Every finding on record at Green Hills Center

Based on record review, resident interview, staff interview, and policy review the facility failed to ensure care conferences were conducted quarterly. This affected four (#12, #38, #39, and #51) of four residents reviewed for care conferences. The facility census was 67. 1.Review of medical record for Resident #12 revealed an admission date of 04/29/25 with diagnoses including but not limited to type two diabetes, congestive heart failure, chronic atrial fibrillation, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. Review of care conference notes revealed the last care conference was held on 11/19/24 and only two members of the interdisciplinary team (IDT) were present. 2.Review of Resident #38's medical record revealed an admission date of 12/18/24, diagnoses included cerebral infarction, fistula of stomach and duodenum, ventral hernia, atrial fibrillation, acute gastric ulcer with perforation, type 2 diabetes, dysphagia, gastrointestinal hemorrhage, and bed confinement status. Review of Resident #38's MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #38's care plan dated 7/17/25 revealed the resident has cognition related issues stemming from episodes of confusion with interventions to encourage resident to make decisions and choices related to care and daily routine. Review of Resident #38 medical records from 1/25 through 9/25 revealed no care conferences were conducted. 3.Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including but not limited to type two diabetes, dementia, major depressive disorder, and hypertension. Review of MDS assessment dated [DATE] revealed Resident #39 had moderately impaired cognitive impairment. Review of care conference summary dated 05/20/25 revealed the conference was attended by the Director of Nursing and Activities and the resident representative. The summary form was blank except for the activities section. 4.Review of medical record for Resident #51 revealed an admission date of 05/23/23 with diagnoses including but not limited to chronic obstructive pulmonary disease, essential tremor, hypertension, and emphysema. Review of MDS assessment dated [DATE] revealed Resident #51 was cognitively intact. Review of care conference documentation revealed the last care conference was held on 08/21/23 with no one in attendance besides the social worker. Interview on 09/10/25 at 3:14 P.M. with the Administrator revealed the home office had conducted a mock survey on 08/08/25 and identified an issue with care conferences being completed. The Administrator stated she received the report on 08/20/25 and started education with the IDT on care conferences. The Administrator verified the care conference have not been completed as of the survey date. The Administrator verified that Residents #12, #38, #39, and #51 did not have quarterly care conferences or the appropriate IDT members in attendance. Review of policy titled Comprehensive Care Planning Policy dated 11/13/2017 revealed the facility encourages the resident and/or resident representative to participate in the care planning process.

Based on record review, observation, interview, and policy review the facility failed to ensure resident dignity when giving insulin injections. This affected one (#39) resident of one resident reviewed for insulin injections. The facility census was 67.Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including type two diabetes, dementia, and major depressive disorder.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment.Review of current physician orders revealed an order initiated on 09/08/25 following the observation in the dining room indicating may give medications, check blood sugar and give insulin in public spaces and dining room.Observation on 09/08/25 at 11:22 A.M. of Registered Nurse (RN #360) revealed the nurse came up to Resident #39 sitting at a table in the dining room and informed the resident she had her insulin to administer. RN #360 proceeded to lift the resident's shirt and administer the insulin in the resident's abdomen. One family member and three other residents were observed sitting at the same table. RN #360 did not have gloves on during the administration of the insulin, nor did she perform hand hygiene prior to administering the insulin.Interview on 09/08/25 at 11:23 A.M. with RN #360 revealed the nurse verified she gave insulin in the dining room with other residents at the table. RN #360 stated she should have pulled the resident away from the table before administering the insulin. RN #360 stated she should have donned gloves prior to administering the insulin.Review of policy provided by the facility titled Subcutaneous injection revised 05/19/2025 revealed perform hand hygiene, provide privacy, explain the procedure to the patient, position the patient and expose the injection site, perform hand hygiene, put on gloves if contact with blood or bodily fluids is likely or if your skin or the patient's skin isn't intact. Gloves are not required for routine subcutaneous injections because they do not protect against needlestick injury.This deficiency represents noncompliance investigated under Complaint Number 2601174.

Based on record review, interview, and policy review the facility failed to ensure residents were provided written bed hold notices. This affected two (#75 and #78) of three reviewed for hospitalizations. The facility census was 67. 1. Review of Resident #75 medical record revealed an admission date of 6/10/25, diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, heart failure, hypo-osmolality and hyponatremia, chronic lymphocytic leukemia of B-cell, atherosclerotic heart disease, chronic obstructive pulmonary disease, hypertension, and cerebral infarction. Review of Resident #75's Minimal Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required partial assistance with activities, and required a wheelchair for ambulation. Review of Resident #75's care plan dated 6/10/25 revealed the resident was at risk for alteration in their respiratory status related to chronic obstructive pulmonary disease. Interventions included to monitor for shortness of breath, chest pain, or change of condition. Review of Resident #75's progress notes dated 6/18/25 from 9:55 A.M. to 3:14 P.M. revealed the resident was alert and easily fatigued, had increased shortness of breath while on 4 liters of oxygen, was complaining of shortness of breath and was coughing and expelling white and pink tinged sputum. A new order for a chest x-ray was received. Chest x-ray results revealed the resident had bilateral airspace disease with modest pleural effusions, with pneumonia considered due the resident's clinical condition. Further review revealed that the resident's family was contacted and they requested that the resident be transported to the hospital. Review of Resident #75 discharge information revealed no bed hold notice was provided to the resident or their representative. Interview on 9/11/25 at 10:15 A.M. with the Executive Director confirmed the facility did not have documentation to support they provided a bed hold notice to Resident #75 or their representative upon Resident #75's discharge to the hospital. 2. Review of medical record for Resident #78 revealed an admission date of 07/10/25 and discharge date of 08/18/25. Diagnoses included metabolic encephalopathy, type two diabetes, hypertension, congestive heart failure, depression, seizures, and post traumatic seizures. Review of MDS assessment dated [DATE] revealed Resident #78 had moderate cognitive impairment. Review of progress note dated 07/27/25 revealed Resident #78 had a decline in speech, appetite, and alertness. Resident #78 was sent to the hospital and required admission. Family/representative was contacted regarding situation. Review of progress note dated 08/17/25 revealed Resident #78 was sent to the Emergency Department and returned at 10:08 A.M. with a diagnosis of urinary tract infection. Interview on 09/11/25 at approximately 10:15 A.M. with the Administrator revealed the facility did not provide a bed hold notice for the hospital stay on 07/27/25 or the emergency room visit on 08/17/25. Review of policy titled Bed Hold Policy dated 11/14/2017 revealed all residents/elders and representatives are notified of the bed hold policy at the time of admission, prior to any transfer, therapeutic leave and at time of transfer. If the transfer is emergent, the resident/elder and representative must be notified within 24 hours.

Based on record review, interview, and policy review the facility failed to ensure wounds were assessed weekly for Resident #67, and the facility further failed to ensure treatments were in place and completed per physician order for Resident #52. This affected two (#67 and #52) residents of three residents reviewed for wounds. The facility census was 67. 1.Review of medical record for Resident #67 revealed an admission date of 01/19/25 with diagnoses including but not limited to acute transverse myelitis in demyelinating disease of central nervous system, paraplegia, pressure ulcer of right buttock stage four (severe form of skin damage involving full-thickness tissue loss exposing muscle, tendon, or bone), and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 had a stage four pressure ulcer not present on admission. Review of weekly skin observations revealed Resident #67 had weekly assessments completed from 06/07/25 through 07/19/25, on 07/29 and 08/19, and then again weekly from 08/19/25 through 09/02/25. None of the weekly skin observations completed by the nursing staff contained wound measurements or wound descriptions. Review of wound clinic documentation dated 06/30/25, 07/09/25, 07/21/25, 08/04/25, 08/18/25, and 09/08/25 revealed Resident #67 was not seen weekly. The wound clinic documentation did include wound measurements and a wound description. Interview on 09/11/25 at approximately 1:15 A.M. with the Director of Nursing (DON) revealed the DON verified Resident #67 did not go to the wound clinic weekly. The DON verified the weekly skin assessments completed by nursing did not contain wound measurements or wound descriptions. Review of policy titled Skin Care Management Procedure revised on 12/09/2022 revealed with each dressing change or at least weekly at a minimum, documentation should include the date observed, location and staging, size, depth, and the presence, location and extent of any undermining or tunneling/sinus tract, exudates if present, type, color, odor and approximate amount, pain if present, wound bed color and type of tissue/character, including evidence of healing or necrosis and percent of tissue, and description of wound edges and surrounding tissue. 2.Review of Resident #52's medical record revealed an admission date of 3/23/25 and diagnoses including of chronic diastolic heart failure, atherosclerotic heart disease, chronic pain, sarcoidosis of the lung, hyperlipidemia, protein-calorie malnutrition, history of venous thrombosis and embolism, pressure ulcer of right heal, pressure ulcer of left heel, pressure ulcer of left ankle and lymphedema. Review of Resident #52's wound care order dated 8/20/25 revealed the resident's right heel was to have Hydrofera blue moisten with saline to applied to the wound bed, covered with four by four gauze, secured with Kerlix and tape, and change daily starting on 8/21/25. Further review of the wound care orders revealed a second wound order also dated 8/20/25 for Resident #52's left ankle. The left ankle was to have silver alginate applied to the wound bed, covered with a four by four gauze, and secured with Kerlix with dressing changes daily, and start on 8/21/25. Review of Resident #52's August treatment records revealed no documentation the wound care orders dated 8/20/25 for the left and right heel were implemented until 08/23/25. Interview with the Director of Nursing on 09/11/25 at 11:50 A.M. confirmed the treatment order written on 08/20/25 for wounds to Resident #52's left and right heels were not started on 08/21/25 as ordered and further verified there was no evidence the wound treatments were completed on either 08/21/25 or 08/22/25. Review of the facility policy titled Skin Care Management Procedure, dated 12/09/22 stated the physician will be notified of all skin areas of concern and consulted for treatment orders.

Based on record review and interview the facility failed to ensure pre and post dialysis communication forms. This affected one (#55) resident of one resident reviewed for dialysis. The facility census was 67.Review of medical record for Resident #55 revealed an admission date of 06/20/25 with diagnoses including but not limited to type two diabetes, end stage renal disease, and dependence on renal dialysis.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact.Review of current physician orders revealed an order to complete the pre dialysis communication form every night shift on Tuesday, Thursday, and Sunday and to complete the post dialysis form every Monday, Wednesday, and Friday.Review of pre dialysis communication forms revealed the following dates were not completed 07/07/25, 07/09/25, 07/11/25, 07/16/25,07/21/25, 07/28/25, 08/06/25, 08/11/25, 08/18/25, 08/20/25, 08/29/25, and 09/05/25.Review of post dialysis communication forms revealed the following dates were not completed 07/07/25, 07/11/25, 07/18/25, 07/21/25, 07/25/25, 08/04/25, 08/13/25, 08/15/25, 08/22/25, 08/25/25, and 08/27/25.Interview on 09/10/25 at 2:15 P.M. with the Administrator verified the pre and post dialysis forms for Resident #55 were not completed as ordered and they should have been.

Based on observation, interview, and facility policy review the facility failed to ensure gloves and/or hand hygiene was completed prior to administering an insulin injection. This affected one resident #39 of one resident observed for insulin administration. Further more, the facility failed to provide sanitary environment when passing meal trays in resident's rooms. This affected two residents (#41 and #43) out of seven room trays observed. Census was 67. 1.Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including type two diabetes, dementia, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment. Review of current physician orders revealed an order initiated on 09/08/25 following the observation in the dining room indicating may give medications, check blood sugar and give insulin in public spaces and dining room. Observation on 09/08/25 at 11:22 A.M. of Registered Nurse (RN #360) revealed the nurse came up to Resident #39 sitting at a table in the dining room and informed the resident she had her insulin to administer. RN #360 proceeded to lift the resident's shirt and administer the insulin in the resident's abdomen. One family member and three other residents were observed sitting at the same table. RN #360 did not have gloves on during the administration of the insulin, nor did she perform hand hygiene prior to administering the insulin. Interview on 09/08/25 at 11:23 A.M. with RN #360 revealed the nurse verified she gave insulin in the dining room with other residents at the table. RN #360 stated she should have pulled the resident away from the table before administering the insulin. RN #360 stated she should have donned gloves prior to administering the insulin. Review of policy provided by the facility titled “Subcutaneous injection” revised 05/19/2025 revealed perform hand hygiene, provide privacy, explain the procedure to the patient, position the patient and expose the injection site, perform hand hygiene, put on gloves if contact with blood or bodily fluids is likely or if your skin or the patient's skin isn't intact. Gloves are not required for routine subcutaneous injections because they do not protect against needlestick injury. 2.Observation on 09/10/25 at 12:42 P.M. revealed Certified Nursing Assistant (CNA) #366 carried Resident #41's lunch tray into her room. Before placing lunch tray on bedside tray, CNA #366 removed tissue box and a cup. CNA #366 placed lunch tray on bedside table and removed the lid from the top of the food and took the silverware out of a plastic wrap, and adjusted bedside tray. CNA #366 walked out of Resident #41's room up to food cart and grabbed Resident #43's food tray, walked into Resident #43's took the lid off food, and walked out the door. No hand hygiene was performed at the start of meal tray pass and no hand hygiene was performed in between serving Residents #41 and #43 their meals in different rooms. Interview on 09/10/25 at 12:50 P.M. with CNA #366 verified no hand hygiene was completed before passing meal trays and no hand hygiene was completed between serving Resident #41 and Resident #43's their meal meal trays in their individual rooms. Review of facility policy Hand Hygiene Procedure, dated 03/27/25, hand hygiene is to be after contact with inanimate objects in the immediate vicinity of the patient. This deficiency represents noncompliance investigated under Complaint Number 2601174.

Based on record review, review of the facility policy, staff interview, and resident interview, the facility failed to ensure all care was provided to residents with pressure ulcers per thier physician's orders. This affected one (Resident #2) out of four residents reviewed for pressure ulcer care. The current census is 67. Findings include: Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #2 include neuromyelitis, neurogenic bladder, chronic pain, and osteomyelitis. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed upon admission the resident had one unhealed stage 3 pressure ulcer and one unhealed stage 4 pressure ulcer. Review of Resident #2's MDS assessment dated [DATE] revealed the resident had intact cognition and two unhealed pressure ulcers. Review of Resident #2's care plans dated 12/20/24 revealed the resident was at risk for pressure ulcers due to mobility. Interventions included treatment per order, medications per order, monitor for changes and report to physician, and measure and monitor wound healing. Review of Resident #2's wound clinic documentation dated 10/28/24 revealed the resident was being cared for by the community wound physician in the clinic since 03/20/23. Per the wound documentation the resident had multiple chronic pressure ulcers which healed and then were reacquired due to her medical condition. On 10/28/24 the wound physician documented the resident had a stage 4 chronic pressure ulcer to the left buttock measuring 0.4 centimeters (cm) by 0.1 cm by 0.9 cm on 11/24/23. No pain was noted per resident report. Per the documentation the wound physician ordered the dressing change to be cleansing with normal saline, apply Medi honey get into wound bed and cover with gauze, to be changed every other day. Review of Resident #2's wound clinic documentation dated 02/03/25 revealed the resident had acquired a chronic pressure ulcer stage 4 on her right buttock measuring 1.9 cm by 2.5 cm by 1.7 cm depth with a moderate amount of serosanguineous drainage on 12/09/24. Per the documentation the wound physician ordered to have a wound vac placed on 02/05/25 for healing of the wound. Review of Resident #2's skin assessment dated [DATE] completed by Licensed Practical Nurse (LPN) #100 revealed on the 38 page assessment there was no documentation of any skin breakdown or wounds on the right buttock or gluteal fold. Review of Resident #2's physician orders dated 12/2024 to 02/2025 revealed on 11/07/24 the physician ordered to cleanse an open area to the right inner gluteal fold with normal saline and cover with dry foam dressing every other day at bedtime. On 12/10/24 the physician ordered to cleanse the right gluteal fold with normal saline, pat dry, and apply collogen and cover with gauze every day and as needed. On 12/16/24 the right gluteal fold dressing was changed to cleanse with normal saline, pat dry, apply Medi honey and cover with a foam dressing, change every other day and as needed. On 01/21/25 the right gluteal dressing order was cleanse with normal saline, pat dry, apply Santyl to wound bed pack with normal saline and cover with foam dressing to be changed every day and as needed. On 12/18/24 the physician ordered the left gluteal dressing order to be cleanse with normal saline, pat dry, apply border gauze every other day. Per the physician orders dated 02/04/25 the facility was to apply the wound vac to the right buttock wound. A large green foam to the wound bed, bridge away from pressure points, 125 mmHg continuous suction and the dressing was to be changed three times a week, Monday at wound clinic, Wednesdays and Fridays at the facility. The wound vac order was active at the time of the survey. Review of Resident #2's Treatment Administration Record (TAR) dated 12/2025 revealed there was no documentation of the resident receiving the dressing changes to the left gluteal fold on 12/11/24. Per the TAR dated 01/2025 Resident #2 did not receive the treatments to the left gluteal fold wound per physician order on 01/07/25, 01/11/25, 01/15/25, 01/17/25, 01/21/25, and 01/29/25. Resident #2 did not receive treatment to the right gluteal wound per physician order on 01/06/25, 01/07/25, 01/11/25, 01/15/25, 01/16/25, 01/17/25, and 01/19/25. Per the TAR dated 02/2025 Resident #2 did not receive the wound vac care on 02/18/25 and 02/19/25 per physician order. No corresponding documentation for the missing treatments was noted elsewhere in the medical records. Interview on 02/19/25 at 1:30 P.M. and on 02/20/25 at 11:15 A.M. with Resident #2 revealed she knew she had open wounds on her backside prior to the wound vac being applied. Resident #2 stated due to her conditions she would probably always have wounds. Resident #2 stated the nurses did not change the dressings daily. Resident #2 stated she hasn't had any increased pain due to the wounds and stated she feels the wounds will heal eventually as long as she continues to see the wound physician in the clinic. Interview on 02/20/25 at 8:22 A.M. with LPN #100 revealed the nurse was the unit manager for Resident #2's unit. LPN #100 stated she does all the rounding with the in-house wound providers and reviews all the skin assessments and dressing changes for the residents. LPN #100 stated she was not aware of when the dressing changes were to be made for Resident #2's left buttock dressing but stated she knew the wound vac was changed in the wound clinic on Tuesday. The surveyor encouraged LPN #100 to review the orders on the computer to ensure accurate interview. LPN #100 stated Resident #2's wounds were cared for by an outside wound clinic and the dressing changes were to be added to the medical records. LPN #100 denied any reports from Resident #2 regarding her treatments not being completed Interview on 02/20/25 at 12:10 P.M. with Quality Assurance Manager (QAM) and LPN #100 verified there were missing documentation in the treatment records for 12/2024, 01/2025, and 02/2025's dressing changes for both her right and left buttock wounds and the wound vac. Interview on 02/20/25 at 12:30 P.M. with the Physician revealed the primary physician stated due to Resident #2's chronic medical conditions she would always be prone to having pressure ulcers. Per the Physician, all staff are to be careful with transfers and to report any changes in the resident's skin. The Physician stated the resident's wounds are being managed by an outside provider but stated he believed all the treatments were appropriate and to be completed by the nursing staff. Interview on 02/20/25 at 2:50 P.M. with LPN #100 revealed after Resident #2 returned from her wound clinic appointment on 12/09/24 she and the previous DON assessed the resident's right buttock. LPN #100 stated she felt the wound was Moisture-Associated Skin Damage (MASD) and not a pressure ulcer. LPN #100 stated the previous DON contacted the primary physician for orders for the dressing care for the right buttock before the wound clinic had sent their orders to the facility. LPN #100 verified she had documented on the resident's left buttock the day after she returned from the wound clinic but could not recall the right buttock's condition of wound during her assessment. Review of the facility policy titled, Skin Care Managment, dated 11/17/22 revealed the facility staff is to provide care for all skin breakdown to promote healing the pressure ulcers. This deficiency represents non-compliance investigated under Complaint Number OH00162641 and OH00162467.

Based on medical record review, review of the facilities Self-Reported Incident (SRI) including investigation, observations, staff interview, and review of the facilities abuse policy, the facility failed to ensure a resident was free from physical abuse. This affected one (#200) of four residents reviewed for abuse. The facility census was 66. Findings include: Review of the medical record for Resident #200 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia with psychotic disturbance, major depression, anxiety, mild neurocognitive disorder, psychosis, and primary insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200's cognition was impaired. Resident #200 required substantial/maximal assistance from staff with eating and shower/bathe and dependent on staff for toileting, upper and lower body dressing, and personal hygiene. Review of the revised care plan dated 08/06/24 revealed Resident #200 was at risk for social isolation related to dementia, psychotic disorder and new environment. Resident #200 should be encouraged to participate in recreational activities, social situations, and provide positive enforcement with resident participates in activities. Review of the facilities SRI dated 08/24/24 revealed an allegation of physical abuse when State tested Nursing Aide (STNA) #3 positioned a desk chair to block Resident #200's wheelchair from moving back away from the counter. Resident #202 reported two STNAs sitting at the nurses' station and were pushing Resident #200's head down onto the pillow positioned on the counter periodically trying to get her to sleep. The facility substantiated the allegation of abuse by verified evidence and notified the local police department (LPD) that staff physically abused Resident #200. Review of the facility's investigation and witness statements dated 08/24/24 revealed on 08/24/24, STNA #44 and Hospitality Aide #33 reported to work at 5:49 A.M. to find Resident #200 sitting in her wheelchair at the nurses' station desk with STNA #3 (who worked for agency staffing) sitting next to Resident #200. A desk chair was positioned to block Resident #200's wheelchair from moving back away from the counter blocking her movement. Witness statement from STNA #44 stated she witnessed Resident #200's wheelchair lodged with a chair underneath the wheelchair wheel. Witness statement from STNA #3 acknowledged placing the chair in that position. The witness statement from Resident #202 revealed she was awakened by noise at the nurses' station and got up about 2:00 A.M. and observed two STNAs sitting at the nurses' station and were pushing Resident #200's head down onto the pillow positioned on the counter periodically trying to get her to sleep. Resident #200's wheelchair was pushed up to the counter and the desk chair was blocking her chair. Review of the LPD report dated 08/24/24 at 3:00 P.M. documented a report of allegation of abuse had occurred overnight, to which an STNA held Resident #200's head down onto a pillow to make the resident sleep and placed a desk chair against the resident's wheelchair from moving away from the desk. Further documentation on 08/29/24 at 4:00 P.M. reported the Administrator contacted the LPD stating the allegation was substantiated and wanted the police to investigate as a criminal matter. Observation on 09/04/24 from 8:47 A.M. to 9:22 A.M. revealed Resident #200 sitting at the nurse's station and Resident #200 was asleep. Interview on 09/04/24 at 9:50 A.M. with the Director of Nursing (DON) verified Resident #200 was physically abused by two STNAs on 08/24/24. Interview on 09/04/24 at 11:30 A.M. with the Administrator verified Resident #200 was physically abused by two STNAs on 08/24/24. The Administrator stated the SRI was substantiated after the investigation found that an agency staff restrained Resident #200 in wheelchair using another chair to block her ability to move the chair or stand. The facility was unable to obtain statements from the two Alleged Perpetrators, STNA #3 and STNA #4 as they were uncooperative with the investigation. STNA #3 and STNA #5 were put on the Do Not Return and were barred from picking up shifts at the facility. Attempts to contact STNAs #3 and #4 during the survey were unsuccessful. Review of the policy titled Abuse and Neglect with a revision date of 11/21/16, revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This deficiency represents non-compliance investigated under Control Number OH00157383 and Complaint Number OH00157352.

Based on medical record review, observations, staff interviews, and review of the facility policy, the facility failed to ensure a resident's plan of care was revised when changes were made for the resident's comfort and positioning. This affected one (#200) of four residents reviewed for plan of care. The facility census was 66. Findings include: Review of the medical record for Resident #200 revealed admitted [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia with psychotic disturbance, major depression, anxiety, mild neurocognitive disorder, psychosis, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had cognition impairment. Resident #200 was dependent on staff for upper and lower body dressing and personal hygiene. Review of Resident #200's comprehensive plan of care dated 05/06/24 revealed it was silent for the utilization of a custom wheelchair/ tilt and space wheelchair. Review of Resident #200's physician order revealed it was silent for orders for a tilt and space wheelchair. Interview with State tested Nursing Aide STNA #11 on 09/04/24 from 8:46 A.M. verified Resident #200 was in a tilt and space wheelchair with no footrests. STNA #11 stated Resident #200's wheelchair was supposed to have footrest but STNA #11 had not put them on yet. Observation on 09/04/24 from 8:47 A.M. to 9:22 A.M. revealed Resident #200 was asleep and sitting at the nurse's station in a tilt-space wheelchair, with no footrests and both feet dangling with the inability to touch the floor. Interview on 09/04/24 at 9:50 A.M. with the Director of Nursing (DON) verified Resident #200 was placed in the custom- tilt and space wheelchair after Resident #200 received therapy for positioning and comfort. Interview on 09/04/24 at 11:15 A.M. with Occupational Therapist (OT) #19 stated Resident #200 was seen by therapy for positioning/comfort and they placed her in the custom tilt and space wheelchair. OT #19 verified Resident #200 was to have wheelchair footrest for feet and tilted at a slight angle for comfort. Resident #200 was discharged from OT on 08/22/24. Interview on 09/05/24 at 3:30 P.M. with License Practical Nurse (LPN) #10 verified Resident #200's plan of care, and physician orders were silent for documentation of the utilization of a custom- tilt and space wheelchair with wheelchair foot rests. LPN #10 verified the care plan should have been updated when therapy placed Resident #200 in the chair. Review of the facility policy titled Comprehensive Resident Centered Care Plans dated 11/01/18 revealed the care plans are modified between care plan conferences with appropriate to meet the resident's current needs, problems and goals. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, record review, staff interview, and facility policy review the facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate exceeding five percent (%). 32 opportunities were observed with two medication errors, resulting in 6.3% error rate. This affected one (Resident #450) of four residents observed during the medication administration. The facility census was 66. Findings include: Review of the medical record for Resident #450 revealed an admitted [DATE]. Diagnoses included constipation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #450 had severe cognitive impairment. Review of the physician orders dated September 2024 revealed Resident #450 was to receive Senna concentrate 8.6 milligrams (mg) give two tablets orally two times a day for constipation. The physician orders dated September 2024 were silent for physician orders for two bisacodyl (treats constipation) five mg tablets. Observation and interview on 09/05/24 between 8:25 A.M. to 8:40 A.M. revealed Licensed Practical Nurse (LPN) #25 was observed administering medication to Resident #450. At the time of the administration, LPN #25 provided medications scheduled for 8 A.M. including observation of two bisacodyl five mg tablets being administered to Resident #450. Review of Resident #450's medication administration record (MAR) with LPN #25 confirmed she documented she administered two Senna concentrate 8.6 mg tablets for 8:00 A.M. on 09/05/24. LPN #25 verified she had given the wrong medication to Resident #450. LPN #25 verified she administered two bisacodyl five mg tablets instead of two senna concentrate 8.6 mg tablets. LPN #25 verified Resident #450 did not have a physician's order for bisacodyl. Review of the undated facility policy titled Medication Administration General Policies and Procedures revealed medications are administered as prescribed in accordance with nursing principles and practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Complaint Number OH00157352.

Based on record review, facility policy review and resident and staff interviews, the facility failed to ensure medications were administered to the residents without any significant medication errors. This affected two (#100 and #125) of six residents reviewed for medication administration. The facility census was 66. Findings include: 1. Review of the medical record for Resident #100 revealed an admitted [DATE]. Diagnoses included vascular dementia, protein calorie malnutrition, and gastrointestinal hemorrhage. Resident #100 did not have a diagnosis of diabetes mellitus. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had cognitive impairment. Review of Resident #100's physician's orders revealed they were silent for physician orders for Lantus insulin, melatonin (sleep aide), Pepcid (treats heartburn), Risperdal (antipsychotic) or trazodone (antidepressant and sedative). Resident #100's medical record did not have any documentation of a medication error on 07/29/24 and the monitoring of the resident status post the medication error. Review of the facilities Resident Medication Incident Report dated 07/29/24 revealed Resident #100 received another resident's insulin during the 8:00 P.M. medication pass. The incident occurred on 07/29/24 at 7:00 P.M., with physician notification at 8:07 P.M. First aid/ treatment was blood sugar every hour and vitals every hour. The possible adverse side effects were complaints of head feeling funny and slurring speech. The follow up to the medication error revealed there were no residual effects, resident to be her normal baseline, and physician notification. Licensed Practical Nurse (LPN) #500 was the agency nurse who administered the wrong medication to Resident #100 on 07/29/24 and marked as a Do Not Return to the facility. There were no physician orders to complete blood sugar and vital signs every hour and no documentation to support this was completed. Interview with Physician #50 on 09/05/24 at 1:30 P.M. verified the staff should have written physician orders for his the order he gave for Resident #100 on 07/29/24, which was to complete blood sugar and vital signs every hour. The physician stated when a resident has a change of a change of condition including medication error/issues relating to a resident, he would expect the nursing staff to assess the resident, document and communicate those findings. Interview on 09/05/24 at 2:50 P.M. with Nurse Manager (NM) #18 revealed she completed the investigation of the medication error on 07/29/24 with Resident #100 and found that Resident #100 received Resident #300's 8 P.M. medications including, Lantus insulin 20 units, melatonin five milligrams (mg), Pepcid 20 mg, Risperdal 1.5 mg, and trazodone 50 mg. NM #18 verified Resident #100's medical record did not have any documentation of the medication error and the monitoring of the resident after the medication error was identified. NM #18 notified the physician regarding the error and a verbal order was obtained to monitor Resident #100's blood sugar and vital signs and NM #18 verified she did not write the physicians order resulting in only three blood sugars being obtained. NM #18 was unable to recall what the physician order was supposed to be, but verified Resident #100 should have had blood sugar monitoring three more times because of the long-acting effects of the 20 units of Lantus insulin that was administered. 2. Review of the medical record for Resident #125 revealed an admitted [DATE]. Diagnoses included heart failure, chronic obstructive pulmonary disease, osteoarthritis, hypertension, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #125 had intact cognition. Review of Resident #125's physician orders revealed they were silent for orders for multivitamin, cetirizine duloxetine (antihistamine), hydrochlorothiazide (diuretic), losartan potassium (treats high blood pressure) and pregabalin (idiopathic neuropathy). Resident #125's medical record did not have any documentation of a medication error on 07/25/24 and the monitoring of the resident status post the medication error. Review of the facilities Resident Medication Incident Report dated 07/25/24 revealed Resident #125 received the roommates 5:00 A.M. medications. The incident occurred on 07/25/24 at 5:00 A.M., with physician notification at 7:55 A.M. on 07/25/24. There was nothing listed under first aid/ treatment. The possible adverse side effect was decreased blood pressure. The follow up included physician notification and monitoring of vital signs. Licensed Practical Nurse (LPN) #500 was an agency nurse and was the nurse who administered the medications to the wrong resident. LPN #500 was sent home and staffing agency was informed of LPN #500's medication error and requested LPN #500 be educated. Interview on 09/05/24 at 9:10 A.M. with Resident #125 stated she was not sure what medications was given to her, but remembers she was given another resident's medications. Resident #125 stated now she pays attention and ask about her medications since the medication error. Interview on 09/05/24 at approximately 2:50 P.M. with Nurse Manager (NM) #18 stated she completed the investigation of the medication error on 07/25/24 with Resident #125. NM #18 verified Resident #125 received Resident #126's morning medications including, multivitamin one tablet, cetirizine five milligrams (mg), duloxetine 60 mg, furosemide 20 mg, hydrochlorothiazide 25 mg, losartan potassium 50 mg, and pregabalin 25 mg. NM #18 verified nursing should have monitored for adverse reactions of the medication error and should have documented for at least 48 hours after the medication error. NM #18 verified she was unable to provide documentation of such monitoring for Resident #125. Review of the undated facility policy titled Medication Administration General Policies and Procedures revealed medications are administered as prescribed in accordance with nursing principles and practices and only by persons legally authorized to do so. This deficiency represents non-compliance investigated under Complaint Number OH00157352.

Based on medical record review, staff interview and policy review, the facility failed to ensure a resident representative was notified of a resident elopement timely. This affected one (#46) resident out of the three residents reviewed for notification of changes. The facility census was 73. Findings include: Review of the medical record for the Resident #46 revealed an admitted [DATE] with medical diagnoses of cerebral infarction, dementia, chronic obstructive pulmonary disease, diabetes mellitus, and Depression. Review of the medical record for Resident #46 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/03/24, which indicated Resident #46 had moderate cognitive impairment and required supervision to partial/moderate staff assistance for wheelchair mobility, was dependent for toilet hygiene and bathing, and required substantial staff assistance for transfers and bed mobility. The MDS indicated Resident #46 had a wander/elopement alarm in place daily. The MDS did not indicate Resident #46 wandered during the assessment time frame. Review of the medical record for Resident #46 revealed an elopement risk assessment dated [DATE], which indicated Resident #46 was at risk for elopement due to history of elopement, wandering, and resident expressed desire to return home. Review of the medical record for Resident #46 revealed a plan of care dated 07/24/23 which stated Resident #46 was at risk for elopement/wandering behavior due to dementia. The interventions included wander guard as ordered. Review of medical record for Resident #46 revealed a physician order dated 10/12/23 for wander guard (device to prevent elopement) to be placed and function checked every shift. Review of the medical record for Resident #46 revealed an incident note dated 05/26/24 at 11:46 P.M. which stated Resident #46 was outside of the facility during shift unattended. Returned to facility by a visitor. Roam alert in place on wheelchair. Assessment for skin and injury. None noted at this time. Resident known to roam around the facility freely in wheelchair. Staff were not alerted by alarms. Roam alert checked for safety red light on. Physician on call sent message through tiger text. Power of Attorney was notified. Resident was returned to room and slept throughout night without further incident. Fifteen-minute checks initiated. Interview on 05/30/24 at 10:26 A.M. with Administrator confirmed Resident #46 had an elopement from the facility on 05/26/24. Administrator confirmed Resident #46 had a wander guard device attached to her wheelchair. Administrator stated staff responded to the door near Foundation Hall alarming around 7:58 P.M. on 05/26/24. Administrator stated the facility staff looked around the hallways and didn't see any residents and cleared the alarm at 8:04 P.M. Administrator stated on 05/26/24 at 8:52 P.M. a visitor brought Resident #46 back into the facility and the visitor stated Resident #46 was sitting in the parking lot. Administrator stated nursing staff immediately assessed the resident for any injuries and none were noted. Administrator stated she was notified of the elopement on 05/26/24, and an investigation was initiated. Administrator confirmed Resident #46's family was not notified of the elopement until 05/27/24 at 5:15 A.M. Review of the facility policy titled, Notification of Changes, revised 11/18/21, revealed the staff would notify the resident and/or resident representative and his/her physician or delegate of changes in the residents' condition or status in order to obtain orders for appropriate treatment and monitoring and promote resident's rights to make choices about treatment and care preferences. The policy stated the nurse would notify the resident and/or representative and physician of an accident involving the resident which resulted in injury or has the potential for requiring physician interventions. The policy stated the family was to document the notification in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number OH00154269.

Based on medical record review, review of a facility self-reported incident (SRI), staff interviews and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#46) resident out of three residents reviewed for elopement. The facility census was 73. Finding include: Review of the medical record for the Resident #46 revealed an admitted [DATE] with medical diagnoses of cerebral infarction, dementia, chronic obstructive pulmonary disease, diabetes mellitus, and Depression. Review of the medical record for Resident #46 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/03/24, which indicated Resident #46 had moderate cognitive impairment and required supervision to partial/moderate staff assistance for wheelchair mobility, was dependent for toilet hygiene and bathing, and required substantial staff assistance for transfers and bed mobility. The MDS indicated Resident #46 had a wander/elopement alarm in place daily. The MDS did not indicate Resident #46 wandered during the assessment time frame. Review of the medical record for Resident #46 revealed an elopement risk assessment dated [DATE], which indicated Resident #46 was at risk for elopement due to history of elopement, wandering, and resident expressed desire to return home. Review of the medical record for Resident #46 revealed a plan of care dated 07/24/23 which stated Resident #46 was at risk for elopement/wandering behavior due to dementia. The interventions included wander guard as ordered. Review of medical record for Resident #46 revealed a physician order dated 10/12/23 for wander guard (device to prevent elopement) to be placed and function checked every shift. Review of the medical record for Resident #46 revealed an incident note dated 05/26/24 at 11:46 P.M. which stated Resident #46 was outside of the facility during shift unattended. Returned to facility by a visitor. Roam alert in place on wheelchair. Assessment for skin and injury. None noted at this time. Resident known to roam around the facility freely in wheelchair. Staff not alerted by alarms. Roam alert checked for safety red light on. Physician on call sent message through tiger text. Power of Attorney was notified. Resident was returned to room and slept throughout night without further incident. Fifteen-minute checks initiated. Interview on 05/30/24 at 10:26 A.M. with Administrator confirmed Resident #46 had an elopement from the facility on 05/26/24. Administrator confirmed Resident #46 had a wander guard device attached to her wheelchair. Administrator stated staff responded to the door near Foundation Hall alarming around 7:58 P.M. on 05/26/24. Administrator stated the facility staff looked around the hallways and didn't see any residents and cleared the alarm at 8:04 P.M. Administrator stated on 05/26/24 at 8:52 P.M. a visitor brought Resident #46 back into the facility and the visitor stated Resident #46 was sitting in the parking lot. Administrator stated nursing staff immediately assessed the resident for any injuries and none were noted. Administrator stated she was notified of the elopement on 05/26/24, and an investigation was initiated. Administrator confirmed Resident #46's family was not notified of the elopement until 05/27/24 at 5:15 A.M. Interview on 05/30/24 at 11:00 A.M. with Director of Nursing (DON) stated she was notified on 05/26/24 around 10:00 P.M. that Resident #46 had eloped from the facility and was returned to the building by a visitor. DON stated an investigation was completed and determined Resident #46 wheeled herself past the front lobby to the doors that lead to Foundation Hall. DON stated the doors in the front lobby lock when a resident with a wander guard is near, so Resident #46 was not able to exit through those doors. DON stated Resident #46 was able to push open the locked doors (the doors will unlock after being pushed for 15 seconds) to enter Foundation Hall area and the door alarm sounded. DON stated Resident #46 made her way down the hallway to the sliding doors near Foundation Hall entrance/exit. DON stated the sliding doors near Foundation Hall did not have the ability to lock or alarm when a resident with a wander guard was near. DON stated staff responded to the door alarm but did not see any residents in the hallway, so the alarm was cleared, and staff did not complete a resident head count to ensure a resident had not eloped. DON stated Resident #46 was found in the parking lot outside of Foundation Hall doors by a visitor and had been outside approximately 45-50 minutes. DON confirmed Resident #46 did not sustain any injuries from the incident. DON stated a company was at the facility today to provide an estimate for installation of alarms and locks to the sliding doors near Foundation Hall. Review of the SRI dated 05/26/24 revealed staff interviews were conducted to determine how Resident #46 eloped from the facility. Resident #46 was put on fifteen-minute checks on 05/26/24 and 05/27/24, and the staff was educated on elopement and notification of changes on 05/27/24 and 05/28/24. Review of the SRI revealed the facility had not completed the investigation, training, and audits for the elopement. Review of facility policy titled Elopement, revised 12/19/23, revealed the facility was to safely and timely redirect residents to safe environment. This deficiency represents non-compliance investigated under Complaint Number OH00154269.

Based on observations, staff interviews, medical record review, review of Joerns Hoyer user instruction manual and Invacare patient slings operator's manual, review of the facility's Self-Reported Incident (SRI) and investigation including witness statements, review of the emergency medical services (EMS) report, review of hospital documentation, review of the facility policies on transfer, mechanical lifts, and the mechanical lift checklist, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. This resulted in Immediate Jeopardy when Resident #15 experienced serious life-threatening injuries during an avoidable fall from a mechanical lift when the lift pad was incorrectly placed on the Hoyer lift and only one-person assisted in the transfer, resulting in a head injury, and severe fractures of the left lower leg which subsequently required an above the knee amputation of the left lower leg. This affected one (Resident #15) of three residents reviewed for utilization of a mechanical lift for transfers and placed an additional 14 current residents (#101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, and #114), identified by the facility as requiring the use of a mechanical lift for transfers, at risk for potential serious injuries and/or negative health outcomes as the facility was utilizing Invacare slings for the two Joerns Hoyer lifts for the 14 current residents. The facility census was 69. On 01/09/24 at 10:02 A.M., the Administrator and Chief Executive Officer (CEO) #200 were notified Immediate Jeopardy began on 12/25/23 at 10:40 A.M., when Nursing Assistant (NA) #20 transferred Resident #15 from her bed to the wheelchair using a mechanical lift without another staff member present. NA #20 utilized the wrong color-coded sling loops and positioned them incorrectly on the Hoyer lift, resulting in Resident #15 sliding out of the Hoyer lift while it was suspended five feet in the air and her head hitting the ground first and her left leg getting tangled up in the lift. The facility policy and Resident #15's plan of care required two staff members to be present when completing a mechanical lift transfer. Resident #15 was sent to a trauma level one hospital via EMS where she was diagnosed with comminuted fracture (a bone that is broken into more than two pieces) of the proximal left tibia, open fracture (a broken bone that causes an open wound in the skin) of left fibula, hemorrhagic shock requiring a blood transfusion, head contusion and multiple hematomas throughout the body. Surgical treatment of the left leg resulted in an above the knee amputation due to the severity of the traumatic wound and catastrophic fractures sustained to both the left tibia and fibula. On 01/08/24, interviews and observations revealed the facility was utilizing Invacare slings for the two Joerns Hoyer lifts for 14 current residents. Invacare manufacturer instructions state not to intermix slings and lifts of different manufacturers for the safety of the patient. The Immediate Jeopardy was removed on 01/12/24 when the facility implemented the following corrective actions: On 12/25/23 at 11:25 A.M., Resident #15 was transferred to the hospital and did not return to the facility. On 12/25/23 at 11:35 A.M., the Director of Nursing (DON) suspended NA #20 pending investigation. On 12/25/23 at 11:35 A.M., the DON removed the Hoyer lift used in Resident #15's transfer (Hoyer LPL700 serial number 1000021257) and sling from service pending investigation. On 12/25/23 at 11:50 A.M., the DON, Unit Manager (UM) #431, Registered Nurse (RN) #430, and Therapy Director (TD) #440 completed education to State tested Nurse Aides (STNAs), licensed nursing, and therapy staff on utilizing two staff to transfer a resident using a Hoyer lift, checking the sling, and checking the Hoyer lift to ensure it was properly functioning prior to use. On 12/28/23 at 1:30 P.M., all active STNAs, licensed nursing and therapy staff had completed the education. On 12/26/23, a Quality Assurance Performance Improvement (QAPI) meeting was held with the interdisciplinary team (IDT) which included Quality Assurance (QA) Nurse #202, CEO #200, TD #440, Maintenance Director #512, UM #518, and the DON to discuss the incident involving Resident #15 with the improper Hoyer transfer. Medical Director #500 was updated by telephone. On 12/27/23, the DON, TD #440, and UM #518 began audits to ensure proper use of Hoyer lifts. The audits included observing nurses, STNAs, and therapy staff on proper use of lifts and slings. On 12/29/23, NA #20's employment was terminated. On 12/29/23, Outside Engineer Provider #500 inspected all Hoyer lifts, and they were found to be functioning. The Hoyer lift (Hoyer LPL700 serial number 1000021257) used in Resident #15's transfer on 12/25/23 was returned to service. On 01/08/24, observations and interviews revealed the facility was utilizing Invacare slings for the two Joerns Hoyer lifts for 14 current residents. Invacare manufacturer instructions state not to intermix slings and lifts of different manufacturers for the safety of the patient. On 01/09/24, the IDT met to discuss the plan for the day to limit any use of Hoyer lifts with the current slings until the new lifts and slings arrived that day (01/09/24). All residents' needs will be met at bedside including care, meals, activities, etc., as able. On 01/09/24, CEO #200 ordered and received nine [NAME] Chairs from Medical Equipment Supplier #600. [NAME] Chairs allow transfer of residents from bed to chair safely without a lift. Medical Equipment Supplier #600 will provide five Hoyer lifts with corresponding slings on 01/09/24. On 01/09/24, another QAPI meeting was held to discuss the further findings of the investigation into Resident #15's unsafe transfer. On 01/09/24, the DON, QA Nurse #202, and TD #440 reviewed the manuals for the new chairs, mechanical lifts, and slings. They evaluated the 14 residents for the proper sling for each resident. The resident's plan of care and STNA report sheets were updated with the proper sling for each resident. Education began with nursing staff on the proper operation of the equipment. All nursing and therapy staff will be educated by 01/12/24. On 01/10/24, the DON/designee will conduct random audits to observe staff utilizing the chairs, Hoyer lift, and slings properly. The audits will begin on 01/10/24 and three staff will be observed weekly for three weeks, monthly for three months and randomly thereafter. On 01/10/24 at 3:15 P.M., observation of a Hoyer lift transfer with the facility's new Hoyer lift revealed the Hoyer lift legs buckled inward during Resident #112's transfer. Resident #112 did not sustain any injury because of the legs buckling inward during the transfer and the resident was safely transferred to bed. The facility immediately removed the Hoyer lift from service. All residents that were mechanical lifts were transferred using the [NAME] chairs without issues. At 4:00 P.M., maintenance staff tightened the nuts and bolts and checked the wires of the Hoyer lift to ensure nothing was loose. On 01/10/24 and 01/11/24, interviews with STNAs #411, #318, #428, and #436 and Licensed Practical Nurse (LPN) #623 verified they received in-service training on mechanical lift transfers and had no concerns. On 01/11/24, the DON, QA Nurse #202, UM #431, Administrator, and CEO #200 reviewed slings and mechanical lift manuals, watched sling and lift video tutorials and completed multiple transfers using the Hoyer lift among staff members to ensure the Hoyer lift and sling was functioning properly prior to putting back into service. On 01/11/24 at 1:30 P.M., the Hoyer lift was put back into service for residents. On 01/11/24, two current residents requiring a mechanical lift for transfers were observed during the transfer process. Resident #114 was observed at 2:00 P.M. and Resident #108 was observed at 2:30 P.M. Both residents were transferred with a mechanical lift device with two staff members present, utilizing the proper lift pads that were new, in good condition, labeled with their respective names and unique identification numbers for the lift pad. There were no identified problems observed during the mechanical lift transfers. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #15's closed medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiparesis, left non-dominant side, systolic congestive heart failure, type two diabetes mellitus, contracture of left elbow, and lymphedema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had cognitive impairment. She required total dependence on staff for chair to bed transfers. Review of the plan of care dated 12/02/22 revealed Resident #15 had the potential for self-care deficits related to weakness, inability to care for self, left upper extremity contracture and limited mobility. Interventions included monitoring and assistance as needed with Activities of Daily Living (ADL), and transfer with use of mechanical lift with two staff personnel. Review of Resident #15's nursing progress notes dated 12/25/23 at 11:50 A.M. revealed LPN #240 was called into Resident #15's room by NA #20. Upon entry into the room, Resident #15 was on the floor with her left leg caught in the lift. There was blood seeping through her jeans. There was also blood from the lump on the back of her head. LPN #240 called for assistance from other staff. LPN #240 stayed with Resident #15 and applied pressure to her head while NA #20 applied pressure to the laceration on her left leg. On 12/25/23 at 12:22 P.M., RN #356 was summoned to Resident #15's room by staff. Resident #15 was lying in a prone position under the Hoyer lift. There was bleeding from the left leg and the back of the head. The left lower leg appeared to be externally rotated and a large wound noted under the left knee and fatty tissue was exposed. Cold pressure dressing applied until EMS arrived. EMS dispatcher arrived, and Resident #15 was going to be life flighted from [NAME] Park in [NAME] Liberty due to the appearance of the wound. Review of the facility's SRI dated 12/25/23 revealed on 12/25/23 at 10:40 A.M., NA #20 attempted to transfer Resident #15 with a Hoyer lift by herself, contrary to the facility policy. During the transfer of Resident #15 with the Hoyer lift, Resident #15 slipped out of the sling onto the floor. LPN #240 entered Resident #15's room and then initiated evaluation and emergency treatment for observed injuries. EMS responded and transported Resident #15 to the hospital. NA #20 was suspended. The Hoyer lift and sling involved in the incident were removed from service until they could be evaluated. Local police were informed of the incident. Review of NA #20's written statement dated 12/25/23 revealed NA #20 went to get Resident #15 changed and ready for lunch. NA #20 decided to get Resident #15 up using the Hoyer lift by herself and didn't think about asking for help. NA #20 stated she was stressed out all morning. NA #20 turned the lift to put Resident #15 into the chair and Resident #15 slid out onto floor. NA #20 stated I do know better; thought I could handle it by myself. Review of the EMS report dated 12/25/23 at 11:09 A.M. revealed EMS was on scene with Resident #15 for a call to address a fall with a laceration to the leg. EMS was advised that Resident #15 dropped from approximately five feet in the air and struck her head during the fall. A full trauma assessment was performed with finding of a small laceration to the back of the head with bleeding stopped, altered mental status, pain in the middle to lower back, and pain and deformity to the lower left leg with the laceration. Care provided to Resident #15 included left leg trauma dressing and vacuum splint, cervical collar, vital signs, and transport to life flight helicopter. Review of Resident #15's hospital records from 12/25/23, revealed Resident #15 required life flight transport to a level one trauma hospital. During the multiple physician assessments, and imaging required while at the trauma center, Resident #15 was found to have multiple traumas including a comminuted fracture of the proximal left tibia, open fracture of left fibula, hemorrhagic shock requiring a blood transfusion, head contusion and multiple hematomas throughout the body. Resident #15 required an intensive care hospital unit with intubation, intravenous pain control, intravenous antibiotics, intravenous hydration, and surgical intervention for the left leg fractures. Surgical treatment of the left leg resulted in an above the knee amputation due to the severity of the traumatic wound and catastrophic fractures sustained to both the left tibia and fibula. Review of NA #20's telephone interview statement dated 12/26/23 at 10:30 A.M. revealed NA #20 reported she thought she used the wrong color-coded sling loops which incorrectly positioned Resident #15 in the sling causing Resident #15 to slide out of the body sling. Resident #15 hit headfirst on the floor and landed on her buttocks and back. LPN #240 entered Resident #15's room to bring in medications to Resident #15. LPN #240 told STNA #318, who had entered the room, to obtain assistance. EMS asked where she had fallen from, and she told EMS she had fallen from five feet. EMS decided to life flight Resident #15. Review of RN #356's telephone interview statement dated 12/26/23 at 11:30 A.M., revealed RN #356 walked into Resident #15's room after requests for assistance, and found Resident #15 on the floor with LPN #240 holding pressure on the back of Resident #15's head. There was a small amount of blood on her head, and when RN #356 looked down toward her legs there was a pool of blood under her leg. RN #356 attempted to cut the pant leg with a small pair of bandage scissors without success but managed to rip the pant leg far enough to see a very large deep wound. RN #356 requested STNA #318 to obtain a wet compress and directed her to apply pressure and then went and called emergency 9-1-1 (EMS). EMS arrived and asked NA #20 where Resident #15 fell from. NA #20 told EMS the Hoyer lift's height had not been moved, and EMS responded that was five feet in the air and indicated the need for life flight for a trauma hospital. Review of LPN #240's telephone interview statement dated 12/27/23, revealed LPN #240 entered Resident #15's room after NA #20 had opened the door stating Resident #15 had fallen. LPN #240 found Resident #15 on the floor on her back, requested STNA #318 to get another nurse's assistance. RN #356 arrived and requested STNA #318 apply pressure to Resident #15's leg, and RN #356 went to make phone calls. EMS arrived and questioned about the height of the Hoyer lift and noted the Hoyer was really high and EMS decided to life flight Resident #15 to a trauma center. Review of STNA #318's telephone interview statement dated 12/28/23 revealed NA #20 opened the door of Resident #15's room and stated Resident #15 was on the floor. LPN #240 requested assistance, STNA #318 obtained RN #356 and returned to Resident #15's room. RN #356 was trying to find where all the blood was coming from and was told to apply pressure. STNA #318 observed Resident #15's chair was at the other side of the room and the Hoyer with the body sling attached. STNA #318 observed the color-coded straps of the body sling with the longer straps at the resident's head and the shortest straps at the feet, which would cause the feet to be higher than the head of the patient when lifted. An observation of the use of a mechanical lift of Resident #105 on 01/08/24 at 10:10 A.M. with the DON, STNAs #318 and #411 revealed a Joerns Hoyer lift was used to lift the body sling with Resident #105 from the bed into a wheelchair. Interview with the DON, during the observation, revealed a medium size Invacare body sling was used for the transfer. Interview on 01/08/24 at 11:20 A.M. with Quality Assurance Coordinator #202 verified the facility had only Invacare slings utilized for Hoyer transfers currently. Interview on 01/08/24 at 2:05 P.M. with CEO #200 verified the facility only used two Joerns Hoyer's for mechanical lifts of residents currently. CEO #200 verified the facility concluded the investigation into Resident #15's fall from the Hoyer was a result of NA #20 transferring Resident #15 without staff assistance and NA #20 applied the body sling loops inappropriately to the Hoyer lift causing Resident #15 to slide during the transfer. CEO #200 verified it was the facility's policy and in Resident #15's plan of care to provide two persons for transfers with the Hoyer lift. Interview on 01/08/24 with RN #365 verified the sequence of events on 12/25/23 involving Resident #15, indicating Resident #15 fell from about five feet because of the extended height of the Hoyer lift when she came into the room to assist Resident #15. Interview on 01/08/24 with LPN #240 stated upon entering Resident #15's room, Resident #15 was lying on the floor on her back with blood coming from Resident #15's head. Resident #15 was under the Hoyer lift, with the body sling still attached to Hoyer. NA #20 explained she was transferring Resident #15 in the Hoyer lift by herself when Resident #15 slid out of the body sling, hitting her head on the floor. LPN #240 stated at that point she requested staff get assistance and began assessing for head injury. An attempt to interview NA #20 during the investigation was unsuccessful. Review of the facility policy titled Transfer Policy, dated 11/20/17, revealed the purpose was to assist residents with transfers and ambulation in a way that provides safety and protection to the resident and employee. The type of transfers included mechanical lifts which required two staff. Review of the facility's policy titled Mechanical Lifts, dated 07/01/18, revealed the policy was to prevent injury to yourself and residents during transfer. Steps included were to prepare the resident for transfer by attaching the sling to lift using the corresponding loops for the upright position, partial reclining position, and the full reclining position. Review of the facility's undated policy titled Mechanical Lift Checklist revealed to never use a mechanical lift by yourself. All lifts require two people for operation. Review of the undated Invacare manufacturer's operator and maintenance manual for patient slings revealed, Invacare slings are made specifically for the use with Invacare lifts. For the safety of the patient, do not intermix slings and lifts of different manufacturers. When connecting body sling color coded straps, the shortest of the straps must be at the back of the patient for support. Review of the undated manufactures user instruction manual for the Joerns Hoyer HPL700 revealed warnings included Do not use a sling unless it is recommended for use with the lift; Hoyer slings and lifts are not designed to be interchangeable with other manufacturer's products. Using other manufactures' products on Hoyer products is potentially unsafe and could result in serious injury to patient and or caregiver; Further stating caution, have someone assist you when attempting to transfer a patient. This deficiency represents non-compliance investigated under Complaint Number OH00149663 and Control Number OH00149636.

Based on record review, staff interview, review of a facility investigation, and review of a self-reported incident, the facility failed to ensure care plans were developed and implemented for residents with wandering and eloping behaviors. This affected two (#53 and #20) of five residents reviewed for behaviors. The current census was 68. Findings include: 1. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #53 include dementia, aphasia, heart failure, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has impaired cognition and was not coded as having wandering behaviors. Review of Resident #53's care plans dated April 2023 revealed there was no focus for behaviors including elopement and wandering. Review of a self-reported incident (SRI) dated 05/15/23 revealed on 05/15/23 Resident #53 walked out of the locked dementia unit, but did not leave the building. Per the report, the resident was observed on the hallway outside of the locked unit knocking on the door to get back into the dementia unit. Further review of the report revealed the resident's wife had visited and the resident may have followed her out of the unit and then attempted to return to the locked unit. Review of a facility investigation on 05/15/23 revealed the resident's wife had been to visit the resident and was leaving the locked unit, and the resident followed her out of the unit. Resident #53 then knocked on the door to return to the unit. Resident #53's Wandergaurd (alerting device worn by individuals at risk for elopement) was checked, and the Wanderguard locked all doors leading outside of the facility. A code alert bracelet was added as an intervention to lock the dementia unit doors. Review of the Resident #53's progress notes dated 05/24/23 at 8:51 A.M. revealed the resident continued to have wandering behaviors of attempting to enter other resident's rooms and trying to exit the unit causing alarms to sound. Interview on 07/12/23 at 3:30 P.M. with State tested Nurse Aide (STNA) #108 and Hospitality Aide (HA) #216 stated Resident #53 had wandering behaviors and needed to be checked on frequently. STNA #108 was unsure if the resident had a Wanderguard and code alert bracelet or just a Wanderguard. HA #216 stated Resident #53 had wandering behaviors to the point of trying to exit the doors of the unit. Neither STNA #108 nor HA #216 were able to see the behaviors and interventions for such behaviors in the resident's care plans. Interview on 07/13/23 at 11:20 A.M., with the Administrator verified there was no behavior or elopement care plan for Resident #53 to address his wandering and elopement behaviors. 2. Review of Resident #20's medical record revealed the resident was admitted to the facility 05/23/23. Diagnoses for Resident #20 include dementia, heart disease, diabetes type two, and encephalopathy. Review of the MDS assessment dated [DATE] revealed the resident had impaired cognition and was coded with the behavior of wandering. Review of Resident #20's care plans dated May 2023 revealed there was no focus for behaviors or elopement. Review of Resident #20's progress notes dated 07/02/23 at 8:51 A.M. revealed the resident was observed outside of the unit on the secured courtyard when the door alarm sounded. Staff returned the resident inside the dementia unit and the staff continued to monitor the resident. Interview on 07/13/23 at 11:20 A.M. with the Administrator verified there was no focus for behaviors including elopement in Resident #20's care plans prior to 07/12/23.

Based on medical record review, staff interviews, review of facility policies, and review National Pressure Injury Advisory Panel (NPIAP) information, the facility failed to complete pressure ulcer treatments as ordered, assess pressure ulcers weekly, and accurately stage wounds. This affected three (#14, #26, and #48) of three residents reviewed for wounds. The facility census was 64. Findings include: 1. Review of medical record for Resident #14 revealed admitted [DATE], with diagnoses of pressure ulcer of sacral region, chronic pain syndrome, neuromyelitis optica, neuromuscular dysfunction of bladder, need for assistance with personal care, depression, hypertension, hyperlipidemia, pressure ulcer of left heel stage two (partial thickness skin loss into but not deeper than the dermis), and bed confinement status. Review of physician order 02/21/23, from the wound clinic for Resident #14 revealed left buttock ischial tuberosity apply santyl to wound bed and cover with bordered foam daily; and apply bordered foam dressing to left heel every other day for protection, with weekly skin grid. Review of Treatment Administration Record (TAR) for Resident #14 dated March 2023, revealed the treatment to left buttock ishchial tuberosity wound was not documented as completed on day shift 03/02/23, 03/04/23, and 03/07/23. The weekly skin grid was not documented as completed on 03/02/23. Review of the physician order dated 02/27/23, for Resident #14 revealed to the right great toe, cleanse with normal saline and cover with dry dressing. Monitor for signs and symptoms of infection until healed daily. Further review of physician orders dated 03/05/23, for Resident #14 revealed treatment to right great toe to cleanse with normal saline and cover with Band-Aid daily for three days then discontinue. Further review of TAR for Resident #14 dated March 2023 revealed the treatment to right great toe: cleanse with normal saline and cover with dry dressing daily was not documented as completed on 03/02/23, 03/03/23, and 03/04/23. Order changed to right great toe on 03/05/23 to cleanse with normal saline and cover with Band-Aid for three days then discontinue. Treatment not documented as completed on 03/07/23. Further review of TAR for Resident #14 dated March 2023 revealed treatment to left heel was not documented as completed on 03/02/23, and 03/04/23 and the weekly skin grid was not documented as completed on 03/02/23. Review of skin evaluation form dated 03/09/23 for Resident #14 revealed sacrum wound measured 3.8 centimeters (cm) in length by 4.5 cm in width by 1.6 cm in depth with granulation, serosanguineous drainage and a stage four (full thickness skin loss extending through the fascia with considerable tissue loss with involvement of muscle, bone, tendon or joint), wound vac treatment, wound improving in overall size. Ischium tuberosity wound measured 1.0 cm in length by 1.0 cm in width by 0.1 cm in depth with granulation, bloody/sanguineous moderate drainage. Wound classified as healing stage two pressure ulcer. Interview on 03/14/23 at 3:10 P.M., with Director of Nursing (DON) verified for Resident #14 weekly skin grid was not documented on 03/02/23, treatment to left heel was not documented as completed on 03/02/23 and 03/04/23, treatment to right great toe was not documented as completed on 03/02/23, 03/03/23, 03/04/23, and 03/07/23, and treatment to left buttock ishchial tuberosity was not documented as completed on 03/02/23, 03/04/23, and 03/07/23. 2. Review of medical record for Resident #26 revealed admitted [DATE], with diagnoses of Alzheimer's disease, dysphagia, cognitive communication deficit, anemia, heart failure, hypertension, morbid obesity, depression, fibromyalgia, migraine, constipation, and anxiety. Review of MDS dated [DATE] for Resident #26 revealed BIMS score of eight which indicated moderately impaired cognition. Resident #26 required extensive assist for activities of daily living. Review of care plan for Resident #26 revealed the resident was at risk for altered skin integrity due to decreased mobility. Resident had history of picking at skin until achieved an open area. Interventions included provide preventative measures as ordered, provide diet as ordered, treatments as ordered, encourage resident to turn and reposition every two hours while in bed as she allows, encourage resident to reposition self or allow staff to reposition while in chair, and pressure reducing mattress with bed bolsters. Review of physician orders for Resident #26 dated 10/16/22 revealed an order for right inner ankle, cover with foam dressing every three days and as needed, and weekly skin grid. Review of TAR for Resident #26 dated March 2023 revealed the treatment to right inner ankle was not documented as completed on 03/01/23, 03/02/23, 03/05/23, and 03/10/23. Review of skin evaluation dated 01/22/23 revealed redness to right inner ankle bone unchanged measured 2.0 cm in length by 2.5 cm in width with no depth. Review of skin evaluation dated 02/14/23 for Resident #26 revealed dark pink to right inner ankle measured 1.0 cm in length by 0.6 cm in width with no depth. Review of skin evaluation dated 02/28/23 for Resident #26 revealed pink fragile skin to right inner ankle bone/area with no open areas measured 2.0 cm in length by 1.5 cm in width with no depth. Review of skin evaluation dated 03/05/23 for Resident #26 revealed pink fragile skin to right inner ankle bone/are with no open areas measured 2.0 cm in length by 1.5 cm in width with no depth. Interview on 03/14/23 at 3:10 P.M., with DON verified for Resident #26's treatment to right inner ankle was not documented as completed on 03/01/23, 03/02/23, 03/05/23, and 03/10/23 and there was no weekly skin grid from 01/22/23 to 02/14/23. 3. Review of medical record for Resident #48 revealed admitted [DATE], with diagnoses of pneumonia, chronic obstructive pulmonary disease, anemia, osteoarthritis, sepsis, multiple fractures of ribs, need for assistance with personal care, pain in right arm, chronic kidney disease stage four (severe), hypertension, and unspecified fall. Review of MDS for Resident #48 dated 12/12/22 revealed a BIMS score of 11 which indicated moderate impairment. Resident #48 required extensive assist for bed mobility, transfers, walking in room, toileting, and personal hygiene. Resident #48 required set up assist for meals. Resident #48 required limited assist with dressing. Review of care plan for Resident #48 revealed resident had the potential for impaired skin integrity due to decreased mobility, age, incontinence, and disease processes. Resident #48 had a stage two pressure injury to coccyx. Interventions included provide preventative measures as indicated, provide diet as ordered, treatments as ordered to coccyx, and monitor for signs and symptoms of infection, worsening, or improvement, air mattress to bed, skin grid weekly, Braden scale as ordered, apply barrier cream to buttocks, coccyx, and peri area every shift as needed for prevention, and incontinent care as needed. Review of physician orders dated 02/15/23 for Resident #48 revealed wash area to coccyx with normal saline, apply calcium alginate and Allevyn dressing daily and as needed, and weekly skin grid. Review of TAR for Resident #48 dated December 2023 revealed weekly skin grid not documented as completed on 12/12/22 and 12/19/22. Clean coccyx with soap and water, apply hydrogel and Allevyn daily was not documented as completed on 12/22/22, 12/23/22, 12/24/22, 12/25/22, 12/28/22, and 12/29/22. Review of TAR for Resident #48 dated January 2023 revealed to clean coccyx with soap and water, apply hydrogel and Allevyn daily was not documented as completed on 01/07/23. Wash area to coccyx with normal saline, apply optifoam dressing daily was not documented as completed on 01/10/23 and 01/24/23. Weekly skin grid was not documented as completed on 01/09/23, 01/16/23, 01/23/23, and 01/30/23. Cleanse right lower extremity with soap and water, pat dry, apply Band-Aid change daily ordered 01/12/23 discontinued on 01/26/23 was not documented as completed on 01/14/23, 01/16/23, 01/23/23, 01/24/23, and 01/25/23. Review of TAR for Resident #48 dated February 2023 revealed wash area to coccyx with normal saline, apply medihoney and Allevyn daily was not documented as completed on 02/02/23, 02/06/23 and 02/09/23. Wash area to coccyx with normal saline, apply calcium alginate and Allevyn dressing daily was not documented as completed on 02/16/23 and 02/28/23. Weekly skin grid not documented as completed on 02/06/23 and 02/27/23. Review of TAR for Resident #48 dated March 2023 revealed wash area to coccyx with normal saline, apply calcium alginate and Allevyn daily was not documented as completed on 03/03/23. Review of skin evaluation record dated 01/10/23 for Resident #48 revealed coccyx wound measured 3.5 centimeters (cm) in length by 3.5 cm in width with no depth, wound edges intact, surrounding skin red, slough in wound bed and classified as a stage two. Review of skin evaluation record dated 03/07/23 for Resident #48 revealed coccyx wound measured 1.2 cm in length by 1.0 cm in width with no depth, wound edge intact, surrounding skin pink, slough noted in wound bed and classified as stage two. Observation on 03/14/23 at 11:50 AM for Resident #48 of wound care revealed wound measurements of coccyx 0.8 cm in length by 0.6 cm in width no depth noted. Skin surrounding wound pink. Wound bed had small amount of slough. No drainage noted. Interview on 03/13/23 at 2:48 P.M. with DON verified Resident #48 weekly skin grids were not documented as completed on 12/12/22, 12/19/22, 01/09/23, 01/16/23, 01/23/23, 01/30/23, 02/06/23, and 02/27/23. The DON verified treatment to coccyx was not documented as completed on 12/22/22, 12/23/22, 12/24/22, 12/23/22, 12/28/22, 12/29/22, 01/07/23, 01/10/23, 01/24/23, 02/02/23, 02/06/23, 02/09/23, 02/16/23, 02/27/23, 02/28/23, and 03/03/23. The DON verified treatment to right lower extremity was not documented as completed on 01/14/23, 01/16/23, 01/23/23, 01/24/23, and 01/25/23. The DON verified if a wound has slough this not a stage two description. Review of policy titled Wound Care dated 04/06/11 revealed residents at risk for pressure ulcer development and those with wounds should be monitored daily for changes in their skin condition this may occur during the course of the resident's daily care and/or bathing. The nursing assistant should perform a head to toe check of the resident's skin, paying particular attention to: the surfaces of the skin that come in contact with the bed and chair, bony prominence's, surfaces of the skin that come in contact with each other and any other orthotic device, tube, brace, or positioning device, and backs of the ears that come in contact with oxygen tubing and neck secondary to trach collar/ties. Any abnormal finding/changes should be reported to the licensed nurse assigned to the resident for assessment and follow up. Review of policy titled Wound Evaluation dated 04/06/11 revealed evaluation of wounds will be performed on admission, discovery, and as needed. Evaluation should result in treatment approaches including elimination or compensation for causative factors and a prognosis for healing. Objective evaluation components may include location, measurement, appearance, drainage, odor, presence of undermining/tunneling, healing, stage if a pressure ulcer, pain, and edema. Treatments should also be re-evaluated every two to three weeks. If no wound progression is noted, treatment change should be considered. If there is no change in treatment, documentation should occur as to why current treatment is being maintained. Review of information from the NPIAP website (https://npiap.com/page/PressureInjuryStages?&hhsearchterms=%22stages%22) revealed a stage two pressure injury is defined as partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). This deficiency represents an incidental finding while investigating Complaint Number OH00140332.

Based on record review, staff interview, and policy review, the facility failed to administer medications as ordered and according to policy. This affected two (#48 and #14) of three residents reviewed for medications. Facility census was 64. Findings include: 1. Review of Medical Record for Resident #48 revealed admitted [DATE] with diagnoses of pneumonia, chronic obstructive pulmonary disease, anemia, osteoarthritis, sepsis, multiple fractures of ribs, need for assistance with personal care, pain in right arm, chronic kidney disease stage four (severe), hypertension, and unspecified fall. Review of monthly physician orders for March 2023 for Resident #48 revealed orders for Hydralazine 50 milligrams (mg) by mouth three times daily at 6:30 A.M., 11:00 A.M. and 8:00 P.M., Zyrtec 10 mg by mouth at 8:00 P.M. Bausch and Lomb lubricating eye ointment to lower lid of affected eye apply one quarter inch of ointment to the inside of eyelid at 8:00 P.M., Mucinex 600 mg by mouth every twelve hours at 8:00 A.M., norco 5/325 mg take half tablet twice a day, zinc 50 mg by mouth daily at 8:00 A.M., vitamin c tablet by mouth daily at 8:00 A.M., multivitamin by mouth daily at 8:00 A.M., miralax 17 grams by mouth daily 8:00 A.M., Remeron 15 mg take half a tablet by mouth at 8:00 P.M., Eliquis 2.5 mg by mouth twice daily at 8:00 A.M. and 8:00 P. M., tizanidine 4 mg by mouth twice daily, norco 5/325 mg by mouth at 8:00 P.M., hydrochlorothiazide 25 mg by mouth at 8:00 A.M., isosorbide mononitrate extended release 30 mg by mouth at 8:00 A.M., losartan 100 mg by mouth at 8:00 A.M., prednisone 5 mg by mouth at 8:00 A.M., and amlodipine 10 mg by mouth 8:00 A.M. Review of Medication Administration Record (MAR) for Resident #48 for March 2023 revealed Hydralazine 50 milligrams (mg) scheduled at 6:30 A.M., 11:00 A.M. and 8:00 P.M. was administered as follows: on 03/01/23 at 9:21 A.M., 1:25 P.M., 9:11 P.M.; on 03/02/23 at 8:45 A.M., 12:44 P.M., 9:04 P.M.; on 03/03/23 at 9:09 A.M., 12:44 P.M., 9:55 P.M.; on 03/04/23 at 9:08 A.M., 1:33 P.M., 10:17 P.M.; on 03/05/23 at 9:12 A.M., 1:05 P.M., 9:46 P.M.; on 03/06/23 at 9:06 A.M., 1:16 P.M., 10:34 P.M.; on 03/07/23 at 9:03 A.M., 1:32 P.M.; 8:00 P.M.; on 03/08/23 at 8:42 A.M., 1:33 P.M., 10:21 P.M.; on 03/09/23 at 9:58 A.M., 1:20 P.M., 9:39 P.M.; on 03/10/23 at 8:43 A.M., 12:20 P.M., 8:00 P.M.; on 03/11/23 at 8:18 A.M., 11:00 A.M., 9:38 P.M.; on 03/12/23 at 8:10 A.M., 12:07 P.M., 9:17 P.M.; and on 03/13/23 at 8:55 A.M. Eliquis 2.5 mg and Mucinex 600 mg was scheduled twice a day at 8:00 A.M. and 8:00 P.M. and administered as follows: on 03/01/23 at 9:21 A.M. and 9:11 P.M.; 03/02/23 at 9:04 P.M., 03/03/23 at 9:16 A.M. and 9:55 P.M.; 03/04/23 at 9:08 A.M. and 10:17 P.M.; 03/05/23 at 9:13 A.M. and 9:46 P.M.; 03/06/23 at 9:07 A.M. and 10:34 P.M., 03/07/23 at 9:03 A.M., 03/08/23 at 10:21 P.M.; and 03/09/23 at 9:59 A.M. and 9:39 P.M.; 03/11/23 at 9:38 P.M. and 03/12/23 at 9:17 P.M. Prednisone 5 mg, Fluticasone furoate 100 microgram (mcg)/dose inhalation powder, Hydrochlorothiazide 25 mg, isosorbide mononitrate extended release 30 mg, and losartan 100 mg, scheduled for 8:00 A.M. was administered as follows: on 03/01/23 at 9:21 A.M., 03/03/23 at 9:16 A.M., 03/04/23 at 9:08 A.M., 03/05/23 at 9:13 A.M., 03/06/23 at 9:07 A.M., 03/07/23 at 9:03 A.M., and 03/09/23 at 9:59 A.M Eliquis 2.5 mg scheduled at 8:00 P.M. was administered as follows: 03/01/23 at 9:11 P.M., 03/02/23 at 9:04 P.M., 03/03/23 at 9:55 P.M., 03/04/23 at 10:17 P.M., 03/05/23 at 9:46 P.M., 03/06/23 at 10:34 P.M., 03/08/23 at 10:21 P.M., 03/09/23 at 9:39 P.M., 03/11/23 at 9:38 P.M. and 03/12/23 at 9:17 P.M. Interview on 03/13/23 at 1:56 P.M., with Registered Nurse (RN) #526 stated medication times are upon rising, around lunch, dinnertime, at 8:00 P.M. as well as some scheduled timed medications. RN #526 stated for scheduled timed medications they have one hour before and one hour after to administer medications. Interview on 03/13/23 at 2:48 P.M., with Director of Nursing (DON) verified Hydralazine was ordered at 6:30 A.M., 11:00 A.M., and 8:00 P.M. and was given past the one hour after timeframe at 6:30 A.M. 03/01/23 through 03/13/23, 11:00 A.M. on 03/01/23 through 03/12/23 with the exception of 03/11/23, and 8:00 P.M. 03/01/23 through 03/12/23 with the exception of 03/07/23 and 03/10/23. Verified 8:00 A.M. medications were given past the one hour medication time 03/01/23 through 03/09/23 with the exception of 03/02/23 and 03/08/23. The DON verified 8:00 P.M. medications were given past the one hour medication time 03/01/23 through 03/12/23 with the exception of 03/07/23 and 03/10/23. DON stated the facility had an open medication policy and verified some medications are scheduled for specific times. 2. Review of medical record for Resident #14 revealed admitted [DATE], with diagnoses of pressure ulcer of sacral region, chronic pain syndrome, neuromyelitis optica, neuromuscular dysfunction of bladder, need for assistance with personal care, depression, hypertension, hyperlipidemia, pressure ulcer of left heel stage two (partial thickness skin loss into but not deeper than the dermis), and bed confinement status. Review of physician orders dated 02/21/23, for Resident #14 revealed ertapenem (antibiotic) 1 gram solution for injection to run over 30 minutes intravenous every day for osteomyelitis of vertebra, sacral, and sacrococcygeal region scheduled at 12:00 P.M. Review of MAR for Resident #14 dated February and March 2023 revealed ertapenem 1 gram was not given on 02/25/23 and 03/02/23. Interview on 03/14/23 at 3:10 P.M., with DON verified intravenous antibiotic ertapenem 1 gram was not documented as administered for Resident #14 on 02/25/23 and 03/02/23 per physician order. Review of policy titled Open Medication Pass Policy revised 06/08/11, revealed medication orders that are time specific can be written as directed by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00140332.

Based on record review, observation and staff interview, the facility failed to ensure residents lift recliner, which is missing, was either found or a resolution to the missing personal item. This affected one resident (#37) of two reviewed for missing items. The census was 67. Finding included: Review of the medical record for Resident #37 revealed resident was admitted to facility 12/27/16 with diagnoses including hypertension, hypothyroidism, restless leg syndrome, and presence of artificial right eye. Review of the minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. She did not have any behaviors, required extensive assistance of two for hygiene and bathing. She was dependent for transfers, uses an electric scooter and mechanical lift for transfers. Observation on 11/29/22 at 11:00 A. M. of the room of Resident #37 revealed there was not a recliner in the room. Interview on 11/29/22 at 11:15 A.M. with Director of Nursing she verified that there was no recliner in Resident #37's room. She verified she was unaware that she was still missing items. Interview with Life Enrichment Director #300 on 11/29/22 at 12:41 P.M. stated that she was aware resident's recliner was missing from room on 06/17/22, she had correspondence with resident's family through July 2022 and she is currently unaware that the residents recliner was not in her room. She verified that she has had no other correspondence with the family regarding the recliner. This deficiency shows non compliance for Complaint Number OH00137425 and Complaint Number OH00138139.

Based on medical records, observation, staff interview, review of documents regarding elopement and review of facilities policies for elopement, abuse and neglect , the facility failed to report an elopement for one (# 51) of three residents reviewed in the dementia unit. The census was 67. Finding included: Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included dementia, difficulty in walking and need for assistance with personal care. Review of the minimum data set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and uses a walker which he can stabilize without staff assistance. Review of the physician's orders for Resident #51 revealed orders dated 12/08/22 to check Wander Guard function and code alert every day at bedtime (HS). There was not order for this prior to this date. Review of care plan relative to impaired behavior interventions necessary to ensure resident safety revealed individualized interventions with measurable goals. Review of the documents of Elopement of Resident #51 revealed a document from Nurse Manager #200 which she was notified he was missing on 11/06/22 at 8:15 P.M. by an aide. She and the aide searched dementia unit and he was not found. The aide stayed on the unit while the nurse manager began searching the center. She notified staff the resident was not on the unit and needed to check rooms for the resident. After checking all areas of the building, she exited the facility checking the courtyard, parking lot, and track. She then notified the Administrator. She returned to building to be notified the resident was found at 8:42 P.M. in the women's bathroom. She performed a head-to-toe assessment with no concerns found. The doctor and family were notified. It was determined resident had a Wander Guard but not a code alert. Review of a document from the Administrator dated 11/06/22 at 8:30 P.M. revealed she received a call from Nurse Manger #200 who was notifying her of Resident #51 was not on the dementia unit and a search was in progress. She was notified he was found in a women's bathroom at 8:42 P.M. it was determined he had a Wander Guard but not a code alert. He went through the dining room doors to exit the unit. A code alert was added immediately. Staff was educated on elopement policy and procedures for dining room doors in the dementia unit. Review of Resident #51's elopement, Wander Guard, code alert assessment dated [DATE] revealed resident is cognitively impaired with the diagnose of dementia. He uses a walker, does not have a safety alarm device, resides on the secured unit, requires frequent monitoring, and is not an elopement risk. The next review was completed on 12/08/22 after the surveyor brought to the attention of the administrator attention revealed the resident resides on the secured unit, requires frequent monitoring, has a Wander Guard bracelet and his photo on wander list. Interview on 12/08/22 at 1:20 P.M. with Administrator revealed the residents on the dementia unit with Wander Guard should be assessed quarterly per physician's order. There should be an order for each resident for the nurses to check the Wander Guards. She verified Resident#51 did not have orders to check his Wander Guard, but it was checked the day he eloped from the dementia unit, and it was working. The problem was he only had Wander Guard not the pendent which is what allowed him to leave through the kitchen door to the floor. The aide who was working the floor had left the dining room doors unlocked and the door to the kitchen open which allowed the resident to go missing. There are testers for both Wander Guards and pendants. There was not a self-reported investigation completed and sent to state agency. Observation on 12/08/22 at 1:25 P.M. of the kitchen area where Resident #51 went through to get to the other floor revealed there was a refrigerator and freezer with food in it, there was an unlocked cabinet with poisonous chemicals and there was utensil which included knives. This was verified by the Administrator; this was unsafe for the resident to be in this area. A Wander Guard was tested which did not set off an alarm and the code pedant tested ; did set off an alarm when entering the kitchen door. Interview on 12/08/22 at 3:00 P.M. with Nurse Manager #200 revealed there is a code system for residents to be safe in the dementia unit which is the emerald pendant. The Wander Guard system keeps the resident from exiting the building but not the unit. There were no alarms sounding when Resident #51 left the unit. He should have had a pendant along with the Wander Guard. Interview on 12/08/22 at 3:00 P.M. with agency Licensed Practical Nurse (LPN) #220 who was working the dementia unit revealed she completes Wander Guard checks on residents who have an order. She showed surveyor the Wander Guard tester. She verified Resident (#51) did not have an order to check his Wander Guard. She did not have knowledge of a tester for pendants. Interview with Administrator on 12/22/22 at 10:31 A.M. revealed she did not have a written statement from the aide on duty, she did not have documentation of staff ensuring all other residents were on the dementia unit at the time when Resident #51 was missing, and she educated staff for ensuring the dining room doors were closed and locked after meals Review of the Wander Guard Policy undated revealed it is the policy of the facility to provide the safest environment possible for wandering residents. A Wander Guard device is an added feature of our wander management program and is one of the many potential interventions. The nurse is to obtain physicians order for the device and is responsible to monitoring of resident bracelet. Review of the elopement policy undated revealed safely and timely redirect residents to a safe environment. A prompt investigation will be conducted if a resident is considered missing. Once the resident is located, the administrator is to notify the appropriate agencies. Review of the Abuse and Neglect policy date 11/21/16 revealed the facility does not condone abuse or neglect by anyone including facility staff. At any time resident abuse or neglect is suspected an immediate investigation will be initiated and appropriate actions will be taken, including notification of appropriate authorities. Neglect is defined means reckless failing to provide resident with any services necessary to maintain health and safety of the resident. This deficiency shows noncompliance for Complaint Number OH00138139 and Complaint Number OH00138406.

Based on medical records, observation, staff interview, review of documents regarding elopement and review of facilities policy for elopement, abuse and neglect , the facility failed to throughly investigate an elopement for one (# 51) of three residents reviewed in the dementia unit. The census was 67. Finding included: Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included dementia, difficulty in walking and need for assistance with personal care. Review of the minimum data set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and uses a walker which he can stabilize without staff assistance. Review of the physician's orders for Resident #51 revealed orders dated 12/08/22 to check Wander Guard function and code alert every day at bedtime (HS). There was not order for this prior to this date. Review of care plan relative to impaired behavior interventions necessary to ensure resident safety revealed individualized interventions with measurable goals. Review of the documents of Elopement of Resident #51 revealed a document from Nurse Manager #200 which she was notified he was missing on 11/06/22 at 8:15 P.M. by an aide. She and the aide searched dementia unit and he was not found. The aide stayed on the unit while the nurse manager began searching the center. She notified staff the resident was not on the unit and needed to check rooms for the resident. After checking all areas of the building, she exited the facility checking the courtyard, parking lot, and track. She then notified the Administrator. She returned to building to be notified the resident was found at 8:42 P.M. in the women's bathroom. She performed a head-to-toe assessment with no concerns found. The doctor and family were notified. It was determined resident had a Wander Guard but not a code alert. Review of a document from the Administrator dated 11/06/22 at 8:30 P.M. revealed she received a call from Nurse Manger #200 who was notifying her of Resident #51 was not on the dementia unit and a search was in progress. She was notified he was found in a women's bathroom at 8:42 P.M. it was determined he had a Wander Guard but not a code alert. He went through the dining room doors to exit the unit. A code alert was added immediately. Staff was educated on elopement policy and procedures for dining room doors in the dementia unit. Review of Resident #51's elopement, Wander Guard, code alert assessment dated [DATE] revealed resident is cognitively impaired with the diagnose of dementia. He uses a walker, does not have a safety alarm device, resides on the secured unit, requires frequent monitoring, and is not an elopement risk. The next review was completed on 12/08/22 after the surveyor brought to the attention of the administrator attention revealed the resident resides on the secured unit, requires frequent monitoring, has a Wander Guard bracelet and his photo on wander list. Interview on 12/08/22 at 1:20 P.M. with Administrator revealed the residents on the dementia unit with Wander Guard should be assessed quarterly per physician's order. There should be an order for each resident for the nurses to check the Wander Guards. She verified Resident#51 did not have orders to check his Wander Guard, but it was checked the day he eloped from the dementia unit, and it was working. The problem was he only had Wander Guard not the pendent which is what allowed him to leave through the kitchen door to the floor. The aide who was working the floor had left the dining room doors unlocked and the door to the kitchen open which allowed the resident to go missing. There are testers for both Wander Guards and pendants. There was not a self-reported investigation completed and sent to state agency. Observation on 12/08/22 at 1:25 P.M. of the kitchen area where Resident #51 went through to get to the other floor revealed there was a refrigerator and freezer with food in it, there was an unlocked cabinet with poisonous chemicals and there was utensil which included knives. This was verified by the Administrator; this was unsafe for the resident to be in this area. A Wander Guard was tested which did not set off an alarm and the code pedant tested ; did set off an alarm when entering the kitchen door. Interview on 12/08/22 at 3:00 P.M. with Nurse Manager #200 revealed there is a code system for residents to be safe in the dementia unit which is the emerald pendant. The Wander Guard system keeps the resident from exiting the building but not the unit. There were no alarms sounding when Resident #51 left the unit. He should have had a pendant along with the Wander Guard. Interview on 12/08/22 at 3:00 P.M. with agency Licensed Practical Nurse (LPN) #220 who was working the dementia unit revealed she completes Wander Guard checks on residents who have an order. She showed surveyor the Wander Guard tester. She verified Resident (#51) did not have an order to check his Wander Guard. She did not have knowledge of a tester for pendants. Interview with Administrator on 12/22/22 at 10:31 A.M. revealed she did not have a written statement from the aide on duty, she did not have documentation of staff ensuring all other residents were on the dementia unit at the time when Resident #51 was missing, and she educated staff for ensuring the dining room doors were closed and locked after meals Review of the Wander Guard Policy undated revealed it is the policy of the facility to provide the safest environment possible for wandering residents. A Wander Guard device is an added feature of our wander management program and is one of the many potential interventions. The nurse is to obtain physicians order for the device and is responsible to monitoring of resident bracelet. Review of the elopement policy undated revealed safely and timely redirect residents to a safe environment. A prompt investigation will be conducted if a resident is considered missing. Once the resident is located, the administrator is to notify the appropriate agencies. Review of the Abuse and Neglect policy date 11/21/16 revealed the facility does not condone abuse or neglect by anyone including facility staff. At any time resident abuse or neglect is suspected an immediate investigation will be initiated and appropriate actions will be taken, including notification of appropriate authorities. Neglect is defined means reckless failing to provide resident with any services necessary to maintain health and safety of the resident. This deficiency shows noncompliance for Complaint Number OH00138139 and Complaint Number OH00138406.