Every finding on record at Franklin Plaza Extended Care

Based on closed record review, hospital record review, facility policy review and interview, the facility failed to ensure staff provided Resident #168 with necessary, adequate and safe assistance during activities of daily living (ADL)/personal care to prevent fall with major injury, and failed to provide Resident #162 sufficient supervision and intervention to prevent the resident from exiting the facility unsupervised. This affected two residents (Resident #162 and #168) of three reviewed for accidents.Actual harm occurred on 09/14/25 at approximately 7:00 P.M. when Resident #168, who was cognitively impaired, a quadriplegic, and required two-person assistance with ADLs, was being changed (provided personal care) by one staff, Certified Nursing Assistant (CNA) #514, resulting in the resident falling out of bed and landing on the floor. Resident #168 was transferred to the hospital on [DATE], per family request, and was admitted with multiple fractures to his left pelvis, left hand fractures, a hematoma to left eyebrow and abrasions to his right knee and left ankle and toes as a result of the fall. Resident #168 remained in the hospital until 10/01/25 and did not return to the facility post-hospitalization. This affected two residents (Resident #162 and #168) of three reviewed for accidents.Findings include:1.Review of Resident #168's closed medical records revealed an admission date of 10/14/24 and a discharge date of 09/14/25 with diagnoses including quadriplegia, paralytic syndrome muscle weakness, contractures and tracheostomy.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed no cognition score due to Resident #168 was rarely understood. Resident #168 was dependent on staff for toileting, bathing, personal hygiene, bed mobility and transfers.Review of care plan dated 07/27/25 revealed Resident #168 was at risk for falls related to immobility and paralytic syndrome. Interventions included assisting with all transfers and mobility and mechanical lift transfers with assistance of two staff members. Resident #168 had self-care deficits related to immobility, contractures, paralytic syndrome and quadriplegia. Interventions included mechanical lift transfers per order, providing total assistance with bathing, bed mobility, dressing and incontinence care. The care plan did not specify the number of staff required to safely provide assistance with bathing, bed mobility, dressing, or incontinence care.Review of Resident #168's care plan dated 07/27/25 revealed the resident had a communication problem related to aphasia and was able to shake his head up and down for yes and side to side for no. Interventions included to anticipate and meet needs, encourage non-verbal communication and monitor effectiveness of communication strategies by asking simple yes or no questions. The resident was at risk for pain with interventions including administer pain medication per physician orders, assess for pain, if experiencing pain rate pain using [NAME]-BAKER Faces Pain Scale, document/report complaints and non-verbal signs of pain.Review of a progress note dated 09/14/25 timed 7:12 P.M. authored by Licensed Practical Nurse (LPN) #397 revealed an aide had alerted her that Resident #168 had fallen during resident care. LPN #397 had observed Resident #168 in a sitting position on his buttocks and was on his knees with his head against the bed frame. Resident #168 was observed to have shearing to his right knee with no other injuries observed.Review of a progress note dated 09/14/25 time 7:40 P.M. authored by LPN #397 revealed Resident #168 was assessed from head to toe and due to Resident #168's contractures his range of motion was very limited. Resident #168 had shearing to the right knee with no other injuries observed. Resident #168 was noted to have had a pain level of 3-4 (out of 10) that was new after the fall. The note included the family and physician had been notified.Review of a progress note dated 09/14/25 timed 11:50 P.M. authored by Nurse Practitioner (NP) #511 revealed a call had been received as Resident #168's daughter had wanted Resident #168 to be sent to the hospital for evaluation related to fall that had occurred earlier. Resident #168 was unable to express pain, and she was concerned after he had hit the ground hard. NP #168 ordered Resident #168 to be sent to the hospital for evaluation per family request. Review of Resident #168's Medication Administration Record revealed on 09/14/25 at 7:52 P.M. the resident had a recorded pain level of four and was given Ibuprofen. The medical record contained no further follow up related to the resident's pain level. Review of a progress note dated 09/14/25 timed 11:55 P.M. authored by LPN #345 revealed Resident #168's daughter had called and insisted Resident #168 be sent to the hospital from a fall that had occurred at approximately 7:00 P.M. and was concerned Resident #168 had not been able to communicate pain.Review of a progress note dated 09/15/25 timed 9:08 A.M. authored by LPN #500 revealed Resident #168's fall had been reviewed by the interdisciplinary team. The charge nurse (name not identified) had been informed by Certified Nursing Assistant (CNA) (name not identified) that Resident #168 had rolled from bed during patient care. Upon entering Resident #168's room charge nurse observed Resident #168 in a sitting position , sitting on his feet, described as the position of a Muslims pray, facing the window with his head resting against the bed. Nursing assessment stated no injuries and no complaints of pain. Resident #168 was assisted back into bed by the assistance of three staff.Review of a fall investigation dated 09/14/25 revealed a statement authored by CNA #514 that during resident care on 09/14/25 at approximately 7:00 P.M. Resident #168 was placed on his right side and had rolled off the bed. Nurse and additional CNA had been notified for assistance and Resident #168 was assisted back into bed. CNA #464's statement had indicated she was unaware of the incident. The investigation did not identify the root cause of the fall or the level of assistance Resident #168 should have received. The investigation did not include if resident hit his head or not during the fall or evidence neurological checks were completed after the fall.Review of hospital paperwork dated 09/15/25 with a time of arrival of 1:07 A.M. revealed Resident #168 had presented to the emergency department following a four foot fall out of bed during resident care. Emergency Medical Services (EMS) reported the facility staff was initially hesitant to send Resident #168 to the hospital; however, family had requested transportation. Resident #168 had multiple fractures to his left pelvis and left hand. Resident #168 had obvious identified injuries that also included a hematoma to his left eyebrow, abrasions to his right knee and left ankles and toes. Resident #168's hospital paperwork had included no acute surgical interventions; however, Resident# 168 had remained hospitalized from [DATE] through 10/01/25.Interview on 02/24/26 at 8:53 A.M. with Registered Nurse (RN) #406 revealed he had cared for Resident #168 on several occasions prior to his discharge and stated Resident #168 required staff assistance from two (staff) for all care because he was a quadriplegic and was dependent (on staff) for care. RN #406 stated Resident #168 had multiple contractures of his upper and lower extremities and was unable to move himself.Telephone interview on 02/24/26 at 9:16 A.M. with LPN #397 revealed CNA #514 had alerted her that during resident care on 09/14/25 at approximately 7:00 P.M. Resident #168 had rolled out of bed and had fallen on the floor. LPN #397 stated CNA #514 had reported he had lost his grip on Resident #168 during care. LPN #397 stated upon entering Resident #168's room she had observed Resident #168 on the floor in a fetal position on his side and his head was against his feeding tube pole. LPN #397 stated she had observed Resident #168's right knee was reddened, and no other injuries were observed. LPN #397 stated Resident #168 was nonverbal, was dependent with care and required two staff members for care. LPN #397 stated due to Resident #168 being nonverbal he was unable to state pain and she stated she had mediated Resident #168 for pain because he fell. LPN #397 stated she had contacted Resident #168's family and physician and stated x-rays had been ordered; however, the x-rays had not been completed because Resident #168's family had called the facility toward the end of her shift at approximately 11:00 P.M. and had requested Resident #168 be sent to the hospital. LPN #397 stated the oncoming nurse had contacted EMS and Resident #168 had been transported to the hospital after she had left the facility. Telephone interview on 02/24/26 at 9:42 A.M. with CNA #464 revealed she had not witnessed Resident #168's fall on 09/14/25, however she had been made aware CNA #514 had been providing care by himself and Resident #168 had rolled out of bed and fallen on the floor. CNA #514 stated Resident #168 was dependent for all care and was an assist of two staff members for all care. CNA 464 stated she had entered Resident #168's room and had observed Resident #168 in a fetal position on his side on the floor and was wedged between the floor and the nightstand. CNA #464 stated she had observed blood around Resident #168's mouth. CNA #464 stated she had assisted with placing Resident #168 back into bed and he was sent to the hospital a few hours later. Interview on 02/24/26 at 10:35 A.M. with the Director of Nursing (DON) revealed she had received a call from the facility on 09/14/25 (couldn't recall time or staff who had called) and was made aware of Resident #168's fall. The DON stated she had been informed CNA #514 had been providing Resident #168 with care unassisted (by another staff member) and Resident #168 had rolled out of bed and fallen on the floor. The DON stated she had not been made aware of any injuries and stated LPN #500 had completed the fall investigation, and she had reviewed Resident #168's medical records and his care plan had not indicated Resident #168 had required the use of two staff members; however, his care plan had included he was a total care. The DON stated Resident #168 had not returned to the facility after his hospital admission and stated she had not been provided with his hospital paperwork related to his fall.Review of the facility policy titled, Falls - Clinical Protocol, dated 01/06/25, revealed as part of the initial assessment the facility would attempt to identify individuals with a history of falls and risk factors for subsequent falling. For an individual who had fallen, staff would attempt to define possible causes. Based on the preceding assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. Review of Resident #162's medical records revealed an admission date of 05/30/25 with diagnoses including vascular dementia, alcohol abuse, difficulty walking and lack of coordination.Review of the MDS assessment dated [DATE] revealed Resident #162 had impaired cognition. Resident #162 required supervision with ambulation and bed mobility.Review of care plan dated 10/23/25 revealed Resident #162 was at risk for falls. Interventions included assist with all transfers, and mobility. Resident #162 had impaired cognition. Interventions included encourage resident to make routine and daily decisions. Care plan had not included wandering or elopement concerns or interventions.Review of elopement assessment dated [DATE] revealed Resident #162 was at low risk for elopement.Review of physician orders for December 2025 through February 2026 revealed no order for leave of absences.Review of progress note dated 12/22/25 timed 7:48 P.M. authored by Registered Nurse (RN) #468 revealed while on a leave of absence (LOA) Resident #162 had sustained a fall and EMS/police had transported resident to the hospital for evaluation.Review of hospital paperwork dated 12/22/25 with a time of arrival of 7:49 P.M. revealed Resident #162 had presented to the emergency department after she had escaped from the facility and was wandering outside looking for her husband and had sustained a fall. Resident #162 had tripped on a curb falling to the ground and struck her head. Resident #162 had a skin tear to her right elbow and superficial lacerations to multiple digits of her right hand.Review of email dated 12/23/25 timed 2:26 P.M. authored by Administrator regarding unauthorized LOA sent to the Department of Health revealed on 12/23/25 (date was incorrect) at around 6:00 P.M. Resident #162 was going to see her husband and while out she allegedly lost he balance and fell and was taken to the emergency department. Resident #162 was admitted to the hospital to rule out a urinary tract infection and Resident #162's had met resident at the hospital.Review of progress note dated 12/27/25 timed 12:54 P.M. authored by Nurse Practitioner (NP) #510 revealed Resident #162 had presented to the emergency department following a fall while she was wandering outside the facility looking for her husband and had fallen on a curb and stuck her head and aide had reported she had drank with her husband before. Resident #162 had been asked about her blood alcohol level and denied doing anything wrong, however she did wander off and knew she was not supposed to.Interview on 02/19/26 at 12:10 P.M. with Resident #162 revealed resident was confused and unable to recall incident on 12/22/25. Interview on 02/23/26 at 12:00 P.M. with NP #510 revealed Resident #162 was confused and had poor insight and judgement. NP #510 stated she had reviewed Resident #162's medical records and had observed an after visit summary (AVS) that had stated Resident #162 had been brought to the ED following a fall while she was outside. NP #510 stated she could not recall specific information and had used the AVS when she had authored her progress note on 12/27/25. Interview on 02/23/26 at 12:46 P.M. with Licensed Practical Nurse (LPN) #435 revealed Resident #162 was confused and unable to make her own decisions. LPN #435 stated if residents had left the facility they were supposed to sign out at the receptionist desk and she was unaware if physician orders were to be in place for residents to have LOA privileges. LPN #435 stated Resident #162's husband had taken Resident #162 on LOA's after the incident and she had returned severely intoxicated.Interview on 02/23/26 at 2:15 P.M. with Director of Nursing (DON) revealed she had received a call from the facility on 12/22/25 (couldn't recall from who or a time) that stated Resident #162 was outside and had fallen and was taken to the ED for evaluation. DON stated she had not been made aware of where Resident #162 was located when the fall occurred. DON stated the Administrator had sent the email to ODH to inform of an unauthorized LOA. DON confirmed Resident #162 had impaired cognition as her BIMS score was an 11 at the time of the incident and no physician orders had been in place regarding residents ability to have LOA privileges. Interview on 02/24/26 at 11:08 A.M. with LPN #304 revealed she was Resident #162's assigned nurse on 12/22/25 and stated she had seen the resident sometime around 2:00 P.M. when she administered her afternoon medications. LPN #304 stated she had been unaware Resident #162 had left the facility until she had received a phone call from the supervisor that Resident #162 had been taken to the hospital (couldn't recall time). Telephone interview on 02/24/26 at 12:27 P.M. with RN #468 revealed he had received a phone call from the receptionist at approximately 7:00-7:15 P.M. on 12/22/25 that stated the police were on the phone and needed to speak with him. RN #468 stated a female police officer had stated they had found Resident #162 leaving a store and she had fallen and was being transported to the hospital. RN #468 stated he had not asked the police officer where or when the resident had been found. RN #468 stated he had not been aware Resident #162 had left the facility.Telephone interview on 02/24/26 at 12:55 P.M. with Receptionist #414 revealed she had arrived at the facility at approximately 2:30 P.M. on 12/22/25 and had seen Resident #162 shortly after she had arrived. Receptionist #414 stated she had not recalled seeing Resident #162 after that time or any visitors for her. Receptionist #414 stated she had received a call that evening (unable to recall time) from a police officer that stated Resident #162 was at the police station. Receptionist #414 stated she had transferred the call to RN #468.Interview on 02/25/26 at 1:45 P.M. with Administrator revealed he could not recall where he had gotten the time of the incident of 6:00 P.M. that was included in the email sent to ODH. Administrator further stated he was unaware of where he had received the information Resident #162 had been admitted to the hospital to rule out a urinary tract infection and the husband had met Resident #162 at the hospital. Administrator further stated he was unaware of where Resident #162 had been located.Review of facility policy titled Release of Responsibility for Leave of Absence revised 04/28/25 revealed residents who are their own responsible party may leave the facility for a leave of absence, residents are asked to inform their nurse when leaving the building. Residents who are not their own responsible party may leave the facility with a responsible party who may sign them out at the front receptionist desk.This deficiency represents non-compliance investigated under Complaint Number 2623301.

Based on observation, interview, record review, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 160 out of 164 residents who ate meals in the facility's kitchen as four residents (Residents (#7, #89, #123, and #146) received enteral nutrition and did not receive meals from the kitchen. The facility census was 164. Findings include: 1.Observation and interview on 02/19/26 at 10:20 A.M. through 10:40 A.M. of the kitchen with Dietary Manager (DM) #426 revealed the following:-The fridge across from the stove was dirty with various food debris, splatter and dirt along bottom; black residue along back fridge wall, the walk-in fridge had dust on the two fans and dust on the ceiling that had blown from the fans, a container with lemonade that was not dated, a bag of expired arugula, four moldy cucumbers, a staff lunch box and energy drink can. Interview with DM #426 revealed they do not typically keep staff's food in the fridge.-The kitchen floor was extremely sticky and slippery. Large spots of dried black debris build-up. Pieces of yellow tape and other trash near the stove and tray line.-A panel in the freezer was falling off. DM #426 revealed she put in a work order but it was not fixed.-The dishwasher had a large accumulation of water on the ground. DM #426 revealed it was not leaking and that some water drips on the floor from the machine. Water was observed on the floor from the dishwasher to the ice machine approximately 2 feet away.-The wall behind the dishwasher and the wall behind the 3-part sink had pink tile that was extremely dirty with dust and dirt.-The ceiling tiles were extremely dirty with brown and black spots throughout. DM #426 revealed they had not been wiped down since she started 6 months ago.2. Observation and interviews on 02/19/26 at 11:35 A.M. to 1:12 P.M. of lunch tray line revealed the following observations that were confirmed with DM #426 and MS #335:-The vent in-between fridge and freezer of large amounts of black dust between where the ceiling tiles and the wall converge. Confirmed observation with Maintenance Supervisor (MS) #355.-Dust stands hanging from ceiling tiles and large amounts of black dust build up on ceiling tile grids. MS #335 revealed he had ordered new ceiling tiles and some were not up to code due to them being acoustic ceiling tiles. He did not have a receipt for the ceiling tile order.-The floor underneath the prep table had large amounts of built-up dust that was wet and matted on the floor.-Steal shelf holding food steel containers was dirty and had clean containers placed on top.-Dust build up behind the ice machine and on pipes, wires and ceiling. -Splatter on multiple lights in the kitchen.-The trash cans did not have lids.-The window by the freezer and stove was dirty and had staff clothing items, bags and a water bottle.-The warming oven was extremely dirty and had not been wiped down.-Tray carts had visible dried liquid spills and food debris. DM #426 said they are supposed to get wiped down daily but they do not get deep cleaned everyday.3. Observation and interview on 02/19/26 at 1:05 P.M. of lunch on 4th floor revealed the dining room tables had visible debris and liquid stains. Touching the table tops revealed they felt dirty with left over residue on them. Confirmed observation with Assistant Director of Nursing (ADON) #442 who said she was going to wipe down the tables and then never did.Observation and interview on 02/19/26 at 4:00 P.M. of kitchen with DM #426:-Convection steamer bottom compartment door did not close.-Two light bulbs were out in the stove hood.Review of facility policy titled General Sanitation of Kitchen with no date revealed, Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.This deficiency represents non-compliance investigated under Complaint Number 2745381.

Based on observation, interview, record review, and facility policy, the facility failed to ensure the menu was followed. This had the potential to affect 160 out of 164 residents who ate meals in the facility's kitchen, as four residents (Residents #7, #89, #123, and #146) received enteral nutrition and did not receive meals from the kitchen. The facility census was 164. Findings include:1.Review of the lunch menu for 02/19/26 revealed the residents were to receive braised beef tips, rice pilaf, buttered carrots, dinner roll and strawberry pretzel dessert. Observation on 02/19/26 from 11:35 A.M. to 1:00 P.M. of lunch tray line revealed dietary staff prepared the lunch meal that consisted of beef stew with rice, carrots, pears, dinner roll and ice cream. Interview with DM #426 at the time of observation revealed she substituted the beef tips for beef stew and added the rice to the beef stew due to resident preferences. DM #426 revealed she had to substitute the strawberry pretzel dessert due to the high cost of the dessert. Interview on 02/19/26 at 3:11 P.M. with Resident #134 revealed the food is so/so, was often cold, and the menu was often not followed.2. Review of dinner menu for 02/19/26 revealed the residents were to receive bratwurst patty on bun.Observation on 02/19/26 at 5:00 P.M. of dinner tray line revealed bratwurst was substituted for a turkey burger. Interview with DM #426 at the time of observation revealed the facility policy did not allow hot dog shaped bratwurst because it was a choking hazard and she was not able to order a non-hot dog shaped bratwurst. 3. Review of dinner menu for 02/25/26 revealed the residents were to receive confetti cake bar for dessert. Review of the spreadsheet menu for dinner revealed that residents on a pureed diet were to receive pureed confetti cake bar.Observation on 02/25/26 at 4:25 P.M. of dinner tray line revealed DM #426 had not pureed the confetti cake. Interview with DM #426 revealed the cake had not been pureed, she was unsure if they had enough and had planned on giving the pureed diets a different dessert. DM #426 revealed she would puree the confetti cake. Confirmed with Dietician #492 and Regional Director of Food Services #512 that residents on a pureed diet should be receiving the same food being served as the regular diet.Review of a policy titled, Dining and Meal Service, not dated, revealed Individuals will be provided with nourishing, palatable, attractive meals and will support each individual's daily nutritional and special dietary needs.This deficiency represents non-compliance investigated under Complaint Number 2638551 and 2745381.

Based on observations, interviews and facility policy, the facility failed to ensure the environment was maintained in a safe, clean, homelike manner. This affected Resident #31, #46, #74, #95, #109, #128, #130, #141, #148 and had the potential to affect all 164 residents. 1.Observation on 02/19/26 at 8:42 A.M. revealed an unlocked cleaning supply closet on the second floor. Observation on 02/19/26 at 8:53 A.M. revealed Housekeeper #474 had entered the unlocked cleaning room on the second floor and had placed her cleaning cart inside and had left the door unlocked after exiting. Interview with Housekeeper #474 confirmed the cleaning closet had been unlocked and stated she did not have keys to unlock it. Observation on 02/19/26 at 9:07 A.M. revealed an unlocked cleaning supply closet on the third floor. Observation on 02/19/26 at 9:22 A.M. revealed an unlocked cleaning supply closet on the fourth floor. Interview on 02/19/26 at 11:34 A.M. with Housekeeper #388 revealed cleaning supplies were diluted when they were hooked up to the cleaning dispenser. Housekeeper #388 confirmed cleaning supply rooms had not been locked due to there was no keys to the supply rooms and rooms had remained unlocked and further confirmed the unlocked room on the third floor. Observation on 02/19/26 at 1:24 P.M. of fourth floor cleaning supply with Certified Nursing Assistant (CNA) #334 confirmed unlocked cleaning supply room on the fourth floor and CNA #334 stated cleaning supplies were to be secured at all times. 2. Interview and observation on 02/19/26 at 3:11 P.M. of Resident #130's room revealed the wall air-conditioning unit was extremely dusty. The wall behind Resident #130 bed floor trim was off the wall and the dry wall flaking off. Resident #130 revealed her bed did not work and was missing the electric plugins. Licensed Practical Nurse (LPN) #426 confirmed observation and said she would put a work order in. 3. Interview and observation on 02/24/26 at 1:53 P.M. to 2:25 P.M. with Maintenance Supervisor (MS) #335 revealed the following: -The 2nd floor women's shower room had a clogged toilet with feces and urine in it. A towel, hospital gown and socks were on the floor. Paint was peeling off above the shower and the ceiling had water stains. -The 3rd floor women's shower room had no cover for the light fixture and the bulbs were all out. Debris was flacking off light fixture. The tile was cracked under the shower head on the floor. Buildup of mildew and rust in the shower closest to the toilet. In the seated shower room there were 4 tiles missing from the wall revealing a large hole in the wall you could see the wall structure through. Thick pieces of paint were peeling off above the tile. Water was visibly seen leaking from the ceiling and there was rust on the floor. -The 3rd floor men's shower room had a used towel on the shower bench. In the seated shower room [ROOM NUMBER] ceiling tiles approximately 3 feet by 6 feet had large brown water stains. One ceiling tile had a large bubble where it appeared it had stretched due to being filled with water. The standing shower to the right of the door had wall tiles missing and the ceiling tiles was wet to the touch. Interview with MS #335 at the time of observation revealed facility needs a new roof and that was causing so many issues with the ceiling tiles. Interview on 02/24/26 at 4:17 P.M. with Director of Nursing (DON) revealed the facility has new maintenance and housekeeping managers and the facility was getting a grant to replace the roof. Observation on 2/25/26 at 10:49 A.M. of 7 ceiling tiles by the 4th floor east nurses station with large brown water stains. Confirmed observation with Certified Nurse Assistance (CNA) #308. 4. Observation on 02/19/26 at 5:00 P.M. of first floor main elevator not working. The service elevator and the small elevator were still working and residents were able to use these elevators instead. Interview on 02/24/26 at 2:30 P.M. with Maintenance Supervisor #355 revealed he started at the facility six weeks ago and had been trying to figure out the issues with the elevators. He was waiting on a report for all the times the elevator repair company had been at the facility since January 2026. He said residents kick the door and it gets off track and this is what caused the issue on 02/19/26. Maintenance Supervisor #355 figured out one issue with the elevator was it being exposed to cold weather and was working on figuring out a solution. Interview on 02/25/26 at 11:03 A.M. with the Director of Nursing (DON) revealed there had not been a time that the elevators had all been out of order at the same time. The small elevator was down for a while because they replaced it but was now open again. The west elevator did break often and part of the issue is residents ramming into the doors with their electric wheelchairs. DON revealed the repair company comes out the same day or the next day. Residents were able to use the service elevator and they do not need staff to use the elevator. DON was not aware of any residents missing appointments due to the elevator being down. DON revealed the service elevator had not been out of order anytime that she can remember. Observation and interview on 02/25/26 at 5:00 P.M. of the west elevator not working again. Administrator revealed an elevator repair company was coming on 02/26/26 to fix the elevator. Administrator revealed they are working with the repair company to determine how to fix the elevator because it keeps breaking, is repaired and then breaks again. 5. Observation and interview on 02/25/26 at 3:18 P.M. with Maintenance Staff #356 revealed the following: -Resident #31's room had large amounts of paint chipping off the wall by the window and multiple ceiling tiles with large brown waters stains above the bed. -Resident #46's room had a large hole to the right of the wall air-conditioning unit that was stuffed with a towel. -Resident #148's room had multiple ceiling tiles with large water stains. -Resident #95 and Resident #141's room had multiple areas in the floor with holes and large pieces of the floor tiles missing. 6. Interview and observation on 02/25/26 at 3:06 P.M. with Resident #74 revealed the light about her bed was not working and she had asked for it to be fixed multiple times. Resident had a yellow greenish splatter on the wall bed her bed. Resident #74 did not know what splatter was. The floor was dirty and had paint chipping on the wall to right of the window. Resident #74 had a standing fan that was dusty. Water stains on the wall from a leak and a hole in the drywall behind the bed was observed. Interview on 02/25/26 at 3:11 P.M. with Certified Nursing Assistant (CNA) #393 confirmed the observations. 7. Observation and interview on 02/26/26 at 9:23 A.M. of medication cart revealed the cart was dirty and had dried brown splatter on it. Medication Tech #396 confirmed observation. 8. Observation on 2/26/26 at 9:30 A.M. of Resident #128 and Resident #109's room reveled sink was leaking and had basin underneath with water dripping into it. LPN #320 confirmed observation and said she would put in a work order. This deficiency represents non-compliance investigated under Complaint Number 2655262, 2675466, 2645066, 2711653 and 2735835.

Based on record review, observations, interviews and facility policy the facility failed to implement safe smoking policies and procedures. This had the potential affect all 37 smokers at the facility. The facility census was 164.Findings include:1.Review of the medical record for Resident #104 revealed an admission date of 06/29/09. Diagnoses included hypertensive heart and chronic kidney disease, type 2 diabetes, end stage renal disease, atrial fibrillation, dependence on renal dialysis, vascular dementia, post-traumatic stress disorder, anxiety, nicotine dependence.Review of the Significant Change in Status Minimum Data Set (MDS) assessment, dated 12/17/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Review of the Plan of Care dated 12/26/25 revealed the resident had the potential for tobacco use related injuries or infection control issues related to smoking. Interventions included if resident was non-complaint with smoking policy, review smoking facility smoking policy and document education. Make sure the family is aware they are not to give cigarettes and/or lighters directly to the resident, but rather stored at the nurse's station.Record review for Resident #104 revealed a nursing note dated 02/22/26 at 6:02 A.M. of resident drinking vodka and smoking in her room. A nursing note dated 02/22/26 at 1:41 P.M. revealed nurse was notified that resident had a lighter in her room. Resident #104 gave lighter to nurse who provided education about facilities smoking policy. Further review revealed a social services note dated 02/23/26 of Licensed Social Worker (LSW) # 305 who provided education to resident about facilities smoking policy.Review of Resident #104 Smoking Evaluation dated 02/23/26 revealed resident smoked in designated smoking areas only, cannot safely use a lighter, can safely hold smoking materials, demonstrated compliance with facility smoking rules and was a supervised smoker.2. Observation on 02/19/26 at 8:49 A.M. revealed Resident #4 had a pack of cigarettes and a lighter in his room on a bedside table, not in a lockbox. Resident #4 was not present during observation. Observation further revealed an oxygen concentrator that was running in Resident #4's room. 3. Interview on 02/19/26 at 1:24 P.M. with Certified Nursing Assistant (CNA) #334 revealed she had been aware Resident #93 had been smoking in his room while his previous roommate, Resident #175 was in the room and had been wearing oxygen. CNA #334 stated Resident #175's family and also staff had complained about the smoking. CNA #334 stated Resident #175 was at the hospital and stated she was unsure if he would be returning and Resident #93 had been moved to another unit. Interview on 02/19/26 at 2:11 P.M. with Resident #93 revealed he was a smoker, however he denied he had smoked in his room. Interview on 02/23/26 at 10:40 A.M. with CNA #330 revealed she had been aware Resident #93 had smoked in his previous room while Resident #175 was present. 4. Observation on 02/19/26 at 2:33 P.M. revealed Resident #21 had been returning to his room and had a lighter on his bedside table not in a lock box. Interview with Resident #21 revealed he was a smoker and the lighter had belonged to him.5. Observation on 02/19/26 at 2:40 P.M. revealed Resident #105 was in the hallway in his wheelchair and had a pack of cigarettes in his shirt pocket and clothing had multiple burn holes. Interview with Resident #105 revealed he had cigarettes and a lighter on him and stated good luck taking them.Observation and interview on 02/19/26 at 2:48 P.M. of Resident #105 in his room revealed a smoked cigarette on the ground. Resident said it had fallen out of his pocket. Resident #105 had multiple burn holes on his shirt and jacket. Resident said he got them from putting out his cigarettes. The observation was confirmed at 3:36 P.M. through interview with Licensed Practical Nurse (LPN) #501.6. Interview and observation on 02/19/26 at 3:11 P.M. of Resident #134 in her room revealed the resident had cigarettes and lighter at bedside not in a lockbox. Resident #134 revealed she was unable to get to the outside smoking area due to the sidewalk being messed up. Observation and interview on 02/19/26 at 5:10 P.M. with Director of Nursing (DON) of outside smoking area revealed the sidewalk leading up to the smoking area had holes, cracks and was uneven. The smoking area was littered with various trash, cigarettes, an empty blood vial, three metal bars on the ground and the outside door was rusted at the bottom.7. Observation on 02/23/26 at 9:51 A.M. revealed Resident #4 had a lighter on his bedside table, not in a lockbox, while his oxygen concentrator was running and Resident #4 was sleeping. 8. Observation on 02/23/26 at 11:34 A.M. revealed two lighters on the floor in Resident #100's room not in a lockbox. Resident #100 was not present at time of observation and CNA #336 had confirmed the lighters and stated residents were not to have smoking materials kept in their rooms. Observation on 02/23/26 at 1:50 P.M. revealed oxygen in Resident #105's room across the hall from Resident #100's room. Observation of oxygen in Resident #105's room was confirmed by Registered Nurse (RN) #442.Interview on 02/23/26 at 2:14 P.M. with the DON revealed quarterly smoking assessments are completed for residents and as needed if there is a change in condition. If residents were independent they were able to keep their cigarettes in their rooms in a locked box. DON said facility will confiscate any smoking materials if residents are caught in the room smoking and provide education. 9. Observation on 02/24/26 at 11:13 A.M. on 4 [NAME] nursing station revealed smoking paraphernalia that had been smoked was placed on a vitals machine. Interview with Registered Nurse #406 confirmed the observation and placed the smoking paraphernalia in a plastic zipped bag which was given to the DON.10. Observation and interview on 02/26/26 at 11:32 A.M. of Resident #65 in his room revealed a pack of cigarettes on the ground next to him not in a lockbox. Resident said he had just dropped the pack on the ground. The observation was confirmed with Activities Staff #472 and Resident #65 told her he was saving the two half smoked cigarettes in the pack but he did not have a lighter in his room. Activities Staff #472 told resident she would get him a lockbox to keep his smoking material in because he was an independent smoker. 11. Observation and interview on 02/26/26 at 11:40 A.M. of Resident #27 revealed he was sitting on his bed with a pack of cigarettes. When asked if resident keeps his cigarettes in a locked box resident said he keeps them in his trash and no one is taking his cigarettes. Resident #27 placed cigarette pack under pillow and put some cigarettes under his sheets. The observation was confirmed with Licensed Practical Nurse (LPN) #320 who then tried to get the cigarettes from the resident who then yelled at surveyor to leave me the [expletive] alone and refused to give LPN #320 his cigarettes. The DON was informed Resident #27 had cigarettes in his room and was refusing to give them to the nurse. 12. Interview and observation on 2/26/26 at 1:57 P.M. with Receptionist #318 of residents cigarettes at the front desk revealed Receptionist #318 kept the supervised smoking residents smoking items at the front desk and that free will smokers kept their smoking items in a locked box in their rooms or at the nurses stations. Receptionist #318 revealed sometimes residents go to the store or families bring in cigarettes and lighters without their knowledge and the facility does do room sweeps. Observation on 02/26/26 at 2:40 P.M. revealed Resident #103 smoking in front of the facility and not in the designated smoking area in the back of the facility. Confirmed observation with DON who told Resident #103 that he had to smoke in the designated smoking areas. Review of list of smokers at the facility revealed 37 current residents that were smokers.Review of facilities policy titled Resident Smoking with a reviewed date of 01/06/25 revealed the facility has designated smoking times and areas; smoking materials including cigarettes, cigars, pipes, lighters, vapes, E-cigarettes must be locked up when not in use; smoking materials will only be used by the resident personally during smoking times, if it is determined by the interdisciplinary team that the resident can safely smoke independent of observation and assistance; smoking materials will be returned to the nurse's station or locked box; for those residents determined by the interdisciplinary team to require supervision and/or assistance with smoking, smoking materials will be monitored and dispensed by nursing staff, during designated smoking times only, and will not be given to the resident personally; and smoking aprons will be provided by the facility and will be worn by those residents determined to require them by the interdisciplinary team.This deficiency represents non-compliance investigated under Complaint Number 2745381.

Based on observation, interview and record review the facility failed to ensure timely incontinence care was provided to Resident #64 and adequate catheter care was provided to Resident #153. This affected one resident (Resident #64) of three observed for incontinence care and one resident (Resident #153) of two observed for catheter care. The facility census was 164.Findings include:1.Review of Resident #64's medical records revealed an admission date of 10/05/21. Diagnoses included muscle weakness, lack of coordination and diabetes.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had intact cognition. Resident #64 was dependent with transfers, non ambulatory and required max assistance with bed mobility and was incontinent of bowel and bladder.Review of care plan dated 12/22/25 revealed Resident #64 had self care deficits related to lack of coordination and was dependent with toileting. Interventions included staff to assist with completion of activities of daily living (ADL) care on a daily basis. Resident #64 was incontinent of bowel and bladder. Interventions included check resident for incontinence, offer to assist with toileting and if incontinent remove wet or soiled clothes and provide incontinence care.Interview on 02/19/26 at 1:59 P.M. with Resident #64 revealed he was incontinent of urine and had asked to be changed and had not been changed since the previous evening. Resident #64 stated he had recently asked the aide to change him, however the aide stated she was going on a break and would provide him with incontinence care when she returned. Observation revealed Resident #64 had a strong urine odor detected during interview.Interview on 02/19/26 at 2:20 P.M. with Certified Nursing Assistant (CNA) #303 revealed Resident #64 had requested incontinence care prior to her break and she had informed him she would change him when she returned. Observation of incontinence care following interview revealed Resident #64 was heavily soiled with urine that had soaked through his brief, through his clothing and onto his wheelchair. CNA #303 stated she had not provided Resident #64 with incontinence care during her shift and stated she was unaware he required incontinence care until he had informed her a short time prior.2.Review of Resident #153's medical records revealed an admission date of 01/30/26. Diagnoses included urinary retention, stroke with right sided weakness, and muscle weakness.Review of care plan dated 02/01/26 revealed Resident #153 was at risk for infection related to use of urinary catheter. Interventions included foley catheter care every shift.Review of MDS dated [DATE] revealed Resident #153 had intact cognition. Resident #153 was dependent with toileting and had indwelling urinary catheter.Review of current physician orders for February 2026 revealed to provide catheter care every shift and as needed.Observation on 02/26/26 at 11:38 A.M. revealed Resident #153 was calling out for assistance. Upon entering Resident #153's room, resident stated he was upset and stated he was laying in a dirty diaper.Interview on 02/26/26 at 11:48 A.M. with CNA #409 revealed he had provided Resident #153 with incontinence care approximately an hour before and was unaware Resident #153 required additional incontinence care. CNA #409 had proceeded to provide Resident #153 with incontinence care due to resident was incontinent of stool. Further observation revealed Resident #153's urinary catheter had a large amount of brown dried debris around the tubing. CNA #409 stated he had not provided Resident #153 with catheter care during his previous incontinence care and stated he was unsure when catheter care had last been provided.

Based on interview, observation and record review the facility failed to ensure a comprehensive wound management system was in place to properly assess and treat Resident #52's new vascular wounds, and failed to ensure Resident #58's were clean and in good condition. This affected one resident (Resident #58) of four observed for assistive devices, and one resident (Resident #52) of two residents reviewed for skin impairments. Findings include:1.Review of Resident #52's medical records revealed an admission date of 10/09/25 with diagnoses including chronic ulcer of left foot, peripheral vascular disease (PVD) and muscle weakness.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had intact cognition. The assessment revealed Resident #52 was dependent (on staff) for toileting, and transfers, non-ambulatory and required maximum (staff) assistance for bed mobility.Review of care plan dated 01/16/26 revealed Resident #52 had a left heel vascular ulcer. Interventions included check dressing for placement during routine care, document wound status weekly and as needed and notify physician of changes, monitor wound for signs/symptoms of infection, and increase in size, administer treatments per orders and monitor skin surrounding alteration, heel lift suspension boots to be worn to bilateral feet and remove for bathing/hygiene and every shift skin checks. In addition, the plan of care revealed Resident #52 had self-care deficits related to limited mobility. Interventions included maximal assistance with bathing, personal hygiene and bed mobility and assistance with activities of daily living (ADL) on a daily basis.Review of weekly wound documentation dated 02/19/26 revealed Resident #52 had a vascular ulcer of the left heel that measured 3.0 centimeters (cm) in width by 2.0 cm in length and 0.1 cm in depth.Review of physician orders for February 2026 revealed Resident #52 was ordered heel lift suspension boots to be worn to bilateral feet at all times as tolerated, to be removed for bathing and hygiene and every shift skin checks. Treatment orders included cleanse left heel with normal saline, pat dry, apply santyl (topical enzyme ointment used to remove necrotic issue from chronic skin ulcers), cover with an absorbent dressing and wrap with kerlex every night shift. Review of Resident #52's medical record for February 2026 revealed skin checks were not documented every shit per physician orders and the plan of care and there was no evidence of showers/bathing provided.Review of a progress note dated 02/21/26 timed 3:39 P.M. authored by Licensed Practical Nurse (LPN) #320 revealed no new skin issues identified.Review of progress note dated 02/25/26 timed 11:15 A.M. authored by LPN #501 revealed no new skin issues identified.Review of weekly wound documentation dated 02/26/25 revealed Resident #52 had a left posterior vascular ulcer that measured 1.0 cm by 1.0 cm by 0.1 cm, left distal calf vascular ulcer that measured 2.5 cm by 1.0 cm by 0.1 cm, and a right heel vascular ulcer that measured 3.0 cm by 2.3 cm and unable to determine depth.Observation on 02/25/26 at 7:38 A.M. revealed a strong foul odor detected by Resident #52 that had become stronger upon approaching doorway. Resident #52 was sleeping at time of observation. Observation on 02/25/26 at 10:07 A.M. revealed the strong foul odor had continued in Resident #52's room. Observation of Resident #52's ADL care with Certified Nursing Assistant (CNA) #310 and CNA #336 confirmed the odor noted and the CNA #336 stated it smelled like a rotten wound. Observation revealed a Kerlix dressing to Resident #52's left heel that appeared to be clean and intact and was dated 02/25/26. Resident #52 had a pair of tattered, heavily soiled and flattened out heel boots placed under his feet and the left one was placed on upside down. CNA #310 and #336 confirmed the condition of Resident #52's boots and had removed them and stated they would throw them away. CNA #310 and CNA #336 had proceeded to roll Resident #52 on his right side and a circular opened red area was observed to his left mid-calf area. CNA #310 and CNA #336 stated they were not aware of the area prior to observation. Observation of Resident #52 on 02/25/26 at 11:00 A.M. with RN #353 (facility wound nurse) confirmed the area to Resident #52's left mid-calf area. RN #353 stated she had not been made aware of the area previously and stated she would contact the wound nurse practitioner. RN #353 assessed the area and stated it was a skin tear and stated she was going to place a Xeroform and foam dressing to the area and the wound rounds were to be performed on 02/26/26.Review of progress note dated 02/25/26 timed 11:38 A.M. authored by Registered Nurse (RN) #353 revealed a new wound to Resident #52's left posterior calf that measured 1.5 cm by 1.0 cm and 0.1 cm in depth. Family and physician had been notified, and orders were to cleanse with normal saline, pat dry, apply xeroform (petroleum based wound dressing).Review of weekly wound documentation dated 02/25/26 revealed Resident #52 had a skin tear to the left posterior calf that measured 1.5 cm by 1.0 cm by 0.1 cm.Review of physician orders dated 02/25/26 revealed orders to cleanse left posterior calf and left distal calf with normal saline, apply xeroform and cover with a foam dressing every night shift.Interview on 02/26/26 at 9:44 A.M. with Wound Nurse Practitioner (WNP) #513 revealed RN #353 informed her of Resident #52's new wound on 02/26/26 when she arrived. Observation of wound care on 02/26/26 at 9:58 A.M. with WNP #513 and RN #353, upon initial assessment, Resident #52 had stated he was having pain in his right heel. WNP #513 had proceeded to remove Resident #52's sock and a large amount of Resident #52's skin was observed to have been seized to the sock and Resident #52's heel had a large half dollar size wound that was open and had a moderate amount of slough and necrotic tissue. WNP #513 had placed Resident #52's heel back down on the bed and had taken a few steps back and stated that was a new wound that she had not been made aware of. Further observation of Resident #52's sock revealed skin appeared to have been embedded into the fibers of the sock and a foul odor was detected. Further observation revealed WNP #513 had then proceeded to remove the Kerlix dressing from Resident #52's left foot and another new wound was observed to the residents left posterior calf that was approximately 4-5 inches above his chronic left heel wound. WNP #513 and RN #353 stated they had not been made aware of the new area. WNP #513 had proceeded to observe Resident #52's distal calf area that she had been made aware upon arrival to the facility on [DATE]. WNP #513 had assessed the new areas and had obtained measurements and stated the three new wounds were vascular wounds and had given orders for treatments to RN #353 at time of observation. WNP #513 revealed the wounds did not develop overnight but did not identify how the wounds occurred. Interview with Resident #52 at time of observation revealed he could not recall when he had last received a shower or when his sock had last been removed or foot had been cleaned. Review of progress note dated 02/26/26 timed 3:15 P.M. authored by RN #353 revealed a new wound to Resident #52's left distal calf that measured 2.5 cm by 1.0 cm by 0.1 cm, and a new wound to Resident #52's right heel that measured 3.0 cm by 2.3 cm and unable to determine depth due to 50% slough/necrotic tissue was present. Review of Resident #52's physician orders revealed orders to cleanse right heel with normal saline, apply santyl, cover with absorbent dressing and kerlex every night shift. Review of facility policy titled Skin Care Management revised 01/06/25 revealed residents with identified skin breakdown will have a documented skin assessment weekly including wound description and measurements, and treatments as ordered.2. Review of Resident #58's medical records revealed an admission date of 03/14/24. Diagnoses included contractures of the left upper arm and muscle weakness.Review of MDS assessment dated [DATE] revealed Resident #58 had intact cognition. Resident #58 was dependent with bathing, personal hygiene, bed mobility and transfers.Review of care plan dated 01/26/26 revealed Resident #58 was at risk for skin alterations related to contractures and hand splints. Interventions included examine skin before and after use of splinting.Review of Resident #58's current physician orders for February 2026 revealed orders to apply left hand/wrist splint and monitor for redness, open areas and may remove for bathing/hygiene.Observation on 02/19/26 at 11:30 A.M. revealed Resident #58 had his hand splint in his hand and had approached CNA #436 and asked her to apply it. Observation further revealed Resident #58's hand splint was heavily soiled with areas of dried dark colored debris. CNA #436 had proceeded to place Resident #58's hand splint on his left hand. Interview with CNA #436 after observation revealed she had observed Resident #58's hand splint to have been heavily soiled prior to placing it on his left hand and CNA #436 stated its been like that for a while.

Based on resident and staff interviews, observation, review of the facility's Self-Reported Incident (SRI) and investigation, record review, and review of the facility policy, the facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse. This affected one (Resident #1) of three residents reviewed for sexual abuse. The facility census was 165.Findings include: Record review for Resident #1 revealed an admission date of 05/30/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired. Resident #1 used a walker for mobility and was independent with ambulation and dressing. Resident #1 had no hallucinations or delusions. The Smoking Evaluation dated 10/03/25 revealed Resident #1 required supervised smoking. Record review for Resident #2 revealed an admission date of 03/04/25. Diagnoses included injury of the head and essential hypertension. Record review revealed Resident #2 was Resident #1's roommate. The quarterly MDS assessment dated [DATE] revealed Resident #2's short- and long-term memory was ok. Resident #2 was able to recall the season, location of room, staff names and faces, and they were in a nursing home. Record review for Resident #93 revealed an admission date of 06/17/21. Diagnoses included type two diabetes mellitus, cognitive communication deficit, and nicotine dependence. The quarterly MDS assessment dated [DATE] revealed Resident #93 was cognitively intact. Resident #93 was independent with eating, used a walker for mobility and was independent for chair/bed to chair transfers. Resident #93 had no hallucinations or delusions and had no behavioral symptoms directed towards others. The Smoking Evaluation dated 09/02/25 revealed Resident #93 required supervised smoking. Review of the SRI tracking number 266056 dated 10/06/25 at 2:08 P.M. created by the Director of Nursing (DON) revealed an allegation of sexual abuse involving Resident #1. There was no effect on the resident and also revealed there was no perpetrator. The narrative summary included Resident #1's husband reported to the Administrator he received a voicemail stating another resident (#93) pulled his wife's (Resident #1) pants down and touched her. The husband played the voicemail which was left by another resident. Resident #1 refused to go to the hospital stating no one touched her, revealing another resident (#93) pulled at her pants in a joking manner. Resident #1 initially revealed it was during smoke break then revealed it was not during the smoke break, it was in the common area. Resident #1 could not recall if anyone else was around. The DON and Administrator interviewed named Resident #93 (male resident) who stated nothing happened, they were sitting near each other making jokes but he never touched her. The allegation was unsubstantiated. Review of the typed statement dated 10/06/25 signed by the DON and Administrator included Resident #1 stated that yesterday after smoke break her and Resident #93 were sitting in the common area and he made a joke about pulling her pants down. Ahe stated she could not remember if anyone else was around. Review of the typed statement dated 10/07/25 signed by the DON and Administrator included Resident #93 stated that after smoke break they (#1 and #93) were both sitting in the common area and talking. Resident #93 stated they were joking around but he never touched her. Resident #93 stated he was told she was telling people he pulled her pants down. Resident #93 denied the allegation and revealed there were no staff or other residents in the area at that time. The facility's investigation did not have any staff statements and did not identify what staff members supervised smoke breaks on 10/05/25, did not include staff statements to identify who assisted with smoke breaks on 10/05/25, and did not identify who worked with Residents #1 and #93 to investigate if anyone staff members heard or witnessed the incident. The investigation did not have Resident #2's statement who reported it to Resident #1's husband. Interview and observation on 10/22/25 at 10:22 A.M. revealed Resident #1 was well groomed and sitting on the edge of her bed. Resident #1 revealed there was a man who pulled her pants down, he would go out to smoke with the smoking group. Resident #1 revealed he did not touch her private area and stated, He just came up from behind me and pulled them down. Resident #1 demonstrated while stating that he grabbed the sides of her pants and pulled them down to her lower thighs. Resident #1 stated she told him (#93), You're an idiot pulled her pants up and went directly to her room. Resident #1 confirmed she was upset and when she returned to her room, her roommate (Resident #2) was present and discussed why she was so upset. Resident #1 stated she forgets things but not that. Resident #1 stated he (Resident #93) was just joking or something. Interview on 10/22/25 at 10:39 A.M. with Resident #2 stated her roommate (Resident #1) was sexually assaulted on 10/05/25 and she came up to their room upset. Resident #2 stated Resident #1 came from smoking, she was crying, she said she was grabbed by the waist, he (Resident #93) pulled her (Resident #1) pants down and grabbed her 'private'. Resident #2 revealed Resident #1's husband came the following morning. Interview on 10/22/25 at 11:32 A.M. with the Administrator revealed Resident #2 reported the allegation to Resident #1's husband via telephone. An SRI was initiated, and the allegation was investigated. The SRI was unsubstantiated. Resident #1 refused to go to the hospital for an evaluation. The Administrator revealed the incident occurred where residents wait to go outside to smoke according to Resident #1. Resident #93 denied he pulled her pants down and said there were no witnesses. The Administrator stated Resident #1 said 'someone' pulled her pants down, and Resident #1 could not remember who did it. Resident said the resident was joking. Interview on 10/22/25 at 1:31 P.M. with the DON revealed she interviewed Resident #1 with her husband and the Administrator. The DON stated she asked Resident #1 what happened and Resident #1 said after the smoke break, her and a guy (#93) were sitting in the common area near where the residents go out to smoke. Resident #1 said he (#93) pulled her pants down. She asked if he touched her inappropriately (in her private area), she stated no. The DON told Resident #1 the facility would send her to the hospital for an evaluation. Resident #1 refused and said no one touched her, they were joking around. The DON confirmed Resident #1 told her that he pulled her pants down but did not touch her private area. The DON confirmed there were no staff interviewed regarding the incident or for potential like behaviors from Resident #93 with other residents. The DON stated Resident #1 had never made up stories in the past while residing at the facility. The DON confirmed the facility's investigation did not have any staff interviews and confirmed no staff were interviewed regarding the incident or any potential like incidents. The DON confirmed the facility did not interview the residents and staff who went on the same smoke break as Resident #1 and #93. The DON confirmed the police was not called regarding the incident. Observation on 10/22/25 at 1:44 P.M. revealed a small room near the exit to the smoking area. Observation revealed eight residents were outside smoking. Resident #1 and #93 were present but not near each other. Activities Assistant #395 was also present and assisted residents' back into the facility from the smoking break. Resident #93 ambulated with a steady gait while using a walker without staff assistance. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 01/06/25 revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment including injuries of unknown source. Facility staff should immediately report all such allegations to the Ohio Department of Health (ODH). In cases where a crime is suspected, the Administrator will report the same to local law enforcement. Sexual Abuse included non-consensual sexual contact of any type with a resident. The investigation protocol included to interview the resident, the accused and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members), and employees who worked closely with the accused employees and or alleged victim the day of the incident. If there are no direct witnesses, then the interviews may be expanded. For example, you may wish to interview all employees on the shift or the unit, as appropriate, as well as other residents on the unit. This deficiency represents non-compliance investigated under Complaint Number 2647625.

Based on observation, staff interview and facility policy review, the facility failed to maintain the kitchen area in a clean and sanitary manner and failed to ensure foods were labeled and dated properly. This had the potential to affect all but four (Residents #3, #158, #99 and #153) identified by the facility who received nothing by mouth and did not receive food from the kitchen. The facility census was 163. Findings include:Tour of the facility kitchen area on 08/25/25 between 8:28 A.M. and 9:00 A.M. with Dietary Manager (DM) #713 revealed the following undated containers of the following in the walk-in cooler including: Four cups of milk 12 bowls of chocolate pudding Nine cups of prune juice 28 bowls of Jell-O Two chocolate pies in original packaging with broken seals A brown, crusty substance stuck on the outside of nine cups and 12 bowls in the walk-in cooler. A large amount of greasy food residue on the left outside wall of an oven. DM #713 was unable to say when that oven was last cleaned. Black spotted substance on right inside wall of ice bin; DM #713 stated it appears to be mold. All of the above findings were confirmed by the Dietary Manager #713 upon discovery during the initial kitchen tour on 08/25/25. Review of the undated policy entitled Food Preparation and Storage revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. The policy also stated foods will be received, checked and stored properly as soon as they are delivered and food in broken packages or swollen or dented cans, cans with a compromised seal, or food with an abnormal appearance or odor will not be served. This deficiency represents noncompliance investigated under Complaint Number 2560412.

Based on record review, observation, interview and facility policy review, the facility failed to ensure a safe, clean, comfortable and homelike environment for six (Residents #18, #146, #130, #65, #87 and #102) of 12 residents reviewed for environment. This had the potential to affect all residents residing in the facility. The facility census was 163. Findings include:1. 1. review of the medical record revealed Resident #130 was admitted to the facility on [DATE] with diagnoses including type II diabetes, injury of head, major depressive disorder, long term use of hypoglycemic, long-term use of inhaled steroids, hypertension, sciatica, adult failure to thrive, chronic pain, lack of coordination, history of falling, and reduced mobility. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #130's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Resident #130 did not reject care or hallucinate or display delusional behaviors. Resident #130 was independent for toileting hygiene, independent to transfer to the toilet and to walk ten feet. Resident #130 was occasionally incontinent of urine and always continent of bowel. Observation on 08/28/25 at 10:40 A.M. revealed the door of the shared bathroom with Resident #18 revealed a sign posted on the bathroom door indicating that the toilet was out of order and directed Resident #130 to use the shower room toilet. Inside Resident #130's bathroom the toilet was nonfunctional and covered with a plastic sheet. Behind the toilet the wall exhibited visible damage of ceramic tiles that were displaced and protruded from the wall and floor that created an uneven edge. Interview on 08/28/25 at 10:45 A.M. with the Administrator verified the toilet was backed up and unsafe to use. The Administrator stated Resident #130 was not to use the common area bathroom that was two doors down from her room because there was no call light in the bathroom; therefore, it was unsafe for Resident #130 to use. Resident #130 was provided with a bedside commode and was to use the shower room. Observation on 08/28/25 at 10:50 A.M. revealed the common area was located two doors away from Resident #130's room. The common area had a restroom located in the room, the door was locked and had a sign posted on the door that read Visitors Restroom Only. The word visitors was circled multiple times, emphasizing restricted access for non-visitors. Housekeeping Supervisor #642 retrieved a key from the nurse's station to unlock the door and provide access to the common area restroom. The restroom was observed to be clean and orderly. A functional call light was positioned adjacent to the toilet; the call light was intact and available for use. At the nurse's station, the Administrator and Maintenance Director #772 confirmed that the call light within the restroom successfully rang, indicating the system was operable and able to alert staff when assistance was needed. Interview on 08/28/25 at 10:53 A.M. with Resident #130 revealed she could not use the bathroom in her room for the past two months. She stated sometimes she was incontinent and could not make it to the shower room. Resident #130 stated she felt this was inhumane and stated she asked to use the common area bathroom but was told it was for visitors only. Resident #130 stated she liked her room location and did not want to move. Resident #130 also stated she could not use the toilet shower because she did not know the code for using the room. On 08/28/25 at 11:00 A.M. the Administrator verified residents did not know the code for the shower room, and only staff had access to the shower room code. Observation on 08/28/25 at 11:08 A.M. of the 400-unit shower room revealed the shower room was situated approximately 20 steps from Resident #130's room. Upon entering the shower room, the toilet was non-functional due to a blockage. Fecal matter was within the toilet preventing flushing. Maintenance Director #772 confirmed the toilet was plugged and was not working until repairs were completed. Interview with the Administrator on 08/28/25 at 3:40 P.M. revealed the facility was aware of the sinking toilet in Resident #130's room, but the plumber was on vacation. 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including type II diabetes, pressure ulcer of right buttocks, hypertensive chronic kidney disease, atrial fibrillation, spinal stenosis, Cauda Equina, schizoaffective disorder, cerebral infarction, and anxiety disorder. Review of the MDS 3.0 admission assessment dated [DATE] revealed Resident #18's cognition was intact (BIMS 15/15). Resident #18 did not exhibit hallucinations or delusions and did not reject care. Resident #18 needed maximum assistance for toilet transfers and did not attempt to walk ten feet. Observation on 08/28/25 at 10:45 A.M. revealed a sign on Resident #18's bathroom door that stated, Out of Order use Shower Room. The Administrator verified Resident #18's toilet was shared with Resident #130 and was backed up, and the tiles behind the toilet were coming up that made the toilet unsafe to use. 3. Review of the medical record revealed Resident #146 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, hypothyroidism, anemia, hypertension, gastro esophageal reflux, glaucoma, cataract, and hearing loss. Review of the MDS 3.0 annual assessment dated [DATE] revealed resident #146's cognition was intact (BIMS 13/15). Resident #146 did not display hallucinations or delusions and did not reject care. Resident #146 needed supervision for toilet transfers. Interview on 08/28/25 at 8:58 A.M. with Resident #146 revealed she was upset because the last two days her toilet was not working and did not flush. She stated she had to use the toilet in the shower room and had to wait for staff to let her in because she did not know the code for the shower room. Observation on 08/28/25 at 9:00 A.M. revealed Licensed Practical Nurse (LPN) #618 attempted to flush Resident #146's toilet, but it would not flush. LPN #618 stated she would let maintenance know. Interview on 08/28/25 at 10:31 A.M. with Resident #146 revealed she was concerned because her toilet did not flush in her room when she held the lever down. Observation on 08/28/25 at 10:32 A.M. with the Maintenance Director #772 verified the toilet did not flush. Maintenance Director #772 stated Resident #146's toilet was shut off, and she needed to use the toilet in the shower room. 4. Review of the medical record for Resident #87 revealed an admission date of 12/09/24 with diagnoses including diabetes, schizoaffective disorder, and diarrhea. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #87 had cognitive impairment and required supervision with toileting hygiene and was independent with transfers. He was occasionally incontinent of urine and bowel. Review of the care plan dated 12/20/24 revealed Resident #87 had activities of daily living self-care performance deficit related to impaired mobility, anxiety, and major depression. Interventions included Resident #87 transferred independently including toilet transfers, and staff was to provide supervision or touching assistance with toileting hygiene. Interview on 08/25/25 at 9:58 A.M. with Resident #87 verified there was bowel movement in his toilet as he revealed his toilet was not working. He was unable to flush it, and this had been an issue since he was admitted . He revealed he was upset because he did not have a working toilet to use as he did not know what to do. Review of the medical record for Resident #102 revealed an admission date of 05/28/21 with diagnoses including congestive heart failure, anxiety, dementia, and schizoaffective disorder. Review of the care plan dated 06/08/21 revealed Resident #102 had an activity of daily living self-care deficit related to dementia and weakness. Interventions included supervision or touching assistance with toilet transfer and toileting hygiene. Review of the quarterly MDS assessment dated [DATE] revealed Resident #102 had impaired cognition. He required supervision with toileting hygiene and transfers. He was occasionally incontinent with urine but always continent of bowel. Attempted interview on 08/25/25 at 9:56 A.M. with Resident #102, but he was unable to participate due to cognitive ability. Review of the medical record for Resident #65 revealed an admission date of 10/21/13 with diagnoses including paranoid schizophrenia, Alzheimer's disease, and constipation. Review of the care plan dated 06/08/21 revealed Resident #65 had an activity of daily living self-care deficit related to dementia and weakness. Interventions included supervision or touching assistance with toilet transfer and toileting hygiene. Review of the quarterly MDS assessment dated [DATE] revealed Resident #65 had impaired cognition. He required supervision with toileting hygiene and transfers. He was always continent of urine and bowel. Attempted interview on 08/25/25 at 10:02 A.M. with Resident #65, but he was unable to participate due to cognitive ability. Observation on 08/25/25 at 9:58 A.M. in the bathroom shared by Residents #65, #87, and #102 revealed in the toilet was a moderate amount of bowel movement. Interview on 08/25/25 at 10:00 A.M. with Registered Nurse (RN) #674 verified the toilet was unable to flush, and she would notify maintenance. She verified Residents #65, #87, and #102 utilized the toilet. Interview and observation with the Administrator and Maintenance Director #772 on 08/28/25 at 10:09 A.M. verified there was bowel movement in the toilet in Residents #65, #87, and #102's bathroom. Maintenance Director #772 attempted to flush the toilet, and the toilet would not flush. Maintenance Director #772 revealed he was not aware the toilet was not working. He revealed he needed to schedule to shut off the water on non-dialysis days. Review of the facility policy labeled, Resident Rights and Facility Responsibilities, dated 01/06/25, revealed the rights of residents of a home shall include the right to safe and clean-living environment which included lightly, sound, closet space, clean bed and lines and general maintenance of sanitary interior. This deficiency represents non-compliance investigated under Master Complaint Number 2603375 and Complaint Numbers 2589394 and 2568834.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure a safe, functional, sanitary and comfortable environment. This affected 10 (Residents #11, #37, #53, #94, #103, #143, #144 #155, #156, and #160) out of 12 residents reviewed for environment and had the potential to affect all residents residing in the facility. The facility census was 163. Findings include:1. Review of the medical record for Resident #53 revealed an admission date of 03/30/23 with diagnoses including diabetes, anxiety, and chronic obstructive pulmonary disease (COPD). Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had impaired cognition. Observation on 08/25/25 at 9:41 A.M. revealed Resident #53 was lying in bed and above his bed was a large circular brown stain approximately one foot (ft) by one ft. Attempts to interview Resident #53 were unsuccessful due to his cognitive ability. Interview and observation with the Administrator and Maintenance Director #772 on 08/28/25 at 10:06 A.M. verified the large circular brown stain above Resident #53's bed. Maintenance Director #772 revealed the stain was from an old water leak but he started in July 2025, and he was not aware of the stained ceiling tile. Observation on 09/02/25 at 9:28 A.M. revealed Resident #53's ceiling tile above his bed remained with a large circular brown stain. 2. Review of the medical record for Resident #94 revealed an admission date of 08/06/21 with diagnoses including schizoaffective disorder, Parkinson's disease, and dementia. Review of the quarterly MDS dated [DATE] revealed Resident #94 had impaired cognition as he was rarely or never understood. Observation on 08/25/25 at 9:43 A.M. revealed Resident #94's bathroom was missing two ceiling tiles (approximately two ft by four ft each) in the bathroom exposing a large hole in the ceiling and plumbing pipes. The ceiling tile in the center of the bathroom had a large circular brown stain approximately one ft by one ft. Attempts to interview Resident #94 were unsuccessful due to his cognitive ability. Interview on 08/25/25 at 9:44 A.M. with Certified Nursing Assistant (CNA) #767 verified there were missing ceiling tiles exposing the plumping fixtures and a stained ceiling tile in the center in Resident #94's bathroom. He revealed Resident #94's tiles were missing and/or stained for about a month. Interview and observation with the Administrator and Maintenance Director #772 on 08/28/25 at 10:06 A.M. verified the missing and stained tiles in Resident #94's bathroom. Maintenance Director #772 revealed he was not aware. Observation on 09/02/25 at 9:29 A.M. revealed Resident #94's bathroom continued to have two missing tiles exposing plumbing fixtures, and the ceiling tile in the center was stained. 3. Review of the medical record for Resident #156 revealed an admission date of 09/09/22 with diagnoses including congestive heart failure, diabetes, dementia, and adult failure to thrive. Review of the annual MDS assessment dated [DATE] revealed Resident #156 had impaired cognition. She was dependent on staff for toileting hygiene, personal hygiene, rolling left and right and transfers. She was always incontinent with bowel and bladder. Attempts to interview Resident #156 on 08/25/25 at 10:04 A.M. were unsuccessful due to cognitive impairment. Review of the medical record for Resident #103 revealed an admission date of 05/22/23 with diagnoses including dementia and diabetes. Review of the quarterly MDS assessment dated [DATE] revealed Resident #103 had impaired cognition. Observation on 08/25/25 at 10:04 A.M. revealed Residents #103 and #156's sink faucet in their room was running and unable to be turned off. Resident #156's telephone outlet cover by her bed was off and hanging with exposed wires. Resident #103 register cover by her bed was off and lying on the floor. Interview on 08/25/25 at 10:09 A.M. with Registered Nurse (RN) #674 verified the sink in Residents #103 and #156's room was moderately running and was unable to be turned off. RN #674 revealed the faucet had been constantly running and stated it had been like that for a while. She also verified the telephone outlet cover by Resident #156's bed was off with exposed wires, and the register cover by Resident #103's bed was off and on the floor. Observation on 08/25/25 at 10:14 A.M. of incontinence care for Resident #156 completed by CNA #746 revealed during the incontinence care she removed Resident #156's gown that had yellow-brown urine stains and put it on the floor. She then washed Resident #156 with a towel and put the towel on the floor. She then proceeded to rinse and dry Resident #156 and put both towels on the floor. She then removed the washable under pad that also had a yellow-brown urine stain and placed on the floor. After CNA #746 placed the items on the floor she revealed I know not supposed to throw on the floor, but I do not have a bag. She then proceeded to dry Resident #156 with a towel and put the towel on the floor. After applying a new incontinence brief, new washable under pad, gown, and sheet, she took a plastic bag out of her pocket and picked up the dirty towels, gown, sheet, washable under pad that she had placed on the floor and placed them in the bag. Interview on 08/25/25 at 10:22 A.M. with CNA #746 verified she should not have put the dirty linens on the floor. Interview on 08/25/25 at 2:32 P.M. with the Director of Nursing (DON) verified dirty linen should not be placed on the floor as this was an infection control issue. Observation on 08/26/25 at 8:35 A.M., 08/26/25 at 1:31 P.M., 08/27/25 at 12:21 P.M., revealed the faucet in Resident #103 and #156's room was still running with a constant moderate flow and was unable to be shut off. Interview and observation with the Administrator and Maintenance Director #772 on 08/28/25 at 10:11 A.M. verified the faucet continued to run and was unable to be shut off. They also verified the telephone outlet cover by Resident #156's bed remained off with exposed wires. Maintenance Director #772 revealed he was not aware. 4. Review of the medical record for Resident #37 revealed an admission date of 04/14/14 with diagnoses including schizoaffective disorder, dementia, and chronic kidney disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #37 had impaired cognition. She required partial to moderate staff assistance with toileting hygiene and was frequently incontinent if urine. Attempted interview on 08/25/25 at 10:36 A.M. with Resident #37 was unsuccessful due to cognitive impairment. Observation on 08/25/25 at 10:36 A.M. revealed a strong pervasive urine odor in the hallway next to Residents #37 and #144's room. Observation revealed inside the bathroom of Residents #37 and #144's room was two disposable incontinent products lying on the floor next to the toilet. Observation and interview on 08/25/25 at 10:37 A.M. with CNA #746 revealed she walked into Resident #37 and #144's room and stated, wow and oh, that is strong as she took out of her pocket a spray scent deodorizer to cover up the pervasive smell. She verified there were two soiled incontinent briefs lying on the floor next to the toilet. She donned gloves to pick up the briefs and as she picked up the briefs she jumped back as several gnats flew out of the briefs. CNA #746 stated the incontinence briefs had to be lying on the floor a long time to have that many gnats on them. She revealed she believed the briefs belonged to Resident #37. 5. Review of medical record for Resident #143 revealed an admission date of 02/16/13 with diagnoses including dementia, schizoaffective disorder, and aphasia following cerebrovascular disease. Review of the quarterly MDS dated [DATE] revealed Resident #143 had impaired cognition as he was rarely or never understood. Observation on 08/25/25 at 11:20 A.M. revealed Resident #143 was missing two ceiling tiles (approximately two ft by four ft each) in the bathroom exposing a large hole in the ceiling and plumbing pipes. Attempted interview with Resident #143 was unsuccessful due to cognitive impairment. Interview and observation with the Administrator and Maintenance Director #772 on 08/28/25 at 10:17 A.M. verified Resident #143's bathroom was missing two ceiling tiles exposing a large hole in the ceiling and plumbing pipes. Maintenance Director #772 revealed he was not aware. Observation on 09/02/25 at 9:43 A.M. revealed Resident #143's bathroom continued to be missing two ceiling tiles. 6. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertension, chronic kidney disease, congestive heart failure, type two diabetes, chronic pulmonary disease, anemia, depression and lymphedema. Review of the quarterly MDS assessment dated [DATE] revealed Resident #11's cognition was intact. Resident #11 had no hallucinations or delusions, and rejection of care was not exhibited. Observation on 08/28/25 at 10:42 A.M. of Resident #11's room revealed a plastic baseboard that led towards Resident #11's bathroom had a section peeled away from the wall that protruded outward. Maintenance Director #772 verified the baseboard needed repaired at the time of the observation. 7. review of the medical record revealed Resident #155 was admitted to the facility on [DATE] with diagnoses including respiratory failure, type two diabetes, colostomy, chronic obstructive pulmonary disease, congestive heart failure, atherosclerotic heart disease, pulmonary hypertension, myocardial infarction, adjustment disorder, and dependence on oxygen. Review of the physician order dated 06/14/25 revealed Resident #155 was to have oxygen at three liters per minute via nasal cannula. Review of the quarterly MDS assessment dated [DATE] revealed Resident #155's cognition was intact. Resident #155 did not display hallucinations or delusions but had rejected care one to three days during the seven-day look back period. Observation on 08/28/25 at 10:35 A.M. of Resident #155's room revealed three empty oxygen tanks in the room. Housekeeping Supervisor #642 verified the three empty oxygen tanks in the room and stated nurse's aides were to take the oxygen tanks out of resident's rooms. 8. Review of the medical record revealed Resident #160 was admitted to the facility on [DATE] with diagnoses including fibromyalgia, multiple sclerosis, hyperlipidemia, neuromuscular dysfunction of bladder, hypothyroid, anxiety, borderline personality disorder, overactive bladder, difficulty walking, and lack of coordination. Review of the quarterly MDS assessment dated [DATE] revealed Resident #160's cognition was intact. Resident #160 did not exhibit hallucinations or delusions and did not reject care. Observation on 08/28/25 at 10:42 A.M. revealed Resident #160's door had a large circular area of chipped paint on its front surface. Maintenance Director #772 verified that the chipped region measured five by five (inches) and confirmed that the paint chip could be peeled off the door. 9. Observation on 08/28/25 at 10:20 A.M. revealed on floor tile block on the 200-hall by the receptionist desk had a loose tile that moved back and forth when stepped on. The Administrator verified the loose tile and stated the tile was loose due to the shifting of the building. 10. Observation on 08/08/25 at 10:25 P.M. of the Two [NAME] shower rooms revealed dark mildew on the shower's right wall and floor and four ceiling tiles exhibiting a blackish substance. The shower on the left side had rust like stains at the corners where the walls met. Maintenance Director #772 verified these findings and stated that the showers needed recaulking. Review of the undated facility document titled Room Inspection Checklist revealed housekeeping was to keep bathroom floors free of debris check all crevices, scrub and clean for mold and mildew, scrub and clean toilets and put in maintenance work-orders for wall patch paint any scuffs, chips, holes or damage. Review of the facility policy labeled, Resident Rights and Facility Responsibilities, dated 01/06/25, revealed the rights of residents of a home shall include the right to safe and clean-living environment which included lightly, sound, closet space, clean bed and lines and general maintenance of sanitary interior. Review of the facility policy labeled, Incontinence Care, dated 01/06/25, revealed to dispose of soiled linen appropriately but did not have anything in the policy not to place soiled linen on the floor. This deficiency represents non-compliance investigated under Master Complaint Number 2603375 and Complaint Numbers 2589394, 2568834 and 2560412.

Based on record reviews, interviews, facility policy review and review of facility staff training, the facility failed to provide trauma-informed care to Residents #17 and #28. This affected two (Residents #17 and #28) out of two residents reviewed for trauma-informed care. The facility reported nine Residents #2, #4, #17, #18, #28, #74, #93, #117 and #119) who had trauma-related diagnoses. The facility census was 163. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 03/20/25 with diagnoses of schizoaffective disorder depressive type, bipolar disorder and chronic post-traumatic stress disorder (PTSD). Review of Resident #17's hospital transfer dated 03/10/25 indicated the resident had PTSD with a history of cocaine and alcohol abuse. Resident #17 was a poor historian and not forthcoming with information. Review of the admission Minimum Data Set (MDS) assessment completed 03/27/25 revealed Resident #17 had no cognitive impairment and PTSD. Review of Resident #17's social service admission assessment dated [DATE] and the social service quarterly assessment dated [DATE] indicated the resident denied experiencing or witnessing a traumatic event. There was no additional trauma-related information collected on these assessments to promote trauma-informed care. Review of Resident #17's progress notes from March 2025 to August 2025 revealed no documentation relevant to the resident's trauma or trauma-informed care. Review of Resident #17's psychiatric notes dated 03/25/25, 05/28/25, 07/08/25 and 08/26/25 revealed a documented history of PTSD, alcohol and cocaine abuse, and reports of six previous psychiatric hospitalizations for instability. There was no detailed information related to the resident's trauma history for staff to provide trauma-informed care. Review of Resident #17's plan of care initiated 06/11/25 revealed a focus for psychosocial well-being problem related to PTSD. Interventions included to assist with developing coping skills to manage situational crises related to history of trauma; assist, encourage and/or support to set realistic goals; attempt to identify, reduce or eliminate causes and contributing factors; encourage to relax or participate in relaxing activities of interest; provide pastoral care, social services, psychiatric services and/or community services as needed; and when conflict arises, move to a calm, safe environment and allow to vent/share feelings. Interview on 08/27/25 at 10:58 A.M. with Resident #17 described the staff as not always understanding his personal care needs related to trauma but was unable to provide an example. Interview on 08/27/25 at 11:01 A.M. with Licensed Practical Nurse (LPN) #787 regarding Resident #17's trauma care denied having knowledge of any triggers or details about the trauma. LPN #787 indicated not witnessing any behaviors but would report any to the psychiatrist, and if the nursing assistants needed to be aware of any needs, it would be put on the care card. Review of Resident #17's Certified Nursing Assistant (CAN) care card dated 08/27/25 revealed under behaviors, the aides were to assess comfort levels and treat as needed and encourage interaction and participation during care. There was no information specific to promote trauma-informed care. Interview on 08/27/25 at 11:19 A.M. with CNA #610 regarding Resident #17's trauma care denied being aware of the resident having any trauma history or needs related to the trauma. Interview on 08/27/25 at 11:34 A.M. with Licensed Social Worker (LSW) #788 denied addressing any resident needs who had PTSD, but if someone mentioned any concerns then the psychiatric nurse practitioner would be contacted to receive guidance. Thereafter any services needed would be set up. LSW #788 indicated initial and quarterly assessments were completed in which questions were asked such as if a trauma had occurred, but if a resident answered no, then there were no additional questions asked to probe for information. LSW #788 denied being aware of Resident #17 having trauma related diagnoses, but explained the staff relied on psychiatric services to identify needs and relate those to nursing or social services to be care planned. Interview on 08/27/25 at 1:05 P.M. with MDS nurse, LPN #800 indicated because Resident #17 failed to divulge any trauma-related information on the social service admission assessment dated [DATE] and the social service quarterly assessment dated [DATE], then there was nothing to care plan, but because there was a diagnosis of PTSD and potential for issues, there was a general focus put into the care plan, but confirmed it was not individualized. 2. Review of the medical record for Resident #28 revealed an admission date of 11/01/23 with diagnoses of schizoaffective disorder bipolar type, PTSD, generalized anxiety disorder, borderline personality disorder, alcohol dependence, cannabis dependence, auditory hallucinations, a personal history of suicidal behavior, and suicidal ideations. Review of Resident #28's hospital transfer dated 10/28/23 indicated the resident had PTSD, was a victim of rape/sexual assault as a child, had a history of 33 psychiatric hospitalizations, had multiple previous suicide attempts and a history of polysubstance use disorder including nicotine, alcohol and cannabis. Review of the admission MDS assessment completed 11/07/23 revealed Resident #28 had moderate cognitive impairment and PTSD. Review of Resident #28's social service admission assessment dated [DATE] and the social service quarterly assessments dated 02/01/24, 08/20/24, 11/07/24, 02/04/25, 05/09/25 and 06/10/25 indicated the resident acknowledged experiencing a traumatic event involving sexual abuse as a child. Social service notes included Resident #28 having no cognitive impairment and denied issues with appetite, focus, concentration, energy level, taking pleasure in doing things, and thoughts of worthlessness, self-harm or harming others. Resident #28 expressed depression but was working with a therapist and counselors, which was helpful. There was no additional trauma-related information collected on these assessments to promote trauma-informed care. Review of Resident #28's progress notes from November 2023 to August 2025 revealed the resident had multiple incidences of suicidal ideations in which staff provided 15-minute safety checks, auditory hallucinations and desire for self-harm. The staff provided psychiatric services as an intervention until 08/14/25 when staff forced Resident #28 to be hospitalized via pink slip (involuntary hospitalization) due to suicidal thoughts which did not subside with distractions, conversation and sitting by the nurse's station. There was no documentation relevant to providing trauma-informed care. Review of Resident #28's psychiatric notes dated 01/07/25, 01/21/25, 02/05/25, 03/13/25, 04/15/25, 07/01/25, 08/05/25, 08/14/25 and 08/22/25 revealed a documented history of PTSD and self-injurious behaviors. There was no detailed information related to the resident's trauma history for staff to provide trauma-informed care. Review of Resident #28's plan of care initiated 11/02/23 revealed a focus for a psychosocial well-being problem related to traumatic life events and PTSD. Interventions included assisting in developing coping skills to manage situational crises related to history of trauma; attempt to identify, reduce or eliminate causes and contributing factors; provide pastoral care, social services, psychiatric services and/or community services as needed; and provide emotional support. Interview on 08/26/25 at 8:25 A.M. with Resident #28 described the staff as not fully understanding her trauma care needs and provided an example of staff forcing her to go to the hospital by a pink slip in the previous week knowing that hospitals really upset her. Interview on 08/27/25 at 11:05 A.M. with LPN #618 expressed being aware of Resident #28 having behaviors but was unable to identify any triggers for the behaviors related to the resident's trauma history, but indicated staff watch closely for depression, self-injury and suicidal behavior. LPN #618 indicated if there were any triggers it would be outlined in the care plan and on the care card for the nursing assistants. Interview on 08/27/25 at 11:34 A.M. with LSW #788 denied addressing any resident needs who had PTSD, but if someone mentioned any concerns then the psychiatric nurse practitioner would be contacted to receive guidance. Thereafter any services needed would be set up. LSW #788 indicated initial and quarterly assessments were completed in which questions were asked such as if a trauma had occurred but if a resident answered no, then there were no additional questions asked to probe for information. LSW #788 denied being aware of Resident #28 having trauma related diagnoses, but explained the staff relied on psychiatric services to identify needs and relate those to nursing or social services to be care planned. Interview on 08/27/25 at 11:55 A.M. with MDS nurses, LPNs #660, #738 and #800, verified Resident #28's care plan was non-specific to the trauma, but more detailed trauma information was drawn together by social service assessments before being included. Review of Resident #28's CNA care card dated 08/27/25 revealed under behaviors, the aides were to assess comfort levels and treat as needed and encourage the resident to express feelings. There was no information specific to promote trauma-informed care. Interview on 08/28/25 at 12:35 P.M. with the Director of Nursing (DON) confirmed although Resident #28's CNA care card and care plan were not specific or individualized, the resident was followed by psychiatry and a therapeutic behavioral services (TBS) therapist at least weekly and would contact the provider to obtain more detailed information related to the resident's trauma. Interview on 08/28/25 at 9:58 A.M. with MDS nurses, LPNs #660, #738 and #800, confirmed although Resident #28 had a documented history of sexual assault, it care planning process was the responsibility of social services to complete that portion. During an interview on 08/28/25 at 10:10 A.M. with the DON the trauma history of both Residents #17 and #28 was discussed. The DON verified the staff's approach to both residents' care lacked detailed trauma-related information and was unable to provide evidence of such. However, the DON provided medical record information she had just received from Resident #28's psychiatric provider which included trauma counseling notes and a trauma care plan dated 07/17/25, but verified it was just obtained and was not used by facility staff to provide trauma-informed care. Review of the staff training related to trauma informed care dated 01/03/25 revealed all facility staff were educated on the definition of trauma, to identify causes and effects of trauma, and how the facility's structured environment could trigger traumatic memories including noise, smell, temperature, physical sensation, and visual scenes. A trauma-informed approach included recognizing signs of trauma through assessments, training, and integrating knowledge about trauma into policies, procedures and practices, and to resist re-traumatization by recognizing how organizational practices may trigger painful memories and re-traumatize residents. Staff were to exercise strategies to become trauma informed including demonstrating active listening skills and a knowledge of resident history, be aware of resident's personal preferences, identify indications of stress, and incorporate person-centered care planning processes. Review of the facility policy, Trauma Informed Care, revised 01/06/25, revealed trauma informed clinical practices include demonstrating active listening skills, demonstrating knowledge of resident history, being aware of resident's personal preferences, identifying indications of stress and providing sufficient notice and preparation when changes are necessary.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure advanced directives were accurate. This affected one (Resident #129) of one resident reviewed for advanced directives. The facility census was 163. Findings include:Medical record review revealed Resident #129 was admitted to the facility on [DATE] with diagnoses including type two diabetes, right foot ulcer, weakness, tachycardia, and gastro esophageal reflux. A Brief Interview for Mental Status (BIMS) dated [DATE] revealed a score of 15/15, which indicated Resident #129's cognition was intact. Further review of Resident #129's medical records revealed the electronic medical record and the hard copy chart included conflicting advanced directives. The electronic medical record physician orders dated [DATE] revealed an order for Do Not Resuscitate-Comfort Care (DNR-CC), this specified cardiopulmonary resuscitation (CPR) was not to be initiated in the case of cardiac arrest. The DNR-CC was ordered by the physician in the electronic medical record on admission [DATE]. Review of the hard copy medical record for Resident #129 revealed a DNR-CC form was in front of the medical record that was not signed by the physician or the resident. Review of the admission assessment dated [DATE] revealed Resident #129 was admitted to the facility on [DATE] at 8:00 P.M. The code status revealed Resident #129 was to be Full Code. Review of the care plan initiated on [DATE] revealed Resident #129 had chosen advanced directives of Full Code. The care plan was revised by Activities Director #637. Interventions included facility would review code status when significant change in condition warranted discussion. Interview on [DATE] at 10:13 A.M. with Registered Nurse (RN) #655, revealed nursing staff was to look in the electronic medical record or the front of the hard copy of the medical record to see what code status a resident was. RN #655 verified the DNR-CC form in Resident #129's hard copy medical record was not signed or filled out and the order in Resident #129's electronic medical record was DNR-CC. Interview on [DATE] at 10:29 A.M. with RN Shift Supervisor #651 verified a code status paper was located in the front of the hard copy medical record and verified the DNR-CC form for Resident #129 was not signed by the physician and should be signed by a physician. Interview with RN #655 on [DATE] at 10:50 A.M. revealed he spoke with Resident #129, and Resident #129 stated he wanted to be a Full Code and not a DNR-CC. Interview on [DATE] at 10:55 A.M. with Resident #129 revealed he wished to be a Full Code and wanted CPR to be done in the event of an emergency. Interview on [DATE] at 2:43 P.M. with Activities Director #637 verified she updated the advanced directive care plan to Full Code on [DATE] after she noticed the order was changed. Interview on [DATE] at 2:00 P.M. with the Administrator revealed the facility did not have a policy for advanced directives. Review of the facility policy titled Do Not Resuscitate Order, dated [DATE], revealed a Do Not Resuscitate (DNR-CC) order must be obtained by the resident's attending physician and the physician's order sheet maintained in the medical record. Review of DNR-CC Form would be completed upon admission, if not completed prior to admission.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #59 was free from restraint. This affected one (Resident #59) out of one resident reviewed for use of a device/restraint. The facility census was 163. Findings include:Review of the medical record for Resident #59 revealed an admission date of 03/28/24 with diagnoses including schizoaffective disorder, dementia, severe protein calorie malnutrition, bilateral osteoarthritis of the hips, and history of falling. Review of the care plan dated 06/22/23 revealed Resident #59 wandered aimlessly and was disoriented. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book, monitor for fatigue, and document wandering behavior. There was nothing in the care plan regarding tilting her wheelchair back, preventing her from getting up. Review of the care plan dated 06/23/23 revealed Resident #59 was at risk for falls due to dementia, history of falls, poor safety awareness, and weakness. Interventions included call light in reach, offer tabletop activities, restorative ambulation program, non-skid footwear, offer assistance with toileting and fall mat to floor. There was nothing in the care plan regarding tilting her wheelchair back, preventing her from getting up. Review of the care plan dated 10/05/23 revealed Resident #59 was on a restorative ambulation program for impaired physical mobility related to balance problems, cognitive deficit, limited endurance, limited range of motion, unsteady gait and weakness. Interventions included ambulation program three to seven days a week, prompting the resident to ambulate 50 feet with handheld assistance, encouragement to wear non-skid footwear, and monitoring the resident for fatigue. Review of the Occupational Therapy Discharge Summary, dated 02/06/25, completed by Rehabilitation Director/Occupational Therapist #675 revealed at discharge Resident #59 was able to transfer from bed to chair with minimal assist of one person. The discharge instructions were to use the tilt in space wheelchair when out of bed for meals and positioning out of bed. The geri chair (a chair that reclines back on wheels) was as needed when resident was restless or had behaviors lifting legs and hips causing it to be unsafe to stay in the tilt in space wheelchair. Review of the Restorative Enabler assessment dated [DATE] and completed by Restorative/Licensed Practical Nurse (LPN) #786 revealed under initial analysis the following devices were evaluated to determine impact on the resident's function: geri chair without tray, bed against wall, hi low bed, and transfer handlebar. The evaluation noted that none of the above devices restricted the freedom of Resident #59's movement. The assessment revealed Resident #59 had physical limitations as she required the assistance of one staff and her standing balance was fair. There was nothing in the assessment regarding the evaluation of her tilt in space wheelchair including if her wheelchair was tilted all the way back with leg rests above her waist. Review of the quarterly Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had impaired cognition as she was rarely or never understood. She had behaviors including physical, verbal and other behaviors identified. She utilized a wheelchair and a walker. She required substantial to maximum assistance to transfer and partial to moderate assistance to ambulate up to 50 feet. She was not identified to have a restraint. Review of the August 2025 physician's orders revealed Resident #59 had an order for a tilt in space wheelchair for comfort and positioning, and geri chair while up for proper positioning, comfort and safety. There was nothing in the orders regarding frequency of reclining the wheelchair. Interview on 08/25/25 at 3:02 P.M. with Resident #59's son revealed that since she received the new wheelchair, staff always reclined it all the way back causing her feet to dangle preventing her from being able to get up. He revealed he was concerned Resident #59 was losing her ability to transfer and ambulate since they kept her in her chair almost upside down all day as that was how far they reclined the chair back. He revealed when he visited, he walked her all around the unit to try to maintain her strength and that she was able to ambulate by herself. Observation on 08/26/25 at 1:53 P.M. revealed Resident #59 was in her a tilt in space wheelchair that was reclined all the way back with her footrests above her waist. Resident #59 was rocking back and forth in the chair appearing to sit upright. Interview on 08/26/25 at 1:55 P.M. with LPN #745 verified Resident #59's tilt in space wheelchair were reclined all the way back causing her footrests to be above her waist because she stated if the chair was not reclined Resident #59 will get up. LPN #745 revealed Resident #59 can ambulate by taking a few steps but would fall which was why they kept her chair reclined. Interview on 08/26/25 at 2:01 P.M. with Certified Nursing Assistant (CNA) #721 revealed she frequently was assigned Resident #59, and Resident #59 was able to stand and ambulate up to five minutes but at times was unsteady. She revealed she always kept her tilt in space wheelchair reclined all the way back because if Resident #59 sat upright, she would attempt to stand and possibly fall. Observation on 08/27/25 at 8:15 A.M. revealed Resident #59 was up in her tilt in space wheelchair sitting in the dining room. The chair was reclined all the way back with her feet at waist level. Observation on 08/27/25 at 8:30 A.M. revealed Resident #59 was sitting at the dining room table in her tilt in space wheelchair upright being assisted per CNA #744 with breakfast. Observation on 08/27/25 at 8:45 A.M. revealed after breakfast Resident #59 was taken to in front of the nursing station and her tilt in space wheelchair reclined back causing her leg rests to be above her waist. She was rocking back and forth attempting to sit upright. Interview on 08/27/25 at 8:46 A.M. with CNA #744 revealed she reclined Resident #59 back in her tilt in space wheelchair as she stated to stop from getting up. CNA #744 revealed Resident #59 can ambulate and stated she ambulated pretty good as she could ambulate throughout the unit. She revealed if Resident #59 ambulated on the unit, then she started pulling on the linen, pulling on other residents', and getting into things. She verified that was the reason they reclined her back in her chair. Interview on 08/27/25 at 11:24 A.M. with Director of Nursing (DON) revealed Resident #59 was reclined back in her chair for comfort and that it was not considered a restraint. Reviewed interviews (LPN #745, CNA #721, and CNA #744) with the DON as they had stated they reclined Resident #59 to prevent her from either ambulating, getting up, falling, getting into items, pulling on other residents' and/or getting into things. She verified based on the interviews how that can then appear as a restraint. Interview on 08/27/25 at 11:39 A.M. with Restorative/LPN #786 revealed he had been responsible for the restorative program for three years including looking at devices to see if they were a potential restraint. He verified he had completed the Restorative Enabler Assessment dated 06/25/25 for Resident #59 but he was unsure if he evaluated her tilt in space as a possible restraint. He verified the tilt in space wheelchair was not identified in the assessment. He was unsure if the tilt in space was reclined, if Resident #59 was able to get out of the chair, and he had not assessed if she could. He was asked if he remembered if he knew if she was on a restorative ambulation program and he stated he was unsure. Interview on 09/02/25 at 10:22 A.M. with Rehabilitation Director/Occupational Therapist #675 revealed she had consulted February 2025 when they had ordered and received Resident #59's new tilt in space wheelchair. She revealed they had recommended the tilt in space wheelchair especially for Resident #59 to sit upright with better posture to eat. Resident #59 was able to ambulate and was on a restorative ambulation program. They had not assessed Resident #59's tilt in space wheelchair for a potential restraint when in a reclined position. Review of the facility policy labeled, Resident Rights and Facility Responsibilities, dated 01/06/25, revealed residents had the right to be free from physical or chemical restraints or prolonged isolation except to the minimum extent necessary to protect the resident from injury to self, others or to property as authorized in writing by the attending physician for specified and limited period of time and documented in the resident's record. Prior to authorizing the use of a physical or chemical restraint the attending physician shall make a personal examination of the resident and an individualized determination of the need to use the restraint. Review of the facility policy labeled, Restraint and/ or Enabler, dated 01/06/25, revealed the definition of a physical restraint was defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy revealed each time a device was considered for a resident the facility would determine how the device affects the resident. The facility would complete an enabler assessment to clearly define the benefit of the device and educate for proper use.

Based on record review and interview, the facility failed to accurately complete resident assessments. This affected one (Resident #15) of three residents reviewed for resident assessments. The facility census was 163. Findings include:Review of the medical record for Resident #15 revealed an admission date of 09/02/11. Diagnoses included schizoaffective disorder bipolar type, bipolar disorder, anxiety disorder and dementia. Review of the significant change in condition Preadmission Screening and Resident Review (PASRR) identification screen completed on 01/18/22 due to a decline revealed Resident #15 had indications of serious mental illness and within the previous two years had utilized psychiatric services including emergency mental health services and inpatient psychiatric hospitalization due to the mental disorder. Review of the notice of PASRR level II outcome dated 01/24/22 revealed Resident #15 was approved for continued nursing facility services with recommended mental health services and supports put into place by the facility. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed section A1500 for PASRR was coded as no for Resident #15 being considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Review of the annual MDS assessment dated [DATE] revealed section A1500 for PASRR was coded as no for Resident #15 being considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Interview on 08/27/25 at 11:55 A.M. with MDS nurses, Licensed Practical Nurses (LPNs) #660, #738 and #800, verified Resident #15's annual MDS assessments dated 01/27/24 and 12/13/24 were inaccurately coded.

Based on record reviews, interviews and observations, the facility failed to revise care plans for Resident #62 and Resident #63. This affected two (Residents #62 and #63) of two residents reviewed for revision of care plans. The facility census was 163. Findings include:1. Review of the medical record for Resident #62 revealed an admission date of 11/09/23 with diagnoses of malignant neoplasm of prostate, history of falling, need for assistance with personal care, anxiety disorder and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was cognitively intact and had no history of falls. He required substantial assistance for toileting and supervision for showers. He had no recent falls. Review of the Annual MDS 3.0 dated 08/02/25 revealed Resident #62 was cognitively impaired. He required substantial assistance with toileting and set-up for showers. Review of progress note dated 12/26/24, timed for 3:22 P.M. revealed the team reviewed a fall from 12/25/24 at 12:00 P.M. Resident #62 was found on the floor between his bed and wheelchair with two skin tears behind his ear. Hospice was notified. Review of the fall assessment on 12/25/24 revealed Resident #62 was a high risk for falls. Review of the August 2025 orders for Resident #62 revealed an order dated 07/22/25 for bed against wall on right side for safety and an order dated 05/03/24 for Call don't fall sign in room. Review of the care plan initiated on 11/24/23 for Resident #62 revealed a care plan related to fall risk due, in part, to impaired balance and mobility, incontinence and poor coordination. Interventions included an electric high/low bed in low position at all times while the resident was lying in bed added 07/11/24 and call staff for assistance sign posted in room on wall added on 04/13/24. Review of restorative progress noted dated 08/02/25 and timed at 5:08 P.M. revealed device used was hi/low bed in low position. Review of the Annual Fall assessment dated [DATE] for Resident #63 revealed he was at a high risk for falls indicating he was unable to stand without physical assistance and was unsteady while standing without physical support. 2. Review of the medical record for Resident #63 revealed an admission date of 11/09/23 with diagnoses of dementia, arthritis and hyperlipidemia. Review of the orders for Resident #63 revealed an order dated 11/09/23 for a high/low bed with instructions to keep in low position except during care; an order dated 07/22/25 for call don't fall sign in room; and an order on 07/22/25 for bed against the right wall for safety. Review of the care plan dated 11/09/23 for Resident #63 revealed a care plan for fall risk related to confusion and impaired balance and mobility. Interventions included a high/low bed which was to be kept in low position except during care and visual reminder call don't fall sign posted in room. Review of progress notes dated 07/28/25 and dated 12:34 P.M. revealed the resident was complaining of back pain stating she had a fall on 07/25/25 around 5:00-6:00 P.M. but did not report it. Nursing continued to follow plan of care. Review of the annual MDS 3.0 dated 08/01/25 revealed she was cognitively intact. Observation on 08/25/25 at 11:03 A.M. revealed Resident #62 and Resident #63 lying in a bariatric bed together with the head of the bed positioned against the wall and the length of the bed positioned out toward the center of the room with approximately four feet of space on either side of the bed. No call staff for assistance sign was noted. Resident #62 was lying on the right side of Resident #62. The bed was in a standard height position. There was no other bed in the room. Interview on 08/25/25 at 11:14 A.M. with Certified Nursing Assistant (CNA) #606 verified Resident #62 and Resident #63 were sharing a bed and it was in the standard height position. Observation and interview on 08/27/25 at 10:54 A.M. revealed Resident #62 was alone in the bariatric bed which was in the standard position. Interview with CNA #606 verified the resident was in bed in standard position, and there was no signage on wall about asking for help. Interview on 08/27/25 at 11:07 A.M. with Registered Nurse (RN) #641 and RN #651 revealed the bed was new to the residents approximately three weeks ago per residents' request. They stated they thought hospice ordered the bed. Neither RN was sure about current fall interventions. Review of Resident #62 and Resident #63's hard charts with RN #641 revealed hospice note dated 07/31/25 mentioning bariatric bed but no order. Further interview with RN #641 verified orders in the electronic medical record and hard chart, for both residents, had current orders for fall interventions (bed against wall, bed in low position); however, there was no order in either chart for bariatric bed. She also verified there was no care plan revisions about falls or any mention of their preference to share a bed. Subsequent interview on 08/27/25 at 11:31 A.M. with RN #641 revealed she spoke to hospice nurse who stated she gave a verbal order for the bed but not a written order. Interview and review of the orders and care plan on 08/27/25 at 12:13 P.M. with Director of Nursing (DON) verified there were no revisions made to the care plan and the orders were not added or changed.

Based on observation, interview, record review, time punch review and review of the facility policy, the facility failed to ensure timely incontinence care was provided. This affected one (Resident #156) out of two residents reviewed for incontinence care. This had the potential to affect 63 (Residents #1, #2, #3, #6, #9, #13, #22, #26, #30, #31, #36, #37, #39, #44, #50, #53, #55, #57, #58, #59, #60, #67, #70, #73, #78, #81, #89, #91, #92, #97, #99, #100, #103, #105, #114, #117, #125, #126, #128, #131, #133, #134, #135, #138, #140, #143, #144, #145, #150, #154, #155, #156, #157, #158, #160, #161, #162, #165, #167, #168, #170, #171, and #174) identified by the facility as incontinent. The facility census was 163. Findings include: Review of the medical record for Resident #156 revealed an admission date of 09/09/22 with diagnoses including congestive heart failure, diabetes, dementia, and adult failure to thrive. Review of the care plan dated 09/26/22 revealed Resident #156 had an activities of daily living self-care mobility and performance deficit related to impaired physical mobility, weakness, and cognitive deficit. Interventions included staff was to provide total assistance with toileting hygiene, and she required assistance with bed mobility. Review of the care plan dated 09/26/22 revealed Resident #156 had bladder incontinence related to dementia, impaired mobility, and diabetes. Interventions included check for wetness before and after meals, at night and on rounds during the night, monitor for signs of urinary tract infection, and note any changes in urine including amount, frequency and odor. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #156 had impaired cognition. She was dependent on staff for toileting hygiene, personal hygiene, rolling left and right and transfers. She was always incontinent with bowel and bladder. Review of the time punch report dated 08/25/25 revealed Certified Nursing Assistant (CNA) #746 had punched in on 08/25/25 at 7:00 A.M. Observation on 08/25/25 at 10:04 A.M. revealed upon entrance into Resident #156's room a strong foul urine smell was identified, and Resident #156 was lying in bed positioned on her side towards the wall partially uncovered. Resident #156's gown was noted to have yellow-brownish stains from her left hip region all the way up under her shoulder/back region. Attempts interview Resident #156 were unsuccessful due to cognitive impairment. Interview on 08/25/25 at 10:09 A.M. with Registered Nurse (RN) #674 verified the yellow-brownish stains on Resident #156 were from dried urine. She revealed Resident #156 had not been changed for a while to have dried urine stains from her buttocks to her shoulder region. Interview on 08/25/25 at 10:10 A.M. with CNA #746 revealed she was assigned to Resident #156 and was called into the facility to work as it was her day off. She revealed she thought she had punched-in around 8:00 A.M. but was unsure of exact time. She was unsure when the last time Resident #156 was changed, but she had not changed her since her arrival at the facility. She revealed she was unsure who was assigned to Resident #156 prior to her as she did not receive report of when the last time Resident #156 was changed. Observation on 08/25/25 at 10:14 A.M. of incontinence care for Resident #156 completed by CNA #746 revealed Resident #156 had dried yellow-brownish discolorations to her gown from her buttocks to her shoulder as well as a large yellow-brownish ring to her washable under pad that was laying underneath her, and her incontinence brief was moderately saturated in urine. CNA #746 verified the above findings and revealed Resident #156 appeared to have urinated several times since the last time she was changed. Interview on 08/25/25 at 2:32 P.M. with the Director of Nursing (DON) revealed CNA #746 was assigned to Resident #156 on 08/25/25 at 7:00 A.M. and that was what her time clock punch revealed. She revealed she was unsure why CNA #746 stated she had not started work until 8:00 A.M. She verified CNA #746 should have provided incontinence care prior to 10:14 A.M., and Resident #156 should not have had dried yellow-brown urine stains if timely incontinence care was provided. Review of the facility policy labeled, Incontinence Care, dated 01/06/25, revealed the purpose of the policy was to keep the resident's skin clean, dry, free of irritation, and odor, identify skin problems as soon as possible, prevent skin breakdown, and prevent infection. The policy did not identify frequency incontinence care was to be completed. This deficiency represents non-compliance investigated under Complaint Number 2588569.

Based on record review, interviews and job description review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for Resident #26. This affected one (Resident #26) of two residents investigated for medically related social services. The facility census was 163. Findings include:Review of the medical record for Resident #26 revealed he was admitted on [DATE] with diagnoses of schizoaffective disorder, alcohol dependence with alcohol-induced persisting dementia, alcohol dependence with alcohol-induced persisting amnestic disorder, bipolar disorder, delusional disorders, paranoid personality disorder, hearing loss, legal blindness. Pertinent orders for August 2025 in the medical record included Risperdal Oral Tablet 0.5 milligrams (mg) (Risperidone) give 0.5 mg (antipsychotic) by mouth two times a day for schizophrenia, Advanced Directives: Do Not Hospitalize, no percutaneous endoscopic gastrostomy (PEG) tube per legal guardian, Aricept tablet 10 mg (Donepezil HCl) ((medication to treat dementia) give one tablet by mouth one time a day for dementia. Review of the care plan for Resident #26 dated 01/24/17 revealed Resident #26 displayed impaired cognitive function/impaired thought processes due to dementia and impaired decision making. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #26 dated 07/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS also revealed Resident #26 was dependent on staff for all activities of daily living (ADL) and required substantial/maximum assistance with mobility. Observation of Resident #26 on 08/26/2025 at 10:53 A.M. revealed his pleasant confusion and inability to participate in meaningful conversation. He was an unreliable historian during an attempted interview at this time. He did not make eye contact and was unable to follow simple directions during the attempted interview. On 08/26/25 at 11:00 A.M., a phone call was placed in an attempt to contact the primary contact person listed on Resident #26's face sheet for representative interview, an employee at Adult Protective Services (APS). The unnamed person who answered the phone stated that the primary contact listed on Resident #26's face sheet no longer worked at APS. A call was then placed to the APS hotline to confirm; spoke with a representative who confirmed resident #26's primary contact no longer worked for APS, and they had no active case for Resident #26 since a legal guardian was appointed in March 2023. A call was then placed to the Cuyahoga County Probate Court for additional information and confirmed Resident #26's legal guardian resigned, and the Probate Judge confirmed the resignation in July 2024. These court documents were uploaded into Resident #26's medical record. Interview with Social Worker #788 on 08/26/2025 at 2:40 P.M. revealed multiple people were responsible for making sure the medical record was correct. Social Worker #788 went on to say when she received updated information, she updated the record. She further confirmed that no one was responsible for Resident #26. She stated several people dropped ball regarding Resident #26. She was unaware who staff called for changes in Resident #26's condition, who authorized his money to be spent, or who represented him at his annual Medicaid redetermination. She also confirmed incorrect and outdated emergency contact information on Resident #26's face sheet and confirmed Resident #26's medical record contained direction for staff to refer to the legal guardian for direction about hospitalization and other medical interventions. An additional interview with Social Worker #788 on 08/26/2025 at 4:09 P.M. revealed the former business office manager uploaded documents to the medical record when the guardian resigned. Review of Social Worker #788's job description revealed the Social Worker is required to ensure medically related social services are provided to maintain or improve each resident's ability to control everyday mental and psychosocial needs (e.g., sense of identity, coping abilities, and sense of meaningfulness or purpose). The job description also stated the Social Worker is responsible to address the residents' need for legal services and to refer residents/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. This deficiency represents noncompliance investigated under Complaint Number 2588569.

Based on observation, interviews, review of diet spreadsheets, and review of facility policy, the facility failed to ensure residents on a controlled carbohydrate diet (CCD) diet with regular or mechanically altered consistency, liberalized renal diet with a regular or mechanically altered consistency, or a renal diet with a regular or mechanically altered consistency received the appropriate food items at meals. This affected 44 residents (#5, #7, #8, #16, #23, #24, #26, #30, #49, #51, #54, #56, #59, #61, #66, #70, #71, #72, #78, #80, #83, #85, #88, #91, #92, #93, #99, #101, #105, #108, #110, #112, #121, #125, #127, #130, #132, #139, #142, #143, #149, #151, #153, #156) the facility identified as being on a CCD with regular or mech soft consistency, two residents (#24, #109) the facility identified as being on a liberal renal diet with regular or mechanically altered consistency, and four residents (#65, #70, #84, and #87) the facility identified as being on a renal diet with regular or mechanically altered consistency out of 158 residents receiving meals from the kitchen. The facility identified four residents (#41, #116, #147 and #161) who did not eat by mouth. The facility census was 162.Findings include:Review of the facility's week three diet spread sheet for Monday day 16 of the four-week cycle menu (07/07/25) revealed for lunch the regular diets were to receive three ounces of herb roasted pork loin, one four-ounce spoodle (a type serving utensil) of candied sweet potatoes, and one four-ounce spoodle of buttered cabbage. Residents on a CCD diet were to receive one four-ounce spoodle of sweet potatoes instead of the candied sweet potatoes. Residents on a renal diet were to receive one four-ounce spoodle of unsalted buttered noodles instead of the candied sweet potatoes, and residents on a liberal renal diet were to receive one four-ounce spoodle of buttered noodles instead of the candied sweet potatoes. Observations on 07/10/25 of the kitchen tray line from 11:22 A.M. until 12:58 P.M. revealed on the steam table there was a large pan of sliced pork loin, a large pan of candied sweet potatoes, and a large pan of buttered cabbage. There were smaller pans of mechanical soft pork loin, pureed pork loin, pureed cabbage, and pureed sweet potatoes. There was no observation of any buttered noodles or plain sweet potatoes on the steam table. Interview with Dietary [NAME] #412 during the tray line process revealed when she had made the sweet potatoes and had added brown sugar. She stated all diets with regular or mechanically consistency were receiving the same food items for the meal except the mechanical soft diet would receive ground pork loin. Observation of the tray line from start to finish revealed everyone on a regular or mechanically altered diet had received the 3 ounces pork loin, one four-ounce spoodle of candied sweet potatoes, and one four ounce spoodle of buttered cabbage except the mechanical soft diets received one #8 (four ounce) scoop of ground pork loin. There were several residents who were served grilled cheese, hamburgers, chicken breast or mashed potatoes due to a dislike. There was no observation of any spreadsheets in sight of the tray line. Interview with Dietary Manager (DM) #487 on 07/07/25 at 12:56 P.M. revealed spread sheets were kept in the back of the Cook's Book. Observation at the time of interview of binder labeled Cook's Book, which was sitting on the windowsill to the left of the steam table, revealed there were no spread sheets in the book. DM #487 confirmed at the time of observation there were no spread sheets in the book and went on to state I print them out daily and they were on my desk.Review of the week three's facility diet spread sheet for Mondays lunch on 07/07/25 at 1:07 P.M. and interview with DM #487 revealed the dietary manager confirmed the residents on a CCD regular or mechanical soft diet should have received regular sweet potatoes instead of candied sweet potatoes and the residents on either a liberal renal or renal regular or mechanical soft diet should have received buttered noodles instead of the candied sweet potatoes. When asked why the spread sheet hadn't been followed for the CCD, Liberal Renal or Renal diets, DM #487 replied that the facility usually had pretty liberal diets, and she hadn't double checked to ensure everyone was receiving the appropriate items for the diet. Interview on 07/08/25 at 3:15 P.M. with Dietitian #457 confirmed the dietary spread sheets should have been followed for lunch on 07/07/25.Review of the facility's undated policy Menu and Guidelines revealed there was nothing in the policy regarding following spreadsheets. This deficiency represents non-compliance investigated under Complaint Number OH00164551.

Based on observation, interview, and record review, the facility failed to ensure palatable meals were served to the residents. This affected two residents (#112 and #129) out of three residents reviewed for food/nutrition. The facility census was 162.Findings include: 1.Review of the medical record for Resident #112 revealed an admission date of 03/04/25. Diagnoses included type two diabetes mellitus, injury of head, hypertension (high blood pressure), and adult failure to thrive. Review of physician orders revealed an order dated 03/10/25 for CCD (carbohydrate controlled diet), regular Texture, thin liquids. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/11/25, revealed Resident #112 was cognitively intact, had no significant weight changes, and was prescribed a therapeutic diet. Review of Resident #112's care plan, dated 03/10/25, revealed the resident had altered nutritional status related to diabetes mellitus and hypertension. Interventions included diet per physician order.Further review of Resident #112's medical record revealed a progress note dated 04/04/25 where it was noted Resident #112 was complaining about the amount of salt in the food coming from the kitchen. An interview on 06/30/25 at 10:08 A.M. with Resident #112 revealed she stated the food was so salty and it lacked appeal due to how much salt was in the food. 2. Review of the medical record for Resident #129 revealed an admission date of 02/21/25. Diagnoses included end stage renal disease (ESRD), hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, dependence on renal disease, localized edema, and personal history of sudden cardiac arrest. Review of Resident #129's physician orders revealed an order dated 03/11/25 for a renal diet, regular texture, thin liquids. Review of the quarterly MDS 3.0 assessment, dated 06/06/25, revealed Resident #129 was moderately impaired cognitively, required setup or clean up assistance for eating, had no significant weight changes, and was on a therapeutic diet. Review of the care plan, dated 02/27/25, revealed Resident #129 had altered nutrition as evidenced by ESRD and needing hemodialysis, heart disease, and fluctuating weights. Interventions included diet per dietitian recommendation and physician order; encourage adequate meal intakes; monitor and record resident's intake of foods/fluids after each meal; monitor post-dialysis weights monthly or as needed; report weight loss/gain or more to the physician and dietitian; and visit at meal rounds. In an interview with Resident #129's spouse on 06/30/25 at 11:54 A.M. revealed Resident #129 had expressed to him that the food was too salty and she was concerned about it being too salty. 3. Review of week three day 16 (07/07/25) of the facility's menu revealed for lunch herb roasted pork, candied sweet potatoes, and buttered cabbage was to be served. Review of the recipe for buttered cabbage for 161 servings, revealed after the cabbage was cooked in water until fork tender, the cabbage was to be drained and one pound and ten ounces of margarine and one tablespoon and one fourth teaspoon salt if iodized was to be added to the cooked cabbage. There was no indication seasoned salt should have been added in addition to the iodized salt. Review of recipe for herb roasted pork loin for 161 servings revealed in a bowl three fourths of a cup of mince garlic, three fourths of a cup of basil leaves, six tablespoons and one teaspoon of dried thyme, three fourths of a cup of crushed rosemary, six tablespoons and one teaspoon of salt, and six tablespoons and one teaspoon of black pepper was to be mixed into one quart and one cup of vegetable oil. The marinade was to be rubbed over the entire surface of the pork loins and then roasted until the internal temperature reached 145 degrees F for four minutes and then sliced into serving portion. There was no indication brown gravy should have been added to the herb pork loin. Observation on 07/07/25 between 11:22 A.M. and 12:58 A.M. revealed on the steam table there was a large container of pork loin with gravy on it, candied sweet potatoes, and buttered cabbage, and there were smaller containers of ground pork with gravy, pureed pork, pureed candied sweet potatoes, and pureed cabbage. There was one five pound container of seasoned salt sitting on the stainless counter to the side of the steam table. Interview on 07/07/25 with Dietary [NAME] #412 during tray line observation between 11:22 A.M. to 12:58 A.M. revealed she had made the items for the lunch meal. She stated she had added seasoned salt and brown gravy to the pork loin, had added brown sugar, cinnamon, butter, garlic powder, onion powder, seasoned salt, and black pepper to the sweet potatoes, and had added seasoned salt, garlic powder, onion powder, iodized salt, and butter to the cabbage. She stated she usually added either seasoned salt or iodized salt or both to the food items so the items would have a taste. She stated she hadn't followed any recipes for items for lunch that day since she knew how to make those items. Dietary [NAME] #412 stated recipes for meals items were located in the Cook's book. Observation on 07/07/25 at 12:56 P.M. of the binder labeled Cook's Book located on the window sill to the left of the steam table revealed there were no recipes in the binder. Interview at the time of observation with Dietary Manager (DM) #487 confirmed there were no recipes in the binder. She stated she usually put the recipes in the binder weekly, but she hadn't put any recipes in the binder for that week. Observation on 07/07/25 at 12:50 P.M. revealed the last food cart was being loaded with resident meal trays and a test tray was requested for that cart. At 12:57 P.M. a test tray was plated and left the kitchen at 12:58 P.M. At 1:00 P.M. the food cart was delivered to the two East unit and by 1:07 P.M. the last tray had been served. DM#487 at 1:08 P.M. took the test tray out of the covered food cart and took the test tray to the counter at the nurse's station. Using a facility thermometer DM #487 took the temperature of the food items. The pork loin was tender, tasted warm but tasted heavily salted to the point the salt flavor was the prominent flavor. The pork loin was served with brown gravy on it and was 121 degrees Fahrenheit (F). The candied sweet potatoes had a nice sweet flavor and tasted warm. The candied sweet potatoes were 161 degrees F. The cabbage tasted warm but also tasted heavily salted. The cabbage was 156 degrees F. After DM #487 had taken the temperature of all the test tray items, she then tasted the pork loin, cabbage, and candied sweet potatoes. DM487 # confirmed both the pork loin and cabbage were salty and gravy had been put on the pork loin and it should not have had gravy. An interview on 07/08/25 at 3:15 P.M. with Dietitian #457 confirmed recipes should have been followed as written and no extra seasonings should be added if it was not on the recipe. Review of the facility's undated policy Menu and Guidelines revealed there was nothing in the policy regarding following recipes as written. This deficiency represents non-compliance investigated under Complaint Number OH000165404.

The following survey finding pertain to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on interview, record review, and facility policy review, the facility did not ensure physician orders and care planned interventions were implemented to prevent elopement for one resident (Resident #61) who was identified with poor judgement skills and had an appointed guardian. This resulted in Immediate Jeopardy and the potential for life-threatening harm and/or serious injuries when Resident #61, left the facility and was later found by the police approximately 2.4 miles from the facility. This affected one, Resident #61, of three residents reviewed for elopement. The facility identified 22 residents at risk for elopement. The facility census was 166. On 06/07/22 at 11:50 A.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 06/05/22 at 5:30 P.M. when Resident #61 was not provided appropriate supervision and eloped from the facility. On 06/05/22 at 5:00 P.M. Resident #61 was outside visiting and was asked to return to his room. Upon return to his room, Resident #61 became angry and began throwing items in his room and at the staff. Resident #61 was observed by State tested Nurse Aide (STNA) #176 and Registered Nurse Supervisor (RNS) to pack his belongings and express that he was leaving the facility. Resident #61 refused to sign the Against Medical Advice (AMA) paperwork and walked out of the building without any intervention from staff. Resident #61 walked approximately 2.4 miles from the facility trying to locate a friend's house. Resident #61 called the police when he could not remember how to get back to the facility on his own. Resident #61 was returned to the facility at approximately 9:18 P.M. on 06/05/22, four hours after he left the facility. On 06/05/22 at 8:30 P.M. after speaking to Resident #61's guardian on the phone, RNS determined Resident #61 was unable to make the decision to leave AMA and had eloped. On 06/05/22 at 9:18 P.M. while on the phone notifying the police of the elopement, Resident #61 returned to the facility accompanied by the police. The Immediate Jeopardy was removed on 06/06/22, and the deficient practice corrected on 06/06/22 when the facility implemented the following corrective actions: · On 06/05/2022, at 9:18 P.M. Resident #61 returned to the facility. · On 06/05/2022, at 9:20 P.M. a head-to-toe assessment was completed on Resident #61 by Registered Nurse Supervisor (RNS) and Resident #61 was wearing jogger pants, a shirt and tennis shoes. Resident's vital signs were normal, and Resident #61 denied any pain. · On 06/05/2022, the resident's guardian was updated by RNS that the resident returned at 9:20 P.M. · On 06/05/2022, at 9:30 P.M. the Medical Director was updated on the resident's status by Director of Nursing (DON). · On 06/5/22 at 9:45 P.M. elopement assessment completed on Resident #61 by RNS. · On 06/5/22 at 9:20 P.M. a Wanderguard (secure device which alarms when exiting through any exit door in the facility) was placed on the wheelchair by the nurse. Resident #61 refused to allow staff to apply the Wanderguard to his ankle. · On 06/5/22 the care plan was updated by Social Service Designee (SSD) for elopement risk with interventions including the placement of a wanderguard. · On 06/6/22 at 2:00 P.M. the elopement assessments were completed on all residents by the nurse managers on each nursing unit. No other residents were affected. · On 06/5/22 from 9:45 P.M. 11:30 P.M. the DON educated all staff including licensed nurses, state tested nursing assistants, housekeepers, receptionists, social service staff, maintenance, dietary, activity staff, on the elopement policy and procedure. · On 06/6/22 at 4:45 P.M. Elopement drill was completed by the Staff Development Coordinator. (Registered Nurse (RN) #175. · On 06/10/2022, a Quality Assurance Committee Meeting will be conducted and then monthly for three months to review the effectiveness of the corrective action plan. · Two staff members (direct care staff) would be interviewed by DON/Designee weekly for four weeks to ensure understanding of the elopement policy · Elopement drills would be conducted once a week for four weeks by DON/Designee. Findings include: Resident #61 was admitted on [DATE] with diagnoses including pulmonary disease, alcohol dependence with withdrawal, heart disease, [CONDITION(S)] disorder, [CONDITION(S)] type, depression, anxiety, polyneuropathy, obstructive sleep apnea, nicotine dependence, vitamin D deficiency and [CONDITION(S)]. A review of Resident #61's nursing progress note dated 06/05/22 at 5:25 P.M. revealed Resident #61 became very upset with the nursing staff. The charge nurse, Licensed Practical Nurse (LPN) #179, notified the Registered Nursing Supervisor (RNS) of Resident #61's behavior including cursing and throwing items at the staff. Attempts to reason with Resident #61 were unsuccessful and Resident #61 continued to curse and throw things. Resident #61 was observed to pack his belongings and informed the staff he was leaving the facility. RNS informed Resident #61 if he left the facility, it would be considered against medical advice (AMA). Resident #61 continued to curse at the staff and refused to sign the AMA paperwork. A review of Resident #61's physician's order, dated 03/20/21, indicated special instructions for the facility to contact the psychiatry services on-call personnel for afterhours change in condition. A review of Resident #61's plan of care initiated on 03/22/21 indicated a mood problem related to depression. Resident #61 admitted to a history of, and current feelings of depression. Resident #61 stated that he had no family involved in his care. He admitted to feelings of despair, and at times had thought about hurting himself. Resident #61 admitted to being an alcoholic and was unsure if he would be able to return to the place he was residing before his admission to this facility. Resident #61 stated that he was being treated for depression at a hospital-based facility and added that he had not been there in months. The goal of the plan of care included Resident #61 would have improved mood state: happier, calmer appearance, no signs or symptoms of depression, anxiety, or sadness through the next review. The care plan indicated to administer medications as ordered, monitor for side effects and effectiveness; allow time and encourage to express feelings; arrange for clergy or spiritual leader of choice to visit as requested; assist in developing a program of activities that is meaningful and of interest; encourage and provide opportunities for exercise, physical activity; assist to identify strengths, positive coping skills and reinforce these strengths; behavioral health consults as needed and encourage activities of choice, give reminders and escort as needed. A review of Resident #61's Statement of Expert Evaluation dated 07/12/21 indicated a licensed physician had assessed Resident #61. The physician's assessment indicated Resident #61 had significant mental illness and voiced thoughts of both harming himself and others. Resident #61 exhibited a flat affect and could become extremely depressed and critical of himself at times. Resident #61's anxiety level reached a point at times where it limited him physically. Resident #61 had impaired motor behavior, thought processes and judgement. Resident #61 was impatient, impulsive and at times verbally aggressive. Resident #61's diagnosis of [CONDITION(S)] disease had resulted in [CONDITION(S)] making communication difficult. The physician indicated Resident #61 was not capable of caring for himself or managing finances and property. Resident #61's condition was irreversible. The physician recommended to establish a guardian to manage his health decisions and financial responsibilities. An interview with Resident #61's guardian on 06/07/22 at 8:55 A.M. revealed the facility left a message on his voice mail at approximately 5:30 P.M. on 06/05/22 regarding Resident #61 leaving the facility against medical advice (AMA). Resident #61's guardian stated Resident #61 was deemed incompetent and unable to make his own decisions. The guardian stated the resident was unable to leave the facility AMA but eloped from the facility. Resident #61's guardian advised the Registered Nurse Supervisor (RNS) to call the police and inform them of the elopement. The guardian indicated RNS argued with Resident #61's guardian insisting he had left the facility AMA. Resident #61's guardian finally convinced RNS to call the police and report the elopement. The police found Resident #61 walking down the street and took him back to the facility later in the evening at approximately 9:00 P.M. An interview with Director of Nursing (DON) on 06/07/22 at 9:05 A.M. indicated on 06/05/22 in the afternoon Resident #61 became belligerent and throwing items at the staff. Resident #61 refused to sign the paperwork to leave against medical advice (AMA) and proceeded to leave the building. The RNS started to chart the incident in Resident #61's record and realized he had a guardian. RNS called the guardian who advised RNS to call the police. The DON stated the RNS did not know Resident #61 had a guardian at the time he left the building and did not try to stop him from leaving. An interview with Resident #61 on 06/07/22 at 10:50 A.M. indicated he had been really stressed and anxious on Sunday 06/05/22. Resident #61 stated he wanted to go across the street to the garden to calm down, but the staff would not let him leave the building. He just left the faciity on his own on 06/05/22 after packing some of his personal belongings. Resident #61 stated he walked about an hour to a house where his friend used to live approximately 2.4 miles from the facility. Resident #61 stated he tried to call his friend on the phone, but the phone number had been disconnected. Resident #61 stated he couldn't remember how to get back to the facility, so he called the police. The police came and picked him up and brought him back to the facility. Resident #61 was unsure what time he returned to the facility. Resident #61 stated he was very upset at the time he left and unable to control his emotions. An interview with Psychiatric Nurse Practitioner (PNP) on 06/07/22 at 11:33 A.M. revealed she provided psychiatry services for Resident #61. PNP indicated she had last assessed Resident #61 approximately one month ago. PNP indicated she was not notified when Resident #61 eloped from the facility and was unaware if the psychiatrist was notified. PNP indicated she was informed of Resident #61's elopement on Monday 06/06/22. An interview with State tested Nurse Aide (STNA) #176 on 06/07/22 at 2:00 P.M. revealed she was present when Resident #61 was angry and throwing items in his room. STNA #176 stated the RNS attempted to calm him and talk to Resident #61. Resident #61 continued to escalate his behavior and threatened to leave the facility. Resident #61 was informed if he left the facility the discharge would be considered leaving AMA. Resident #61 indicated he didn't care and proceeded to pack his belongings and left the facility. STNA #176 stated no staff attempted to stop him from leaving and she did not know when he returned to the facility. There was no documentation that any additional residents had eloped from the facility since the previous annual survey dated 06/06/19. Two residents (Resident #13, Resident #44), who resided on the locked secured unit, were reviewed for elopement. Both residents were assessed for risk of elopement upon admission and quarterly since their admission to the facility. A plan of care was initiated to address their risk of elopement with individualized interventions implemented. The doors to the secured nursing unit were locked and a code was needed to enter and exit the nursing unit. Observations every one to two hours of Resident #61, Resident #13, and Resident #44 during the survey on 06/07/22 and 06/08/22 revealed no concerns with exit seeking behavior. Residents on the secured nursing unit were re- directed away from the doors when staff were entering and exiting the nursing unit. No concerns were observed pertinent to the allegations. A review of the facility investigation of the elopement was conducted on 06/06/22 to 06/07/22. Staff working at the time of the incident were interviewed and corroborated the information as indicated above. The facility interviewed Resident #61 upon his return to the facility and implemented an intervention to apply a Wanderguard to alert staff of attempts to exit the facility. Corrective actions were implemented immediately including re-training staff on the policy and procedure for elopement and discharge AMA. A review of the facility policy and procedure titled Elopement Prevention dated 07/08/16 indicated the facility would place residents at risk of elopement on the facility elopement prevention program. The procedure for prevention of elopement indicated all residents at risk of elopement would be assessed upon admission, quarterly and as needed by the interdisciplinary team. If the resident was deemed at risk for elopement, the staff should obtain a physician order for an intervention, contact the responsible party and implement the intervention. Residents with secured care bracelets (wanderguard) would be monitored each shift for placement and functions. The Elopement Information Form would be kept in a book at the reception desk and nursing station. Elopement drill would be conducted quarterly. Secure wanderguard doors would be checked daily. When a resident was missing a Code Brown message would be announced to alert staff of the missing resident. Staff should check the sign out sheet at the reception desk and musing station. An extensive search of the building would be conducted. If resident was not found, The Administrator/Designee and Director of Nursing would be notified within the first 15 minutes of the search. The Administrator/Designee would alert the supervisor if the need to implement a driving search within a mile of the area. The resident's family and police would be called by the Administrator/Designee no longer than 20 minutes after the resident was found missing from the facility. Upon return to the facility the family and all persons contacted including the physician would be notified of resident's safe return to the facility. When found the attending physician or licensed nurse would physically assess the resident and report negative findings to the physician. The resident's plan of care would be updated to review and revise interventions for the behavior. A review of the facility policy and procedure titled Discharge of Residents Against Medical Advice (AMA) dated 11/30/18 indicated the policy included for the facility to assist residents with adequate and effective discharge planning through an assessment of needs. Assessment of the resident's appropriateness to be discharged to a more independent setting was completed by the staff and facility's clinical team (physician, nursing, therapy staff and other appropriate disciplines). The facility acknowledges residents with capacity may elect to leave the facility AMA. Under these circumstances, the facility advised the resident of their right to leave the facility, explain possible negative outcomes and off the assist with referrals to appropriate community agencies to monitor the resident and provide services upon discharge. The procedure included upon notification of a resident's intent to leave the facility AMA, nursing, social worker, and other appropriate facility staff would discuss the risks associated with the decision. The risks should include safety concerns and medical risks. If a resident had impaired mental status or if they had a guardian who makes decisions for them, the resident cannot leave AMA on their own accord. The guardian must come to the facility and sign appropriate paperwork and pick up the resident. Discharge instructions would be provided to the resident/guardian via certified mail if the resident leaves before receiving the instructions. Obtain an order from the physician for the AMA. In every case of a resident leaving AMA, the facility shall evaluate the risk of imminent harm to the resident due to the resident's mental and physical condition and the environment outside the facility. In all cases, the facility would contact the resident's personal and/or legal representative to inform of the resident's departure AMA. If the resident is judged to be at risk for imminent harm and the resident departs the facility the police would be alerted along with Adult Protective Services. If the resident is not at risk for imminent harm the facility would contact Adult Protective Services. This deficiency substantiates Control Number OH 173

Based on record review and interview the facility failed to ensure appropriate positioning in bed prior to turning Resident #157 for incontinence care. Actual Harm occurred when Resident #157 was rolled off the bed during incontinence care resulting in a hematoma to the left forehead and hospitalization . This affected one (Resident #157) of five residents observed for accidents. The facility census was 156. Findings include: Review of the medical record revealed Resident #157 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including persistent vegetative state, chronic [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], gastronomy, heart failure, and [CONDITION(S)]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was in a persistent vegetative state and total care with activities of daily living (ADL). The resident was noted to require the assistance of two staff for bed mobility, transfers, toilet use, and hygiene. Review of the resident's record revealed no order for side rails. Review of the state tested nursing assistant (STNA) care card dated 09/07/21 indicated the resident required a mechanical lift using two staff for transfers. ADL care required one staff assist. Review of the STNA documentation for September 2021 revealed there was a combination of both one to two staff assist with ADL. Review of the care plan for ADL care revealed the resident required one staff assist. The nursing progress note dated 09/21/21 stated aide called to nurse to let him know that the resident is on the floor. When the nurse entered the room, he found the resident on the floor. The aide and the nurse picked the resident up and did skin checks and vitals. The resident sustained a hematoma to the left forehead. The family and the physician were notified. The resident was sent to the hospital and had not returned to the facility at the time of the survey. Interview with the Director of Nursing on 10/04/21 at 4:25 P.M. to review the incident report, revealed an agency STNA was providing incontinence care to the resident, and when she rolled her to her side, the momentum of the roll caused the resident to fall out of the bed. The fall resulted in the resident sustaining a hematoma to the left side of the forehead requiring hospitalization . This deficiency substantiates Complaint Number OH 060.

Based on closed medical record review, interviews with staff and Resident #181's family, review of the facility's investigation including witness statements, review of the facility's Wandering Elopement Prevention Policy, Incident by Incident Type report, and in-service training, the facility failed to provide adequate supervision when Resident #181 left the facility unattended and was located by a person in the community 0.9 miles away from the facility. This resulted in Immediate Jeopardy for one resident (Resident #181) who displayed exit seeking behaviors and staff failed to implement measures to prevent elopement. Thirty-six residents were identified as at risk for elopement. The facility census was 180. On 11/12/14 at 2:45 P.M., the Administrator, Director of Nursing (DON), Chief Clinical Officer #17, and Clinical Support Specialist #18 were notified that Immediate Jeopardy began on 10/14/14 at 11:45 A.M. when Resident #181 attempted to exit the building, stating she wanted to go home. Licensed Practical Nurse (LPN) #20 obtained a new physician's orders [REDACTED]. On 10/14/14 at 3:02 P.M., Receptionist #21 received a call from an unidentified nurse in the community reporting she was with Resident #181 approximately 0.90 miles from the facility in an industrial area. The Administrator and Bookkeeper #28 went to this location on 10/14/14 at 4:34 P.M., and Resident #181 was returned to the facility by ambulette. Resident #181 was assessed upon return without injury. The Immediate Jeopardy was removed on 10/16/14 when the facility implemented the following corrective actions: ? On 10/14/14 at 3:05 P.M., inservice training was initiated by the Registered Nurse (RN) #25, Housekeeping and Laundry Supervisor #23, LPN #25, Activity Director (AD) #26, and Occupational Therapist #31for all facility staff regarding the Wandering Elopement Prevention Policy. The training continued through 10/15/14 and included eleven registered nurses, 23 LPNs, 63 State tested Nurse Aides (STNA), 14 dietary staff, 18 housekeeping and laundry staff, seven activity staff, three physical therapy staff, two occupational therapy staff, five receptionists, two maintenance staff, three social workers, and one central supply staff. This training encompassed all employees of the facility. ? On 10/14/14 at 4:30 P.M., every 15 minute checks were implemented for Resident #181. ? On 10/14/14 at 10:29 P.M., LPN #22 applied the Wanderguard device to Resident #181's ankle. ? On 10/15/14 at 9:00 A.M., during the morning meeting attended by the DON, RNs #24, #30, #32, and LPNs #25, #33 and #34, 51 residents previously identified as a high risk for elopement were reassessed for elopement potential by the interdisciplinary team. ? On 10/15/14 at 9:30 A.M., 36 residents identified as high risk for elopement were reassessed for the continued use of a Wanderguard device. ? On 11/12/14, interview with RN #24, LPN #46, LPN #49, STNA #29, STNA #47, and STNA #48; on 11/13/14 with Housekeeper #45; and on 11/17/14 with Receptionist #50, Maintenance Staff #55, and Social Worker #57 revealed they were all knowledgeable about the elopement policy and procedure. ? On 11/12/14 at 3:50 P.M., interview with Director of Nursing (DON) #16 revealed the Wanderguard devices for the 36 residents assessed to require this device were checked each shift for proper functioning. Documentation was also provided on the Treatment Administration Records (TAR) for each resident to indicate the nurse had checked the Wanderguard device each shift. ? On 11/13/14, review of the facility Incident by Incident Type report revealed no evidence of any other elopements occurred at the facility from 09/01/14 through 11/13/14. ? On 11/13/14 at 5:25 P.M. the facility completed the reassessment of all 180 facility residents and determined the only residents at risk for elopement were the 36 residents reassessed on 10/15/14. There were no additional residents found as an elopement risk. Although the Immediate Jeopardy was removed when the facility took measures to protect Resident #181 and those residents identified as an elopement risk in order to prevent subsequent elopements, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility continues to train staff to ensure they are aware of measures to prevent resident elopements, and immediately respond to residents who demonstrate exit seeking behaviors by implementing interventions to prevent elopement including elopement drills. Findings include: Review of the medical record revealed Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set Assessment ((MDS) dated [DATE], revealed Resident #181 had no cognitive impairment, and her speech was unclear but she was usually understood. Resident #181 required the extensive assistance of two or more staff for all activities of daily living, including bed mobility, transfer, toileting, and dressing. The resident required a wheelchair for mobility throughout both in and outside of the facility. The resident needed supervision and one person physical assistance for locomotion off the unit. The resident had functional impairment to her bilateral lower extremities and was not steady, needing the staff's assistance to stabilize for balance and during transitions. Review of the plan of care related to physical mobility indicated Resident #181 required the assistance of two persons during transfers, may use electric wheelchair for mobility, required monitoring for fatigue and provided rest periods. The admission note dated 08/25/14 at 5:27 P.M., written by LPN #20 indicated Resident #181 was not at risk for elopement, and an identification bracelet was placed on the resident's wrist which was part of the admission process. According to the progress note written by LPN #20 on 10/14/14 at 11:45 A.M., Resident #181 was on the first floor pounding on the door yelling "I'm going home, call my daughter." LPN #20 also noted she called the residents daughter informing her that Resident #181 was trying to leave and cursing at staff. A new physician's telephone order dated 10/14/14 was obtained for a Wanderguard device. On 10/14/14 at 4:04 P.M., LPN #20 noted she contacted Resident #181's daughter regarding the resident eloping from the facility in the electric wheelchair. On 10/14/14 at 4:26 P.M. LPN #20 noted the daughter refused placement of Resident #181 on the secured unit but agreed to the Wanderguard device. Review of the facility's investigation and witness statements dated 10/14/14, 10/15/14, and 10/16/14 revealed on 10/14/14, Receptionist #21 noted Resident #181 was asking to go home and talk to her daughter. At one point the resident went to the door at 10:30 A.M. began tapping on it and the keypad trying to get out. Receptionist #21 informed RN #24 who redirected the resident back to her unit on the fourth floor and indicated they were going to apply a Wanderguard device. Receptionist #21 noted that she said to RN #24, "good, she needs one." Receptionist #21 received a telephone call at 3:02 P.M. from an unidentified nurse in the community indicating she was with Resident #181 on the Fulton Bridge between Bailey and Vega streets. Receptionist #21 noted on 10/14/14 at 3:10 P.M., RN #24 called to inform her they were going to put a Wanderguard device on Resident #181 and Receptionist #21 informed her it was too late, as Resident #181 was found on the Fulton bridge. An undated statement by Central Supply Staff #27 indicated he was asked on 10/14/14 around 12:00 P.M. by RN #24 to bring a Wanderguard device to the fourth floor. He stated as the day continued he forgot about the Wanderguard device. On 10/14/14 at 4:30 P.M. a physician's orders [REDACTED].#181. Review of the every 15 minute check resident observation forms revealed Resident #181 was observed every 15 minutes beginning on 10/14/14 at 4:30 P.M. and concluded on 10/21/14 at 2:15 P.M. Interview with the DON on 11/12/14 at 11:25 A.M. revealed the physician determined the 15 minute checks were no longer necessary. A progress note written by LPN #20 on 10/14/14 at 4:34 P.M., indicated Resident #181 returned to the facility after being found on the Fulton Bridge at 4:15 P.M. Resident #181 did not sustain any harm. Fifteen minute checks were implemented for this resident upon her return to the facility until the Wanderguard device was placed on the resident at 10:29 P.M., by LPN #22. Review of the minutes from the clinical staff meeting held on 10/15/14 at 9:00 A.M. attended by the DON, RN #24, RN #30, RN #32, LPN #25, LPN #33, and LPN #34 indicated the action plan to identify residents at risk for elopement included an assessment that would be completed upon admission and readmission; quarterly and significant change assessments that would be completed per the MDS schedule for current residents; and an assessment that would be completed as a resident presents with exit seeking behavior to determine if further interventions were needed. At this meeting, 51 residents who were already identified as a risk for elopement were reassessed. The team determined 36 of the 51 residents (#1, #2, #3, #6, #13, #14, #22, #23, #26, #29, #30, #40, #42, #49, #50, #52, #54, #55, #58, #62, #64, #72, #73, #87, #96, #99, #115, # #116, #120, #122, #127, #131, #133, #139, #164, and #171) would benefit from the use of a Wanderguard device to prevent elopement. The remaining 15 residents were in a secured unit and it was determined a Wanderguard device was not necessary for these residents. Interview with Resident #181's daughter on 11/12/14 at 10:42 A.M. revealed she removed her mother from the facility on 11/01/14 after skilled services were completed. Interview with State tested Nurse Aide (STNA) #29 on 11/12/14 at 11:30 A.M. indicated Resident #181 resided on the fourth floor and was admitted for rehabilitation. STNA #29 reported it took two staff to provide care for the resident. STNA #29 reported Resident #181 used an electric wheelchair for mobility and indicated she was unsafe because she would run into staff and other residents, as well as move very fast in the electric wheelchair. The wheelchair speed would be turned down by staff, but the resident would increase it herself. On 11/12/14 between 3:05 P.M. and 3:40 P.M., all 36 residents who used Wanderguard devices were observed by the surveyor and the DON. Each resident had a Wanderguard device in place. The DON tested each Wanderguard device and confirmed they were functioning. The DON also showed the surveyor documentation by the nurse on the Treatment Administration Record (TAR) that the Wanderguard device was check and functioning properly. Review of the facility Incident by Incident Type report for the dates of 09/01/14 through 11/13/14 revealed no evidence of any other elopements that have occurred at the facility. Interview with Receptionist #21 on 11/13/14 at 9:51 A.M. indicated Resident #181 began trying to leave the facility on 10/14/14 at 10:30 A.M. She informed RN #30 of the resident's attempts to leave the facility. Receptionist #21 stated the resident was redirected to her unit on the fourth floor but returned to the lobby two to three more times. Receptionist #21 stated she was informed by RN #24 that a Wanderguard device would be provided to Resident #181 between 11:00 A.M. and 11:30 A.M. She stated the Wanderguard device was never applied before the resident left the building on 10/14/14. Receptionist #21 stated she received a telephone call from an unidentified R.N. who reported seeing Resident #181 on the Fulton Bridge wearing an identification bracelet. She then requested the Admission Director #19 to talk to the caller on the phone. On 11/14/14 at 1:10 P.M., interview with the DON revealed on 11/13/14 the three assessment nurses (RN #40, LPN #41, and LPN #42) reviewed all 180 residents in the facility and completed a Wandering/Elopement worksheet by 5:25 P.M. for each resident. They confirmed the only residents at risk for elopement were the 36 residents that were identified on 10/15/14. There were no additional residents who were found at risk for elopement. On 11/17/14 at 12:30 P.M., interview with Receptionist #50 revealed she had a binder that contained information on all 36 residents who wore Wanderguard devices and were at risk for elopement. She also had the pictures of 17 residents identified at high risk for elopement within her view as she watched a monitor that showed video images of 16 areas in the building that were exit doorways or exit corridors leading to the exit doorways. She said a receptionist was at this front desk 24 hours a day, and when she took a break, one of the administrative staff or trained office staff monitors the area until she returns. She showed the surveyor how she can easily lock the entrance door to the parking lot from the desk area, and would do so in the event she saw a resident attempting to go out that door. The remaining doors were alarmed and had video camera monitoring to prevent unknown exit from these doorways. Interview with Maintenance Staff #55 on 11/17/14 at 1:00 P.M., revealed he checks each exit door every day to assure the alarms are working properly. He was knowledgeable with the proper response according to the facility procedure if he should see a resident attempting to leave. Interview with Social Worker #57 on 11/17/14 at 1:15 P.M., revealed the facility has conducted elopement drills where staff respond to a planned simulation where a resident cannot be found. Interview with the administrator on 11/17/14 at 2:00 P.M., revealed the facility conducted one elopement drill on 09/16/14 on the day shift in order to keep staff knowledgeable of what to do in the event a resident could not be found. Documentation of this drill showed it was attended by 56 staff from all departments. There was no evidence of an elopement drill conducted since Resident #181 eloped from the facility on 10/14/14.