist. The right wrist was visually swollen, redness noted to bilateral side of the incision line, two centimeter distal incision note to be an early eruption starting. No drainage noted at the moment. The NP #65 was notified and recommended resident be transferred back to the university hospital where she would have better continuity of care. The resident and spouse agree, and spouse will transport resident. Review of Resident #56's wound culture results dated 01/05/23 revealed on 01/07/23 the final culture indicated the organism was staphylococcus aureus (moderate) and was sensitive to Augmentin. Review of Resident #56's Medication Administration Records (MAR) and orders dated 01/09/23 revealed the resident received one dose of Augmentin on 01/09/23, two doses on 01/10/23, one dose on 01/11/23, and one dose was sent with the resident on 01/11/23. Review of Resident #56's hospital discharge records dated 01/17/23 revealed on 01/11/23 a [AGE] year old female presented with pain, swelling, and infection to a post-surgical right wrist incision site. The redness and pain had increased over the last two weeks and now progressed significantly to redness, pain, and purulent drainage. The resident was in a severe motor vehicle collision on 12/09/22 and sustained multiple fractures. Upon evaluation at the hospital on 01/11/23, Resident #56 did have significant white pus drainage to right wrist. The surgical site had a partial dehiscence with the distal one third of the wound with some serous drainage. The resident was diagnosed with cellulitis and possibly osteomyelitis that required admission to the hospital for intravenous Vancomycin and Unasyn antibiotic treatment. Interview on 01/25/23 at 12:30 P.M., with Resident #56 revealed she had reported to staff that her right wrist was infected, and they kept telling her it was just the healing process. The night nurse had removed the soft cast off the right wrist and the wrist was hot to touch and swollen. Licensed Practical Nurse (LPN) #2 cultured the wound, but she did not culture the wound correctly. Per Resident #56, LPN #2 had swabbed the outside of the wound and not inside the wound. After four or five days, the resident had not heard anything about the culture results so she had to track down her own culture results (the resident identified this meant that she had to keep asking staff multiple times to check on her lab results). The NP started her on antibiotics finally and after the 3rd day of antibiotics the swelling and abscess was so bad she asked to go the hospital. The abscess ruptured at the hospital requiring intravenous treatments and she was on the hospital from 01/11/23 to 01/27/23. Interview on 02/15/23 at 11:45 A.M. via email with the DON revealed she did not have any documented evidence why there was delay in Resident #56's treatment to the right wrist. The DON confirmed Resident #56's wound culture was collected on 01/04/22, sent to lab on 01/05/23, culture results were final on 01/07/23, however the resident was not started on treatment until 01/09/23. This deficiency represents non-compliance investigated under Master Complaint Number OH00138950 and Complaint Number OH00136553.

Based on record review, review of narcotic control sheet, review of starter kit replacement forms, observation, interview, and policy review the facility failed to implement an effective and timely pain management program, including the timely administration of the opioid medication, Percocet administered at the correct ordered dose, for Resident #56. This affected one (#56) of three residents reviewed for pain. Actual Harm occurred to Resident #56 on 01/26/23 when Nurse Practitioner (NP) #65 increased the resident's Percocet to 7.5/325 milligrams (mg) every four hours as needed for acute pain. The order was written, however the Percocet 5 mg/325 mg tablets were not removed from the narcotic box and the resident received the lower dose (5 mg/325 mg) from 01/27/23 until 01/29/23 resulting in Resident #56 experiencing unnecessary and unmanaged pain leading to Resident #56 being unable to participate in stair training therapy on 01/27/23 and 01/30/23 due to right lower extremity pain and being unable to participate in therapy on 01/31/23 due to her pain being uncontrolled. Findings included: Record review revealed Resident #56 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including acute pain related to trauma, laceration of the spleen, fractured shaft right femur, open [NAME] fracture, fractured distal end right radius, multiple rib fractures, and low back pain. Review of Resident #56's pain plan of care related to bilateral rib fracture, right wrist fracture, right tibia fracture, surgical incisions with external fixation, and spleen laceration revised on 01/18/23 revealed make sure pain medication was ordered, administered, and evaluated. a. Observation revealed on 01/25/23 at 12:28 P.M., Resident #56's call light sounding as State tested Nurse's Aide (STNA) #25 was getting ready to take in Resident #56's lunch meal tray. The resident refused the lunch tray and requested a Tylenol and pain pill. The nurse was three doors down from Resident #56's room getting ready to administer medication to another resident. STNA #25 went immediately to Registered Nurse (RN) #59 and reported Resident #56 was requesting medication for pain. The nurse never returned to administer pain medication to Resident #56. The resident reported to the surveyor, her pain was currently rated a 7-8 on a scale of one to 10 and indicated her tolerable pain level was 3-4. On 01/25/23 at 1:05 P.M., the surveyor went to the nurse's station. RN #59 was not visible, however the medication cart was sitting across from the nurse's station. The surveyor explained to RN #3 and the Administrator that Resident #56 had requested something for pain around 12:28 P.M. from RN #59 and she still had not received her pain medication. RN #3 reported RN #59 had gone to lunch, however she would address it immediately. Interview on 01/25/23 at 1:31 P.M. with the Administrator revealed he had spoken to RN #59 and she did not have a reason why she did not administer pain medication to Resident #56 upon request and would go apologize to the resident. b. Interview on 01/25/23 at 12:30 P.M., with Resident #56 reported she had requested to see a physician since she was readmitted [DATE] due to her pain not being managed. The resident also voiced concerns staff didn't administer her pain medication timely and she has had to wait up to 40 minutes for staff to answer call light to request pain medications before. The resident reported was not full weight bearing yet and was not supposed to get up on her own, but if she didn't she would never get pain medication or assistance timely. The resident reported she usually had to track the nurse down because she could not wait any longer because the pain would be so bad. Interview on 01/25/23 at 2:29 P.M., with the Director or Nursing (DON) confirmed the resident had not been seen by a physician since she had returned from the hospital on 01/17/23. The DON indicated physician had been out of town and the Nurse Practitioner (NP) was covering his residents. The NP would be in the facility tomorrow and the DON indicated she would see if the NP would see the resident for pain and anxiety. Observation on 01/25/23 at 4:58 P.M. revealed Resident #56 was in the hall waiting for the nurse to come out of a room. The resident requested pain medication and RN #3 administered a Percocet 5/325 mg to the resident. RN #3 asked the resident her pain level. The resident reported no one had ever asked her her pain level before. Review of Resident #56's NP note, dated 01/26/23 revealed the resident reported her pain was not controlled in her wrist and leg. The resident was requesting to see pain management. New orders were received to increase Percocet to 7.5/325 mg every four hours and if not effective she would refer to orthopedics for adjustments. Review of Resident #56's physician orders, dated January 2023 revealed on 01/26/23 an order to administer Percocet 5/325 mg every four hours until 6:00 A.M. on 01/27/23. On 01/27/23 a new order was written for Percocet 7.5/325 mg every four hours as needed for pain. Review of Resident #56's narcotic control sheet dated 01/21/23 revealed 60 (5/325) mg Percocet tablets were delivered on 01/21/23. On 01/27/23 one tablet was administered at 8:30 A.M. and 8:00 P.M. On 01/28/23 one tablet was administered at midnight, 4:30 A.M., 8:21 P.M., and on 01/29/23 one tablet was administered at 4:23 A.M., 10:30 A.M., and 1:00 P.M The Percocet 5/325 mg order was discontinued on 01/27/23 at 6:00 A.M., however staff continued to administer this dose of the medication. Review of Resident #56's narcotic control sheet dated 01/29/23 revealed 60 Percocet 7.5/325 mg tablets were signed in 01/29/23. The label was dated 01/28/23 and the instructions were to administer one tablet every four hours as needed. On 01/29/23 one tablet was administered at 7:18 P.M. and 11:42 P.M. Review of the starter kit replacement forms dated 01/17/23 to 01/31/23 revealed no evidence Percocet 7.5/325 mg tablets were removed for Resident #56. Review of Resident #56's Medication Administration Records (MAR) dated 01/2023 revealed the Percocet 5/325 mg was administered on 01/27/23 at 9:05 A.M., on 01/28/23 at 8:21 P.M., and 01/29/23 at 4:23 A.M., 10:17 A.M., 1:00 P.M., 7:18 P.M., and 11:42 P.M. when it was supposed to have been discontinued on 01/27/23 at 6:00 A.M. Review of Resident #56's therapy notes dated 01/27/23 to 01/31/23 revealed the resident was not able to participate in stair training therapy on 01/27/23 and 01/30/23 due to right lower extremity pain. The resident was not able to participate in therapy at all on 01/31/23 due to pain. Interview on 01/30/23 at 10:25 A.M., with Resident #56 revealed she did not complete therapy today due to her pain not being controlled. The NP wrote new orders for medication Thursday (01/26/23) night, however staff reported the pharmacy had not delivered it yet. Observation and interview on 01/30/23 at 3:02 P.M., with Director of Nursing and Registered Nurse (RN) #59 revealed the Percocet 5/325 mg and the 7/325 mg reconcile with the narcotic sheets, which indicated the MARs were incorrect. The DON confirmed the resident received eight doses of the wrong strength of Percocet from 01/27/23 to 01/29/23. The resident should have received 7.5/325 mg, however received 5/325 mg. Interview on 01/31/23 at 5:30 P.M., with Resident #56's reported she was miserable and in pain over the weekend. The resident indicated the pain medication was still not helping today. She stated she did not go to therapy at all today due to the pain being so bad. The resident reported, the NP (NP #65) told her she didn't think she needed pain management, even though the hospital recommended it. Review of the facility's policy titled Pain Management dated 08/22/22 revealed the facility must ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Referral to pain management clinic for other interventions that need to administer under the close supervision of pain management specialist will be considered for residents with more advanced, complex, or poorly controlled pain. Review of the facility's policy titled Medication Administration dated 08/22/22 revealed mediation would be administered as ordered by a physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR to identify mediation to be administered and if the medication was a controlled substance, sign narcotic book. This deficiency represents non-compliance investigated under Complaint Number OH00138950.

Based on medical record review and staff interview, the facility failed to ensure staff members provided proper transfer assistance as ordered by the physician. Actual Harm occurred on 03/13/21 when Resident #59 was transferred from her bed to her wheelchair by one staff member rather than two staff members as indicated in Resident #51's physician's orders, resulting in a fall with fracture to the right tibia and fibula. This affected one (Resident #59) of three residents reviewed for falls. The facility census was 57 residents. Findings include: Review of Resident #59's closed medical record revealed an admitted [DATE] with diagnoses that included [CONDITION(S)] with [CONDITION(S)] and [CONDITION(S)]. Review of the physician's orders and fall care plan revealed they indicated Resident #59 required two staff members for assistance with all transfers when ordered on 09/06/20. Further review of the progress notes revealed a fall on 03/13/21 when only one staff member assisted Resident #59 during transfer. Additional progress notes revealed Resident #59 complained of pain to the right leg and knee; staff notified the physician and x-rays were completed which revealed fractures to the right tibia and fibula (bones of the lower leg). Resident #59 was provided a leg immobilizer per physician's order and referred to an orthopedist. Resident #59 was evaluated by the orthopedist on 03/19/21 and placed in a lower leg cast for further immobilization of the right leg fractures. An additional fall on 11/03/20 was also discovered with only one staff member assisting with resident transfer. No injuries were observed with the fall. Interview with Registered Nurse (RN) #33 on 08/19/21 at 9:55 A.M. verified Resident #59 suffered two falls on 11/03/20 and 03/13/21 when assisted by only one staff member even though there were physician orders in place for assistance by two staff members for transfers. Additionally, RN #33 verified Resident #59 suffered fractures to the right tibia and fibula from the fall on 03/13/21. This deficiency substantiates Master Complaint Number OH 050 and Complaint Number OH 926.

Based on closed record review, review of hospital records, review of the facility policy and procedures related to Notification, interviews with facility staff, Medical Director #81 and Certified Nurse Practitioner (NP) #80 the facility failed to seek proper, timely and adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to timely report the abnormal lab result to the physician, failed to hold the resident's routine dose of K+ and failed to immediately transfer the resident to the hospital for treatment following the identification of the abnormal laboratory result. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] at 4:17 A.M. when the lab reported Resident #1 had a critical/ lethal high potassium level of 9.2 (normal 3.,d+[DATE].1) with no evidence the resident was immediately transferred to the hospital or evidence the physician was notified. On [DATE] at 10:10 A.M. the facility was notified by the laboratory, a repeat K+ level was 9.9 (critically/lethally high). There was no evidence the resident was immediately transferred to the hospital or the physician was notified at that time. On [DATE] at 11:55 A.M. on call Nurse Practitioner (NP) #80 ordered intravenous (IV) fluids and the medication, [MEDICATION(S)] (used to treat high K+ levels) for Resident #1 which were never initiated. Resident #1's condition continued to decline and on [DATE] at 3:10 P.M. the resident was found without a pulse and cardiopulmonary resuscitation (CPR) was initiated. The resident subsequently expired at the hospital on [DATE] at 4:46 P.M. due to the critical lab values and no progression of treatment provided. This affected one resident (Resident #1) of three residents reviewed for change in condition/quality of care. On [DATE] at 12:27 P.M. the Executive Director, Director of Nursing (DON), and Corporate Nurse #100, were notified Immediate Jeopardy began on [DATE] at 4:17 A.M. when the facility was notified of Resident #1's critical/lethal K+ level of 9.2 with no evidence of timely or adequate medical intervention. Resident #1 continued to decline throughout the day, without timely medical care provided or physician notification completed. Resident #1 was found without a pulse at 3:10 P.M. and was pronounced dead at 4:46 P.M. at the hospital due to results of the critical labs values. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 5:30 P.M. the facility Medical Director (MD) #81 was notified of the incident involving Resident #1. · On [DATE] from 3:00 P.M. to 5:00 P.M. the DON/designee completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. No concerns were identified. · On [DATE] at 5:00 P.M., Licensed Practical Nurse (LPN) #26 and Registered Nurse (RN) #15 who were responsible for Resident #1's care and condition on [DATE] were suspended pending investigation. Both employees received disciplinary action. · On [DATE] from 4:00 P.M. to 5:00 P.M. the DON/designee reviewed all abnormal labs from [DATE] to [DATE] to ensure appropriate interventions and notifications were completed. · On [DATE] form 4:00 P.M. to 5:00 P.M. the DON/designees reviewed all residents who had been discharged to the hospital from [DATE]- [DATE] to ensure proper care was in place. · On [DATE] from 4:00 P.M. to 6:00 A.M. the DON/designee provided education to facility licensed nurses (five RNs and eight LPNs) related to change of condition and physician notification regulations, as well as the facility policy and procedures. A plan was implemented for any staff members who had not received the education as of this time to not work a shift until the education was completed by the DON/designee. · On [DATE] from 4:00 P.M. to 6:00 P.M. the DON/designee provided education to 31 State tested Nursing Assistants (STNAs) related to change of condition regulations to promote their situational understanding and to facilitate communication with licensed nurses. A plan was implemented for any staff members who had not received the education as of this time to not work a shift until the education was completed by the DON/designee. · On [DATE] the DON/designee updated the facility Notification policy and procedure. · On [DATE] a plan for all new hires (licensed nurses and nurse aides) to be educated on change of condition and physician notification regulations, as well as facility policy and procedure by the DON/designee was implemented. · On [DATE] a plan for the DON/designee to audit the 24-hour report daily to monitor for change in resident condition was implemented on an ongoing basis. · On [DATE] a plan for the DON/designee to complete chart audits/health document assessments as follows: o Three residents weekly for four weeks then; o Two residents weekly for two weeks then; o Two residents a month for two months. · On [DATE] a plan for facility Regional Corporate Consultant Nurse #100 to visit the facility weekly to provide general oversight and monitoring of the plan. · On [DATE] a plan for all audits to be reviewed through the facility Quality Assurance/Performance Improvement (QAPI) was implemented. · On [DATE] from 12:21 P.M. to 12:23 interviews with RN #59, STNA #14 and STNA 54 revealed the staff members were knowledgeable of the facility policy and regulation related to change in resident condition and timely resident care Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #1's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident was admitted with a Full Code advance directive status. Resident #1 expired at the hospital on [DATE]. Review of Resident #1's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which reflected the resident had intact cognition. The assessment revealed the resident required supervision from staff for eating and extensive assistance from staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of Resident #1's admission history and physical dated [DATE] revealed the resident was alert and oriented to name, month and year. A cardiac echocardiogram (echo) showed normal left ventricular (LV) function with a left ventricular ejection fraction (LVEF) of ,d+[DATE]% with Grade 1 diastolic dysfunction, mild pulmonary hypertension, and mild [CONDITION(S)]. The resident was admitted to the skilled facility for intravenous (IV) antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The history and physical revealed the resident's [CONDITION(S)] and hypertension were stable. Review of Resident #1's physician orders, for [DATE] revealed orders including a two liter (2L) per 24 hour fluid restriction and Potassium 20 milliequivalent (mEq) twice daily. Record review revealed a plan of care related to Alteration/Potential for alteration in cardiac output related to coronary artery disease, [CONDITION(S)] (CHF), hypertension and [CONDITION(S)]. The goal was for the resident to have no signs/symptoms of alteration in cardiac output as evidence by stable vital signs and no complaints of chest pain. Interventions included to inspect for signs of reduced cardiac out with [CONDITION(S)] (weak pulse) dizziness, [CONDITION(S)], shortness of breath (SOB), or chest pain and tachycardia (rapid pulse) reduced blood pressure, dizziness, SOB, fatigue and restlessness. The care plan revealed to note not all patients were symptomatic with each episode. In addition, care plan interventions included to review labs as ordered and alert the physician of any abnormalities. Further review of Resident #1's plan of care revealed the resident had a potential for activity intolerance, fluid overload and dyspnea related to CHF. Interventions included to review lab work, especially K+ and notify the physician if necessary. Review of Resident #1's nursing progress notes, dated [DATE] to [DATE] revealed the resident was ordered [MEDICATION(S)] [MEDICATION(S)] (Pepto) on [DATE] for complaint of an upset stomach. On [DATE] he was ordered an abdominal x-ray. On [DATE] Resident #1 was experiencing dry heaves, denied nausea and had no emesis noted. The resident was administered Pepto at that time. A dietary progress note, dated [DATE] revealed the resident had a 24.4 pound weight loss in one month and a 4.4 pound loss in one week. The weight loss was most likely due to [CONDITION(S)] and poor intakes in the last week due to complaints of nausea/vomiting. The physician was aware and started mediation. The dietary note revealed the resident's intakes would possibly show improvement once his upset stomach issues were resolved. Review of Resident #1's nursing progress note, dated [DATE] at 9:41 P.M. and authored by Physician Assistant (PA) #85, revealed PA #85 ordered STAT laboratory (lab) testing, a comprehensive metabolic profile (CMP), complete blood count (CBC), and lipase as staff had reported the resident had ongoing dry heaving and epigastric discomfort. The lab work was obtained and on [DATE] at 4:17 A.M. the facility (RN #15) was verbally notified the resident's potassium (K+) level was critical/lethal at 9.2 (normal 3.,d+[DATE].0). The lab requested the CMP be re-drawn due to the potassium result. However, there was no evidence RN #15 notified the physician of the critical laboratory result, plan for the lab to be re-drawn or to update the physician on the resident's status at that time. Review of Resident #1's laboratory results dated [DATE] revealed blood work for the lab testing was collected on [DATE] at 11:55 P.M. and the CBC and Lipase results were faxed to the facility at 3:09 A.M. The CMP results were called to the facility at 4:17 A.M. (per the above nursing note). Review of laboratory testing revealed a repeat CMP was collected on [DATE] at 5:56 A.M. Review of a nursing progress note dated [DATE] at 9:28 A.M. revealed LPN #26 was called to Resident #1's room. The resident was not answering the nurse, his pupils were reactive to light, and a fingerstick (blood sugar) was 50 (low) that morning. The note indicated [MEDICATION(S)] was administered for the low blood sugar and then when re-checked the resident's blood sugar was 95. The note did not contain any additional assessment of the resident at that time including vital signs or an assessment of the resident's mental status. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the facility initiated a telemedicine visit [DATE] at 9:28 A.M., for the resident with an on call Nurse Practitioner (NP), NP #80 regarding the resident's [CONDITION(S)] (low blood sugar), respiratory rate being slightly elevated at 22 breaths per minute and the resident's white blood cells (WBC) being elevated a 14 per nursing. The resident was slow to respond but followed commands. Nursing reported to NP #80 the resident's blood sugar had come up to 95. However, there was no evidence nursing staff reported the resident's critical/ lethal K+ level to NP #80 during the telemedicine visit at that time. The resident, who normally exhibited intact cognition was assessed to be alert and oriented times one at that time. NP #80 ordered a STAT chest-x-ray, urinalysis, fingerstick blood glucose monitoring every four hours and indicated she would provide close follow up with the primary care team. The facility was to notify the on-call provider immediately if the resident's symptoms worsened. Review of laboratory testing results revealed on [DATE] at 10:05 A.M. the CMP results were faxed to the facility. The results were called to the facility, LPN #26 at 10:10 A.M. The lab reported Resident #1's potassium (K+) level was 9.9 critically high. Record review revealed no evidence the physician/NP were immediately notified of this abnormal lab or to update on the resident's status/condition at that time. In addition, there was no assessment completed of the resident at that time. On [DATE] at 11:55 A.M. NP #80 made a notation in the nursing notes indicating Resident #1's K+ level was 9.9 (critically high), blood urea [MEDICATION(S)] (BUN) was 98 high (normal ,d+[DATE]) and the resident's creatinine level was critically high 9.8 (normal 0.,d+[DATE].30) NP #80 gave an order to provide intravenous fluids, normal saline (NS) at 75 milliliters (ml) per hour, administer [MEDICATION(S)] (an oral medication to treat high levels of potassium), a nephrology consult and to repeat labs in the morning. [CONDITION(S)] is defined as an elevated level of potassium (K+) in the blood. Normal potassium levels are between 3.5 and 5.0 mEq/L) with levels above 5.5 mmol/L defined as [CONDITION(S)]. [CONDITION(S)], when severe it can cause palpitations, muscle pain, muscle weakness or numbness. [CONDITION(S)] can cause an abnormal heart rhythm which can result in cardiac arrest and death. Review of Medscape information related to the use of [MEDICATION(S)] revealed it was best used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In severe [CONDITION(S)], consider a more immediate treatment modality, including IV calcium, [MEDICATION(S)], glucose and insulin. On [DATE] at 2:41 P.M. LPN #26 documented she was in the resident's room to obtain the urine specimen. The resident's breathing was documented to be in the same condition. This nurse and another nurse attempted to start an IV but were unsuccessful. The note revealed an RN was called and scheduled to come to the facility to start the IV. Record review revealed no evidence the physician/NP were notified staff were unable to start the IV. Record review revealed no evidence the [MEDICATION(S)] medication was administered. In addition, record review revealed no evidence the resident's condition was assessed at that time. On [DATE] at 3:10 P.M. LPN #26 documented she was called to the resident's room because the resident was unresponsive. The note indicated the resident was a full code and cardiopulmonary resuscitation (CPR) was started by this nurse and LPN #51. 911 and the family were called. The resident was subsequently transferred to the emergency room . Review of Resident #1's hospital record, dated [DATE] revealed Emergency Medical Services (EMS) was called at 3:21 P.M., arrived at the facility at 3:33 P.M. and then arrived at the emergency room (ER) at 3:44 P.M. EMS had administered cardiopulmonary resuscitation (CPR), two doses of [MEDICATION(S)] (EPI) and [MEDICATION(S)]. The resident was asystole (without pulse) on the cardiac monitor. The ER staff continued life saving measures, however due to the resident's critical lab values and no progression (with treatment modalities), he was pronounced deceased at 4:46 P.M. Review of Resident #1's hospital laboratory records, dated [DATE] at 4:12 P.M. revealed the resident had a critical K+ of 9.4, critical magnesium level of 5.0 (normal 1.,d+[DATE].2), critical BUN of 125, critical creatinine of 9.81, and critical [MEDICATION(S)] of 15.8 (normal 0.,d+[DATE].4). On [DATE] at 10:33 A.M. interview via telephone with LPN #26 revealed she was Resident #1's nurse on dayshift on [DATE]. LPN #26 reported the night shift nurse had ordered STAT labs to be completed for the resident. LPN #26 revealed that morning the resident was not responding well, and his eyes were non-reactive, (which was abnormal for the resident), so she requested a telemedicine call. A virtual visit with a medical practitioner in lieu of an in person assessment. During the interview, LPN #26 revealed the resident was a full code and the LPN thought he should go the ER, however NP #80 wanted to treat him in-house. The NP gave orders for fluids, [MEDICATION(S)], and to continue to monitor the resident because he had some critical lab results. The LPN revealed she attempted to start an IV but was unsuccessful, so she called an ancillary service to come to the facility to start the IV. LPN #26 revealed around 2:45 P.M. she and LPN #51 went to check on the resident. LPN #26 indicated his condition was the same, he was still not responding. At 3:10 P.M., STNA #46 reported the resident was unresponsive. LPN #26 revealed she then called for LPN #51's assistance, grabbed the crash cart and back board and went to the resident's room. The resident was not breathing and did not have a pulse. LPN #26 revealed CPR was initiated within 5 to 8 minutes of being notified by STNA #46. 911 was called. EMS arrived shortly after that and took over. The resident was transported to the hospital where he expired. During the interview LPN #26 revealed in her opinion NP #80 was not listening to her and the resident should have been sent out to the hospital earlier. Attempts to reach LPN #26 following the initial interview above to obtain additional information were unsuccessful. On [DATE] at 10:49 A.M. interview with STNAs #45 and #46 revealed they had worked dayshift on Resident #1's hall. The STNA staff reported a little after 7:00 A.M., they had taken the resident his breakfast tray, but he wouldn't wake up (which was not normal for the resident). The night shift STNA staff had also reported the resident was not acting right. STNA #46 stated these findings were reported to the nurse and the STNAs were aware the nurse had called NP #80 twice but the resident was still not responding. Around 11:00 A.M., the STNAs revealed they went into the resident's room to give the resident a bath, he was not properly responding, and his eyes were rolled back into his head. The STNAs revealed they again notified LPN #26. STNA #46 revealed around approximately 3:,d+[DATE]:25 P.M. she entered Resident #1's room and the resident was not breathing. She called for LPN #26 and CPR was started. The fire department and ambulance arrived but the STNA stated she thought the resident had expired, however EMS continued CPR and transported him to the hospital. On [DATE] at 1:35 P.M. interview with the DON revealed the facility had a change in Medical Director (MD) effective [DATE]. The current Medical Director, MD #81 visited the facility once or twice a week and NP #82 was available Monday through Friday from 7:00 A.M. to 1:00 P.M. After 1:00 P.M. and on the weekends the company had a rotation of different types of providers who covered for the MD and NP. The providers had access to the facility electronic medical record and were to be available 24 hours a day seven days a week. Record review revealed as of [DATE] the medical director was assigned as Resident #1's primary care physician in the facility. On [DATE] at 2:17 P.M. telephone interview with NP #80 revealed she had done a virtual (telemedicine) visit with Resident #1 on [DATE]. NP #80 revealed this had been her first encounter with the resident and she did not know the resident, nor had she assessed him prior to this date. NP #80 recalled the resident was alert but slow to respond. During the interview, NP #80 denied knowledge the resident had a critical/life threatening K+ level of 9.2 from the lab work obtained on [DATE] that was reported to the facility at 4:17 A.M. NP #80 revealed the facility nurse had initially called due to the resident having a low blood sugar. NP #80 revealed if she had known about the critical K+ level, she would have started an IV and if there was no improvement in the resident after 30 minutes, she would have sent him out the hospital. During the interview with NP #80, the NP revealed she was later (time not provided) made aware of the resident's critical K+ level of 9.9 and verified she gave orders for the nurse to give IV fluids and to administer the oral medication, [MEDICATION(S)]. NP #80 revealed she was not aware the IV had not been started and indicated had she known by 1:00 P.M. that staff could not start an IV she would have sent him to the hospital for treatment. NP #80 revealed although she had access to the resident's electronic medical records, she did not have access to the laboratory results from [DATE]. On [DATE] at 2:45 P.M. and 4:05 P.M. interview with the Administrator, DON and Corporate Nurse #100 verified RN #15 was notified Resident #1 had a critical K+ level of 9.2 on [DATE] at 4:17 A.M. but failed to notify the physician/NP. Corporate Nurse #100 verified LPN #26 had administered [MEDICATION(S)] to Resident #1 on [DATE] for low blood sugar even though the resident did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] During the interview with the Administrator, DON and Corporate Nurse #100, the administrative staff verified LPN #26 documented the administration of the resident's routine medication, Potassium 20 mEq on [DATE] upon rising even after laboratory testing (at 4:17 A.M.) showed the resident's K+ level was critically high. During the interview, the DON verified a second CMP was obtained on [DATE] at approximately 6:00 A.M., with results noted at approximately 10:00 A.M. The results, which showed a critically high/life threatening K+ level, were faxed to the facility at 10:05 A.M. and called to LPN #26 at 10:10 A.M. However, there was no evidence the physician or NP were immediately notified or evidence the resident was immediately sent to the hospital for treatment. The DON verified communication with NP #80 was documented at 11:55 A.M. with orders for IV fluids and [MEDICATION(S)]. The DON verified LPN #26 failed to document she administered the [MEDICATION(S)] to the resident but indicated she (the DON) found a pharmacy slip which reflected the medication was pulled from the facility contingency (stock) box at 12:20 P.M. The DON also verified the IV was not started as nursing staff in the facility were unable to start it and verified NP #80 was not notified of this. On [DATE] at 9:35 A.M. interview with an unidentified staff member from the facility contracted laboratory revealed she had called the hospital that performed the STAT CMP for Resident #1 on [DATE] at 11:55 P.M. The laboratory staff revealed the resident's K+ level from this blood draw was 9.8 (critical/lethal). The facility was unable to provide a printed lab result from this lab test as the test had been re-ordered and re-drawn on [DATE] at 5:56 A.M. On [DATE] at 12:39 P.M. telephone interview with Medical Director (MD) #81 revealed a K+ level for a resident of 9.2 or 9.9 would be lethal. MD #81 revealed a K+ level that critical would need immediate emergency room level of care and would usually be treated with IV insulin and fluids. Review of the facility undated policy titled Notification of Change revealed the facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the residents representatives when there was a significant change in the resident's physical, mental, psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) or need to alter treatment significantly or a decision to transfer or discharge the resident from the facility as specified. Review of the undated facility policy titled Notification of Physician Procedure revealed the nurse should notify the Primary Care Physician when a resident had a significant change in clinical status such as ad decline in condition, new/worsening symptoms, abnormal labs, or an event that puts the resident's safety at risk. If the physician had not called back by the end of the shift, the information should be passed to the next shift and attempts to contact continued until notification was successful. The notification and attempt should be document and the DON/ADON should be kept aware of unsuccessful notification attempts. This deficiency substantiates Master Complaint Number OH 019 and Complaint Number OH 003.

Based on record review and interview the facility failed to ensure Resident #72 was safely transferred during a mechanical lift transfer. Actual harm occurred on 03/02/21 when Resident #72, who required two staff for all transfers, was transferred with one staff person using a sit to stand lift and fell , resulting in the resident sustaining a hematoma (an abnormal collection of blood under the skin when a blood vessel is ruptured), laceration, and urgent transfer to the hospital. This affected one of three residents reviewed for transfers. Findings include: Review of the medical record revealed Resident #72's initial admitted was 01/03/20 and most recent admitted was 01/09/21. [DIAGNOSES REDACTED]. Review of the care plan dated 07/08/20 revealed Resident #72 needed assistance with his activities of daily living (ADL) related to weakness, being on [MEDICAL TREATMENT], shortness of breath and oxygen use. He used a sit to stand lift for all transfers, had episodes of passing out during transfers and required two staff to assist with transfers with extensive assistance of two staff for transferring. Review of the admission Fall Risk Evaluation dated 01/09/21 revealed Resident #72 was at moderate risk of falls. Review of the Significant Change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #72 was alert, oriented and had intact cognition. This assessment indicated he required extensive assistance with two staff members for bed mobility, transfers, dressing, and toilet use. Review of the Care Area Assessment worksheet dated 02/17/21 revealed Resident #72 was at risk for falls and required a sit to stand lift for transfers. Review of the monthly March, 2021 physician's orders revealed Resident #72 had current orders for two staff to assist with all transfers every shift and an order for [REDACTED]. Review of the nursing note dated 03/02/21 at 4:10 A.M. revealed State tested Nursing Assistant (STNA) #312 was providing care for Resident #72 before going to [MEDICAL TREATMENT], he apparently became lightheaded and fell , hitting the back of his head and causing a cut and hematoma. The note said the cut was immeasurable due to the bleeding. A call was made to the physician and there was an attempt to do a telemed visit, however the resident began to have blurred vision and confusion, so the call was ceased. A physician order was given on 03/02/21 for Resident #72 to go to the emergency room (ER) for evaluation of the hematoma and laceration on his head. Review of the facility fall investigation dated 03/02/21 revealed at 4:10 A.M. the STNA was providing care for Resident #72 before [MEDICAL TREATMENT] when the resident apparently became lightheaded and the STNA assisted him to the floor. The STNA reported the resident passed out. It was an assisted fall with the resident hitting the back of his head and causing a cut and hematoma. The resident was transported to the ER for an evaluation. Review of the physician assistant progress note dated 03/02/21 at 4:55 A.M., revealed Resident #72 had sustained a fall and hit his head and had an approximately one inch long, gapping, bleeding laceration on his head. Resident #72 was on apixaban (Eliquis), which is a blood thinner. The physician assistant indicated a telemed appointment was arranged but prior to the appointment, he/she was told the resident developed confusion, blurred vision and appeared to need stitches. The physician assistant said given the use of the blood thinner and the neurological changes an order was given to send Resident #72 to the hospital for evaluation and care. Review of the nursing note dated 03/02/21 at 3:01 P.M. revealed the interdisciplinary team (IDT) met and reviewed Resident #72's fall. The STNA was assisting the resident in the bathroom and as he was standing in the doorway of the bathroom, he stated that he needed to sit down. The STNA went to sit the resident back on the toilet and he went limp and passed out. The STNA attempted to assist him to the floor but was unable to prevent his head from hitting the floor. The resident was noted to have a hematoma and laceration to the head. The resident had blurred vision and confusion and was transferred to the ER. The resident was admitted for observation related to syncopal (loss of consciousness) episode. The IDT meeting indicted the resident's pathway was clear, non-skid footwear was in place,the call light was in place and the resident gave no indication of dizziness prior to passing out. Review of the written employee statement from STNA #312, dated 03/02/21, revealed Resident #72 had pulled his call light for assistance to be cleaned up after using the toilet. She said she did not have a lot of room to wash him up, so she was in the process of taking him out of the bathroom to make space for her body to get in and then bring him back. She said she got him to the doorway of the bathroom before she tried turning him around. The resident started to mention, with slurred speech, that he needed to sit down. She started to get him back to the toilet as fast as she could and he passed out on her. She quickly moved herself under the lift arms (of the mechanical lift) and tried to lower him (mostly over his lower back) as he went limp. She had her knee under him when he landed, and she tried to catch his head, but it hit too hard. She removed herself and said his name to make sure he was responsive. She pulled the string of the bathroom call light and waited a few seconds. She asked him if he was okay and made him comfortable. She then went to the doorway and called for the nurse. The nurse arrived and took over. Telephone interview on 03/17/21 at 10:50 A.M. with Resident #72's daughter confirmed he was sent to the hospital after this fall and required six staples for the laceration on his head. She verified her father did not return to this nursing facility. Interview on 03/17/21 at 2:15 P.M. with the Director of Nursing (DON) verified she had completed the investigation. She said she must have misunderstood because she thought Resident #72 had walked to the bathroom. She verified the witness statement from STNA #312 indicated she had to move herself under the lift arms. Interview on 03/17/21 at 6:00 P.M. with STNA #312 revealed she had to get Resident #72 up for [MEDICAL TREATMENT] and he thought he had to have a bowel movement, so she asked him if he wanted to walk to the bathroom or use the lift. She stated the resident told her to use the lift because he felt weak and tired. She indicated she hooked him up to the sit to stand lift and double checked everything to make sure he was strapped in correctly. She indicated she put him on the toilet and went out of the room. She said he put his call light on and she went in to get him ready for [MEDICAL TREATMENT]. She stated she stood him up using the lift to wipe him off and wash him up, but she could not reach to wash him properly, so she pulled the sit to stand away from the toilet at an angle. She said she was washing him up and he stated he need to sit down so she started to move him over to the toilet as quickly as possible, but he just fell out of the lift. She stated she tried to break his fall, but he was so much bigger than her and she couldn't do it. She said he hit his head on the floor. She tried to get him to respond to her, but he did not and she did not want to leave him, so she turned the call light on and waited for about 30 seconds and no one came. She said he started coming around and she asked him if he was okay. He said he was so she ran to the doorway and yelled for the nurse. The nurse came down immediately. She stated she usually transferred residents by herself with the sit to stand lift. Review of the user manual for the Invacare Stand Up Patient Lift revealed the stand-up lift may be operated by one healthcare professional for all lifting preparations, transferring from and transferring to procedures with a cooperative, partial weight-bearing patient. However, since medical conditions vary, Invacare recommended the healthcare professionals evaluate the need for assistance and determine whether more than one assistant was appropriate in each case to safety perform the transfer. Review of the facility policy, Fall Management, dated 01/19/20, revealed the facility would identify each resident who was at risk for falls and would develop a Plan of Care and implement interventions to manage falls. The facility would provide an environment that was free from potential hazards. This deficiency substantiates Master Complaint Number OH 848 and Complaint Number OH 734. This deficiency is an example of continued noncompliance from the survey dated 03/08/21.

Based on observation, record review, review of the facility's investigation, review of a report from local law enforcement, staff interviews, and policy review, the facility failed to provide adequate supervision and implement appropriate elopement prevention interventions for one resident (Resident #20), who was assessed by the facility to be cognitively impaired, express the desire to return home and to be a high risk for elopement. This resulted in Immediate Jeopardy on 10/24/20 at 9:35 P.M. when Resident #20 exited the facility through an unsecured door while unsupervised and unbeknownst to the facility. The likelihood of actual harm, serious injury or death occurred as the resident was found approximately 45 minutes later about a mile from the facility walking along the road by facility staff. The risk for actual harm, serious injury or death continued when upon his return to the facility on [DATE], Resident #20's previously ordered elopement prevention interventions were not implemented resulting in the resident eloping from the facility a second time on 11/16/20 at 10:10 P.M. The resident was found by local law enforcement about a mile and a half away from the facility. He was lying in a ditch improperly dressed for the inclement weather conditions that existed outside the facility when found a little over an hour after he was known to be missing. Both times he was transported to the local emergency room where he was evaluated for cold exposure before being returned to the facility. This affected one of three sampled residents (Resident #20). The facility identified the resident as being the only resident who had eloped from the facility in the past three months but identified two additional residents (Resident #17 and #67) who were at risk for elopement. On 11/23/20 at 2:47 P.M., the Administrator, Director of Nursing (DON) and Clinical Corporate Support were notified Immediate Jeopardy began on 10/24/20 at 9:35 P.M. when Resident #20 eloped from the facility through an unsecured door that led into the enclosed courtyard. Facility staff located the missing resident approximately 45 minutes later a mile to a mile and a half from the facility heading north. He was dressed in pajama pants, a sweatshirt and had gripper socks on. His pajama pants were slightly wet, and he had a tear on the upper leg area of his pajama pants. He was transported to the local hospital and returned to the facility after being evaluated for his exposure to the cold environment. Immediate Jeopardy continued when a subsequent elopement occurred on 11/16/20 through the same unsecured door that led to the courtyard at 10:10 P.M. Previously ordered elopement prevention interventions (wanderguard device and every 15-minute checks) were not implemented upon his return to the facility after an inpatient psychiatric stay from 10/25/20 through 11/16/20. He was located by local law enforcement about a mile and a half from the facility at 11:22 P.M. lying in a ditch along the side of the road. The outside temperature was 36 degrees Fahrenheit (F.) and the resident was only dressed in a polo shirt with shorts on with no shoes or socks on. He was transported to the local hospital again and evaluated for environmental exposure to cold temperatures. Immediate Jeopardy was removed on 11/20/20 when the facility implemented the following corrective action: · On 10/24/20 at 9:30 P.M. Resident #20 was last seen by a State tested Nurse Aide (STNA) #1. · On 10/24/20 At 9:35 P.M. the facility staff was alerted by a gentleman next door that a resident was observed off the property. Resident #20 left the facility without supervision by means of the side door that led to the courtyard. It was determined through the facility's investigation and written statements from Maintenance Director #7 that this resident kicked the slats out of the vinyl fence leaving a space to crawl through, in order to leave the facility. · On 10/24/20 at 10:13 P.M. Resident #20 was assisted back to the facility property by staff and was placed on one-to-one monitoring to ensure he was safe and unable to attempt actions that could result in harm. Staff member remained with the resident as a 1:1 until 10/24/20 at 11:50 P.M. until he was transferred to the ER for further evaluation. · On 10/25/20 at 10:10 A.M. Resident #20 was readmitted to the facility from the ER and the 1:1 staff monitoring resumed. · On 10/25/20 at 10:31 A.M. a wanderguard device was initiated for Resident #20. · On 10/25/20 at 5:30 P.M. Resident #20 was transferred from the facility to a psychiatric hospital, per family request, for further evaluation and treatment. Resident remained at the psychiatric hospital until 11/16/20, while the resident remained out of the facility the wanderguard device was removed. · On 11/16/20 at 5:30 P.M. Resident #20 was readmitted to the facility and the wanderguard device was not immediately reapplied. · On 11/16/20 at 10:00 P.M. a facility STNA heard yelling outside and Resident #20 was noted to not be in his room. · On 11/16/20 at 11:21 P.M. Resident #20 was located by staff and local police and was immediately taken to the ER for evaluation. · On 11/16/20 at 11:21 P.M. all residents were accounted for and in the facility via head count by RN #13. · On 11/16/20 at 11:30 P.M. the VP of Clinical Operations and Regional Director of Operations were notified of Resident #20's elopement by the Administrator and DON. The Administrator and DON were immediately educated on the Elopement policy, exit seeking behaviors, complete assessments on admission and readmission, as well as appropriate interventions, and reinitiating previous interventions, to include wanderguard orders and placement upon readmission by the VP of Clinical Operations. The DON and Administrator's education was completed by 11:35 PM on 11/16/20 by the VP of Clinical Operations. · On 11/16/20 at 11:41 P.M. the DON and Administrator began educating all staff on the Elopement policy and all direct care nursing staff on completion of wandering assessments, appropriate interventions, and initiating previous interventions, to include wanderguard orders and placement on re-admission. Education continued until 11/17/20 at 3:00 P.M. when all 78 staff members were educated by the Administrator and DON. This included 8 dietary employees, 10 Laundry/Housekeeping employees, 6 therapy employees, and 9 department heads/other, 4 RN's, 9 LPN's and 32 STNA's that were educated on Elopement policy. In addition, all 13 direct care nursing staff were educated either via phone or in person by the DON, this included 4 RN's, 9 LPN's that were educated regarding completion of wandering assessments, appropriate interventions and initiating previous interventions, to include wanderguard orders and placement, on readmission. · On 11/16/20 at 11:45 P.M. the DON initiated interviews of staff and witness statements were distributed regarding Resident #20's elopement. All interviews were completed by DON and all witness statements were returned to the DON by 11:55 P.M. · On 11/17/20 at 12:15 A.M. the DON, Unit Manager and MDS Coordinator began resident assessments. Residents were assessed for cognition and risk of wandering or elopement. All 70 residents were assessed and discussed by the interdisciplinary team to determine if they were at risk, and if interventions were appropriate and in place. This was completed on 11/17/20 at 3:00 P.M. As a result of the assessments, one additional resident (Resident #17) was identified as a new risk for wandering and a wanderguard was initiated. This resident's care plan was updated on 11/17/20 at 1:23 P.M. by the DON. · On 11/17/20 at 2:58 A.M. Resident #20 returned to the facility and was immediately placed on a 1:1 staff supervision and the wanderguard device was reapplied. As of 11/23/20 Resident #20 currently remains a 1:1 with staff supervision and the wanderguard remains in place and functioning properly. Both interventions will remain in place until the resident is discharged . The resident's care plan is reflective of these interventions. It was determined through the facility's investigation that the resident exited the building the second time through the same side door to the courtyard, removed the temporary straps used to secure the gate and was off the property approximately 1 hour and 21 minutes. No injuries occurred during the incident. · On 11/17/20 by 3:00 P.M. all resident care plans were reviewed and validated, all wanderguards orders, and all wanderguard ordered devices were validated to be in place by the DON, unit manager, and MDS coordinator. · On 11/17/20 by 4:00 P.M. the DON reviewed all incident reports over the last 60 days and no like instances were noted with the exception of Resident #20's elopement on 10/24/20. · On 11/17/20, audits were instituted using a new audit tool initiated on 11/17/20 to verify all staff understood the Elopement policy and education regarding completion of wandering assessments, appropriate interventions, and initiating previous interventions. The audit tool would be completed by the DON or designee and reviewed by the DON after completion. · On 11/17/20, new audits of residents were instituted to ensure all new admissions were assessed completely, interventions were added as appropriate, and previous interventions were re-initiated upon re-admission. These audits of all new admissions will occur for all new admissions and re-admissions upon occurrence for three months by the DON or designee. No new admissions or readmissions occurred between 11/17/20 and 11/19/20. · On 11/17/20, new audits of current residents were instituted to ensure all current resident assessments remained accurate, interventions remained in place and appropriate, and no changes needed to be made. The audit results will be overseen by the DON. · On 11/17/20 and 11/18/20 Elopement drills were completed on all shifts by the Maintenance Director and no issues were noted. Elopement drills were completed on 11/17/20 at 8:00 A.M. and 4:00 P.M. and again on 11/18/20 at 5:00 P.M. and again at 7:00 P.M. Elopement drills will continue on all three shifts by Maintenance Director or designee once a week for four weeks and then quarterly as required. In addition to the elopement drills the Maintenance Director or designee will audit the security of the fence, and all other doors for secured pads five times a week for four weeks. Drills will be reviewed by QA monthly with recommendations for changes to be made as necessary. · On 11/17/20 at 12:00 P.M., a maglock was installed with a keypad to the side door leading to the courtyard. · On 11/17/20 at 2:00 P.M., all other doors were checked by the Maintenance and all doors were noted to be secured. · On 11/18/20 at 8:30 A.M. and 3:00 P.M. and again on 11/19/20 at 8:00 A.M. and 4:00 P.M., the maglock and keypad were re-inspected by the Maintenance Director and no issues were found. · On 11/19/20 at 1:00 P.M. re-education of staff of the same topics was again initiated by the DON and Administrator. By 8:00 P.M. education to all 78 staff members regarding the Elopement policy was completed. By 8:11 P.M. all nursing staff was also educated by the DON regarding completion of assessments, appropriate interventions, and re-initiating interventions, to include wanderguard orders and placement, upon re-admission. This included 4 RN's and 9 LPN's. All 13 nursing direct care staff was completed either via phone or in person and all staff stated understanding. No staff member returned to work prior to receiving education. · On 11/19/20 at 1:00 P.M. all resident assessments and care plans were reviewed again by the DON, Unit Manager and MDS coordinator. By 3:00 P.M. on 11/19/20 reviews were completed, and no changes were noted. · On 11/19/20 by 1:30 P.M. five residents were audited by the DON. All five residents were deemed to have accurate assessments, appropriate interventions, and interventions were validated to be in place. These audits of five residents will be completed three to five times a week and continue for three months by the DON or designee. Audits will be reviewed by QA monthly with recommendations for changes to be made as necessary. · On 11/19/20 at 2:00 P.M. five direct care staff were interviewed by the DON. All five staff verified that they had been educated and verified understanding of the Elopement policy and education regarding completion of wandering assessments, appropriate interventions, and reinitiating previous interventions upon re-admissions. · On 11/19/20 at 2:30 P.M. five non-direct care staff members were interviewed by the DON. All five staff verified that they had been educated and verified understanding of the education. · On 11/19/20 audits of five staff members will be completed by the DON or designee three to five times a week beginning and will completed for four weeks. Audits will be reviewed by QA monthly with recommendations for changes to be made as needed. · On 11/20/20 at 3:30 P.M., the courtyard gate was repaired and reinstalled, the maglock remains in place to the door. · On 11/23/20 at 8:00 A.M. one new RN was hired and began training. This new RN was educated by the DON on Elopement policies, and completion of assessments, appropriate interventions, and re-initiating previous interventions, to include wanderguard orders and placement, upon re-admission. · On 11/23/20 by 5:12 P.M. 5 RN's and 9 LPN's were re-educated by the DON regarding wanderguard devices being applied immediately upon re-admission, review of previous orders of readmitted resident, and order entry process of previous interventions to include placement of orders on the MAR/TAR. Education included placing the device on the resident appropriately. Although the Immediate Jeopardy was removed on 11/20/20 , the deficiency remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of completing additional staff training, developing a process to ensure elopement prevention interventions were implemented upon a resident's readmission into the facility as previously ordered, and conducting audits to ensure the effectiveness of the staff training and the new processes developed. Findings include: A review of Resident #20's medical record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of Resident #20's wandering/ elopement assessment dated [DATE] revealed the resident had intermittent confusion, forgetfulness and disorientation. He was able to ambulate independently with or without the use of an assistive device (including a wheelchair). He had stated he wanted to leave the facility and the family had reported increased confusion. At home, he displayed no regard to safety awareness. The assessment determined he was at risk for wandering and was a high risk for elopement. Appropriate interventions were indicated to have been initiated and included exit alarms. It did not include the use of a wanderguard to reduce his risk for elopement. A review of Resident #20's admission Minimum Data Set 3.0 (MDS) assessment, an assessment tool used by the facility to identify a resident's level of care for reimbursement purposes, dated 09/23/20 revealed Resident #20's cognition was moderately impaired. Wandering behavior occurred one to three days of the seven-day assessment period. He required supervision with the assistance of one for transfers, ambulation in the hall and locomotion on the unit. He required a limited assist of one for ambulation in the room. Locomotion off the unit only occurred once during that assessment period and no set up help of physical help from staff was needed. A review of Resident #20's care plans revealed he had a care plan in place for impaired cognitive process for daily decision making. He was at risk for further decline in his cognitive status and had intermittent confusion. The care plan was revised on 11/17/20. He also had a care plan in place for having adjustment issues related to his admission to the nursing home. The care plan indicated he was unable to return home safely as he lived alone and had dementia which fluctuated. He was unaware of his safety awareness and did not understand why he couldn't leave the facility. Per his family request, he was to remain long term care. That care plan was revised on 11/24/20. There was another care plan for him exercising his right to refuse care and treatment to include staying in the facility. He again was indicated to not be safe to live alone and did not want to stay within the facility. That increased the risk for further elopement. That care plan was last revised on 11/17/20. A review of Resident #20's progress notes revealed a note dated 10/24/20 at 9:35 P.M. that indicated the facility received a call from a man that stated he was stopped by a man asking him for directions to town. The caller stated the man was wearing only one shoe, holding the other shoe in his hand. The caller stated he gave him directions and the man walked away heading towards the bridge at the end of the road the facility was on. A nurse's progress note dated 10/24/20 at 9:36 P.M. revealed the facility staff initiated the elopement procedure within the facility. The head count was noted to be short by one resident. The search was then moved outside the facility on foot. No resident was found outside on the facility grounds. A nurse's progress note dated 10/24/20 at 9:50 P.M. revealed an internal head count on elopement showed one resident missing. The nurse took an STNA with her and began searching by car. A nurse's progress note dated 10/24/20 at 10:13 P.M. revealed Resident #20 was observed walking along the roadside approximately a mile and a half from the facility. The resident was wearing gripper socks, pajama pants and a sweatshirt. His pajama pants were slightly wet and there was a large tear in the pants in the upper leg area. The resident was visibly and verbally agitated and stated he was going home. The facility staff were able to convince the resident to get into the vehicle and he was returned to the facility. He refused to reenter the facility and sat out on the bench in front of the facility. A nurse's progress note dated 10/24/20 at 10:15 P.M. revealed Resident #20 was safely returned to the facility following an elopement. His wheelchair was noted out on the resident patio over by the fence where he exited on foot. At 9:00 P.M., the temperature outside was noted to be 45 degrees F. A nurse's progress note dated 10/24/20 at 11:38 P.M. revealed the facility staff were still unsuccessful with getting Resident #20 back into the building. He had been given [MEDICATION NAME] (an antipsychotic) 5 milligrams intramuscularly as ordered for agitation. They attempted to contact the resident's son to have him come to the facility to assist them with getting the resident to go back into the building. The resident continued to display agitative behavior and the son was unable to calm his father. An ambulance service and local law enforcement was called to take Resident #20 to the local hospital. A review of the facility's investigation for Resident #20's elopement on 10/24/20 revealed an incident report that indicated the immediate action to be taken following the resident's elopement was the use of a wanderguard alarm (an alarm that was placed around the resident's wrist/ ankle that would alarm if he approached a door equipped with the wanderguard system) to his ankle and every 15 minute checks. He was transferred to the emergency room after refusing to go back into the facility. A timeline was documented as part of the incident report and was consistent with the timeframes identified in the progress notes. The facility's investigation included witness statements obtained from the facility staff, who worked at the time of Resident #20's elopement on 10/24/20. The witness statements indicated the resident was last seen in the facility at 9:25 P.M. A written statement from Maintenance Director #7 revealed he checked the courtyard area after he arrived at the facility at 11:05 P.M. and found the resident's wheelchair at the back gate. There were several slats broken loose from the back fence. He replaced the slats and secured the back gate. He planned to have the fence company repair the fence and replace the back gate the following Monday. He also planned to add an alarm lock to the smoker's exit that led to the smoking area/ courtyard. A review of the hospital records for Resident #20's emergency room visit on 10/24/20 at 11:57 P.M. revealed he was confused but coherent when he was assessed at the hospital. The hospital nurse spoke with the resident's son, who informed the nurse he would not be picking the resident up to take him to the son's home due to the resident's explosive behaviors. The son stated the resident had threatened to kill his wife many times in the past. The son reported the house the resident owned was still in his name but there were no utilities turned on for him to reside there. The son stated multiple times the resident had dementia with explosive behaviors and was not safe to live by himself. The son stated the nursing facility had spoke with him that morning and was attempting to get an emergency guardianship for the resident. A review of a nurse's progress note dated 10/25/20 at 10:10 A.M. revealed Resident #20 returned to the facility from the hospital. He was tearful upon his return and reported to the nurse that he just wanted to go home. A nurse's progress note dated 10/25/20 at 10:31 A.M. revealed a wanderguard was applied to Resident #20's right ankle as ordered. At 1:50 P.M., the resident's family wanted the resident to be sent out for a psychiatric evaluation. The physician was notified of the family's request and gave the order for the resident to be transferred. He left the faciity on [DATE] at 5:30 P.M. He remained out of the facility for an inpatient psychiatric stay through 11/16/20. A review of Resident #20's inpatient psychiatric records revealed his [DIAGNOSES REDACTED]. The history of his present illness revealed he had eloped from the nursing facility the night before and was found by a person the resident stopped to ask directions from. The resident was non-compliant with medications and had poor decision making. He was at high risk for running away. He was known to be confused and disoriented while at the inpatient psychiatric facility. He thought he was at his house and had to be reoriented that he was in the hospital. He had impaired judgement and impaired insight. Delusional disorder was added to his diagnoses. He had a long history of untreated paranoia and anxiety. The resident denied having any memory impairment despite testing completed during his inpatient stay showing he met the criteria for dementia. He had no insight and deemed not to be able to live independently. It was determined he would need a locked unit if he could not successfully stay in an assisted living facility. A review of Resident #20's nurses' progress notes revealed he returned to the facility on [DATE] at 5:30 P.M. The note did not indicate whether the resident's previously ordered wanderguard alarm was in place or not or if every 15-minute checks were resumed upon his return. The nurse's note indicated he did not voice the desire to leave the facility at that time. A review of Resident #20's treatment administration record (TAR) for November 2020 revealed the elopement intervention for the use of a wanderguard and for every 15-minute checks to be done was not on the TAR when the resident was readmitted to the facility on [DATE] at 5:30 P.M. A nurse's progress note dated 11/16/20 at 10:10 P.M. revealed the nurse was notified by an STNA that Resident #20's wheelchair was noted to be right outside the smoker's patio door with the resident not in sight. The nurse and other staff began to search for the resident out on the patio, smoking area and courtyard. A portion of the fence was noted to be down and laying to the side in the grass. The nurse and staff then extended the search outside of the facility. The resident was not able to be located and the local law enforcement was notified. A review of an incident report dated 11/16/20 at 10:10 P.M. revealed the facility staff notified the local police department of Resident #20's elopement from the facility when he could not be located inside or around the perimeter of the building. The outside temperature was indicated to be 36 degrees F. at the time of his elopement. Some staff left the facility via a vehicle to search for the resident. The resident was indicated to have been found a short distance from the facility by staff/ police. He was transferred to the hospital for an evaluation and returned to the facility without injuries. He was placed on one on one supervision upon his return. A review of written statements provided by the staff on duty at the time of Resident #20's elopement on 11/16/20 revealed the last time the resident was seen inside the facility was at 9:00 P.M. LPN # 41 reported the resident was observed wearing an orange/ tan polo shirt with shorts on. He was up in his wheelchair. An STNA working the secured unit heard yelling outside by females she thought was from the apartment complex next to the facility. A written statement from STNA #18 revealed she was made aware Resident #20 was missing at 10:00 P.M. She and STNA #24 left the building to go search for the resident off the facility grounds via a vehicle. They crossed the bridge at the end of the road the facility was located on and turned left. After 30 seconds into their turn, they saw lights from a police car. They pulled over to verify if it was the resident. Resident #20 was on the ground, so they covered him with a blanket and stayed with him until the ambulance arrived. The resident was noted to not have shoes, socks or a jacket on. A written statement from STNA #24 revealed she was notified at 10:00 P.M. that Resident #20 was missing. She confirmed she left the facility in a vehicle with STNA #18 to search for the missing resident. She too indicated they crossed the bridge and turned left coming up on police car lights 30 seconds into their turn. She confirmed they verified it was Resident #20, who was on the ground. They covered him with a blanket and stayed with him until the ambulance arrived. A statement taken from Resident #20 revealed he was disoriented to the month and year at the time his statement regarding his elopement on 11/16/20 was taken. He reported he did not know he tried to elope but was always trying to get home. When asked what caused him to be agitated, he responded being in the facility as he just wanted freedom and to go home. A review of the police report from the local police department revealed they were dispatched to the facility in reference to Resident #20 leaving the facility on 11/16/20 at 10:22 P.M. The charge nurse (RN #13) advised them the resident was suffering from dementia and was not able to care for himself. They advised the officer; the resident was last seen around 9:00 P.M. His wheelchair had been discovered right outside the side door, but the resident was no where to be found. He was known to have had a similar incident at the end of October 2020. RN #13 informed the officer that the resident could possibly be heading towards his prior residence, but last time was found walking near the hospital. He was indicated not to have been dressed for the weather and the night had gotten cold out. The local police could not locate him, and dispatch contacted the local Sheriff's office to see if they could assist in checking the area. A deputy was in the area right past the end of the road where the facility is located when he observed Resident #20 lying in a ditch along the road at 11:20 P.M. The resident's identity was confirmed, and an ambulance was called to transport him to the hospital. The resident advised the officer that he had fallen and had been lying in the ditch for over an hour. A review of Resident #20's hospital records for his transfer to the emergency roiagnom on [DATE] revealed he was seen at 11:58 P.M. for environmental (cold) exposure. He was known to have had a history of [REDACTED]. He left the facility and was found by law enforcement. He was confused and slightly agitated when examined. He was cold but his temperature was found to be relatively normal. It improved with warming blankets. A review of a nurse's progress note dated 11/17/20 at 2:58 A.M. revealed Resident #20 returned to the facility from the hospital. Wanderguard indicated to be on the left ankle. A review of the TAR's for November 2020 revealed the use of a wanderguard was not documented as having been implemented as an elopement prevention intervention until 11/17/20 (day after he was admitted and after his second elopement occurred). It showed an order date of 11/17/20 despite it previously being ordered on [DATE], the day after his first elopement from the facility. There was also no documented evidence that he was placed back on every 15-minute checks as previously ordered on [DATE] when he returned to the facility on [DATE] at 5:30 P.M. A review of the facility's self-imposed corrective action plan revealed Resident #20 did leave without staff assistance. Upon his return to the facility, after he was sent to the emergency room , revealed a wanderguard alarm was applied to the resident. One on one supervision was initiated at that time until the facility could find appropriate alternate placement for the resident. A review of a service charge authorization form from RT Technologies dated 11/17/20 revealed the company was contacted about installing a new lock to the smoke door (side door leading to courtyard). The work was indicated to be needed as soon as possible. On 11/19/20 at 10:30 A.M., an interview with the DON confirmed Resident #20 had two elopements from the facility occurring on 10/24/20 and again on 11/16/20. She reported he exited through the same side door that led to the courtyard before he was able to make his way through the vinyl fence that enclosed the courtyard allowing him to leave the facility grounds. She denied there was any kind of lock or alarm on that door at the time of his elopements that would have prevented him from gaining access to the courtyard. She confirmed a wanderguard was ordered after his first elopement on 10/24/20 as well as every 15-minute checks. She denied he had the wanderguard on when he eloped from the facility a second time on 11/16/20. She reported it had been removed when he was in the psychiatric hospital between 10/25/20 and 11/16/20 and did not get reapplied when he was readmitted on [DATE]. She denied they had any documented evidence every 15-minute checks resumed upon his return. On 11/23/20 at 10:15 P.M., an interview with Maintenance Director #7 revealed he responded to the facility on both days Resident #20 eloped from the facility. He confirmed the resident exited the building through the side door going to the courtyard both times he eloped. He reported that door was equipped with a wanderguard alarm system, but the resident would have to have a wanderguard on for that to lock and alarm when the resident approached. He denied they had any residents with wanderguards on at the times the resident eloped. He stated he had a maglock with a keypad installed after the second elopement occurred. He reported with the resident's first elopement the resident kicked a couple of the vinyl slats out of the fence to the left of the gate at the back. He moved another one over giving him a two-foot space to crawl out of. The second time he

Based on record review and staff interview, the facility failed to ensure a resident received the necessary care and services to restore as much normal bladder function as possible. This affected two (Resident #18 and Resident #35) of three residents reviewed for urinary incontinence. Harm occurred for Resident #18 when she had a decline in her urinary continence status from being frequently incontinent to always incontinent without an assessment or an evaluation for the need of a toileting program in an effort to reduce her incontinence episodes as much as possible. Findings include: A review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. She was transferred out of the facility and admitted to the hospital on [DATE] for increased swelling of her extremities, shortness of breath, and wheezes in her bilateral lungs. She was admitted with a febrile illness. An admission nursing assessment dated [DATE] included a section for a bladder and bowel assessment and revealed Resident #18 had been incontinent longer than a year. She was assessed as having incontinence once or more in a shift that occurred during the day and night. She was marked on the assessment as being incontinent of a large amount of urine. She was identified as being on medications that could affect her bladder continence which included the use of diuretics. She was totally dependent on staff for her transfers and toileting needs. The nursing admission assessment also indicated she was alert and oriented to person, place and time. A bladder voiding pattern record that was dated 03/10/15 through 03/12/15, revealed there was missing documentation as Resident #18's voiding pattern was not marked at all for the night shift on those three days. One of the afternoon shifts on 03/12/15 was not marked at all to show whether or not the resident voided or if she was found to be continent or incontinent. The documentation for the day shift and afternoon shift for 03/11/15 was incomplete as it only marked the resident as being dry when checked hourly between 6:00 A.M. and 9:00 P.M. Facility staff did not mark the record to show whether or not she had been toileted or if she had voided during those times. The medical record did not show any evidence of a bladder assessment being completed after her admission that included a review of the bladder voiding pattern record to determine Resident #18's individualized voiding pattern. There was no evidence that her symptoms associated with her urinary incontinence was evaluated to help determine the type of urinary incontinence the resident had. There was no evidence of the resident being evaluated for the need of a toileting program to help eliminate or reduce her episodes of urinary incontinence. An admission Minimum Data Set (MDS) assessment, an assessment tool used by the facility to identify a resident's level of care for reimbursement purposes, dated 03/16/15 revealed Resident #18 was not known to have any communication issues. She was able to make herself understood and was able to understand others. Her Brief Interview for Mental Status (BIMS), a test used to determine the degree of cognitive impairment, score was 15 which identified her as being cognitively intact. The MDS was not coded to show the resident had any behaviors or was known to reject care. The activity of daily living section of the MDS revealed the resident required the extensive assist of two for transfers ad toilet use. She was coded on the MDS as being frequently incontinent of her bladder and not on a toileting program. A quarterly MDS dated [DATE] revealed there was no change in the resident's ability to communicate or with her cognitive status. She continued to not have any behaviors or and still was not known to refuse care. She remained and extensive assist of two for transfers but was only required the extensive assist of one with toilet use. She was coded on the MDS as always being incontinent of her bladder which was a decline in her urinary continence status as compared to the prior MDS completed. She was still coded on the MDS as not being on a toileting program. A care plan for Resident #18's urinary incontinence revealed she required the assistance from staff with her toileting. The care plan indicated that incontinent briefs were used. Her goal was for the her to be clean, dry and odor free. The goals also indicated she would improve in her current continence status. The interventions included on the care plan indicated bladder assessments would be completed as per the facility's policy. They were to monitor her voiding, awareness of need and to assess her pattern providing assistance as needed. The interventions also indicated they were to assist her with her toileting needs and provide incontinence care with routine rounds and on an as needed basis. The care plan specified she was to be checked and changed on routine rounds and on an as needed basis for soiling or when she requested. On 07/22/15 at 1:42 P.M., an interview with State-tested Nurse Aide (STNA) #79 revealed Resident #18 was incontinent of her bladder. She stated the resident would put her call light on to tell them she was incontinent and needed to be changed. She stated in addition to changing her when she put her call light on to let them know that she was wet they checked her every two hours. She denied that they entered the resident's room and offered to take her to the bathroom at designated times. On 07/22/15 at 1:47 P.M., an interview Licensed Practical Nurse (LPN) #66 revealed the facility completed bladder assessments as part of the residents' admissions. She stated the bladder assessments were then completed quarterly after that by the nurses on the floor. She confirmed there was no evidence of a quarterly bladder assessment being completed for Resident #18 after admission or when the MDS showed a decline in her urinary continence status. She also confirmed the bladder assessment that was completed upon admission was not a thorough assessment as it did not identify the signs and symptoms of the resident's incontinence, identify contributing factors or determine the type of incontinence the resident was though to have based on the assessment completed. On 07/22/15 at 2:10 P.M., an interview with the Director of Nursing (DON) revealed she had recognized as part of her review of the facility that they were not completing bladder assessments as they should. She stated she would not be able to find any evidence of a thorough bladder assessment being completed to show the resident was assessed to help determine the type of urinary incontinence she had or determine whether or not a toileting program was appropriate for her. She was asked to provide a copy of the facility's urinary incontinence policy specific to the completion of bladder assessments and reported that she was not able to locate one. On 07/22/15 at 3:05 P.M., an interview with Registered Nurse (RN) #83 confirmed a quarterly bladder assessment had not been completed for Resident #18. She stated one should have been done in June 2015. She was not aware that a bladder diary had been done to help identify the resident's individualized voiding pattern. She acknowledged without completing the bladder voiding pattern record to determine the resident's voiding pattern and completing a thorough assessment it was not possible to identify the type of urinary incontinence the resident had and whether or not she was appropriate for a toileting program. On 07/22/15 at 3:10 P.M., an interview with RN #34 revealed a bladder voiding pattern was put out for three days after a resident was admitted . She stated the unit managers were supposed to review that record and complete a bladder assessment to determine if the resident was appropriate for a toileting program. She stated she did not communicate the decline in Resident #18's urinary continence status with the unit manager as the resident had a urinary tract infection at that time that was being treated. She reported a quarterly bladder assessment still should have been completed as they were supposed to be done on a quarterly basis. She verified the three day bladder voiding pattern record was incomplete as not all shifts documented the resident's continence status for all three days and some of the documentation added was incomplete. She stated the unit managers were the ones who were responsible for ensuring they were completed after they were implemented. 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's electronic and paper medical record revealed no evidence of comprehensive bladder assessment or three day bladder assessment. Further review of the admission nursing assessment dated [DATE] revealed the facility did not know how long the resident had been incontinent, the resident was wet once or more per shift, and had large amounts or urine. Review of the Aide flow records revealed no evidence the facility tracked Resident #35's daily elimination during 01/15 and 02/15. Further review revealed during 03/15 to 07/15, Resident #35 was frequently incontinent on all three shifts and required limited to total dependent with toileting and incontinent care. There was no evidence of a toileting program for Resident #35. Review of nurses notes dated 01/23/15 to 07/23/15 revealed Resident #35 was incontinent of bowel and bladder. There was no evidence of the type or frequency of incontinence. Review of Resident #35's care plan dated 02/12/15 revealed the resident had a potential for complications associated with occasional urinary incontinence. Monitor need for /schedule appropriate diagnostic procedures, report any changes in bladder status, check resident every 2-3 hours and as needed for incontinent episodes and provide incontinent care after each episode. Further review revealed on 06/11/15 the care plan was updated to change Resident #35 to frequently incontinent and offer to toilet every 2 hours while awake. Review of Resident #35's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was occasionally incontinent of urine and was not on a bladder training program. Review of Resident #35's MDS dated [DATE] revealed the resident was frequently incontinent of urine and was not on a bladder training program. Interview with Licensed Practical Nurse (LPN) #37 and Registered Nurse (RN) #9 on 07/23/15 at 4:10 P.M. affirmed Resident #35 was frequently incontinent of urine and affirmed there was no toileting program in writing. LPN #37 and RN #9 affirmed all residents that were incontinent were toileted every two hours. Interview and observation of Resident #35 on 01/23/15 at 4:15 P.M. revealed Resident #35 was not cognitively intact to answer questions and was wearing an incontinence brief. Interview with the DON on 07/23/15 at 4:25 P.M. affirmed Resident #35 did not have a comprehensive bladder assessment, three day bladder assessment, bladder tracking for 01/15 or 02/15, or an individualized toileting program completed after a decline in bladder frequency. The DON affirmed there was no bladder policy or toileting program policy. Interview with Statetested Nurse Aide (STNA) #38 on 07/24/15 at 8:30 A.M. affirmed Resident #35 was incontinent of urine and wore an incontinence brief. STNA #38 affirmed everyone was toileted with meals, upon rising and bedtime. STNA #38 affirmed there was no individualized toileting program for resident #35.