Every finding on record at Greenfield Skilled Nursing and Rehabilitation

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure the Interdisciplinary Team (IDT) determined whether the self-administration of a topical medication was clinically appropriate. This affected one (Resident #09) of one resident reviewed for self-administration. The facility census was 39 residents.Findings include:Review of the medical record revealed Resident #09 originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included edema, cellulitis, malignant neoplasm of skin, and local infection of the skin and subcutaneous tissue.Review of Resident #09's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and had edema and one venous ulcer.Review of Resident #09's prescriber orders revealed an order dated 11/12/25 for triamcinolone acetonide external cream 0.1% (a steroid cream) apply to rash to bilateral arms topically every shift and an order dated 11/12/25 for triamcinolone acetonide external cream 0.1% apply to left lower extremity topically every shift. Further review of the order had no instructions that Resident #09 may self-apply.Review on 04/19/26 of the Medication Administration Records for March 2026 and April 2026 revealed nursing staff signed off as the medication was administered.Review of Resident #09's medical record on 04/19/26 revealed there was no documentation of a medication self-administration assessment and care plan.Observation on 04/19/26 at 8:52 A.M. of Resident #09's bed revealed a tube of triamcinolone acetonide 0.1% cream.Interview on 04/19/26 at 8:52 A.M. with Resident #09 revealed the resident had a biopsy site of the left hand that was not healing. Resident #09 said they were self-applying the triamcinolone to the biopsy site.Observation on 04/19/26 at 1:37 P.M. revealed Resident #09 was resting with eyes closed in a recliner, and the triamcinolone cream was present on the bed.Observation on 04/20/26 at 8:33 A.M. revealed Resident #09 was resting with eyes closed in a recliner, and the triamcinolone cream was present on the bed.Interview with Licensed Practical Nurse (LPN) #109 on 04/20/26 at 8:44 A.M., revealed the LPN was unsure why Resident #09 used the triamcinolone cream and verified the resident was self-applying the medication. Further interview with LPN #109 revealed Resident #09 had cancer removed from the left hand and does not have a treatment order to apply triamcinolone 0.1% to the location.Observation of Resident #09 on 04/20/26 at 9:35 A.M. revealed the resident was resting with eyes closed in a recliner, and the triamcinolone cream was present on the bed.Interview with the Regional Quality Assurance Nurse #247 on 04/20/26 at 11:00 A.M., revealed the resident self-administration assessments were documented in the electronic medical record under assessments. Further review of Resident #09's assessments dated 04/20/26 at 11:04 A.M. revealed no self-administration assessment.Requested documentation from the facility on 04/20/26 at 1:30 P.M. of a medication self-administration assessment for Resident #09. Observation of Resident #09's room on 04/21/26 at 9:02 A.M. revealed the door was open, the resident was not in the room, and the triamcinolone cream was no longer on the bed.Requested documentation from the Director of Nursing (DON) on 04/21/26 at 10:10 A.M. of a medication self-administration assessment for Resident #09.Interview with the Regional Director of Operations #245 on 04/21/26 at 1:15 P.M. revealed the self-administration assessment for Resident #09 was documented under the assessments. Review of Resident #09's assessments revealed a self-administration skills assessment completed on 04/20/26 at 2:32 P.M. Further interview with the Regional Director of Operations #245 revealed the self-administration skills assessment was not completed until yesterday because the facility management was not aware the resident was self-administering the medication until it was brought to their attention.Review of the policy titled Self-Administration of Medications, dated December 2016 revealed as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration.

Based on medical record review and staff interview, the facility failed to develop a plan of care for residents with a gastrostomy tube and receiving tube feedings. This affected one (Resident #07) of two residents reviewed for enteral tube feeding care plans. The facility census was 39.Findings Included:Review of the medical record revealed Resident #07 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, diabetes mellitus type II, chronic obstructive pulmonary disease, depression, atherosclerosis, protein-calorie malnutrition, morbid obesity, hyperlipidemia, chronic pain, sciatica, asthma, cerebral infarction, anxiety, depression, and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #07 had minimally impaired cognition.Review of Resident #07's current comprehensive care plan, last revised on 04/19/26, revealed there was no care plan in place to address Resident #07's care needs addressing tube feedings when she readmitted to the facility on [DATE] with a new gastrostomy tube in place. Review of the physician orders revealed enteral feeding for dysphagia. Provide 2 Cal (Two Cal is a high-calorie high-protein supplement) infuse 60 milliliters per hour (ml/hour) for 12 hours. Initiate at 5:00 P.M. and discontinue at 5:00 A.M. daily. Orders also included water flush, to check placement, and air bolus to check placement routinely. Clean site with soap and water and apply new dressing daily.Interview with the MDS Coordinator #239 on 04/21/26 at 2:19 P.M., verified that a care plan for tube feeding was not in place on Resident #07's nutritional care plan until 04/19/26. MDS Coordinator #239 verified the resident had been receiving feedings via tube feed since 01/12/26.

Based on medical record review, interviews, facility policy review, review of job descriptions, and review of information from the Ohio Board of Nursing, the facility failed to ensure pressure ulcer interventions were implemented timely and weekly assessments, including staging, were completed per the professional standards of practice for Resident #28. This affected one (Resident #28) out of six residents reviewed for pressure ulcer care. The facility census was 39.Findings Included:Review of the medical record for Resident #28, revealed an admission date of 03/11/25. Diagnoses included cerebral infarction due to embolism of right middle cerebral artery, heart failure, neuromuscular dysfunction of bladder, weakness and muscle weakness and multiple sclerosis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of cognitive intactness. Resident #28 was assessed to require total dependence on bed mobility, transfers, toilet hygiene, and shower/bathe self. The resident was also assessed to have an indwelling catheter and an ostomy and not rated for urinary and bowel continence and a stage IV pressure ulcer.Review of the baseline care plan dated 03/11/25 for Resident #28 revealed pressure injury/skin care related to a left buttock pressure ulcer with interventions including to follow the facility skin protocol with no preventative measures such as an air mattress, pressure reducing cushion to wheelchair and offloading the area while in wheelchair.Review of the activities of daily living plan dated 03/11/25 for Resident #28 revealed a wound to the left buttock with extensive assist with positioning and turning with no preventative measures such an air mattress, pressure reducing cushion to wheelchair and offloading the area while in wheelchair.Review of the Braden Scale for Predicting Pressure Sore Risk dated 03/11/25 for Resident #28 revealed a score of 16.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #28 to be at low risk for skin breakdown.Review of the skin grid pressure assessment dated [DATE] completed by Licensed Practical Nurse (LPN) Unit Manager #183 for Resident #28 revealed a left buttock stage II pressure ulcer measured 3.5 centimeters (cm) by 4.5 cm by 0.2 cm with minimal serosanguineous drainage.Review of the Physician #300's admission assessment dated [DATE] of Resident #28 revealed no assessment of the left buttock pressure ulcer.Review of the progress note dated 03/12/25 at 12:00 P.M. for Resident #28 revealed resident maneuvering about the facility in motorized wheelchair with poor safety awareness. Resident transferred to a standard wheelchair and continued to participate in therapy for management of her motorized wheelchair.Review of the skin grid pressure assessment dated [DATE] completed by LPN Unit Manager #183 for Resident #28 revealed a left buttock stage II pressure ulcer measured 3.5 cm by 4.5 cm by 0.2 cm with minimal serosanguineous drainage.Review of the skin grid pressure assessment dated [DATE] completed by LPN Unit Manager #183 for Resident #28 revealed a left buttock stage II pressure ulcer measured 4.0 cm by 4.8 cm by 0.2 cm with moderate serosanguineous drainage.Review of the comprehensive care plan initiated 03/31/25 for Resident #28 revealed at risk for skin integrity related to impaired mobility with no interventions.Review of the skin grid pressure assessment dated [DATE] completed by LPN Unit Manager #183 for Resident #28 revealed a left buttock stage II pressure ulcer measured 4.0 cm by 4.8 cm by 0.2 cm with moderate serosanguineous drainage.Review of the physician orders dated 04/03/25 for Resident #28 revealed an alternating overlay air mattress to bed, to check placement and function and pressure relieving cushion to wheelchair, to check placement each shift. Review of the comprehensive care plan revised on 04/04/25 for Resident #28 revealed at risk for skin integrity related to impaired mobility with interventions including an air cushion to wheelchair and an alternating air overlay to mattress.Review of the skin grid pressure assessment dated [DATE] completed by LPN Unit Manager #183 for Resident #28 revealed a left buttock stage II pressure ulcer measured 5.0 cm by 6.0 cm by 1.8 cm with moderate serosanguineous drainage and slight odor. Physician notified of decline.Review of the medical record for Resident #28 dated 03/11/25 through 04/08/25 revealed no documentation of communication to a Registered Nurse or a physician of the assessment, description and staging of the left buttock pressure ulcer from LPN Unit Manger #183 regarding assessments, including staging on the weekly skin grid pressure ulcer assessments.Further review of the medical record for this resident during that time revealed no documented assessments, descriptions and staging from a Registered Nurse or Physician. Interview on 04/21/26 at 8:56 A.M. with the Director of Nursing (DON) revealed LPN Unit Manager #183 did complete the weekly skin grid pressure assessments from 03/11/25 through 04/08/25 with no documentation of an RN or physician assessment or communication to verify the assessment and staging of the left buttock pressure ulcer. Also verified the baseline care plan for Resident #28 did not have interventions for the pressure ulcer area as she did get transferred to a standard wheelchair from her motorized chair due to safety on 03/12/25 and had a pressure reducing cushion to her motorized wheelchair, but not her standard wheelchair. No documentation to verify when Resident #28 was able to safely use her motorized wheelchair. Verified no orders and plan of care interventions for the left buttock pressure ulcer such as a pressure reducing cushion to the standard wheelchair and the air mattress overlay until 04/03/25 and 04/04/25.Interview on 04/22/26 at 8:45 A.M. with the Regional Quality Assurance Nurse #247 verified LPN Unit Manager #183 was not wound certified but had received some facility education on wounds that included pressure ulcers.Interview on 04/22/26 at 8:47 A.M. with LPN Unit Manager #183 verified she was not wound certified and could not describe the type of education she had received from the facility for pressure ulcer assessments. Verified she was unable to stage pressure ulcers as it was not in her scope of practice but did document her assessment for Resident #28 each week on the skin grid pressure ulcer left buttock assessments dated 03/11/25 through 04/08/25 which included staging. She could not recall if she called the DON about the assessments to confirm the accuracy of the assessment and staging as there was no documentation to support that.A follow-up interview on 04/22/26 at 8:54 A.M. with the DON revealed LPN Unit Manager #183 would call with pressure ulcer assessments for residents to confirm staging, but there is no documentation of the communication for assessments completed for Resident #28's weekly skin grid pressure for the left buttock from 03/11/25 through 04/08/25. Could not recall if she assessed Resident #28's pressure ulcer to the left buttock weekly to verify staging and assessments as there was no documentation and should be. Reviewed the activities of daily living plan dated 03/11/25 and confirmed the resident was an extensive assist with positioning and turning with no preventative measures such an air mattress, pressure reducing cushion to wheelchair and offloading the area while in wheelchair.Review of the facility policy titled Resident Examination and Assessment revised February 2014 revealed the purpose of this procedure is to examine and assess the resident for any abnormalities in health status. Physical examination included skin and the presence of pressure sores with the documentation of the assessment in the residents medical record by the individuals who performed it. Report other information in accordance with facility policy and professional standards of practice.Review of the facility policy titled Charting and Documentation revised July 2017 revealed all services provided to the resident shall be documented in the resident's medical record such as objective observations. Documentation in the medical record will be objective, complete and accurate. Entries may only be recorded in the resident's clinical record by licensed personnel in accordance with the state law and facility policy.Review of the Licensed Practical Nurse job description dated 05/2009 revealed job responsibility that included to monitor resident care on assigned shift to meet standards of practice and state federal regulations and asses newly admitted residents and transcribe findings according to assessment policy and guidelines. Review of the Ohio Board of Nursing information under Section 4723.01 nurse definitions effective 04/06/23 revealed the practice of nursing as a licensed practical nurse means providing individuals and groups nursing care requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences at the direction of a registered nurse. Such nursing care include: observation in a diversity of health care settings and contributions to the planning, implementation, and evaluation of nursing. This deficiency represents non-compliance investigated under Complaint Number 2971657.

Based on medical record review, staff interview, and policy review, the facility failed to accurately transcribe, clarify and follow a prescriber's order for a resident who was on a voiding trial after removal of a Foley catheter. This affected one (Resident #06) of five residents with indwelling urinary catheters. The facility census was 39 residents.Findings include:Review of Resident #06's medical record revealed an initial admission date of 02/26/26 and a readmission date of 04/08/26. Diagnoses included diabetes mellitus, chronic kidney disease stage three, and obstructive and reflux uropathy. Review of the admission assessment dated [DATE] revealed Resident #06 had a urinary catheter upon admission.Review of Resident #06's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and had an indwelling urinary catheter in place. Review of Resident #06's care plan dated 03/17/26 revealed the resident had an alteration in elimination due to diabetes, chronic kidney disease stage three, hypertension, and an indwelling Foley catheter.Review of the prescriber order dated 02/27/26 for Resident #06 revealed an order for discontinuation of the indwelling urinary catheter on 03/02/26.Review of the prescriber order dated 03/02/26 revealed an order to remove Resident #06's indwelling catheter due to a voiding trial on 03/02/26. Additionally, an order dated 03/02/26 to straight catheterize every eight hours as needed for urinary retention; keep leg catheter in place if 2400 milliliters (mL) of urine.Review of the progress note dated 03/02/26 at 9:22 P.M. revealed Resident #06's indwelling catheter was discontinued per order, and the resident was provided a urinal and a bedside commode.Review of the progress note dated 03/03/26 at 6:37 P.M. revealed Resident #06 was straight catheterized and 850 mL of urine was obtained. Further review of the progress notes revealed a note dated 03/03/26 at 8:10 P.M. the straight catheterization procedure for Resident #06 was effective.Review of the Medication Administration Record (MAR) for March 2026 revealed Resident #06 was straight catheterized on 03/03/26. Further review revealed no other documentation of straight catheterization performed for Resident #06 for the month of March.Review of the progress notes revealed a late entry note created on 03/14/26 with an effective date of 03/05/26 at 4:58 P.M. revealed Resident #06 was complaining of abdominal pain, and the resident's abdomen was distended and tender to touch. Further review of the progress note revealed Resident #06 was straight catheterized with 1400 mL of urine obtained, and the straight catheter was left in place per prescriber order.Interview on 04/20/26 at 10:30 A.M., with the Director of Nursing (DON) verified the prescriber order reflected the catheter to be left in place if 2400 mL of urine was obtained with straight catheterization, but the progress note reflected the catheter was left in place when 1400 mL of urine was obtained with straight catheterization.Interview on 04/20/26 at 10:39 A.M., with the Nurse Practitioner #243 and the DON verified the prescriber order for straight catheterization should have reflected to leave the urinary catheter in place if 400 mL of urine was obtained with straight catheterization not 2400 mL. Further interview with the DON verified Resident #06 should have had the urinary catheter left in place sooner since previous catheterization output was greater than 400 mL and the order had not been clarified and was transcribed incorrectly.Review of the policy titled Telephone Orders revised February 2014 revealed verbal telephone orders are recorded in the resident's medical record. The entry must contain the instructions from the physician, date, time, and the signature and title of the person receiving the order. Telephone orders must be countersigned by the physician during his or her next visit.

Based on record reviews, review of resident fund account documentation, review of self reported incident, staff interviews, and facility policy review, the facility failed to ensure appropriate handling of resident funds. This affected four Residents (#6, #24, #42, #46) of four reviewed for resident funds. Facility identified 19 Residents (#2, #3, #6, #7, #8, #15, #19, #21, #24, #25, #26, #29, #37, #42, #43, #44, #45, #46, #47) potentially affected by the accounting practice. Facility census was 41. Findings include 1.Review of the medical record for Resident #42 revealed an admission date of 02/21/21 and discharge date of 08/06/25. Diagnoses included displaced fracture of the right leg, chronic obstructive pulmonary disease (COPD), muscle weakness, and unspecified dementia without behaviors. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of five. Review of fund authorization form dated 04/10/18 revealed Resident #42 opened a personal fund account at the facility. Review of facility withdrawal receipts and store receipts from 01/01/25 to 06/10/25 for Resident #42 revealed:On 01/09/25 a withdrawal of $50.00 was documented for personal items and snacks by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went.On 03/03/25 a withdrawal of $500.00 was documented for clothing and personal items by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went.On 05/07/25 a withdrawal of $200.00 was documented for personal items and snacks by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went.On 06/04/25 a withdrawal of $10.00 was documented the beautician by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went. 2. Review of the medical record for Resident #46 revealed an admission date of 07/20/20 to 06/23/25. Diagnoses included kidney failure, muscle weakness, heart failure, vascular dementia and edema.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively impaired with a BIMS of seven.Review of fund authorization form dated 04/01/22 revealed Resident #46 opened an personal fund account at the facility.Review of facility withdrawal receipts and store receipts from 01/01/25 to 06/10/25 for Resident #46 revealed:On 03/03/25 a withdrawal of $500.00 was documented for clothing and personal items by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went.On 05/27/25 a withdrawal of $150.00 was documented for personal items and snacks by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went.On 06/04/25 a withdrawal of $10.00 was documented for the beautician by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went. 3. Review of the medical record for Resident #24 revealed an admission date of 11/23/22. Diagnoses included non ST elevation myocardial infarction (NSTEMI), respiratory failure, edema, heart failure, diabetes and pulmonary hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact with a BIMS of 15. Review of fund authorization form dated 06/27/24 revealed Resident #24 opened an personal fund account at the facility. Review of facility withdrawal receipts and store receipts from 01/01/25 to 06/10/25 for Resident #24 found:On 02/24/25 a withdrawal of $50.00 was documented for clothing and personal items by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went.On 03/03/25 a withdrawal of $60.00 was documented for Walmart by Social Services #210, a receipt was provided dated 03/11/25 for $26.50. The facility had no documentation of where the money/change went after the purchase. On 05/08/25 a withdrawal of $30.00 was documented for Walmart by Social Services #210, a receipt was provided dated 05/09/25 for $17.04. The facility had no documentation of where the money/change went after the purchase. On 06/04/25 a withdrawal of $10.00 was documented for the beautician by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went. 4. Review of the medical record for Resident #06 revealed an admission date of 03/29/24. Diagnoses included heart failure, unspecified dementia, malnutrition, and muscle weakness.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #06 was cognitively impaired with a BIMS of two. Review of fund authorization form with and eligible date revealed Resident #06 opened an personal fund account at the facility. Review of facility withdrawal receipts and store receipts from 01/01/25 to 06/10/25 for Resident #06 found: On 03/03/25 a withdrawal of $150.00 was documented for clothing and personal items by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went.On 04/29/25 a withdrawal of $20.00 was documented for clothing and personal items by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went. On 05/07/25 a withdrawal of $100.00 was documented for clothing and personal items by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went.On 05/15/25 a withdrawal of $30.00 was documented for clothing and personal items by Social Services #210, no receipts were provided and the facility had no documentation of where the money/change went. Interview on 08/14/25 at 11:03 A.M. with [NAME] Police Officer #500 revealed the criminal investigation had concluded and revealed facility had significant issues with book keeping and facility had very little oversite regarding resident funds. He revealed his investigation found a free for all with staff having unbridled access to funds without having to follow any requirements of providing receipts for purchases made by staff with resident money. Interview on 08/14/25 at 1:35 P.M. with Resident #24 found facility had informed her of potential missing money a few months ago and reported money had been returned. She did not remember if she was asked to sign a blank receipt for staff, but revealed she had never really looked. I just trusted them. Interview on 08/18/25 at 10:20 A.M. with Director of Nursing (DON), Administrator, Business Office Manager (BOM) #55 and Regional Account Manager (RAM) #205 confirmed facility had investigated the allegation of misappropriation. They confirmed Social Services (SS) #210 had taken resident money to go shopping, but confirmed a large amount of withdrawals had no evidence of receipts showing proof of purchases and several purchases that had receipts had no documented evidence of money or change being returned to the resident or returned to the fund account. BOM confirmed facility did not have a process of requiring receipts after staff completing shopping with resident's money. Interview on 08/18/25 at 3:00 P.M. with Administrator and Regional Account Manager #205 confirmed Social Services (SS) #210 took resident money to her home for an unknown amount of time but per her statement in the investigation, they confirmed she had resident money in her possession for several months. They confirmed staff regularly shop for residents and they did not have a standard procedure for staff taking resident money, how long they could keep the money before returning it, or returning the resident's change. They acknowledged facility had no checks and balances and no one making sure staff followed any guidelines when taking residents money out of the building. They also confirmed staff reported concerns of SS #210 asking activity aides to sign blank facility receipts for resident fund withdrawals and when questioned by staff, SS #210 reported she would fill in an amount later once an amount was known. Interview on 08/18/25 at 3:25 P.M. with Activity Aide (AA) #70 confirmed Social Service (SS) #210 had asked her to have residents sign a blank receipt to take out resident funds. She questioned it and SS #210 stated she would fill in an amount later. AA #70 reported she just had residents sign the ones with amounts, and put the receipt book back with the blank receipts left unsigned. Review of the facility policy titled, Deposit of Resident Funds, dated 04/2017 revealed resident personal funds shall be held and managed by the facility and shall be safeguarded. Funds over $50 shall be deposited in an interest bearing account. Facility did not provide any evidence of written policy or procedure regarding staff shopping for residents and signing out resident money to staff. This deficiency represents non-compliance investigated under Complaint Number 1342630 and 2580694.

Based on record review, self-reported incident (SRI) review, review of the facility investigation, resident interview, staff interview, and policy review, the facility failed to ensure a thorough investigation was completed for Resident #51 who had an allegation of abuse and for Residents #7, #42, and #46 who were involved with an allegation of misappropriation. This affected four residents (#7, #42, #46, and #51) out of four reviewed for abuse, neglect, and misappropriation. The facility identified 19 residents (#2, #3, #6, #7, #8, #15, #19, #21, #24, #25, #26, #29, #37, #42, #43, #44, #45, #46, #47) who were potentially affected by the accounting practices related to the misappropriation SRI #261495 and one resident (#51) identified in the abuse SRI #262018. The facility census was 41.Findings Include: 1. Review of the medical record for Resident #51 revealed an admission date of 03/18/25 and a discharge date of 07/25/25. Diagnoses included chronic pulmonary disease, fracture of the left femur, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact.Review of Self Reported Incident (SRI) #262018 revealed Resident #51 reported Registered Nurse (RN) #72 had pushed him. No suspected perpetrator was listed on the intake and no witnesses were listed on the intake. RN #72 was interviewed and named two witnesses who observed the entirety of the interaction, one was an aide and the other was a hospice nurse. No statements were provided from those two staff members stating their observations of the incident.Interview on 08/14/25 at 4:00 P.M. with the Administrator confirmed the suspected perpetrator was not reported appropriately for tracking purposes to the Health Department for SRI #262018. The Administrator also confirmed two witnesses were mentioned in the suspected perpetrators statement, noting those two people were at the nurses station and saw the whole event. The Administrator confirmed those staff were not listed in the report intake either and neither witness had a signed statement of what they observed during the incident in question.2. Review of facility Self Reported Incident (SRI) #261495 investigation dated 06/10/25 to 06/13/25 revealed Social Services (SS) #210 had asked an Activity Aide (AA) #185 to have a resident sign a blank receipt for resident funds. When questioned, SS #210 informed AA #185 she would fill in the amount later. AA #185 had concerns of mishandling of funds and reported an allegation of misappropriation to management who began an SRI investigation. The facility also identified Activity Aide (AA) #70 as the staff who reported the allegation. The investigation found when the facility was taking money out of the resident accounts to shop for the residents, staff were not consistently providing a receipt to account for the disposition of the funds removed and did not keep documentation whether the change was returned and if so, how (cash back to the resident or returned to the fund account). Further review of the investigation revealed Resident #42 was the only resident assigned as a victim through the system (which tracks perpetrators, victims and witnesses), though 19 total residents were included in the investigation (#2, #3, #6, #7, #8, #15, #19, #21, #24, #25, #26, #29, #37, #42, #43, #44, #45, #46, and #47). The investigation stated the residents/responsible parties were immediately advised they would be refunded for any transactions in question. The investigation revealed Activity Aide (AA) #70 was not listed on the SRI intake as a witness and no other witnesses were listed. Staff statements were unclear due to having several statements from the same staff on the same day including AA #70 having three interviews that provided slightly different information, including one statement naming Registered Nurse #95 as a witness. No interviews were included for Activity Aide #185 or Registered Nurse #95, who were named as additional potential witnesses. Staff statements were also written by facility management as an interview without providing interview questions of what was asked. It was unknown if additional information was known by staff, but not specifically asked about. Social Services #210 also had documented two interviews/statements on 06/10/25 that varied in information.Review of the facility investigation revealed audits for 2025. The audits revealed 12 residents (#2, #3, #6, #7, #19, #21, #24, #26, #42, #44, #45, and #46) had withdrawals without receipts. The reimbursement report for 2025 stated a total $3,223.55 was refunded to 11 residents (#2, #3, #6, #19, #21, #24, #26, #42, #44, #45, and #46). It did not include any evidence of Resident #7 being reimbursed the unaccounted for withdrawal from 05/15/25 and 06/04/25 equaling a total of $40.00. Additionally, the accounting for Resident #46 revealed the resident was not reimbursed the accurate amount and was shorted $96.38.Interview on 08/14/25 at 1:35 P.M. with Resident #24 found the facility had informed her of potential missing money a few months ago and reported the money had been returned. She did not remember if she was asked to sign a blank receipt for staff, but revealed she had never really looked and she stated, I just trusted them.Interview on 08/18/25 at 10:20 A.M. with Director of Nursing (DON), Administrator, Business Office Manager (BOM) #55 and Regional Account Manager (RAM) #205 confirmed the facility had investigated the allegation of misappropriation. They stated Social Services (SS) #210 had taken resident money to go shopping, but confirmed a large amount of withdrawals had no evidence of receipts showing proof of purchases, and several purchases that had receipts had no documented evidence of money or change being returned to the resident or returned to the residents fund account. BOM #55 confirmed the facility did not have a process of requiring receipts after staff completed shopping with resident's money. They also confirmed SS #210 had taken a portion of the money home and returned it upon staffs request during the investigation.Interview on 08/18/25 at 2:35 P.M. with Regional Nurse (RN) #200, Regional Account Manager (RAM) #205, and the Administrator confirmed staff statements were completed by interviews without the questions provided on the statement. They also confirmed several statements were in the file from the same staff member that were slightly different. They confirmed not all residents or witnesses were included in the Self Reported Incident Reporting and also not all were included in the listing of refunded residents, as Resident #7 was missing. They further confirmed Resident #46 was not reimbursed the accurate amount and was shorted $96.38. Resident #46 was reimbursed during the survey.Interview on 08/18/25 at 3:00 P.M. with Administrator and Regional Account Manager #205 confirmed Social Services (SS) #210 took resident money to shop for residents on a regular basis. They reported she should have provided receipts for all transactions and provided change back to the residents or to the fund account. The Administrator confirmed the facility did not have a standard procedure for staff taking resident money, how long they could keep the money before returning it, or returning the resident's change. They acknowledged facility had no checks and balances and no one making sure staff followed any guidelines when taking residents money out of the building. The Administrator confirmed all interviews conducted were included in the file.Interview on 08/18/25 at 3:25 P.M. with Activity Aide (AA) #70 confirmed Social Service (SS) #210 had asked her to have residents sign a blank receipt to take out resident funds. She questioned it and SS #210 stated she would fill in an amount later. AA #70 reported she just had residents sign the ones with amounts, and put the receipt book back with the blank receipts left unsigned. AA #70 reported she did not report the incident initially, but another Activity Aide #185 was the first to report the incident to the management team.Review of facility policy titled, Abuse Neglect, Exploitation and Misappropriation Prevention Program, dated 04/2021 revealed residents had the right to be free from misappropriation. The policy stated the facility shall investigate all allegations of abuse.Review of facility policy titled, Abuse Neglect, Exploitation and Misappropriation Prevention Program, dated 09/2022 revealed the facility shall report allegations of misappropriation to the State licensing agency and the verbal/written notices shall include the resident(s) names and names of all persons involved in the alleged incident. Upon receiving allegations, the Administrator was responsible for determining what actions were needed for resident protection.This deficiency represents non-compliance investigated under Complaint Number 1342630 and Complaint Number 2580694.

Based on record reviews, review of resident fund account documentation, review of self reported incident investigation, staff interviews, and policy review, facility failed to ensure residents were free from the potential of misappropriation. This affected three Residents (#7 #42 and #46) of three reviewed for misappropriation. Facility census was 41. Findings include 1.Review of the medical record for Resident # 42 revealed an admission date of 02/21/21 and discharge date of 08/06/25. Diagnoses included displaced fracture of the right leg, chronic obstructive pulmonary disease (COPD), muscle weakness, and unspecified dementia without behaviors. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively impaired with a brief interview of mental status (BIMS) score of five. Review of facility Self Reported Incident (SRI) #261495 investigation dated 06/10/25 to 06/13/25 revealed Social Services (SS) #210 had asked an Activity Aide (AA) #185 to have a resident sign a blank receipt for resident funds. When questioned, SS #210 informed AA #185 she would fill in the amount later. AA #185 had concerns of mishandling of funds and reported an allegation of misappropriation to management who began an SRI investigation. The investigation found when the facility was taking money out of the resident accounts to shop for the resident, staff were not consistently providing a receipt to account for the disposition of the funds removed and did not keep documentation whether the change was returned and if so how (cash back to the resident, or returned to the fund account). Review of a staff statement from SRI #261495 investigation from Social Services (SS) #210 revealed she was asked if she had any additional money or receipts due to money being unaccounted for during the SRI investigation audit. SS #210 reported she had $500.00 in her car for several months for Resident #42. At the time of this interview statement, SS #210 had been suspended since 06/10/25 for an allegation of mishandling funds. 2. Review of the medical record for Resident #46 revealed an admission date of 07/20/20 to 06/23/25. Diagnoses included kidney failure, muscle weakness, heart failure, vascular dementia and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively impaired with a BIMS of seven. Review of a staff statement from SRI #261495 investigation from Social Services (SS) #210 revealed she was asked if she had any additional money or receipts due to money being unaccounted for during the SRI investigation audit. SS reported she had $92.41 in her car for Resident #46. At the time of this interview statement, SS #210 had been suspended since 06/10/25 for an allegation of mishandling funds. Review of Resident fund account from 06/01/25 to 08/14/25 revealed no evidence the $92.41 was returned to resident fund account for Resident #46. Interview on 08/18/25 at 2:35 P.M. with Regional Nurse #200, Regional Account Manager (RAM) #205 and Administrator confirmed Resident #46 did not have the cash money found in Social Service #210's personal vehicle return to his personal fund account. 3. Review of the medical record for Resident #07 revealed an admission date of 09/27/16. Diagnoses included dysphagia, intellectual disabilities, contracture of upper extremities, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #07 was cognitively impaired with a BIMS of six. Review of a staff statement from SRI #261495 investigation from Social Services (SS) #210 revealed she was asked if she had any additional money or receipts due to money being unaccounted for during the SRI investigation audit. SS reported she had $30.00 in her car for Resident #7. At the time of this interview statement, SS #210 had been suspended since 06/10/25 for an allegation of mishandling funds. Interview on 08/18/25 at 10:20 A.M. with Director of Nursing (DON), Administrator and Business office Manager (BOM) #55 and Regional Account Manager (RAM) #205 confirmed facility had investigated the allegation of misappropriation. They confirmed Social Serivces (SS) #210 was suspended pending investigation. They confirmed SS had taken resident fund money home with her. Interview on 08/18/25 at 3:00 with Administrator and Regional Account Manager #205 confirmed Social Services (SS) #210 took resident money to her home. They confirmed staff regularly shop for residents and they did not have a standard procedure for staff taking resident money and how long they could keep the money before returning it, or returning the resident's change. They acknowledged SS #210's statement included a report she had $500.00 for Resident #42 for several months in her personal vehicle. They acknowledged the risk of theft with no checks and balances and no one making sure staff followed any guidelines when taking residents money out of the building. Review of facility policy titled, Abuse Neglect, Exploitation and Misappropriation Prevention Program, dated 04/2021 revealed Residents had the right to be free from misappropriation. Facility shall protect residents from misappropriations by anyone including facility staff. Facility shall develop and implement policies and protocols to prevent and identify misappropriation. This deficiency represents non-compliance investigated under Complaint Number 1342630 and 2580694.

Based on record review and staff interview, the facility failed to ensure a safe discharge plan was implemented. This affected one resident (#48) of three reviewed for discharge planning. The facility census was 41. Findings Include: Review of the medical record for Resident #48 revealed an admission date of 02/19/25 and a discharge date of 05/22/25. Diagnoses included pulmonary disease, respiratory failure, embolism of thoracic aorta, cerebral infarct, bipolar disorder, schizophreniform disorder, skin picking disorder and neuropathy.Review of the plan of care dated 03/05/25 revealed Resident #48 would possibly require discharge planning with interventions to provide information on community resources and utilize resources (for example: home health care) and participate in therapy.Review of the communication in the insurance portal with [NAME] on 05/14/25 revealed Resident #48 had seven benefit days remaining before benefits ran out. The message instructed facility to begin discharge planning.Review of the physical therapy notes dated 05/20/25 revealed Resident #48 required 50 percent (%) verbal instruction for transfer training with 75% physical assistance of two staff due to compromised balance, coordination and safety awareness. The resident transferred to the wheelchair with pivot transfer with two person moderate assistance. When using the slide board Resident #48 required minimum assistance of two staff. Resident #48 continued to need stabilization of lower extremities to keep feet from lifting off the floor during sit to stand transfers.Review of the occupational therapy note dated 05/20/25 revealed Resident #48 had transfer training of stand pivot transfers from the wheelchair to the mat table with maximum assistance of one to moderate assistance of two staff. Resident #48 had increased anxiety with fear of falling requiring increased time to allow the resident to rest.Review of the physical therapy notes dated 05/21/25 revealed Resident #48 and her son were educated on bilateral upper and lower extremity exercises. Skilled interventions focused on transfer training to increase functional task performance. The resident's son was educated on wheelchair mat transfers and the resident's son completed a return demonstration. He stated he felt confident with these transfers at home.Review of the occupational therapy note dated 05/21/25 revealed Resident #48 was educated on compensatory strategies for activities of daily living (ADLs) including wearing a gown for ease, elastic shoe laces to improve the ability to slide shoes on, they discussed recommendations for toileting, encouraged bed level verses one person assistance (with son having to stand and manage clothing items and bed/rails), performed basin bath due to second story shower, and easy open containers and light meals if her family was out for short periods of time. Resident #48 stated her son was taking a leave of absence from work to be a full time caregiver and provide meals and ADL care. Resident #48's family also planned to hire a part-time caregiver in addition to the recommended home healthcare for therapy and nursing.Review of the physical therapy Discharge summary dated [DATE] revealed Resident #48 had requested to return home. It stated the resident had only met one of six goals and required maximum assistance of one to two people for functional transfers and minimum to moderate assistance with the use of a bed rail for bed mobility.Review of the occupational therapy Discharge summary dated [DATE] revealed Resident #48 exhausted her benefits days and declined treatment (private pay). It stated Resident #48 had only met one of seven goals and required substantial maximum assistance for toileting and partial to moderate assistance for activities of daily living.Review of the progress notes dated 05/21/25 from the Director of Nursing revealed Resident #48 was scheduled to discharge home 05/22/25 with referrals to home health services for physical therapy, occupational therapy, nursing and state tested nursing aides (STNA). Resident #48 and her son were aware. The note dated 05/22/25 from Licensed Practical Nurse (LPN) #58 revealed the nurse signed discharge paperwork with Resident #48's son (Power of Attorney (POA)). Resident #48 discharged with her POA. The note dated 05/22/25 from Social Services #210 revealed Resident #48 was discharging home with her son and home health and appointments were set up.Review of Resident #48's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 06 indicating impaired cognition. It stated Resident #48 required set up assistance for eating, substantial maximum assistance for oral hygiene, shower/bathing, upper body dressing, personal hygiene, rolling, sitting up in bed and sitting at the edge of the bed and she was dependent upon staff with toileting assistance, lower body dressing, placing footwear, mobility from sit to stand, chair to bed transfers, toilet transfers, and shower transfers. Car transfers and walking 10 feet were not attempted due to medical or safety concerns.Review of the discharge summary/discharge plan of care dated 05/22/25 revealed Resident #48 was discharged due to meeting therapy goals. It also stated Resident #48 was set up with home healthcare for aide services as well as physical and occupational therapy services and named Ross County Home Health as the provider.Interview on 08/14/25 at 1:15 P.M. with Therapy Director (TD) #60 revealed Resident #48 was cut from therapy and had requested to discharge home with her family at that time instead of paying privately. TD #60 revealed Resident #48's family was reluctant about taking her home and she felt the resident had pressured her family to take her home at discharge.Interview on 08/14/25 at 4:00 P.M. with Administrator revealed Resident #48's insurance informed the facility on 05/14/25 that her days were about to be exhausted and she had seven days left, with the last covered day being 05/21/25. She confirmed the note mentioned the facility was to provide discharge planning.Interview on 08/18/25 at 11:56 A.M. with Home Health Agency: Ross County Home Health revealed they denied the referral for Resident #48 and stated they were out of network with her insurance. They stated they received the referral on 05/22/25 and informed Social Services staff on 05/22/25 they were out of network. They revealed they did not hear back and followed up with a second email informing the facility they were out of network on 06/01/25, and again did not receive any response or confirmation back. They confirmed they had never met with Resident #48 or initiated services.Interview on 08/18/25 at 12:25 P.M. with Director of Nursing (DON) revealed she had an expectation of a safe discharge plan and the previous social services staff should have confirmed acceptance of a home health agency. The DON confirmed the discharge summary did not give an accurate reason for discharge as it stated the resident met therapy goals. She also acknowledged the agency listed did not begin any services and confirmed the facility sent Resident #48 home without the needed and recommended services, which was not a safe discharge plan.Interview on 08/18/25 at 1:55 P.M. with Regional Nurse (RN) #200 confirmed the facility had no evidence of Resident #48 having an accepted home health agency at the time of discharge. RN #200 confirmed the facility only had evidence that two referrals were sent on 05/22/25 and none were sent prior to the day of discharge. RN #200 confirmed the facility had no evidence of prior discharge planning and no evidence a discharge care conference was held. RN #200 confirmed she received an email in June 2025 about referrals for Resident #48 and stated it was not our job to ensure the resident had services arranged prior to discharge to ensure a safe discharge plan.Interview on 08/18/25 at 1:55 P.M. with Regional Nurse (RN) #200 and Regional Account Manager (RAM) #205 reported the facility had discussions with Resident #48 and her family regarding difficulties with the insurance and acknowledged the facility had no evidence of the discussions and no documentation of difficulties with discharge planning.This deficiency represents non-compliance investigated under Complaint Number 2581704.

Based on observation, staff interview and policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner to prevent foodborne illness. This affected all 42 residents who received food from the facility kitchen. The facility census was 42. Findings include: 1. Observation of the milk cooler in the kitchen on 12/02/24 at 9:26 A.M. revealed there were two gallons of milk that were opened with an expiration date of 11/30/24. Interview on 12/02/24 at 9:26 A.M. with [NAME] #27 verified there were two gallons of open milk with an expiration date of 11/30/24 in the milk cooler in the kitchen. Review of the facility's food receiving and storage policy, dated October 2017, revealed food should be stored in a manner that complies with safe food handling practices. 44083 2. Observation on 12/04/24 from 8:02 A.M. to 8:22 A.M. revealed Dietary Manager (DM) #34 was serving breakfast meal to all residents. DM #34 wore gloves and had a towel draped on his shoulder. DM #34 had facial hair and was not wearing a protective facial hair restraint. DM #34 was observed to serve food onto plates for residents with gloved hands then touched the counter, wiped his face and head with the towel, and returned the towel to his shoulder area. Continued observation revealed DM #34 placed toast with his gloved hands onto the serving plates and took the plates to residents in the dining room with his gloved thumb extending onto the plates. DM #34 returned to the food serving area, wiped his face with the towel, and with the same gloved hands put toast onto the next resident's plate. DM #34 was not observed to change his gloves or wash his hands until the end of the meal service. Interview on 12/04/24 at 8:30 A.M. with DM #34 verified he had full facial hair and should have worn a facial hair covering. DM #34 verified he used a towel around his shoulder to wipe perspiration from his head and face. DM #34 verified he placed the toast on resident's plates with the same gloved hands after having wiped his perspiration onto the towel. DM #34 verified he served residents food to the table side and had his thumb extending into the plate with the same gloved hands used to continue food plating. DM #34 verified he did not change his gloves or wash his hands until the end of the meal service. Review of facility policy titled, Food Preparation and Service, dated April 2019, revealed food preparation staff are to adhere to proper hygiene. Gloves are worn when handling food directly and changed between tasks. Food service staff wear hair restraints, (hair nets and beard restraints), so hair does not contact food.

Based on observation, staff interview, medical record review, review of a meal spreadsheet, and policy review, the facility failed to serve food as prescribed for residents on a controlled carbohydrate therapeutic diet. This affected 15 (#8, #3, #28, #33, #25, #37, #7, #32, #16, #2, #29, #147, #145, #148, and #18) of 15 residents who received a controlled carbohydrate diet. The facility total census was 42. Findings Included: Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety, somnolence, migraines, fibromyalgia, encephalopathy, diabetes, anxiety disorder, history of cellulitis of limb, morbid obesity, irritable bowel, cognitive impairment, chronic kidney disease, chronic pain, and psychosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderately impaired cognition and required set assistance with meals. Review of Resident #8's current physician orders revealed the resident had an order for a controlled carbohydrate diet, received insulin via sliding scale, and was ordered the anti-diabetic medication Januvia 200 milligrams one tablet a day. Review of breakfast spreadsheets dated 11/28/24, 11/30/24, and 12/03/24 revealed reduced calorie syrup was to be served for residents receiving a controlled carbohydrate diet. Observation on 12/03/24 at 8:00 A.M. revealed Resident #8 was feeding herself the breakfast meal including pancakes. The meal ticket listed Residents #8 was on a controlled carbohydrate diet and was to receive reduced calorie syrup. The syrup observed on the resident's tray was regular, non-reduced calorie syrup. Observation on 12/03/24 at 8:13 A.M. revealed the Dietary Aide was #32 placing regular syrup on all residents' meal trays, including 14 (#3, #28, #33, #25, #37, #7, #32, #16, #2, #29, #147, #145, #148, and #18) other residents. Interview of 12/03/24 at 8:12 A.M. with Certified Nurse Aide (CNA) #92 verified Resident #8 had regular, non-reduced calorie syrup on her tray and the meal ticket listed the resident should have received reduced calorie syrup. Interviews on 12/03/24 at 8:15 A.M. with Dietary Aide #32 and [NAME] #27 revealed there was no reduced calorie syrup for any of the 15 (#8, #3, #28, #33, #25, #37, #7, #32, #16, #2, #29, #147, #145, #148, and #18) residents who had physician orders for a controlled carbohydrate diet. Both staff members confirmed there was only regular calorie syrup available in the storage room and the food delivery was due that day. Dietary Aide #32 and [NAME] #27 were unsure when the last time reduced calorie syrup was available to be served to the 15 residents on a controlled carbohydrate diet. Interview on 12/03/24 at 2:07 P.M. with Dietary Manager (DM) #34 verified there had been no recent deliveries and no upcoming delivery of reduced calories syrup. DM #34 verified he was not notified there had been an outage of the reduced calorie syrup and had been two breakfast meals the prior week, 11/28/24 and on 11/30/24, requiring reduced calorie syrup. Medical record review for 14 additional residents including; Resident #3, Resident #28, Resident #33, Resident #25, Resident #37, Resident #7, Resident #32, Resident #16, Resident #2, Resident #29, Resident #147, Resident #145, Resident #148, and Resident #18 revealed all residents had a physician order to receive a controlled carbohydrate diet. Review of facility policy titled, Therapeutic Diets, dated October 2017, revealed a therapeutic diet is ordered by a physician as part of a treatment for a disease and to modify the specific nutrients in the diet.

Based on observation, staff interview, review of a facility provided resident list, and review of a menu spreadsheet, the facility failed to ensure residents received food portions based on the menu spreadsheet. This affected 17 (#02, #04, #05, #06, #07, #09, #11, #12, #13, #14, #23, #30, #32, #33, #36, #38 and #40) of 17 residents that received mechanical soft or pureed diets in a facility census of 42. Findings include: Review of the facility's menu spreadsheet for lunch on 12/04/24 revealed mechanical soft diets were to receive four (4) ounces (oz.) of mechanical roast beef, two (2) oz. of gravy, 4 oz. of garlic mashed potatoes, 4 oz. of Normandy vegetable blend, and one slice of wheat bread. Further review revealed pureed diets were to receive 4 oz. of pureed roast beef, two and two-thirds oz. of pureed Normandy vegetable blend, two-thirds slice of pureed bread, and 4 oz. of mashed potatoes. Observation of tray line on 12/04/24 at 11:45 A.M. revealed Dietary Manager (DM) #34 serving residents during the lunch meal. DM #34 provided residents on a mechanical soft diet a 2 oz. scoop of mechanical roast beef, a 4 oz. scoop of garlic mashed potatoes, a 4 oz. scoop of Normandy vegetable blend, and a roll. Further observation of tray line revealed pureed diets received a 2 oz. scoop of pureed roast beef, a 2 oz. scoop of pureed Normandy vegetable blend, and a 4 oz. scoop of mashed potatoes. Interview with DM #34 on 12/04/24 at 11:45 A.M. verified mechanical soft diets received a 2 oz. scoop of mechanical roast beef, a 4 oz. scoop of garlic mashed potatoes, a 4 oz. ounce scoop of Normandy vegetable blend, and a roll. DM #34 stated he mixed the gravy into the mechanical soft roast beef and that was included in the 2 oz. scoop of mechanical roast beef that was provided to residents on mechanical soft diets. DM #34 also verified pureed diets received a 2 oz. scoop of pureed roast beef, a 2 oz. scoop of pureed Normandy vegetable blend, and a 4 oz. scoop of mashed potatoes. DM #32 stated he did not have any pureed bread for residents that received pureed diets on 12/04/24. Review of a list of residents by diet type dated 12/04/24 revealed Resident #02, Resident #05, Resident #07, Resident #09, Resident #11, Resident #06, Resident #30, Resident #32, Resident #33, Resident #36, Resident #38 and Resident #40 received mechanical soft diets and Resident #04, Resident #12, Resident #13, Resident #14 and Resident #23 received pureed diets.

Based on staff interview and medical record review, the facility failed to to ensure resident Preadmission Screening and Resident Review (PASARR) documents were accurate regarding a resident's current conditions and diagnoses. This affected one (#15) of two residents reviewed for PASARR documents. The census was 42. Findings include: Review of Resident #15's medical record revealed an admitted [DATE]. Diagnoses included aphasia following cerebral vascular disease, bipolar disorder, depression, restless legs syndrome, poly-neuropathy, anxiety disorder, anemia, major depressive disorder, hypertension, epilepsy, migraine, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage. Review of Resident #15's medical record revealed the diagnoses of anxiety was present at the time of admission. Review of the 11/01/24 quarterly Minimum Date Set (MDS) assessment revealed Resident #15 was severely cognitively impaired and used a wheelchair to aid in mobility. Review of Resident #15's 07/30/24 PASARR document revealed there was no diagnosis of anxiety listed. Interview with Social Services Designee #77 on 12/04/24 at 3:56 P.M. verified Resident #15 anxiety diagnosis was not recorded on the 07/30/24 PASARR.

Based on medical record review and staff interview, the facility failed to notify the state mental health authority with a significant change Preadmission Screening and Resident Review (PASARR) for a resident with a change in their mental health condition. This affected one (#02) of two residents reviewed for PASARR documents. The facility census was 42. Findings include: Review of Resident #02's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including congestive heart failure, chronic pulmonary disease, type two diabetes mellitus without complications, post traumatic stress disorder (PTSD), brief psychotic disorder, adjustment disorder with mixed anxiety and depressed mood, and unspecified dementia moderate with psychotic disturbance. Review of Resident #02's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required set up assistance with eating. Resident #02 required supervision with oral hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, tub transfers, and walking 10 feet. Resident #02 required moderate assistance with toileting, showering, and personal hygiene. Review of Resident #02's PASARR dated 09/01/23 revealed Resident #02 had mood disorder, panic or other severe anxiety disorder, and other psychotic disorder. Resident #02 did not have indications of serious mental illness. Review of Resident #02's diagnosis list dated 12/04/24 revealed Resident #02 had a diagnosis of PTSD that was added on 06/06/24 during Resident #02's stay at the facility. Review of Resident #02's chart from 09/01/23 to 12/04/24 revealed Resident #02 did not have a significant change PASARR or notification to the state mental health authority of Resident #02's new diagnosis of PTSD on 06/06/24. Review of Resident #02's psychiatric note dated 06/06/24 revealed Resident #02 had a new diagnosis of PTSD and was prescribed Prazosin one milligram (mg) for PTSD related to Resident #02 yelling when she was asleep. Review of Resident #02's physician note dated 06/12/24 revealed Resident #02 was recently prescribed Prazosin one mg at bedtime for PTSD. Interview with the Director of Nursing 12/04/24 at 2:04 P.M. verified Resident #02 received a new diagnosis of PTSD on 06/06/24 and the facility did not complete a significant change PASARR or notification to the state mental health authority of Resident #02's new diagnosis of PTSD on 06/06/24.

Based on observation, resident and staff interview, medical record review, manufacturer user manual review, review of the Long-Term Care Facility Resident Assessment Instrument 3.0 user's manual, and review of a government website, the facility failed to accurately code the status of a non-invasive mechanical ventilation on resident Minimum Data Set (MDS) assessments. This affected one (#24) of one residents reviewed for ventilators. The facility census was 42. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included a non ST elevation myocardial infarction, depression, atrial fibrillation, hypertension, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, anxiety disorder, COVID-19, metabolic encephalopathy, acute respiratory failure, chronic obstructive pulmonary disease, chronic respiratory failure, major depressive disorder, generalized anxiety disorder, myocardial infarction, obstructive sleep apnea, mixed hyperlipidemia, congestive heart failure, and anemia. Review of the 08/26/24 quarterly Minimum Date Set (MDS) assessment revealed Resident #24 was cognitively intact and used a wheelchair and walker to aid in mobility. Resident #24 required partial/moderate assistance for rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair/bed to chair transfer, and toilet transfer. The resident was coded as having an invasive mechanical ventilator. Review of a physician order dated 06/28/23 and discontinued 12/04/23 revealed Resident #24 was ordered an Average Volume Assured Pressure Support (AVAPS) machine to be used during sleeping hours and as needed every night shift for respiratory distress. Review of a physician order for Resident #24 dated 01/02/24 and discontinued 10/14/24 revealed the resident was to use an AVAPS machine to be worn during sleep and as needed for respiratory distress every shift. Review of a physician order for Resident #24 revealed a currently active order dated 10/14/24 for an AVAPS machine to be worn during sleep and as needed for respiratory distress. Observation of Resident #24 on 12/02/24 at 11:40 A.M. revealed the resident had a Beyond ResPlus B-30P bilevel positive airway pressure (BiPAP; a medical device that helps people breathe by delivering pressurized air through a mask, providing different air pressure levels for inhaling and exhaling) machine at her bedside. The machine had a mask attached to it. Resident #24 denied ever being on an invasive ventilator in the facility where she had an endotracheal tube or a trachesotomy tube inserted into her body. Resident #24 states she used the machine observed in her room at night. Review of Resident #24's MDS assessments revealed the 11/09/23 modified quarterly MDS was coded as the resident used an invasive mechanical ventilator while a resident. Additional review of Resident #24's MDS assessments dated 12/12/23, 12/17/23, 01/05/24, 02/07/24, 05/60/24, 06/21/24, and 08/26/24 all coded the resident used an invasive mechanical ventilator. Review of the Beyond ResPlus B-30P Bi-Level PAP user manual, version No.: U.S./20201218/A1, revealed the BiPap was designed for delivery of positive airway pressure to provide non-invasive ventilation for adult patients with respiratory insufficiency or obstructive sleep apnea (OSA) in home or hospital environment. Interview with MDS Coordinator #57 on 12/04/24 at 3:52 P.M. verified Resident #24's MDS assessments were coded as invasive mechanical ventilation since 12/12/23. Interview with Corporate Nurse #102 on 12/05/24 at 9:35 A.M. verified the user manual revealed Resident #24's BiPap machine was a non invasive mechanical ventilator. Review of a government website at, https://www.ncbi.nlm.nih.gov/books/NBK560600/, last updated 08/08/23, revealed non-invasive ventilation has gained increased prominence in the management of a variety of conditions causing acute as well as chronic respiratory failure. Different modalities of non-invasive ventilation exist, with continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) being the most commonly used modes. Average volume-assured pressure support (AVAPS) is a relatively newer modality of non-invasive ventilation that integrates the characteristics of both volume and pressure-controlled non-invasive ventilation. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, revealed, in section O0110F1, Invasive Mechanical Ventilator (ventilator or respirator), staff are to code any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support their own respiration in this item. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator. Residents receiving closed-system ventilation include those residents receiving ventilation via an endotracheal tube (e.g., nasally or orally intubated) or tracheostomy. A resident who has been weaned off of a respirator or ventilator in the last 14 days or is currently being weaned off a respirator or ventilator, should also be coded here. Do not code this item when the ventilator or respirator is used only as a substitute for BiPAP or continuous positive airway pressure (CPAP). Further review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, revealed, in section O0110G1, Non-invasive Mechanical Ventilator, staff are to code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support their own spontaneous respiration by providing enough pressure when the individual inhales to keep their airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of a facility self-reported incident (SRI), review of an emergency medical services (EMS) report, review of a 911 call and dispatch log, interviews with facility staff, Physician #31, Physician #35, Emergency Medical Services (EMS) Chief #86, Paramedic #87, facility policy and procedure review and review of the American Red Cross Basic Life Support manual, the facility failed to initiate effective cardiopulmonary resuscitation (CPR) and immediately contact emergency medical services (EMS) for Resident #201. This resulted in Immediate Jeopardy on [DATE] at 2:50 A.M. when Resident #201, who had advance directives for a Full Code status was found unresponsive, without a pulse or respirations, and was not properly provided CPR. Life threatening harm and death occurred when Resident #201 did not receive immediate effective CPR and EMS was not immediately contacted by staff. The resident subsequently expired. This affected one resident (#201) of three residents reviewed for an emergent change in condition and death. The facility census was 40. On [DATE] at 4:12 P.M., the Administrator, Regional Director of Operations #91, Registered Nurse (RN) #85 and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 2:50 A.M. when the facility failed to immediately initiate effective cardiopulmonary resuscitation (CPR) and immediately contact emergency medical services (EMS) for Resident #201 who was found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. The resident subsequently expired. The Immediate Jeopardy was removed and deficiency corrected on [DATE] when the facility implemented the following corrective actions. On [DATE] at 3:01 A.M., the DON immediately educated Licensed Practical Nurse (LPN) #33 on the CPR policy, initiation of CPR, Ohio Revised Code 4723.36 on determination of death and the Centers for Medicare and Medicaid Services (CMS) regulation on CPR in nursing homes. On [DATE] at 9:00 A.M., the Administrator notified Licensed Practical Nurse (LPN) #33 and LPN #34 (the two nurses on duty at the time of the incident) they were suspended pending investigation. On [DATE] at 9:30 A.M., the DON audited all hard copies of advanced directives in current resident's medical records to ensure they were present, appropriately signed and had a physician's order in place. On [DATE] at 10:15 A.M., Business Office Manager (BOM) #36 audited employee files for all licensed nurses to ensure they had valid active CPR certification. This was completed [DATE] at 2:00 P.M. On [DATE] at 11:45 A.M., the DON audited the advanced directive care plans for all current facility residents to ensure they reflected the hard copy and physician order. This was completed on [DATE] at 12:45 P.M. On [DATE] from 12:00 P.M. to 1:00 P.M., the Administrator and LPN #04 educated all department heads including Dietary Manager #24, Registered Nurse (RN) #45, Business Office Manager (BOM) #36, Maintenance Director #15, Marketing Director #50, Housekeeping Supervisor #03, Social Services #43 and Therapy Director #41 on the facility CPR policy including but not limited to calling 911 as directed by the licensed nurse. On [DATE] from 1:00 P.M. to 5:15 P.M., LPN #04, the Administrator, Business Office Manager (BOM) #36, Housekeeping Supervisor #03, Social Services #43 and Therapy Director #41 educated all 44 staff excluding licensed nurses on the CPR policy including but not limited to calling 911 as directed by the licensed nurse. On [DATE] from 1:00 P.M. to 2:15 P.M., LPN #04 educated all 12 licensed nursing staff on the facility CPR policy, advanced directive policy, Ohio Revised Code 4723.36 on determination of death and the CMS regulation on CPR in nursing homes. On [DATE] at 2:30 P.M., LPN #04 held a mock code blue, and the response was immediate and appropriate. On [DATE] at 2:30 P.M., the Administrator updated new hire orientation packets to include the CPR policy, advanced directive policy, Ohio Revised Code 4723.36 on determination of death and the CMS regulation on CPR in nursing homes. On [DATE] at 2:50 P.M., the facility completed an ad hoc Quality Assurance and Performance Improvement (QAPI) plan related to the abatement. The Administrator, Maintenance Director #15, BOM #36, Marketing Director #50, Physician #88, LPN #04, the DON, and RN #85 were in attendance. The plan was approved by the committee including ongoing compliance. For ongoing compliance, the facility implemented a plan for nursing administration and designee to review all progress notes and new orders related to code status in the daily clinical operations meeting five times weekly for four weeks to ensure all advanced directives have an appropriate physician signature, order in place and are appropriately care planned. All variances would be corrected upon discovery and education and follow up will be provided as deemed necessary. The facility implemented a plan for the DON or designee to audit each new readmission five times weekly for four weeks to ensure advanced directives were ordered, care planned and were present with the physician's signature in the medical record. All variances would be corrected upon discovery and education and follow up would be provided as deemed necessary. The facility implemented a plan for the DON or designee to conduct code blue drills weekly for four weeks on shift to ensure staff respond accordingly with the first one being conducted on [DATE]. All variances would be corrected upon discovery and any additional education and follow up would be provided as deemed necessary. The facility implemented a plan for the DON or designee to reeducate the licensed nursing staff on the CPR policy, advanced directive policy, Ohio Revised Code 4723.36 on determination of death and the CMS regulation on CPR in nursing homes for four weeks to ensure all staff were competent and informed of the facility policy. All variances would be corrected upon discovery and additional education and follow up would be provided as deemed necessary. Results would be reported to the quality assurance committee and further continued ongoing compliance would be maintained through audits as dictated by the facility quality assurance committee. On [DATE] between 2:00 P.M. and 3:00 P.M. interviews with LPN #47, LPN #67, STNA #08, and STNA #10 verified they were educated on the facility CPR policy, advanced directive policy, Ohio Revised Code 4723.36 on determination of death and the CMS regulation on CPR in nursing homes. Findings include: Review of Resident #201's closed medical record revealed Resident #201 was admitted to the facility on [DATE] with diagnoses including muscle weakness, gastroesophageal reflux disease without esophagitis, osteoarthritis, anxiety disorder, panlobular emphysema, insomnia due to other mental disorder, fracture of upper end of unspecified tibia subsequent encounter for closed fracture with routine healing, and unspecified kyphosis thoracolumbar region. Resident #201 expired in the facility [DATE]. Review of Resident #201's code status form dated [DATE] revealed Resident #201 was to receive full measures (Full Code Status). Review of Resident #201's code status physician order dated [DATE] revealed Resident #201 was a Full Code. Review of Resident #201's medical record from [DATE] to [DATE] revealed no documentation Resident #201 or Resident #201's physician changed Resident #201's code status from a Full Code to a Do Not Resuscitate (DNR). Review of Resident #201's code status care plan dated [DATE] revealed Resident #201 had decided she wanted cardiopulmonary resuscitation (CPR) attempted in the event of a code. Interventions included if Resident #201 was in cardiac arrest begin CPR and then call 911. Review of Resident #201's progress note dated [DATE] at 5:16 A.M. by LPN #17 revealed Resident #201 arrived at the facility from the hospital at 11:45 P.M. The note reflected Resident #201 was a Full Code. Review of Resident #201's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #201's was moderately cognitively impaired, required extensive assistance from staff for mobility, transfers, dressing, toileting, and personal hygiene. Resident #201 required supervision from staff for eating. Review of Resident #201's progress note dated [DATE] at 1:01 P.M. by Registered Nurse (RN) #13 revealed Resident #201 was noted with increase work of breathing during a neurological assessment status post fall. Resident #201 stated something isn't right. Vitals were obtained and noted blood pressure ,d+[DATE], oxygen 89% (low) saturation with 3.5 liters per nasal cannula and lungs with rhonchi (adventitious breath sounds) noted. The physician was notified and recommend Resident #201 be sent to the emergency room . However, Resident #201 refused the transfer at that time and a new order was given for a chest x-ray and to start antibiotics and the steroid medication, Prednisone. The note indicated the resident's representative was made aware. Review of Resident #201's progress note dated [DATE] at 6:46 P.M. by LPN #47 revealed Resident #201's x-ray results from [DATE] were positive and were sent to Physician #31. The note revealed Resident #201 was currently being treated with the antibiotic, Levaquin. The resident and family were made aware. Review of Resident #201's progress note dated [DATE] at 2:50 A.M. by LPN #33 revealed the State tested Nursing Assistants (STNAs) came to LPN #33 and stated Resident #201 was non-responsive. The note included LPN #33 and another nurse attempted resuscitation and was ineffective. Resident #201 was pronounced deceased at 2:55 A.M. and Physician #31 and Resident #201's granddaughter were called immediately. The Director of Nursing (DON) and the unit manager were also notified. The note failed to contain any additional information related to the actual physical condition of Resident #201 at the time she was found unresponsive; there were no documented signs of lividity or rigor mortis noted by the nurse on duty and responsible for care at that time. Review of Resident #201's progress note dated [DATE] at 3:50 A.M. by LPN #33 revealed paramedics (who were onsite at this time) declared Resident #201 deceased . The paramedics called the coroner, and the family was there with the resident. The family stated they wanted the resident to be sent to the funeral home. The funeral home was called, and the resident's body was released to the funeral home at 4:55 A.M. Review of Resident #201's physician progress note dated [DATE] and filed [DATE] at 4:53 P.M. by Physician #31 revealed Physician #31 received a phone call on [DATE] at 2:51 A.M. from LPN #33. The note revealed Resident #201 was discovered gray and blue in color. Resident #201 was unresponsive. She was examined by two nurses (identified to be LPN #33 and LPN #34) who noted the resident to be deceased . This physician progress note documented determination of death by this physician was on [DATE] at 2:51 A.M. Review of a facility self-reported incident (SRI) dated [DATE] revealed the facility reported an allegation of neglect/mistreatment to the State agency. A brief description of the allegation/ suspicion revealed Resident (#201) found absent of vital signs. Staff had a potential delay in CPR administration. Resident #201 remained absent of vital sign once EMS arrived. Supporting information in the facility SRI revealed on [DATE] the Director of Nursing (DON) received notification at 2:54 A.M. from LPN #33 that Resident #201 had been found absent of vital signs. The DON returned a phone call to LPN #33 at 3:01 A.M. At that time LPN #33 had communicated Resident #201 was found absent of vital signs and the physician (#31) had been notified. The DON inquired of the resident's code status. LPN #33 informed the DON the resident was a full code. The DON inquired if CPR was in progress, to which the LPN stated no. The DON then instructed LPN #33 to initiate CPR per (facility) policy. Review of the dispatch log dated [DATE] revealed the county 911 number received a call on [DATE] at 3:37 A.M. regarding a deceased person or body being found. The call was assigned at 3:39 A.M., EMS were in route at 3:43 A.M. and arrived at the facility at 3:46 A.M. The 911 call from the facility was reviewed as part of the investigation. The 911 dispatcher could be heard asking for the address of the emergency. The facility caller was noted to be asking someone in the background for the facility's address and the person in the background could be heard laughing. The caller stated the emergency was at the facility. The dispatcher asked what was going on there and the caller stated they just found a resident deceased at 3:00 A.M. and reported they are saying we have to call 911 and the county coroner. The dispatcher stated a squad would be sent to the facility and the age of the resident was asked. The caller stated the resident was [AGE] years old. The dispatcher asked for a call back number and the facility caller was noted asking someone in the background the facility's number. The dispatcher asked if there was anywhere particular they needed to come to, and the caller stated to come to the side door and knock on the door for staff to let them in the facility. Review of an emergency medical services (EMS) report [DATE] revealed EMS were dispatched to the facility on [DATE] at 3:41 A.M. and were in route at 3:43 A.M. EMS was at the scene at 3:46 A.M. Resident #201 was listed as dead at the scene with no resuscitation attempted without transportation. Review of the EMS pre-hospital care report dated [DATE] revealed EMS was dispatched on [DATE] at 3:41 A.M., arrived on the scene on [DATE] at 3:46 A.M. and was with the resident on [DATE] at 3:48 A.M. The report stated Resident #201 was found lying supine in the bed. Per staff, Resident #201 was diagnosed with pneumonia on [DATE] and started on Prednisone and Levaquin. Staff stated Resident #201 was last seen alive at 12:30 A.M. Staff went into check on Resident #201 and found her cold to the touch with no spontaneous breathing or pulse. Staff pronounced Resident #201 at 2:55 A.M. and then they called the DON who told them that they needed to do 30 minutes of CPR and then call 911 to have them pronounce (the resident's death). Staff stated they did as requested but felt that something was not right. EMS staff noted Resident #201 was unconscious and unresponsive, pulseless and apneic with skin that was cold, pale, and dry. Three leads were placed showing asystole in all leads. Time of death was 3:50 A.M. Physician #35 (from the county coroner's office) was contacted and advised Resident #201 could be signed out to the funeral home, and he would be contacting the facility medical director regarding the direction of 30 minutes of CPR prior to calling 911. Review of STNA #02's undated witness statement revealed STNA #02 noted Resident #201 to be unresponsive and immediately reported Resident #201's condition to LPN #33. Review of RN #85's witness statement dated [DATE] revealed RN #85 interviewed LPN #33. LPN #33 verified Resident #201's code status as a full code. LPN #33 and LPN #34 came to Resident #201's bedside to observe the resident's condition. LPN #33 called Physician #31 and the DON. LPN #34 notified the emergency contact for Resident #201 and EMS was dispatched at 3:41 AM. and called the time of death at 3:50 A.M. A witness statement from RN #85's (dated [DATE]) revealed RN #85 interviewed Physician #31 via telephone on [DATE]. Physician #31 reported she took a phone call from the facility at 2:51 A.M. and the phone call lasted one minute. During the phone call, LPN #33 stated Resident #201 was found expired. Physician #31 reported LPN #33 then stated to her that Resident #201 was gray and blue, her arm was dangling off the bed and was discolored and further stated she had been gone a long time and was cold to touch. When asked about Resident #201's code status, LPN #33 stated to Physician #31 that Resident #201 was a full code, but they did not discuss any resuscitative efforts. Physician #31 declared time of death at that time based upon LPN #33's description of Resident #201's body. LPN #33 brought it to Physician #31's attention that there was no funeral home information available and that she would reach out to family. Physician #31 stated she then thanked LPN #33 for the notification and ended the call. Review of a statement from the Administrator dated [DATE] revealed the Administrator notified LPN #33 and LPN #34 they were suspended pending investigation. Review of LPN #33's suspension form dated [DATE] revealed LPN #33 was suspended pending investigation for failing to follow policy and procedures. Review of LPN #34's suspension form dated [DATE] revealed LPN #34 was suspended pending investigation for failing to follow policy and procedures. On [DATE] at 12:41 P.M. telephone interview with Assistant EMS Chief #86 and Paramedic #87 revealed Paramedic #87 was called to the facility on [DATE] regarding Resident #201 being deceased . Paramedic #87 reported facility staff were not doing any CPR or other resuscitative measures when EMS arrived at the facility. Paramedic #87 stated Resident #201 was laying in her bed on her back with the sheet up to her shoulders. Resident #201 was cold to the touch, and it was evident Resident #201 had been deceased for a while at this time. Paramedic #87 reported staff told her they called the DON, and the DON told the staff to call EMS to pronounce Resident #201 as deceased . Paramedic #87 stated she asked staff what happened, and they stated Resident #201 was found unresponsive over an hour ago and they pronounced her dead with two staff and then they called the DON and the DON stated they had to do at least 30 minutes of CPR. Paramedic #87 stated the staff member used air quotes with her fingers when she said 30 minutes of CPR and she was not sure what that was supposed to mean. Paramedic #87 reported staff told her Resident #201 was pronounced deceased at 2:55 A.M. by the facility and Resident #201 was pronounced deceased at 3:50 A.M. by Physician #35 through EMS communications. Paramedic #87 stated she called Physician #35 and told him what she saw, and he told her that the body could go to the funeral home, but she was later informed that Resident #201 was sent for an autopsy. Paramedic #87 reported staff stated they last saw Resident #201 alive at 12:30 A.M. and when they went to check on her at 2:50 A.M. she was deceased . Paramedic #87 stated upon EMS arrival Resident #201's shirt was still in place, there were no signs that CPR was completed and there was no defibrillator in the resident's room. On [DATE] at 1:00 P.M. interview with Physician #35 revealed he was the physician investigator for the county coroner's office. Physician #35 stated he received a call on [DATE] at what he thought was about 3:00 A.M. (exact time not recalled) from Paramedic #87 stating she was at the facility; staff had told her they went to check on Resident #201 and she was cold to the touch with no spontaneous pulse. Physician #35 stated Paramedic #87 told him staff called the DON and were told to do 30 minutes of CPR and then to call EMS. Paramedic #87 also stated staff were providing her with conflicting stories. Physician #35 stated the body was sent to the funeral home for a hold and then the county coroner's staff determined an investigation was needed and records were requested the next morning. Physician #35 stated he spoke with Physician #88, the facility medical director the next morning and was told the resident had pneumonia and was being treated 24 hours prior to her death. Physician #35 stated he reviewed Resident #201's treatment of pneumonia and found this treatment was consistent (with standards of practice) but stated there was some confusion on [DATE] regarding CPR being administered with conflicting stories about if facility staff had performed CPR. Physician #35 stated she spoke with Physician Coroner #89 who reported Resident #201 had passed away from necrotic lung tissue and there was no evidence CPR had been provided or completed for Resident #201 at the time she was found unresponsive. Physician #35 shared awareness of the facility terminating the personnel (LPN #33 and LPN #34) who were working at the time of the incident. On [DATE] at 8:20 A.M. telephone interview with Physician Coroner #89 revealed he completed an autopsy on Resident #201 (results pending at the time of this investigation) and reported there was no indication of CPR being provided to the resident. Physician Coroner #89 reported if provided CPR, Resident #201 would have had some physical indication CPR was completed, such as fractured ribs due to her age. On [DATE] at 8:36 A.M. interview with LPN #34 revealed she was working with LPN #33 when she came back from a break and an STNA reported to her she thought Resident #201 was dead. LPN #34 did not know the STNA's name. LPN #34 reported the STNA told her she was in the room at 12:30 A.M. and Resident #201 was alive. LPN #34 stated Resident #201's arm was laying over the side of the bed and all the blood was rushing to the right arm upon entering the room. LPN #34 reported Resident #201 arm was blue and red from above her elbow to her fingertips and the rest of her body was gray. LPN #34 stated she could tell Resident #201 had been deceased for an hour or more, her spine was barely warm, but the rest of her body was cold to the touch. LPN #34 stated she got her stethoscope and listened for breath sounds and a heartbeat, which were absent. LPN #34 stated she then called Resident #201's granddaughter and told her Resident #201 had passed away while LPN #33 was looking for Resident #201's code status in the resident's hard (paper) chart. LPN #34 stated LPN #33 could not find the resident's code status form and had to pull it up on the computer and then informed LPN #34 Resident #201 was a full code. LPN #34 stated LPN #33 had called the DON and the manager on duty and the DON asked if they had done CPR and they stated they did not because they were looking for the code status sheet. The DON told them to call 911. LPN #34 stated she bagged (artificial respiration) Resident #201, LPN #33 did child compressions using two fingertips and Resident #201's chest did not rise. LPN #34 stated she told LPN #33 it was ridiculous and to stop CPR after just a few minutes. The DON called back again and told them to go home until an investigation was completed. LPN #34 stated she called 911 because they could not pronounce a death and reported that LPN #33 had already called the physician and had Resident #201 pronounced deceased , but the DON told them they still had to call 911. EMS arrived and hooked the resident up to a machine where she had no vital signs. LPN #34 stated she told EMS they had to call them because they could not pronounce a death. LPN #34 reported she did not call EMS until after they had completed a few minutes of CPR and they were not doing CPR when EMS arrived. LPN #34 stated they did not use a defibrillator and she stated Resident #201 was in her opinion, clearly deceased and she was not breaking the woman's ribs as she had no color in her lips and her eyes were fixed. However, LPN #34 then reported she would have started CPR immediately and called 911 if they had the code status form and stated it should not have taken that long to find the code status form for Resident #201. On [DATE] at 9:01 A.M. telephone interview with STNA #10 revealed STNA #10 was taking care of Resident #201 on [DATE] when she was told by STNA #02 that Resident #201 was deceased . She stated she went down to Resident #201's room to help the nurses and she an another STNA did postmortem care on Resident #201 per LPN #33's instruction. STNA #10 stated she never saw any staff doing CPR on Resident #201 and there was no indication that CPR was completed on Resident #201 when she did postmortem care. STNA #10 also stated they did postmortem care on Resident #201 prior to EMS arriving at the facility. STNA #10 stated she was outside of Resident #201's room when EMS arrived, and LPN #33 told EMS that they had done an x-ray and Resident #201 had pulmonary edema. STNA #10 reported EMS asked if CPR was done, and she thinks LPN #33 told them that they did not do CPR. Attempts to interview LPN #33 on [DATE] were unsuccessful. The LPN's attorney (Attorney #90) contacted the surveyor on [DATE] at 10:08 A.M. on behalf of LPN #33 and stated LPN #33 was not to speak with any type of investigator. On [DATE] at 12:28 P.M. interview with Physician #31 revealed she received notice from the facility on [DATE] regarding a deceased resident at approximately 2:50 A.M. LPN #33 stated Resident #201 was deceased , and she provided a description of the resident. Physician #31 reported LPN #33 never told her if staff performed CPR on Resident #201. Physician #31 stated they told her at the end of the conversation the resident was a full code, but she did not address CPR with LPN #33 and could not remember all the details, but stated she did not get the idea they were doing CPR by the way they were acting. Physician #31 stated LPN #33 had not gotten a hold of the resident's family as of that time. Physician #31 stated she would do adult CPR on a resident that was the age and weight of Resident #201. On [DATE] at 1:07 P.M. interview with the DON revealed she was sent a text on [DATE] regarding Resident #201 and then LPN #33 called her on [DATE] prior to her being able to respond to the text message. The DON stated LPN #33 told her Resident #201 was found without vitals, and she asked about Resident #201's code status. The DON reported LPN #33 stated Resident #201 was a Full Code and the DON asked LPN #33 if they started CPR and then the phone went dead. The DON stated it took a while for her to get back in contact with LPN #33 and when she did get back in contact with LPN #33 the DON asked if they had called 911. The DON reported LPN #33 told her she called the non-emergency number. The DON stated she had sent staff a text and told them to call the coroner if staff could not revive Resident #201. The DON stated LPN #33 then stated she had done CPR, but LPN #33 did not tell her any details on the type of CPR administered, the method CPR was administered or length of time the CPR was provided. The DON reported EMS came to the facility after she instructed LPN #33 to call 911 and they pronounced her deceased . The DON also reported LPN #33 stated she called the physician, but LPN #33 never told her any details about the call or Resident #201 being pronounced deceased over the phone with the physician. The DON reported she was informed the physician was called prior to her instructing LPN #33 to call 911. Review of the facility's Emergency Procedure Cardiopulmonary Resuscitation Policy dated February 2018 revealed licensed health care professionals who were certificated in CPR shall initiate CPR if an individual was found unresponsive and not breathing normally unless it was known that a DNR order that specifically prohibited CPR, or an external defibrillation existed for that individual. If the resident's DNR status was unclear, CPR would be initiated until it was determined that there was a DNR or a physician's order not to administer CPR was given. Review of the facility's Advanced Directives Policy dated [DATE] revealed advanced directives would be respected in accordance with state law and facility policy. Review of the American Red Cross basic life support manual dated 2019 revealed use the same approach and technique for recovery positions as you would for an adult for children. The technique for providing chest compressions were similar for an adult and child. Position one hand on top of the other with your fingers interlaced and off the chest centered on the lower half of the sternum. The manual reported the proper technique was critical when providing chest compressions on an adult and included exposing the patient's chest so you could ensure proper hand placement and visualize chest recoil, place the heel of one hand in the center of the patient's chest on the lower half of the sternum. Place your other hand on top of the first and interlace your fingers or hold them up so that they are not resting on the patient's chest and position yourself, so your shoulders are directly over your hands. For an adult, compress the chest to a depth of at least two inches, provide compressions at a rate of 100 to 120 per minute, allow the chest to fully recoil after each compression and avoid leaning on the patient's chest on the top of a compression. Then continue to provide CPR until you see signs of return of spontaneous circulation (ROSC) such as patient movement or normal breathing, other trained providers take over compression or ventilation responsibilities, you are presented with a valid do not resuscitate order, you are alone or too exhausted to continue to the situation becomes too unsafe. This deficiency represents non-compliance investigated under Complaint Number OH00144142.

Based on record review and staff interview, the facility failed to complete a new pre-admission screening and resident review (PASARR) following an addition of a residents's new psychiatric diagnosis. This affected one (Resident #8) of three residents reviewed for PASARR. The facility census was 42. Findings include: Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia, psychotic disorder, anxiety, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/23, revealed Resident #8 had moderate cognitive impairments. Review of the PASARR completed on 03/16/18 revealed the diagnosis of psychotic disorder with hallucinations was not captured on this review. No other PASARR has been completed after this date to reflect the addition of psychotic disorder with hallucinations. Review of the current medical diagnoses revealed a diagnosis of psychotic disorder with hallucinations was added to the resident's record on 02/02/20. Interview with the Administrator on 05/23/23 at 1:38 A.M. verified a new PASARR has not been completed following the addition of the new diagnosis of psychotic disorder with hallucination on 02/02/20. The Administrator verified this diagnosis was not captured on the PASARR that was completed and a new one was started on 05/23/23 to reflect the addition of the psychotic disorder diagnosis.

Based on record review and interview the facility failed to ensure resident representatives were involved in medical decision making for the resident. This affected one (Resident #46) of three sampled residents. The census was 44. Findings include: Resident #46 was admitted to the facility on [DATE]. His diagnoses were dementia, elevated white blood cell count, squamous cell carcinoma, hypertension, type II diabetes, asthma, hyperlipidemia, anxiety disorder, and muscle weakness. Review of the face sheet revealed Resident' #46's wife was his durable power of attorney (DPOA). Review of the Informed Consent for Psychiatric Assessment and Treatment, dated 10/19/22, revealed the psychiatric consultation company documented that Resident #46 gave verbal consent to complete the initial psychiatric assessment and complete psychiatric care as needed. There was no documentation Resident #46's wife had been notified about this assessment or further psychiatric care provided. Review of his minimum data set (MDS) assessment, dated 02/08/23, revealed he was severely cognitively impaired. Review of Resident #46 psychiatric consultation report, dated 02/21/23, revealed the psychiatric consultation company completed a psychiatric care note regarding a psychiatric assessment and follow-up. There was no documentation that Resident #46's wife had been notified of or consulted about this psychiatric assessment. Review of the progress notes from 06/30/22 through 03/03/23, revealed multiple entries in which the facility notified the resident's wife about changes in his condition and took direction from the representative on the type of care that would be desired. During interview on on 04/26/23 at 12:50 P.M., the Administrator and Regional Director #200 stated the psychiatric services were contracted. The psychiatric consultation company did the initial assessment and completed the consent process for each resident. They stated they knew the outside contractor would be completing the initial assessment process with residents to determine their psychiatric needs. They confirmed they have no documentation that Resident #46's wife was notified and consulted about psychiatric services for Resident #46. This deficiency represents non-compliance investigated under Complaint Number OH00141915.

Based on record review, interview and policy review, the facility failed to provide a resident's medical record at the request of the resident's Durable Power of Attorney (DPOA). This affected one (Resident #46) of three sampled residents. The census was 44. Findings Include: Resident #46 was admitted to the facility on [DATE] Review of his minimum data set (MDS) assessment, dated [DATE], revealed he was severely cognitively impaired. Review of the face sheet in Resident #46's medical record listed his wife as his DPOA. Review of the medical records request log documented Resident #46's wife requested the medical records of Resident #46 on [DATE]. The log documented that the request was canceled, but listed no date of the cancellation. Review of a written document by Regional Director #200, dated [DATE], revealed she spoke with Resident #46's wife on that day about the records request they had made. Regional Director #200 stated they had received the request form from Resident #46's wife and they would start the process of speaking with Resident #46 primary care physician to determine if Resident #46 was incapacitated. Resident #46's wife stated she would like the requested documentation prior to Resident #46's imminent death. Review of Resident #46 progress notes, dated [DATE], revealed Resident #46 expired. There was no documentation that Resident #46's wife had ever received his medical record as requested. During interview on [DATE] at 12:50 P.M., the Administrator and Regional Director #200 confirmed Resident #46's wife first requested his medical records on [DATE]. They both confirmed they did not provide the medical records to Resident #46 family because they did not have any formal documentation stating Resident #36 was incapacitated. They stated the facility needed to have documentation of a formal medical records request, and documentation from Resident #46 primary care physician that he was incapacitated. They confirmed progress notes documented Resident #46's wife had been involved in decision making related to his care and she was his DPOA. Review of facility policy titled Access to Personal and Medical Records, dated [DATE], revealed each resident has the right to access and/or obtain copies of his or her personal and medical records upon request. Access to the resident's personal and medical records will be provided to the resident within 24 hours (excluding weekends and holidays) of his or her request. The resident may obtain a copy of his or her personal or medical record within two business days of a written request. The resident, or his/her legal representative, may grant others the right to access the resident's records if such request is made in writing and identifies the information that is the be released and to whom the information is to be released. This deficiency represents non-compliance investigated under Complaint Number OH00141915.

Based on observation, medical record review, resident interview, staff interview, review of facility Self-Reported Incidents (SRI), and policy review, the facility failed to ensure residents were free from physical abuse and neglect. This impacted two ( #51 and #52) of three residents reviewed for abuse and neglect. The facility census was 44. Findings include: 1. Review of the medical record for Resident #52 revealed an admitted [DATE]. Resident #52 discharged from the facility on 01/01/23 and did not return. Diagnoses included dementia and diabetes. Review of the BIMS (Brief Interview for Mental Status) dated 01/01/23 revealed Resident #52 had severely impaired cognition. Review of the care plan dated 12/27/22 revealed Resident #52 was at risk for elopement/wandering related to dementia. Interventions included a wanderguard, monitor and report changes in behavior, provide diversional activities, and redirect as needed. Review of the plan of care dated 12/28/22 revealed Resident #52 exhibited alteration in mood and behavior related to disease process and dementia, yells and screams at times, sexually inappropriate at times, rejects care, hitting, kicking, grabbing, abusive language. Interventions included one-on-one as needed. Review of the a nurse progress note dated 12/31/22 at 3:57 A.M., revealed Resident #52 continuously wandered out of his room and into other resident rooms. Redirection and reorientation was needed continuously. Resident #52 was noted to become combative at times with staff trying to redirect him back to his room. 2. Review of the medical record of Resident #51 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, oropharyngeal dysphagia, essential hypertension, depression, type 2 diabetes mellitus, gastro-esophageal reflux disease, hypothyroidism, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident required extensive assistance of one staff for locomotion and supervision for eating. Review of the weekly skin assessment dated [DATE] at 4:00 A.M. revealed Resident #51 had a red mark on her right shin. Review of the weekly skin assessment dated [DATE] at 11:00 A.M. revealed Resident #51 had a knot on her right shin, measuring 3.2 centimeters (cm) by 2 cm by less than 0.1 cm. Interview on 01/10/23 at 11:52 A.M., Resident #51 stated, on 01/01/23 at approximately 4:00 A.M., Resident #52 came into her room and sat on the chairs at the foot of her bed. Resident #51 stated she asked him what he wanted and he did not respond. Resident #51 stated Resident #52 then walked over by the window-side of the bed and told her to scoot over because he was getting into the bed with her. Resident #51 stated she yelled for help and Resident #52 began coming toward her in the bed, so she kicked at him with her right leg. Resident #51 stated Resident #52 began beating her right leg with his fist and it hurt. Resident #51 stated staff responded promptly when she began yelling and removed Resident #52 from her room. Resident #51 stated, as a result of the altercation with Resident #52, she had a knot on her right shin. Observation on 01/11/23 at 10:48 A.M., of Resident #51 revealed a slight knot on her right lateral shin. Review of the SRI, dated 01/01/23 and timed 4:02 P.M. revealed Resident #51 reported she was sleeping and when she woke up, Resident #52 was hitting her leg. Resident #51 stated her room was dark and Resident #52 appeared to be searching for somewhere to sit down and he became startled when he noticed she was occupying the bed already. Resident #51 did not show any signs of psychosocial distress. Staff present at the time of the incident were interviewed. There were no witnesses to the alleged incident. Resident #51 expressed she did not feel Resident #52 realized what he was doing and was startled when he realized she was in the bed. Resident #52 denied being upset with Resident #51. The police department was notified and an officer interviewed staff upon arrival. No further action was taken. All facility staff were educated on the facility's abuse prohibition policy. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention, dated 04/2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation by anyone, including facility staff and other residents. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated 04/2021, revealed residents should be protected from neglect by anyone, including facility staff, consultants, staff from other agencies, and visitors. This deficiency represents non-compliance investigated under Complaint Number OH00139187.

Based on medical record review, staff interview, and policy review, the facility failed to implement their abuse policy This affected one (#18) of three residents reviewed for abuse/neglect. The facility census was 44. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included dementia with behavioral disturbance, elevated white blood cell count, squamous cell carcinoma of skin, essential hypertension, type 2 diabetes mellitus, asthma, hyperlipidemia, anxiety disorder, difficulty in walking, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/01/22, revealed the resident had severely impaired cognition. The assessment identified the resident exhibited fluctuating inattention and disorganized thinking and wandered daily. The resident required supervision to extensive assistance for locomotion. Review of the elopement risk assessment dated [DATE] revealed the resident was physically capable of leaving the facility. No additional information was provided in the assessment. Review of the elopement risk assessment dated [DATE] revealed the resident was physically capable of leaving the facility. The resident was assessed as confused to time and place and wandered, roamed, or paced. Interventions in place were redirection, contact spouse, offer food/drinks, and a wanderguard to right ankle. Review of the plan of care dated 05/10/22 revealed Resident #18 was at risk for elopement/wandering related to dementia. Interventions included one on one as needed, involve in activities of choice, wanderguard-check placement and function every shift, provide diversional activities of interest as needed, and redirect as needed. Review of physician orders identified an order dated 04/19/22 for a wanderguard to the right ankle. Check placement and function every shift. Review of the nurses notes dated 11/23/22 revealed Resident #18 exited the facility. Resident #18 was noted to be easily redirected by staff. Full body assessment was completed without issues. Physician and responsible party made aware. New orders received to initiate one-on-one supervision. Review of the elopement investigation dated 11/23/22 revealed, on 11/23/22 at 10:01 A.M., the facility was notified via a Good Samaritan that Resident #18 was observed walking on the sidewalk outside of the facility. Licensed Practical Nurse (LPN) #320 was interviewed at 10:03 A.M. and reported she last saw Resident #18 at 9:50 A.M Resident #18 was returned to the facility, without incident. Interviews on 01/10/23 at 10:12 A.M. and 2:18 P.M., Registered Nurse (RN) #331 stated, on 11/23/22, sometime after 9:00 A.M., Resident #18 was sitting at the nurses station on the C-hall, talking to her. At that time, she brought the Resident #18 over to the other nurses station, closer to his room, between the A and B-halls. RN #331 estimated it was approximately 15-20 minutes later when she received the phone call from the concerned citizen. RN #331 stated Resident #18 left the building when an outside vendor was repairing the dining room doors, removed both doors from the hinges, and must have taken a break. RN #331 stated she was not Resident #18's nurse that day, but received a phone call from a concerned citizen, who reported Resident #18 was found outside of the facility. RN #331 stated she went to look for Resident #18 and found him sitting on a porch of a house in the neighborhood, wearing windbreaker pants and a short-sleeved shirt, approximately two blocks away from the facility. RN #331 stated Resident #18 was unable to say what he was doing or where he was going. RN #331 stated Resident #18 did not have any injuries. Interview on 01/10/23 at 12:09 P.M., Resident #18's wife affirmed she was notified Resident #18 exited the facility unaccompanied on 11/23/22. Resident #18's wife stated there were contractors working on the doors in the dining room who completely removed the doors and left the premises and did not tell anyone. Resident #18's wife stated Resident #18 took a walk and got pretty far down the sidewalk. Resident #18's wife stated RN #331 told her Resident #18 was a few houses from the hospital. Resident #18's wife stated Resident #18 had a wanderguard since the day he admitted to the facility. Interview on 01/10/23 at 2:30 P.M., Contractor #400 affirmed he was working on the dining room doors on 11/23/22 and the facility made him aware a resident had exited the facility unaccompanied while the doors were left unattended. Contractor #400 stated he went to the hardware store and was gone for approximately 15-20 minutes and affirmed he did not secure the doors nor tell anyone he was leaving the premises. Review of the facility's Self Reported Incidents (SRI) revealed no incident involving Resident #18's elopement on 11/23/22 reported. Interview on 01/10/23 at 12:46 P.M., the Administrator stated, on 11/23/22, a construction company was at the facility working on the dining room doors. The doors were completely removed and the construction company team left the premises without telling any of the facility staff. The Administrator stated the facility received a call from a concerned citizen, who reported Resident #18 was just right up the street. The Administrator verified an SRI was not completed when Resident #18 eloped from the facility on 11/23/22. The Administrator stated she did not complete an SRI because Resident #18 did not have any injuries. Review of the facility's wandering and elopements policy dated March 2019 revealed the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. When a resident returned to the facility the Director of Nursing (DON) or charge nurse shall examine the resident for injuries, contact the physician and report findings and the condition of the resident, notify the resident's representative, notify search teams the resident was located, complete and file and incident report and document relevant information in the resident's medical record. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 09/2022, revealed all reports of resident abuse, neglect, exploitation, or misappropriation are reported to local, state, and federal agencies as required by current regulations. Further review revealed, if resident neglect is suspected, the suspicion must be reported to the Administrator. The Administrator or designee will report the incident to the state survey agency per the regulation immediately, but not more than 24 hours after the incident was discovered. This deficiency is based on incidental findings discovered during the course of a complaint investigation.

Based on observations, medical record review, staff interviews, review of a police report, review of the facilities Self-Reported Incidents (SRI's), interview with a police officer, interview with community member, review of video footage, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of a resident, without staff knowledge, who was cognitively impaired and assessed as being at risk for elopement. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Resident #100 eloped from the facility and the resident was found by police 1.5 miles away from the facility on a road that had a 55 Miles Per Hour (MPH) speed limit. This affected one (Resident #100) of four residents reviewed of a total of six identified by the facility as being at risk for elopement. The facility census was 41. On [DATE] at 2:30 P.M., the Administrator, Regional Quality Assurance #661 and Regional Director of Operations #660 were notified Immediate Jeopardy began on [DATE] at 3:45 P.M., when Resident #100 was not provided adequate supervision and eloped from the facility. Resident #100 was assessed as being at risk for wandering and elopement. Resident #100 had a history of dementia and behaviors including exit seeking. On [DATE] at 4:00 P.M., the police were dispatched for a suspicious person and the resident was found 1.5 miles away from the facility on a road that had a 55 MPH speed limit. The resident had taken his shirt off and was holding it in his hand, was wearing only pajama pants, and had a Wander Guard bracelet on his ankle. The facility was not aware that Resident #100 had eloped from the facility until the facility was contacted by the police. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: · On [DATE] from 4:15 P.M. to 4:18 P.M., Police Department #550 notified Medical Records Staff #19 that they believed they had custody of Resident #100. Medical Records Staff #19 immediately called Registered Nurse (RN) #05 to notify her that Resident #100 was with the police as they found him walking down State Route 28. Licensed Practical Nurse (LPN) #11 and Admissions Director #39 walked into Resident #100's room with RN #05 to verify that Resident #100 was not in his room. At that time, staff noticed the window had been removed and the Heating Ventilation and Air Conditioning (HVAC) covering was removed. · On [DATE] from 4:18 P.M. to 4:19 P.M., Admissions Director #39 notified the Administrator that Resident #100 had left the facility and was in the custody of the local Police Department (#550). · On [DATE] from 4:19 P.M. to 4:24 P.M., LPN #11 immediately did a head count of all residents in the building. All other residents were accounted for and present in the facility. · On [DATE] from 4:25 P.M. to 4:27 P.M., RN #05 notified Resident #100's responsible party that Resident #100 had exited the facility and was located by and was in the custody of Police Department #550. · On [DATE] from 4:30 P.M. to 4:32 P.M., RN #05 notified Physician #900 that Resident #100 had exited the facility and was found by Police Department #550. · On [DATE] from 4:50 P.M. to 5:05 P.M., Police Department #550 escorted Resident #100 back to the facility. LPN #11 escorted Resident #100 back to his room, and placed Resident #100 on one-on-one supervision. RN #05 completed a head-to-toe assessment of Resident #100 and no injuries or areas of concern were noted. · On [DATE] from 4:55 P.M. to 5:05 P.M., Housekeeping Supervisor #40 checked all Wander Guards for functioning, placement, and expiration. All were placed properly, functioning and within required expiration. · On [DATE] from 5:05 P.M. to 7:20 P.M., LPN #11 completed a wander assessment on all current residents. No new wandering risks were identified at that time. · On [DATE] from 5:15 P.M. to 5:30 P.M., LPN #11 completed an elopement drill. Attendees included Activities Director #20, Medical Records Staff #19, Admissions Director #39, State tested Nurse Aide (STNA) #29, STNA #30, STNA #42, Housekeeping Supervisor #40, LPN #15, and RN #05. Facility staff responded quickly and effectively with no known issues or concerns identified. · On [DATE] from 4:50 P.M. to [DATE] at 7:00 A.M., RN #05, LPN #15 and LPN #28 completed head to toe skin assessments on all current residents. No new areas of concern were noted. · On [DATE] from 9:30 A.M. to 10:00 A.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held to review the QAPI plan related to elopement. Attendees included the Administrator, Physician #900, the Director of Nursing (DON), Activities Director #20, LPN #11, Admissions Director #39, Director of Rehabilitation #34, and Maintenance Director #48. · On [DATE] from 10:00 A.M. to 4:00 P.M., Maintenance Director #48 installed metal brackets on the windows that only open outward to ensure windows could not be removed. Maintenance Director #48 secured only the type of windows that were the same as the window Resident #100 eloped from, that open outward, not all the windows in the facility. The facility has three different types of windows. · On [DATE] from 5:00 P.M. to [DATE] at 7:00 P.M., LPN #11 educated the staff that were working the floor and Medical Records Staff #19, the DON, and the Administrator educated all other facility staff by phone on the elopement and wandering policy. Staff education continued until the last employee was educated. The DON confirmed that staff were not working until educated. · On [DATE] from 3:15 P.M. to 5:05 P.M., the Administrator assessed each resident's window and identified five windows that had screws missing which allowed the windows to open all the way. Regional Director of Operations #660 installed screws on five windows where the screws had previously been removed to ensure windows could not be opened all the way. · On [DATE] from 5:25 P.M. to 5:37 P.M., the Administrator reassessed the windows to ensure they could not open all the way. No further concerns were noted. · The Administrator will conduct elopement drills weekly, starting on [DATE], for four weeks to ensure staff respond accordingly. All variances will be corrected upon discovery and additional education and follow-up will be provided as deemed necessary. · All resident accessible windows will be assessed by the Administrator three times a week for a period of four weeks to ensure brackets and screws are in place, and no further elopement risks are noted with the first audit being conducted on [DATE]. All variances will be corrected upon discovery and additional education and follow-up will be provided as deemed necessary. Results will be reported to the QAPI committee. Ongoing compliance will be maintained through random audits, education and drills as recommended through the QAPI committee meetings. · The DON will complete wander assessments, starting on [DATE], on current residents weekly for a period of four weeks to ensure no changes in behavior patterns are present placing residents at risk for elopement and ensuring that appropriate and effective interventions are in place. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. · Ongoing compliance will be maintained through nursing administration and designee's review of all progress notes and alerts in the daily clinical operations meeting, starting on [DATE], to identify any new wandering, exit seeking or elopement risk behaviors. All variances will be corrected upon discovery and education and follow-up will be provided as deemed necessary. Although the Immediate Jeopardy was removed on [DATE], 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 was still in the process of implementing their corrective action plan to ensure on-going compliance. Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with diagnoses including essential hypertension, [CONDITION(S)] with lower urinary tract symptoms, [CONDITION(S)], [CONDITION(S)], dementia in other diseases classified elsewhere with behavioral disturbance, and unspecified [CONDITION(S)] not due to a substance or known physiological condition. Further Review of Resident #100's chart revealed Resident #100 discharged to the psychiatric hospital on [DATE]. Review of Resident #100's elopement risk assessment dated [DATE] revealed the resident was physically capable of leaving the facility, the resident was confused to time and place and resident wandered, roamed and paced. Review of Resident #100's admission nursing observation, dated [DATE], revealed Resident #100 was alert and oriented to person. Resident #100 was noted to be verbally incomprehensible and required limited assistance with bed mobility, transfers, dressing, toileting, personal hygiene, walking in room and locomotion on the unit. Resident #100 also required supervision with eating. Review of Resident #100's physician order dated [DATE] revealed Resident #100 was to have a Wander Guard to his left ankle and to check placement and function daily every shift. Review of Resident #100's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to have severe cognitive impairment and required supervision with bed mobility, transfers, eating, locomotion on and off the unit and walking in the room and in the corridor. Resident #100 also required limited assistance with dressing, toileting and personal hygiene and was reported to wander during the [DATE] MDS. Review of Resident #100's elopement care plan dated [DATE] revealed Resident #100 was at risk for elopement and wandering due to dementia. Interventions included Wander Guard, assess risk factors per facility procedures, attempt to involve the resident in decision making, follow facility elopement procedures, redirect as needed, and monitor, and report changes in behavior including restlessness and pacing. Review of Resident #100's cognition care plan dated [DATE] revealed Resident #100 was at risk for alterations in thought process due to dementia. Interventions included activities staff will provide resident with a calendar of events and invite the resident to attend those of interest, administer medications as ordered, allow ample time for resident to complete tasks, allow the resident the opportunity to make choices regarding daily routine, allow resident to complete as much personal hygiene and oral care as possible and always explain the activity being performed with a gentle voice. Review of Resident #100's progress note dated [DATE] at 1:45 A.M. revealed Resident #100 struck his roommate with a cane. Resident #100 was immediately removed from the room and placed on one-on-one. Resident #100 became combative with staff. An order was received to send Resident #100 out by squad for a psychiatric evaluation. Review of Resident #100's progress note dated [DATE] at 4:34 A.M. revealed Resident #100 returned from the emergency department and the emergency room doctor denied the need for a psychological evaluation and the resident was placed back on one-on-one care. Review of Resident #100's progress note dated [DATE] at 12:08 A.M. revealed transportation arrived to pick up Resident #100 and take him to the psychiatric hospital. Resident #100 became agitated and was having behaviors. Resident #100 continued on one-on-one supervision. Review of Resident #100's progress note dated [DATE] at 8:41 A.M. revealed Resident #100 attempted to hit staff and was stating he was going to hurt someone. One-on-one with the resident was not effective. Two staff redirections was not effective and Resident #100 continued to try to hit staff and make threats. The physician was notified, and new orders were received to send Resident #100 to the psychiatric hospital for admission. A new order for a diagnosis of acute [CONDITION(S)] was given. Review of Resident #100's progress note dated [DATE] at 5:17 P.M. revealed Resident #100 arrived from the psychiatric hospital. Review of the Resident #100's elopement risk assessment dated [DATE] revealed the resident was physically capable of leaving the facility and the resident had a Wander Guard with alarmed exits. Review of Resident #100's progress note dated [DATE] at 12:28 A.M. revealed Resident #100 was wandering about the interior of the facility thinking someone was looking for him. One-on-one support was provided and ineffective. Redirection was provided and snacks were offered. Resident #100 would go back and forth from his room to the nurses' station and redirection was effective at times. Review of Resident #100's progress note dated [DATE] at 6:11 A.M. revealed Resident #100 was wandering though the hallway nearest the exit door on the hallway where he resides. Wander Guard was in place and functioning properly. Redirection was effective at times. Review of Resident #100's progress note dated [DATE] at 7:15 A.M. revealed Resident #100 was up wandering through the hallways with his wander guard in place and functioning. Resident #100 stated I want to go home with my daughter and when someone opens the door I'm leaving. One-on-one was provided. Breakfast, television, and a snack were also provided. Resident #100 continued to wander, and Nurse Practitioner (NP) #999 was notified. Review of Resident #100's progress note dated [DATE] at 8:45 A.M. revealed Resident #100 continued to wander, and exit seek. One-on-one was provided. Television and talking were provided with negative effect. NP #999 was notified. Review of Resident #100's progress note dated [DATE] at 6:08 P.M. revealed Resident #100 was pacing almost all of the shift and was coming out of his room every couple of minutes. Resident #100 continued to forget to utilize his walker prior to ambulating and would come out of his room stumbling and with a very unsteady gait. Resident #100 was reminded multiple times to use his walker and then Resident #100 would proceed to grab the walker from the wrong side. Resident #100 would push the walker sideways ahead of him and stumble multiple times. Resident #100 was one-on-one most of the shift and staff attempted to redirect the resident away from resident rooms with diversional activities. All activities were only effective for five to ten minutes and then Resident #100 was pacing throughout the building again, mumbling his speech and asking where the door was to leave. Review of Resident #100's progress note dated [DATE] at 6:35 P.M. revealed Resident #100 was noted to be pacing up and down the hallway most of the shift and was redirected multiple times from entering the wrong door. Resident #100 was very unaware of safety and quickly exited his room and was attempting to walk in the hallway without his walker. Resident #100 was noted with a shuffled gait and stumbling. Resident #100 was redirected to get his walker prior to ambulating multiple times. Review of the police report dated [DATE] at 4:00 P.M. revealed caller advised that there was an older male wearing what appeared to be a diaper walking down State Route 28 towards Country Corner Market. Caller advised that they were trying to stop the male. On [DATE] at 4:05 P.M., resident was with the caller at State Route 28. On [DATE] at 4:30 P.M., the resident was transported back to the facility. On [DATE] at 4:37 P.M., the resident was in the custody of the facility. Review of an unlabeled and undated video revealed Resident #100 to be walking along the side of a road while wearing pajama pants and shoes. Review of Resident #100's progress note dated [DATE] at 5:15 P.M. revealed Resident #100 exited the facility and returned with no injuries noted and no adverse effects. One-on-one was initiated with staff and the physician and responsible party were notified. Review of Resident #100's progress note dated [DATE] at 11:30 A.M. revealed Resident #100's Wander Guard was in place and functioned properly. All Wander Guards and doors in the facility were checked for functioning and all were in working order. Review of Resident #100's progress note dated [DATE] at 1:01 P.M. revealed Resident #100 was discharged to the psychiatric hospital by ambulance due to continued behaviors at the facility. Review of the facility's Self-Reported Incidents (SRIs) revealed there was no SRI submitted related to Resident #100's elopement on [DATE]. Interview with the Administrator on [DATE] at 8:05 A.M. revealed Resident #100 eloped from the facility on [DATE]. Resident #100 told the nurse that he was going to watch a baseball game in his room and shut his door. Resident #100 then pushed in the clips on the top of the window and pulled the window out. Resident #100 stepped on the air conditioner unit and window sill and climbed out of the facility window. The Administrator stated Resident #100 was found on State Route 28, but she did not know exactly where he was found on the road. The Administrator reported police returned Resident #100 back to the facility and that was when the facility realized Resident #100 was missing. The Administrator reported she did not know what time Resident #100 was returned to the facility but stated the nurse had seen Resident #100 approximately 20 minutes prior to the incident occurring. The Administrator stated that she did not have a copy of the police report and the facility did not have any cameras. The Administrator verified she did not complete an SRI due to Resident #100 being returned to the facility with no injuries. The Administrator reported Resident #100 was discharged to a psychiatric hospital after the incident and brackets were placed on the windows. Observation of Resident #100's room on [DATE] at 8:10 A.M. revealed Resident #100 had a window in his room that had brackets on it to keep the window from coming out if the clips used to clean the window were engaged. Interview on [DATE] at 8:29 A.M. with STNA #29 revealed Resident #100 eloped from the facility by going out his window. STNA #29 stated she last saw Resident #100 on [DATE] at 3:00 P.M. and she did not know what time he left or returned to the facility. STNA #29 reported the police returned Resident #100 back to the facility and she did not realize that Resident #100 had eloped from the facility until he was returned by the police. STNA #29 stated she was not working on Resident #100's hallway. Telephone interview with Police Officer #500 on [DATE] at 9:44 A.M. revealed the police were notified of the resident walking on the side of State Route 28 on [DATE] at approximately 4:00 P.M. The resident was noted to be stumbling and almost got in traffic multiple times. Resident #100 was in a 55 MPH zone and was wearing only pajama pants and he was noted with a bracelet on his ankle. Resident #100 appeared overheated and dehydrated and the ambulance was called to assess Resident #100. Resident #100 was taken back to the facility after he was released by the paramedics. Police Officer #500 stated that the facility was called while on the scene and the facility was not aware that Resident #100 had left the facility. Police Officer #500 stated Resident #100 was over a mile away from the facility at State Route 28 in [NAME], Ohio. Telephone interview on [DATE] at 9:45 A.M. with Community Member #333 revealed he observed Resident #100 walking down [NAME] Street onto State Route 28 in [NAME] Ohio on [DATE] at approximately 3:45 P.M. Community Member #333 reported that Resident #100 was walking on the edge of the road, right on the line. Community Member #333 stated Resident #100 was wearing pajama pants and he had taken his shirt off. Resident #100 was wearing shoes, but he was not steady on his feet. Community Member #333 stated that he tried to walk after Resident #100 but then he got in his vehicle to drive after Resident #100 because he was unable to catch up to him. Community Member #333 stated he called the police and when he caught up with Resident #100, he just put his arms on him and leaned on him because he was exhausted. Community Member #333 reported Resident #100 wanted to get in his vehicle and Community member #333 put Resident #100 in his vehicle and put the air conditioner on. Community Member #333 stated Resident #100 was approximately 1.2 miles away from the facility when he initially saw him walking down the road and he was in the 55 MPH speed zone when he was able to catch up to Resident #100. Community Member #333 stated Resident #100 was going to Middletown, Ohio which was over one and a half hours away. Community Member #333 stated the police were not able to identify him because of his cognition but they noticed he had a bracelet on his ankle and the police called the facility on [DATE] at 4:10 P.M. Community Member #333 stated the facility had no clue Resident #100 was missing when the police called the facility and the facility reported that Resident #100 had climbed out a window. Community Member #333 reported that the ambulance came to assess Resident #100 and that was when he left. Community Member #333 stated he had a video of Resident #100 walking on the side of State Route 28 in [NAME] Ohio. Interview with the Administrator on [DATE] at 10:16 A.M. revealed the Administrator did not have any witness statements from the incident. The Administrator also reported the only staff that were educated on elopements were the staff that were present on the date of the incident on [DATE]. The Administrator reported no other staff were educated on elopements. Interview on [DATE] at 11:30 A.M. with LPN #11 revealed she was in her office on [DATE] when Medical Records Staff #19 received a call after 4:00 P.M. that the police had found Resident #100. LPN #11 went to Resident #100's room and verified Resident #100 was missing. LPN #11 stated that RN #05, STNA #29 and STNA #30 were working the unit at the time and RN #05 reported that Resident #100 was in his room watching the Reds game and that she had saw him 20 minutes prior to the incident at about 3:30 or 3:45 P.M. LPN #11 stated that Resident #100 returned to the facility and was wearing his Wander Guard, shoes, pajama pants and no shirt. LPN #11 stated that police handed Resident #100's shirt to them when he was returned to the facility. LPN #11 stated that Resident #100 had a history of trying to get out the doors and he always wanted his daughter to come and get him. Interview on [DATE] at 11:33 A.M. with RN #05 revealed Resident #100 had a history of wandering and he would come out to the common area and then go back into his room constantly. RN #05 stated Resident #100 was wearing a baseball team shirt on [DATE] and she asked him if he wanted to watch the baseball game. RN #05 stated she turned on the baseball game and gave Resident #100 a drink and a snack. Resident #100 came out and shut his door. RN #05 reported Resident #100 would shut his door any time he went into his room, but he usually came back out within a few minutes. RN #05 stated she got a call from Medical Records Staff #19 about 15 to 20 minutes later stating Resident #100 was out of the facility. RN #05 stated she went into Resident #100's room and Resident #100's window was wide open, and Resident #100 was not in his room. RN #05 stated nothing was broken in Resident #100's room but Resident #100 could have pushed the clips on the top of the window to pull the window out. RN #05 was unable to provide the exact time that she had last seen Resident #100 but stated it was approximately 20 minutes prior to the time that Medical Records Staff #19 informed her that Resident #100 was found by the police. RN #05 also stated that Resident #100 returned to the facility and was wearing a different outfit from when she had last seen him. RN #05 reported Resident #100 was wearing a baseball shirt and shorts when she last saw him, and he returned in pajama pants and with a different shirt. RN #05 stated Resident #100 had a history of wandering and stating he was going to leave the facility and he had a Wander Guard in place. Interview on [DATE] at 11:42 A.M. with STNA #30 revealed she last saw Resident #100 on [DATE] around 2:30 P.M. STNA #30 stated she did not have any details about the incident but stated she answered the door around 4:30 P.M. when the police returned Resident #100. STNA #30 stated she did not know Resident #100 was missing until he returned. STNA #30 reported Resident #100 had a history of wandering in the facility. Interview with Medical Records Staff #19 on [DATE] at 1:00 P.M. revealed she answered the phone on [DATE] at around 4:00 P.M. and the police asked her if the facility had a resident by a different first name but Resident #100's last name. Medical Records Staff #19 stated she told the police that the facility had a resident by the name of Resident #100, and she heard the police asking Resident #100 in the background if his first name was the name that Medical Records Staff #19 provided. Medical Records Staff #19 reported the police told her that Resident #100 was found on State Route 28. Medical Records Staff #19 stated she put the police on hold and informed RN #05. After informing RN #05, Medical Records Staff #19 went and checked the doors and Resident #100's room. The doors were secure but the window in Resident #100's room was completely open and his air conditioner cover was pushed off. Medical Records Staff #19 stated that she and RN #05 did a head count to make sure no one else was missing and RN #5 took over and spoke to the police. Medical Records Staff #19 stated Resident #100 had a history of pacing and wandering in the facility. Observation of the facility with the Administrator on [DATE] from 3:50 P.M. to 4:20 P.M. revealed windows in vacant Room #120, Resident #31 and Resident #32's room, Resident #18's room, and Resident #27 and Resident #28's room were able to open fully with no device in place to keep residents from being able to elope from the facility. Further observation revealed Resident #16 and #17's window did not have any safety device in place to keep residents from fully opening the window and being able to elope from the facility, but the window was noted to be stuck and unable to open fully due to the window being stuck in the frame. Observation of the facility on [DATE] at 5:14 P.M. revealed all windows were fixed and did not fully open. Review of an undated list of residents with Wander Guards revealed Resident #02, #16 #17, #23 and #32 had Wander Guards in place. Review of the facility's wandering and elopement policy dated [DATE] revealed the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. When a resident returned to the facility the DON or charge nurse shall examine the resident for injuries, contact the physician and report findings and the condition of the resident, notify the resident's representative, notify search teams the resident was located, complete and file and incident report and document relevant information in the resident's medical record. Review of the abuse prohibition policy dated [DATE] revealed the facility will not tolerate neglect, abuse or misappropriation of resident's funds or property by anyone. Facility staff shall report any incident or suspicion of mistreatment, neglect, abuse, injury of unknown source or misappropriation of property immediately to the Administrator or DON. The Administrator or designee will report the incident to the state survey agency per the regulation. Further review of the policy revealed the state surveying agency must be notified immediately but not more than 24 hours after the alleged incident was discovered. This deficiency substantiates Complaint Numbers OH 713.