Every finding on record at Heatherdowns Rehab & Residential Care Center

Based on review of personnel files, staff interview and policy review, the facility failed to implement their policy to ensure all newly hired staff were checked on the nurse aide registry (NAR) to verify eligibility for employment prior to working with residents. This had the potential to affect all residents in the facility. The facility census was 82. Findings include:Review of the personnel file for the Administrator revealed a hire date of 03/09/26. Further review revealed no evidence the Administrator was checked on the NAR for findings of abuse, neglect, exploitation, or misappropriation of property prior to working in the facility.Interview on 07/08/26 at 4:30 P.M. with Human Resources Director (HRD) #268 revealed she performed NAR registry checks for Certified Nursing Assistants (CNA) prior to interviewing them for employment at the facility. HRD #268 stated she did not perform NAR checks for any other applicants at the facility, including administrative staff, dietary, housekeeping, and maintenance. HRD #268 stated she believed the NAR was checked through the corporation's outsourced comprehensive background check. HRD #268 stated the facility began using the outsourced company approximately one year ago.A follow-up interview on 07/09/26 at approximately 8:00 A.M. with HRD #268 revealed 37 non-CNA staff had been hired since 06/05/25 and had background checks completed by the outsourced company. HRD #268 verified the 37 staff were not checked on the NAR for findings of abuse, neglect, exploitation, or misappropriation of personal property and currently worked at the facility.Interview on 07/09/26 at 9:46 A.M. with [NAME] #288, and a review of the list of staff hired since 06/05/25, confirmed [NAME] #286, [NAME] #287, Dietary Aide (DA) #279, DA #280, DA #282, DA #284, and DA #285 were all hired after the date the outsourced company began completing the facility's background checks and went in resident areas in the facility.A follow-up interview on 07/09/26 at approximately 11:00 A.M. with HRD #268, and review of an electronic mail (e-mail) dated 06/05/25, revealed the facility began using the outsourced company for background checks beginning on 06/05/25. Review of the facility provided list of staff hired, excluding CNAs, since 06/05/25 revealed 37 staff, including the Administrator, the Director of Nursing (DON) , Housekeeping Supervisor (HS) #269, Social Services Director (SSD) #231, Minimum Data Set Coordinator (MDSC) #246, Admissions Director (AD) #292, Medical Records Clerk (MRC) #244, Maintenance Technician (MT) #248, Registered Nurse (RN) #232, RN #234, RN #235, RN #236, RN #237, RN #240, RN #241), Licensed Practical Nurse (LPN) #252, LPN #254, LPN #257, LPN #258, LPN #259, LPN #260, LPN #261, LPN #262, LPN #263, LPN #264), Housekeeping Aide (HA) #270, HA #271, HA #274, HA #275), [NAME] #286, [NAME] #287), DA #279, DA #280, DA #282, DA #284, and DA #285.Review of the undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed it was the facility's policy to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks and to screen prospective residents for appropriateness of admission. Additionally, the facility would do the following prior to hiring a new employee: check the nurse aide registry (and attempt to check other state registries if the individual was known to have worked in another state) for all potential new employees (licensed and unlicensed) and new volunteers to determine if there was a finding of abuse, neglect or misappropriation of property against the individual prior to the use of that individual.This was an incidental finding discovered during the complaint investigation.

Based on observation, resident interview, staff interview and policy review, the facility failed to ensure the main dining room floor was free of debris and refuse at the time of meal service. This affected five (#10, #25, #57, #82, and #89) of five residents reviewed for homelike environment. The facility census was 82.Findings include:Observation on 07/07/26 at 11:01 A.M. revealed residents in the main dining room gathering for the noon meal. On the floor were pieces of toast crust, two ketchup packets, two sugar packets, an irregularly shaped yellowish dried substance approximately three inches in diameter, and white paper debris on the floor throughout the main dining room.A follow-up observation on 07/07/26 at 11:17 A.M. revealed the main dining room floor remained littered with debris. Resident #57 was seated at a table in his wheelchair. Resident #57 asked the surveyor, Did you look at the floor? Concurrent interview with Resident #57 revealed the debris on the main dining room floor bothered him. Additional interviews with residents seated in the main dining room, including Resident #82, Resident #25, Resident #10, and Resident #89, revealed the debris on the floor bothered them. Additional observations on 07/07/26 between 11:17 A.M. and 11:28 A.M. revealed residents continued to enter the dining room and seat themselves around tables.Continued observation on 07/07/26 at 11:28 A.M. revealed Dietary Aide (DA) #281 was serving fruit and beverages to residents in the main dining room. Concurrent interview with DA #281 confirmed the main dining room floor was littered with paper and food debris. DA #281 stated dietary staff was not responsible for cleaning the floors between meals. DA #281 stated this was not the first time she had observed the floor being dirty during meal service. DA #281 stated she had not reported concerns regarding the main dining room floor because she did not know who to report it to.Interview on 07/07/26 at 11:30 A.M., an concurrent observation of the main dining room, with the Administrator confirmed there was food and paper debris on the floor throughout the room. The Administrator confirmed it was not a homelike environment.Interview on 07/09/26 at 3:43 P.M. with Environmental Services Supervisor (ESS) #269 confirmed it was the housekeeping department's responsibility to clean the main dining room floor between meals.Review of the facility policy titled, Quality of Life - Homelike Environment, revised May 2017, revealed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included: clean, sanitary and orderly environment.This deficiency represents non-compliance investigated under Complaint Number 3030546 and Complaint Number 3026897.

Based on observation, staff interview and policy review, the facility failed to prepare meals in a sanitary manner. This had the potential to affect all residents, except one (#97), identified by the facility as receiving no food by mouth. Furthermore, the facility failed to ensure meal trays were transported in a sanitary manner. This affected 30 (#30, #47, #48, #49, #51, #52, #53, #54, #55, #56, #58, #59, #60, #61, #63, #66, #68, #69, #70, #72, #74, #77, #78, #79, #81, #83, #84, #86, #88 and #90) residents whose meal trays were transported on the North Hall Tray Cart (NHTC). Lastly, the facility failed to ensure foods were prepared and served at appropriate temperatures to prevent foodborne illness. This had the potential to affect all residents, except one (#97), identified by the facility as being NPCO. The facility census was 82.Findings include: 1. Observation on 07/06/26 at 7:45 A.M. of breakfast preparation revealed [NAME] #288 donned gloves, applied oven mitts applied over the gloves, removed a tray of eggs from the oven and set it on the preparation table, removed the oven mitts from the gloved hands, checked the temperature of the eggs with a thermometer, placed the tray of eggs on the steam table, and removed the gloves. Further observation revealed [NAME] #288 removed butter from the refrigerator and then donned new gloves without performing hand hygiene. [NAME] #288 held the butter in one hand while using a knife with the other hand to cut butter onto the griddle. Without removing the gloves, [NAME] #288 picked up a large frying pan and set it on the stove. [NAME] #288 then picked up the butter and knife and cut more pieces of butter onto the griddle. [NAME] #288 then walk to preparation area, opened a bag of bread with the same gloves on, grabbed approximately five slices of bread, set the slices of bread on the griddle, grabbed an additional five slices of bread from the bag and set them on the griddle. [NAME] #288 then removed the gloves. Concurrent interview with [NAME] #288 verified hand hygiene was not performed between glove changes and further confirmed multiple non-food surfaces were touched with the same gloves that were used to touch the bread. Review of the facility policy titled, Sanitation and Food Safety, dated 07/07/23, revealed hands should be washed immediately before engaging in food preparation including working with exposed food, clean equipment or service utensils. Additionally, hands should be washed during food preparation as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Review of the facility policy titled, Standard Precautions, dated August 2025 revealed staff were to perform hand hygiene after removing personal protective equipment (PPE), including gloves. 2. Observation on 07/06/26 at 12:28 P.M. revealed staff were passing lunch meal trays down the North Hall from a kitchen cart that did not have doors. Further observation revealed 11 meal trays inside the food cart that had desert in an uncovered bowl. Continued observation revealed Certified Nursing Assistant (CNA) #300 removed a tray containing an uncovered desert bowl and walked down the hallway to deliver the food tray to a resident's room. Interview on 07/06/26 at 12:33 P.M. with CNA #300 verified there were no doors on the cart containing resident meal trays, exposing any uncovered foods as they were transported from the kitchen to the hall. Further interview with CNA #300 confirmed the desert bowls were uncovered. CNA #300 confirmed the 30 residents who had meal trays on the NHTC. 3. Observation during the noon meal service on 07/07/26, beginning at 12:00 P.M., revealed a metal cart filled with resident meal trays leaving the kitchen. An uncovered bowl of mandarin oranges was on each resident's tray. There were no doors on the cart. Five additional resident trays were placed an open cart (no sides) with uncovered mandarin oranges. Continued observation revealed the carts were transported from the kitchen and through the lobby near the front door to the North Hall. During transport, a lid fell off one of the resident's plates and landed on the floor at the beginning of North Hall. Staff began passing trays to residents who were eating in their rooms. Interview on 07/07/26 at 12:05 P.M. with CNA #223 confirmed the mandarin oranges were uncovered on the carts. A follow-up interview on 07/07/26 at 12:10 P.M. with CNA #223 revealed Resident #30's plate was without a lid after it fell at the beginning of the hallway. Concurrent observation revealed CNA #223 poured some juice into a glass, placed it on Resident #30's tray, carried it down the rest of the North Hall, turned right at the nurses' station, walked through the assisted dining room, filled with residents, through the activity room, past the South Hall nurses station, and turned down the South Hall to provide Resident #30 with the meal tray. Subsequent interview with CNA #223 on 07/07/26 at 12:14 P.M. confirmed she carried Resident #30's uncovered plate, fruit, and beverage through the halls and past common areas before providing it to Resident #30. Continued observations on 07/07/26 between 12:26 P.M. and 12:35 P.M. revealed CNA #218 and CNA #203 carrying trays from the North Hall to the assisted dining room with uncovered servings of mandarin oranges. Interview on 07/09/26 at approximately 2:00 P.M. with CNA #203 confirmed four (#53, #63, #78 and #79) resident meals trays were on the NHTC with uncovered mandarin oranges and were transported through the North Hall to the assisting dining room. Review of the undated facility policy, Dining Room Service – Using Tray Service revealed no guidance regarding covering of food during transport from the kitchen to other areas of the facility. 4. Observation on 07/07/26 at 11:01 A.M. revealed [NAME] #286 taking temperatures of food for the noon meal. [NAME] #286 obtained a temperature of 125 degrees Fahrenheit (F) for the mashed potatoes. Concurrent interview with [NAME] #286 revealed the mashed potatoes were instant and stated she used the hottest tap water mixed with instant mashed potato flakes to prepare the mashed potatoes. [NAME] #286 stated she did not heat the water or the mashed potatoes on the stove. [NAME] #286 stated the mashed potatoes normally had a higher temperature and asked the Surveyor if they should be reheated on the stove. [NAME] #286 stated the turkey for the meal was still in the oven. Further observation revealed the snap peas had a temperature of 145 degrees F. Observation and interview on 07/07/26 at 11:20 A.M. with [NAME] #286 revealed the turkey was 147 degrees F. [NAME] #286 stated she had reheated the mashed potatoes on the stove burner and rechecked the temperature, obtaining a temperature of 126 degrees F. [NAME] #286 proceeded to serve the noon meal. Observation 07/08/26 at 9:56 A.M. of the box of instant mashed potatoes, with the Administrator, revealed the directions were to mix boiling water with the mashed potato flakes and stir. Review of the facility's recipes for the noon meal served on 07/07/26 revealed the turkey should have been heated to 165 degrees F. Review of the recipe for green peas indicated the peas should be steamed for four to six minutes or until tender and held at 140 degrees F or above for service. Review of the recipe for mashed potatoes revealed instant potatoes should be prepared according to package directions. Review of the facility's undated policy titled, Food Temperatures, revealed hot food should be cooked to a minimum temperature or greater for product of 165 degrees F. Food that was not cooked to the correct temperature was returned to the heating element until temperature was reached. Food should be held at 135 degrees F throughout the service process. This deficiency represents non-compliance investigated under Complaint Numbers 3030331, 3030546 and 3026897.

Based on medical record review, observation, staff interview, policy review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure the use of personal protective equipment (PPE) for residents on contact precautions. This affected two (#13 and #49) of six residents reviewed for infection control. Additionally, the facility failed to ensure appropriate hand hygiene was performed after contact with a resident with Clostridium difficile (C-diff). This affected one (#49) of six residents reviewed for infection control. The facility census was 82. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, cerebral infarction, and chronic obstructive pulmonary disease. Resident #13 also tested positive for Acinetobactor Baumanni in 03/2026 which the facility is currently in an active outbreak of. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/05/26, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of a physician order dated 03/27/26 revealed Resident #13 and an order for contact precautions due to history of multi-drug resistant organism (MDRO). Review of the care plan revised 03/28/26 revealed contact precautions (CP) were to be implemented due to a history of MDRO, Acinetobacter baumanni (drug resistant bacteria). Observation on 07/06/26 at 8:33 A.M. revealed contact precautions signage on the door of Resident #13's room as well as a three-drawer container on the outside of the room containing PPE. The sign stated that providers and staff must put on gloves and a gown prior to room entry. Continued observation revealed Certified Nursing Assistant (CNA) #209 was inside Resident #13's room at the foot of the bed holding onto a bundle of linen. CNA #209 was not wearing PPE Interview on 07/06/26 at 8:33 A.M. with CNA #209 verified that Resident #13 was in contact precautions and she was in the resident's room without PPE. CNA #209 stated she was only delivering a meal tray. CNA #209 asked if PPE needed to be worn to deliver a meal tray. CNA #209 then donned a yellow gown, but no gloves, and re-entered the resident's room. Interview on 07/09/26 at 3:20 P.M. with the Director of Nursing (DON) verified PPE should be worn upon entering the room of a resident on contact precautions, even if just delivering a meal tray. 2. Review of the medical record for Resident #49 revealed an admission date of 06/22/26 with diagnoses of osteomyelitis, multiple sclerosis, and neuromuscular dysfunction of the bladder. Review of the comprehensive admission MDS assessment, dated 06/26/26, revealed Resident #49 had intact cognition. Review of the current physician orders for Resident #49 revealed no order for contact precautions. Further review revealed an order dated 07/02/26 for Vancomycin HCl (hydrochloride) oral capsule 125 milligrams (mg), give one capsule by mouth four times a day for C-diff for 37 administrations. Observation on 07/07/26 at 12:08 P.M. revealed contact precautions signage on the door of Resident #49's room and a three-drawer container on the outside of the room containing PPE. The sign stated that providers and staff must put on gloves and a gown prior to room entry. Continued observation revealed CNA #223 carried a lunch tray into Resident #49's room without donning PPE. Concurrent interview with CNA #223 confirmed Resident #49 was in contact precautions. CNA #233 confirmed she did not wear PPE to deliver Resident #49's lunch tray. Observation on 07/09/26 at 10:47 A.M. revealed Human Resources Director (HRD) #268 knocking on Resident #49's closed door. HRD #268 had a cup of coffee from a fast-food restaurant. Further observation revealed HRD #268 entered the resident's room without donning PPEC and placed the cup on Resident #49's overbed table. Concurrent interview with HRD #268 confirmed Resident #49 was in contact precautions and staff were expected to wear PPE prior to entering the room. HRD #268 confirmed she did not wear a gown or gloves prior to entering Resident #49's room. Further observation revealed HRD #268 performed hand hygiene with an alcohol-based hand sanitizer. Continued interview with HRD #268 revealed she was unaware of the reason Resident #49 was in contact precautions. Interview on 07/09/26 at 11:14 A.M. with the DON confirmed Resident #49 was in contact precautions due to a diagnosis of C. diff. Review of the CDC guidelines titled, C.diff. Facts for Clinicians, dated 04/13/26, revealed to wear gloves and a gown when treating patients with C.diff infection, even during short visits. Gloves are important because hand sanitizer does not kill C.diff. Review of the facility policy titled, Standard Precautions, reviewed/revised August 2025, revealed contact precautions were intended to prevent transmission of infections that were spread by direct or indirect contact with the resident or environment and required the use of appropriate PPE, including a gown and gloves upon entering the room. This deficiency represents non-compliance investigated under Complaint Number 3030383.

Based on medical record review, staff interview, resident interview and policy review, the facility failed to ensure residents received fortified foods as ordered. This affected one (#41) of one resident identified on fortified foods. The facility census was 82.Findings include:Review of the medical record for Resident #41 revealed an admission date of 09/04/25, with diagnoses of moderate protein-calorie malnutrition, encephalopathy, vitamin D deficiency, muscle wasting and atrophy.Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/30/26, revealed Resident #41 had intact cognition and was able to eat independently.Review of the physician order dated 09/04/25, and revised on 02/08/26, revealed Resident #41 received a regular diet with fortified foods with all meals; fortified cereal with breakfast and fortified soup or potatoes with lunch and dinner. Review of a nutrition progress note, dated 02/06/26, revealed Resident #41 was identified with a significant weight loss since the previous month. Interventions included fortified food at all meals.Observation during the noon meal service on 07/07/26 revealed no evidence [NAME] #286 prepared any fortified foods.Interview on 07/07/26 at 5:00 P.M. with [NAME] #289, who was serving the evening meal, revealed she was unaware of any residents who required fortified foods, and did not prepare any fortified foods for the evening meal.Interview on 07/08/26 at 8:15 A.M. with Resident #41 revealed she was worried about her weight. She said the facility offered her nutrition supplements but she did not like them. She said the facility encouraged her to eat more, and said she was able to get extra servings of food when she wanted them. She said she had not heard of fortified foods.Interview on 07/08/26 at 9:56 A.M. with [NAME] #288 revealed no residents in the facility had an order for fortified foods and she was not serving any fortified foods.A telephone interview on 07/08/26 at 2:34 P.M. with Registered Dietitian (RD) #310 revealed he began working at the facility at the end of May 2026 and worked 12 hours per week. RD #310 stated fortified foods were foods prepared with extra butter, whole milk, or extra milk, whatever the recipe called for, to add calories to regular foods. RD #310 estimated fortified foods at all meals could provide approximately an additional 200 calories per meal (600 calories per day). RD #310, who was unable to access his computer at the time of the interview, stated he was not aware Resident #41 had a physician order for fortified foods.Review of the facility's undated policy titled, Fortified Food Program Policy, revealed the purpose was to enhance the nutritional intake of the residents through natural consumption of food.This deficiency represents non-compliance investigated under Complaint Number 3030331 and Complaint Number 3026897.

Based on closed medical record review, review of the facility's investigation, staff interview, local police department (LPD) interview, review of the Ohio Department of Health's (ODH) Certification and Licensure (CALS) system and policy review, the facility failed to ensure a complete and thorough investigation into an allegation of misappropriation. This affected one (#92) of five residents reviewed for misappropriation. The facility census was 82.Findings include:Review of the closed medical record for Resident #92 revealed an admission date of 10/29/25. Diagnoses included acute respiratory failure with hypoxia, congestive heart failure, end stage renal disease, and bipolar disorder. Resident #92 discharged to the hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/04/26, revealed Resident #92 had intact cognition. Review of Resident #92's nursing progress notes dated 12/04/25 through 02/12/26 revealed no documentation of missing personal items. Review of the facility's SRI, number (#) 268265 and initiated on 12/05/25, revealed Resident #92 reported a missing money order in the amount of $450.00. Further review revealed the facility concluded there was no evidence the money order was taken by staff. A report was filed with the LPD, and the money order company was notified to put a stop on cashing the money order. The SRI was closed on 12/11/25. The Ohio Department of Health (ODH) requested the facility complete an addendum if the money order was cashed or if any additional information was received from the LPD, with the facility acknowledging and agreeing to complete an addendum if either of those things occurred. Further review of the SRI revealed the facility did not submit an addendum to the investigation.Review of the facility's investigation file revealed evidence staff were interviewed regarding the missing money order, with each denying any knowledge of it. Further review revealed a copy of the police report dated 12/05/25. Also, the investigation file included a copy of the cashed money order that was made payable to Former Employee (FE) #400. The posted clearing date of the money order was 12/11/25. The file contained no additional information regarding the date the cashed money order was provided to the facility, the date the police were contacted regarding the cashed money order, the date the police came to the facility to get a copy of the cashed money order, who from the LPD came to the facility, or the results of the police visit. Further review revealed no evidence the facility reopened their investigation once a copy of the cashed money order was received that showed it was made payable to FE #400.Interview on 07/07/26 at 3:01 P.M. with the Administrator revealed SRI #268265 was reported by Former Administrator (FA) #305 and additional investigation was completed by Interim Administrator (IA) #298.A telephone interview on 07/08/26 at 9:18 A.M. with IA #298 revealed he worked in the facility in approximately February 2026. IA #298 stated Resident #92's missing money order was reported by a previous administrator in December 2025, and the investigation was closed out due to lack of evidence. Further interview revealed Resident #92's family member brought in a copy of the cashed money order to IA #298. IA #298 stated he notified the LPD and the police came to the facility and met with him. IA #298 stated he provided a copy of the cashed money order to the LPD, and the police officer provided him with a business card. IA #298 further stated the police officer stated they were familiar with the person who cashed the money order and IA #298 stated the police took it from there. IA #298 confirmed the facility did not investigate further once the identity of the individual who cashed the money order was known. IA #298 stated, to my knowledge there was no connection between the individual who cashed the money order and a current facility staff.Telephone interviews on 07/08/26 at 12:54 P.M. and 2:52 P.M. with LPD Records Clerk (RC) #315 revealed there was no evidence of a follow-up to the police's initial investigation on 12/05/25. RC #315 stated the case was not assigned to a detective. Additionally, RC #315 stated there was no subsequent information when searching for more information under Resident #92's name, under Resident #92's family member's name, or under the name of the person who cashed the money order. RC #315 stated there was no evidence the police returned to the facility in reference to Resident #92's money order after 12/05/25.A follow-up telephone interview on 07/08/26 at 3:00 P.M. with IA #298 revealed he was advised by the police officer, who came to the facility and obtained a copy of the cashed money order, to not pursue any further investigation at the facility. IA #298 stated the police did not want anyone tipped off while the police proceeded with their investigation. IA #298 stated he was awaiting further instructions from the police before taking any additional action. IA #298 stated he provided Resident #92's family's contact information to the police officer and notified Resident #92's family member about providing them the contact information. A telephone interview on 07/08/26 at 3:20 P.M. with Resident #92's family member revealed they were never contacted by the police, never received a copy of the police report and did not have the report number. Resident #92's family member stated they provided a copy of the cashed money order to IA #298 and received a voicemail from IA #298 who stated he provided her contact information to the police. Resident #92's family member stated they called back to the facility and thanked IA #298 for providing the information to the police, and stated the police had not yet made contact with her. Interview on 07/08/26 at 3:40 P.M. with the Administrator revealed she could find the business card for the police officer that IA #298 stated he provided a copy of the cashed money order to. Review of the undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revealed evidence of the investigation should be documented in accordance with Quality Assurance protocols.This deficiency represents non-compliance investigated under Complaint Number 3026897.

Based on closed medical record review, staff interview, family interview, local police department (LPD) interview, review of the LPD report, review of the facility initiated Self-Reported Incident (SRI), review of the facility's investigation and review of facility policy, the facility failed to ensure residents were free from misappropriation. This affected one (#92) of five residents reviewed for misappropriation. The facility census was 82.Findings include:Review of the closed medical record for Resident #92 revealed an admission date of 10/29/25. Diagnoses included acute respiratory failure with hypoxia, congestive heart failure, end stage renal disease, and bipolar disorder. Resident #92 discharged to the hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/04/26, revealed Resident #92 had intact cognition. Review of Resident #92's nursing progress notes dated 12/04/25 through 02/12/26 revealed no documentation of missing personal items. Review of a Grievance/Complaint Report, dated 12/02/26, revealed Resident #92 reported his sister brought him a blank money order in the amount of $450.00 to pay his rent. Resident #92 stated he put it in his wallet but did not remember if he took it out later to fill it out and now he was unable to find it.Review of a Grievance/Complaint Report, dated 12/05/26, revealed the Administrator spoke with Resident #92, who believed the missing money order was taken.Review of the facility's SRI, number (#) 268265 and initiated on 12/05/25, revealed Resident #92 reported a missing money order in the amount of $450.00. Further review revealed the facility concluded there was no evidence the money order was taken by staff. A report was filed with the LPD, and the money order company was notified to put a stop on cashing the money order. The SRI was closed on 12/11/25. The Ohio Department of Health (ODH) requested the facility complete an addendum if the money order was cashed or if any additional information was received from the LPD, with the facility acknowledging and agreeing to complete an addendum if either of those things occurred. Further review of the SRI revealed the facility did not submit an addendum to the investigation.Review of the LPD report, dated 12/05/25, revealed a theft report was filed. The report stated Resident #92's sister provided him with a money order for $450.00 on Monday, 12/01/25, and he put it in his wallet, which he kept on his tray at bedside. Resident #92 noticed Tuesday morning, 12/02/25, that it was missing. The resident notified staff, who searched his room thinking it may have been thrown away. It was not found, making them believe it may have been taken but it was unknown by who at the time of the report.Review of the facility's investigation file revealed evidence staff were interviewed regarding the missing money order, with each denying any knowledge of it. Further review revealed a copy of the police report dated 12/05/25. Also, the investigation file included a copy of the cashed money order that was made payable to Former Employee (FE) #400. The posted clearing date of the money order was 12/11/25. The file contained no additional information regarding the date the cashed money order was provided to the facility, the date the police were contacted regarding the cashed money order, the date the police came to the facility to get a copy of the cashed money order, who from the LPD came to the facility, or the results of the police visit. Further review revealed no evidence the facility reopened their investigation once a copy of the cashed money order was received that showed it was made payable to FE #400.Interview on 07/07/26 at 3:01 P.M. with the Administrator revealed SRI #268265 was reported by Former Administrator (FA) #305 and additional investigation was completed by Interim Administrator (IA) #298.A telephone interview on 07/08/26 at 9:18 A.M. with IA #298 revealed he worked in the facility in approximately February 2026. IA #298 stated Resident #92's missing money order was reported by a previous administrator in December 2025, and the investigation was closed out due to lack of evidence. Further interview revealed Resident #92's family member brought in a copy of the cashed money order to IA #298. IA #298 stated he notified the LPD and the police came to the facility and met with him. IA #298 stated he provided a copy of the cashed money order to the LPD, and the police officer provided him with a business card. IA #298 further stated the police officer stated they were familiar with the person who cashed the money order and IA #298 stated the police took it from there. IA #298 confirmed the facility did not investigate further once the identity of the individual who cashed the money order was known. IA #298 stated, to my knowledge there was no connection between the individual who cashed the money order and a current facility staff.Interview on 07/08/26 at 10:28 A.M. with Human Resources Director (HRD) #268 revealed Resident #92's missing money order was discussed during a morning meeting at the facility. HRD #268 stated, to her knowledge, the missing money order did not involve facility employees. HRD #268 stated there was speculation that there was a romantic relationship between FE #400 and current Licensed Practical Nurse (LPN) #320. HRD #268 stated she was not aware of LPN #320 being questioned about the money order and IA #298 and the previous Director of Nursing (DON) stated the facility would not be investigating because the LPD would be investigating.Interview on 07/08/26 at 12:29 P.M. with the Administrator revealed the individual who cashed Resident #92's money order was the boyfriend of an aide, but she did not know who the aide was. The Administrator stated when she started at the facility, she was told the issue was under investigation by the LPD and the facility was told not to investigate. The Administrator was unable to recall who gave her that information.A telephone interview on 07/08/26 at 12:40 P.M. with Regional Director of Operations (RDO) #450 revealed he knew bits and pieces of the situation regarding Resident #92's missing money order and there was speculation that the person who cashed it was affiliated with a current facility staff member. RDO #450 stated the LPD instructed IA #298 to not alert the staff that they were looking into it. RDO #450 stated, to his knowledge, there was no follow-up from the LPD or additional action taken by the facility.Telephone interviews on 07/08/26 at 12:54 P.M. and 2:52 P.M. with LPD Records Clerk (RC) #315 revealed there was no evidence of a follow-up to the police's initial investigation and report on 12/05/25. RC #315 stated the case was not assigned to a detective. Additionally, RC #315 stated there was no subsequent information when searching for more information under Resident #92's name, under Resident #92's family member's name, or under the name of the person who cashed the money order. RC #315 stated there was no evidence the police returned to the facility in reference to Resident #92's money order after 12/05/25.A follow-up telephone interview on 07/08/26 at 3:00 P.M. with IA #298 revealed he was advised by the police officer, who came to the facility and obtained a copy of the cashed money order, to not pursue any further investigation at the facility. IA #298 stated the police did not want anyone tipped off while the police proceeded with their investigation. IA #298 stated he was awaiting further instructions from the police before taking any additional action. IA #298 stated he provided Resident #92's family's contact information to the police officer and notified Resident #92's family member about providing them the contact information. IA #298 verified he did not speak with or interview any additional staff or take any additional action once the identity of the person who cashed the money order was known. A telephone interview on 07/08/26 at 3:20 P.M. with Resident #92's family member revealed they were never contacted by the police, never received a copy of the police report and did not have the report number regarding the missing money order. Resident #92's family member stated they provided a copy of the cashed money order to IA #298 and received a voicemail from IA #298, who stated he provided her contact information to the police. Resident #92's family member stated she has heard nothing back from either the facility or the LPD.Review of the undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Further review revealed to ensure the resident or other residents were protected. If a staff member was accused or suspected, the facility would immediately remove that staff member from the schedule pending outcome of the investigation. Additional review revealed allegations would be investigated and the investigation would be documented in accordance with Quality Assurance Protocols.This deficiency represents non-compliance investigated under Complaint Number 3026897.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure central venous catheter monitoring and treatments were provided in accordance with physician orders. This affected one (#1) of three residents reviewed for central venous catheter care. The facility identified three individuals with central venous catheters in place in a facility. The facility census was 81. Findings include:Review of the medical record for Resident #1 revealed an admission date of 04/23/26, diagnoses included, absence of left great toe, anemia, epilepsy, hypertension, low back pain, major depressive disorder, acute osteomyelitis left ankle and foot, psychoactive substance abuse, peripheral vascular disease, and type II diabetes mellitus. According to the most current Minimum Data Set assessment dated [DATE], Resident #1 was assessed with intact cognition, was independently ambulatory utilizing a walker or wheelchair, required partial to moderate assistance with activities of daily living, received as needed pain medication for occasional moderate pain, and received medications via an intravenous (IV) access. Review of hospital community referral documentation dated 04/23/26 noted Resident #1 admitted to the facility with a peripherally inserted central catheter (PICC) line. Review of physician orders dated 04/23/26 noted instructions to change the intravenous (IV) line dressing every seven days (on Sundays) and as needed for soiling, document IV site appearance every shift: U = unremarkable, R = redness, S = swollen, W = warm to touch, D = drainage every shift and report any changes to physician. Review of the medication administration record and the treatment administration record for Resident #1 revealed a lack of documentation indicating the PICC line dressing was changed, scheduled or as needed, throughout the residents stay until 05/03/26. Further review also revealed a lack of documentation indicating the PICC line insertion site was monitored each shift. On 04/27/26 a nursing plan of care was revised to address Resident #1's IV access indicating the resident was at increased risk of infection or complications related to the PICC line. Interventions included to administer medications/fluids as ordered, monitor for signs and symptoms of infiltration, such as swelling, redness, subcutaneous emphysema and if signs of infiltration are present discontinue the infusion. Additional interventions included to monitor site for bleeding, redness, swelling, purulent drainage, heat and complaints of tenderness at the site, obtain diagnostic work as ordered, report any abnormalities to medical provider, and to provide IV therapy, including flushes, and dressing changes as ordered by the medical provider. According to hospital emergency room evaluation documentation dated 04/28/26 at 1:08 A.M. Resident #1 reported chest tightness. Resident #1 reported today he noticed the IV line had some air in it while his antibiotics were running and chest tightness started right after that. Computed tomography (CT) pulmonary angiogram findings identified no acute pulmonary thromboembolism, no evidence of acute abnormality in the chest, and was negative for acute intrathoracic processes. The cardiopulmonary workup was negative and cardiac enzymes were normal. Resident to be transferred back to skilled nursing facility. The hospital emergency room documentation also lacked documentation to indicate Resident #1's family was notified. Review of nursing note dated 04/28/26 at 6:33 A.M. revealed the nurse spoke with emergency room nurse and obtained report that Resident #1 was having a new PICC line placed and would be returning to the facility. No documentation contained in the medical record noted Resident #1 had a change in health status, an emergency room transfer, or that Resident #1's family was notified of the resident's emergency room hospitalization.Observation on 05/06/26 at 8:08 A.M. with Licensed Practical Nurse (LPN) #300 noted Resident #1 was in bed with a PICC line inserted into the left upper arm. A transparent semi-permeable membrane (TSM) dressing was in place. Under the TSM was a folded gauze dressing covering the catheter insertion site, obstructing the site and surrounding tissue. The dressing was dated 05/06/26. Interview with LPN #300 at the time of the observation verified she was also unable to observe the PICC line insertion site and the surrounding tissue due to the folded gauze under the TSM covering. LPN #300 stated the dress had been changed within minutes of the observation and had been completed by LPN Unit Manager #301. Interview on 05/06/26 at 8:30 A.M. with LPN Unit Manager #301 verified changing the PICC line dressing for Resident #1 on 05/06/26 and 05/03/26. LPN #301 stated the same dressing was placed with the gauze covering the PICC line insertion site on 05/03/26. LPN Unit Manager #301 stated the dressing was due to be changed every seven days but was observed to be peeling so she changed the dressing today. Interview on 05/06/26 at 10:24 A.M. with the Director of Nursing (DON) during an observation of Resident #1 verified Resident #1 had a gauze covering the PICC line insertion site. The DON verified that the facility policy indicates when transparent dressing is used with a gauze, dressings are to be changed every two days. Continued interview with the DON while reviewing the medical record for Resident #1 verified nurses were charting the observation of the PICC line insertion site when in fact they were unable to visualize the insertion site due to the gauze dressing. The DON also verified the resident's order was to complete the PICC line dressing change every seven days and not every two as indicated in the policy for IV sites covered with gauze. In addition, the DON verified Resident #1 had the PICC line replaced on 04/28/26 and the dressing should have been changed within 24 hours of insertion and there was no documentation contained in the medical record indicating that the dressing was changed until 05/03/26. Review of facility Central Venous Catheter Dressing Change policy revised 01/17/209 stated to change transparent semi-permeable membrane (TSM) dressings at least every five to seven days and as needed when wet, soiled, or not intact. If gauze is used, the dressing must be changed every two days. After the original insertion of a central venous catheter, the dressing will consist of gauze and TSM and the dressing will be changed within 24 hours of the insertion. This deficiency represents non-compliance investigated under Complaint Number 2997312.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident family was notified of hospital emergency room transfer with a change in resident condition. This affected one (#1) of three residents reviewed for notification of health status. The facility census 81. Findings include:Review of the medical record for Resident #1 revealed an admission date of 04/23/26, diagnoses included absence of left great toe, anemia, epilepsy, hypertension, low back pain, major depressive disorder, acute osteomyelitis of the left ankle and foot, psychoactive substance abuse, peripheral vascular disease, and type II diabetes mellitus. According to the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #1 was assessed with intact cognition, was independently ambulatory utilizing a walker or wheelchair, required partial to moderate assistance with activities of daily living, received as needed pain medication for occasional moderate pain, and received medications via intravenous (IV) access. Review of the hospital community referral documentation dated 04/23/26 noted Resident #1 admitted to the facility with a peripherally inserted central catheter (PICC) line. Review of physician orders dated 04/23/26 noted instructions to change the intravenous (IV) line dressing every seven days (on Sundays) and as needed for soiling, document IV site appearance every shift: U = unremarkable, R = redness, S = swollen, W = warm to touch, D = drainage every shift and report any changes to physician. Review of the medication administration record and the treatment administration record for Resident #1 revealed a lack of documentation indicating the PICC line dressing was changed, scheduled or as needed, throughout the residents stay until 05/03/26. Further review also revealed a lack of documentation indicating the PICC line insertion site was monitored each shift. On 04/27/26 a nursing plan of care was revised to address Resident #1's IV access indicating the resident was at increased risk of infection or complications related to the PICC line. Interventions included to administer medications/fluids as ordered, monitor for signs and symptoms of infiltration, such as swelling, redness, subcutaneous emphysema and if signs of infiltration are present discontinue the infusion. Additional interventions included to monitor site for bleeding, redness, swelling, purulent drainage, heat and complaints of tenderness at the site, obtain diagnostic work as ordered, report any abnormalities to medical provider, and to provide IV therapy, including flushes, and dressing changes as ordered by the medical provider.According to hospital emergency room evaluation documentation dated 04/28/26 at 1:08 A.M. Resident #1 reported chest tightness. Resident #1 reported today he noticed the IV line had some air in it while his antibiotics were running and chest tightness started right after that. Computed tomography (CT) pulmonary angiogram findings identified no acute pulmonary thromboembolism, no evidence of acute abnormality in the chest, and was negative for acute intrathoracic processes. The cardiopulmonary workup was negative and cardiac enzymes were normal. Resident to be transferred back to skilled nursing facility. The hospital emergency room documentation also lacked documentation to indicate Resident #1's family was notified. Review of nursing note dated 04/28/26 at 6:33 A.M. revealed the nurse spoke with emergency room nurse and obtained report that Resident #1 was having a new PICC line placed and would be returning to the facility. No documentation contained in the medical record noted Resident #1 had a change in health status, an emergency room transfer, or that Resident #1's family was notified of the resident's emergency room hospitalization.Interview on 05/06/26 at 10:24 A.M. with the Director of Nursing during a review of the medical record verified Resident #1's family was not notified when the resident transferred to the hospital on [DATE] with a change in condition. On 05/06/26 at 11:40 A.M. interview with Resident #1 verified no family was informed of his transfer to the hospital on [DATE] and he would have preferred for them to have been notified. Review of the undated facility policy titled Notification of Change, stated the purpose of the policy is to keep family and physician notified of any change of condition of a resident. The facility must immediately inform the resident, consult with the resident's physician and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status, a decision to transfer or discharge the resident from the facility. All changes in condition and physician and family notifications need to be documented in the resident's medical record. This deficiency is an incidental finding discovered during the course of this complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on staff interview, review of facility maintenance work order logs, and review of plumbing vendor documents, the facility failed to ensure hot water temperatures were maintained at acceptable levels. This affected 19 (#8, #12, #15, #24, #29, #31, #32, #36, #45, #57, #60, #62, #65, #67, #69, #71, #73, #77, and #78) residents who were identified by the facility as residing on the Middle North and North Back Halls. The facility census was 77.Findings include:Interview on 01/21/26 at 9:52 A.M. with the Administrator revealed on 12/31/25, the hot water was left running in Mechanical Room Five, leaving no hot water on the Middle North and North Back hallways. When it was identified that there was no hot water on those hallways, Maintenance Assistant (MA) #151came to the facility, turned the faucet off in Mechanical Room Five and waited until the water temperature was back to an acceptable range. On 01/04/26, the Director of Nursing (DON) informed him that there was again no hot water. Maintenance Supervisor (MS) #150 checked Mechanical Room Five and smelled gas, so the hot water was shut off while a replacement part was ordered to repair the hot water tank. The Administrator stated the part was ordered on 01/06/26.Interview on 01/21/26 at 9:54 A.M. with the DON revealed she was aware of the hot water being out on 12/31/25. A group message with management was sent out after the Certified Nursing Assistants (CNAs) reported no hot water on the Middle North and North Back hallways. The DON stated MA #151 reported the issue was fixed and the facility had hot water. Then, on 01/04/26, Resident #73's family member informed her the resident's shower could not be completed due to the facility having no hot water. The family member stated staff informed her the hot water had been out over the weekend, including 01/02/26, 01/03/26 and 01/04/26 The DON stated MS #150 was contacted, as well as the Administrator regarding the hot water concern.Interview on 01/28/26 at 1:08 P.M. with MA #151 revealed on 12/31/25 he received a call to go to the facility and check the North hallway because the water was cold. MA #151 stated there was a sink in Maintenance Room Five that had been left on with the hot water running. MA #151 stated the faucet was turned off and the temperature at the hot water tank increased to an acceptable range after 45 minutes. MA #151 further stated the hot water temperatures were checked in two resident rooms and the nourishment room, with each being within acceptable ranges. MS #151 confirmed there was no monitoring of the water temperatures on 01/01/26, 01/02/26, 01/03/26, and 01/04/26 to ensure the water temperatures were maintained.Interview on 01/28/26 at 1:19 P.M. with Licensed Practical Nurse (LPN) #136 confirmed she worked on 01/03/26 and there was no hot water on the Middle North and North Back hallways, and the CNA made Central Supply (CS) #105 aware.Interview on 01/28/26 at 1:38 P.M. with CNA #176 revealed she worked the day shift on 01/03/26 and there was no hot water on the North Back or North Middle hallways. CNA #176 stated it was reported CS #105.Interview on 01/28/26 at 2:09 P.M. with CS #105 revealed she was present in the facility on 01/02/26 and stated staff did not make her aware of the hot water concern. CS #105 stated she was the manager on duty on 01/04/26 and was present at the facility. CS #105 stated she completed morning rounds and none of the staff reported any concerns with the hot water. At 11:27 A.M., CS #105 stated she was contacted by the DON and asked if she was aware there was no hot water because a resident's family reported to her there had been no hot water for three days on the North hallway. CS #105 denied she had knowledge and went to investigate and was told there had been no hot water for three days. CS #105 stated she ensured there were sufficient hygiene supplies available, such as hand sanitizer and wipes, to provide care for residents on the affected hall.Review of the maintenance work order log from 12/25/25 through 01/04/26 revealed no evidence staff reported any hot water concerns in the facility.Review of the plumbing vendor documents revealed the hot water tank was replaced on 01/07/25.The deficiency was corrected on 01/12/26 when the facility implemented the following corrective actions:On 12/31/25, LPN #148 notified the DON that there was not any hot water on the North hallway. MS #150 was notified and explained that MA #151 entered the facility and shut off the hot water faucet that had been left running. MA #151 was a the facility from 7:00 P.M. to 9:00 P.M. and verified that the water temperature on the hot water tank was 118 degrees Fahrenheit (F).On 01/04/26, MS #150 notified the plumbing vendor of an issue with the hot water on the North Middle and North Back hallways. The vendor scheduled to come to the facility on [DATE]. On 01/04/26, CS #105 provided verbal education to all staff working on first and second shift to obtain hot water from either the Front North Hall or the South Unit for resident care, and showers could be completed in the South Unit shower room. LPN #134 provided the education to staff working third shift that night. On 01/04/26, CS #105 ensured a sufficient supply of hand sanitizer and incontinence wipes were available to provide care for the residents residing on the North Middle and North Back Halls. On 01/05/26, the plumbing vendor assessed the hot water tanks that supplied hot water to the North Middle and North Back Halls and determined one hot water tank was inoperable and the second tank required a new gas valve, which had to be ordered. On 01/05/26, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concern with the hot water on the North Middle and North Back Halls. In attendance were the Administrator, the DON, Admissions Director (AD) #153, Business Office Manager (BOM) #104, Social Worker (SW) #212, Human Resources (HR) #213, Director of Rehabilitation (DOR) #207, Medical Records (MR) #155, Unit Manager (UM) #194, Activities Director (ACT) #101, CS #105, and UM #195. The Administrator instructed each department head to check in with their assigned residents under the Guardian Angel program to explain the situation with the hot water and ensure resident needs were met.Beginning on 01/05/26, CS #105 ensured adequate hand sanitizer and incontinence wipes were available for resident care until the hot water could be restored. Beginning on 01/05/26, the DON or designee began education with nursing department staff to explain options available for providing care, including hand sanitizer, incontinence wipes, obtaining hot water from the South Hall, using the showers on the South Hall or the Therapy Department shower, customer service, infection control, and the reporting of maintenance concerns via work orders and if not resolved, report again to the Administrator and DON for follow-up. On 01/05/26, the DON or designee reviewed all residents residing on the North Middle and North Back Halls to determine any residents who missed showers due to not having hot water on the hall. On 01/06/26, CNA #170 completed showers for residents residing on the North Middle and North Back Halls.On 01/06/26, the plumbing vendor replaced the faulty gas valve on one of the hot water tanks.On 01/07/26, the plumbing vendor replaced the inoperable hot water tank.Beginning on 01/12/26, MS #150 and MA #151 would conduct 10 random water temperature audits throughout the facility daily five times weekly for 30 days to ensure water temperatures were maintained. Any identified concerns would be reported to the Administrator and/or DON and the plumbing vendor notified for service.Random observations on 01/21/26 and 01/28/26 verified hot water temperatures were within acceptable ranges.This deficiency represents noncompliance investigated under Master Complaint Number 2709655 and Complaint Number 2709561.

Based on closed medical record review, staff interview and review of the facility policy, the facility failed to ensure resident preferences for daily care were honored. This affected one (#78) of three residents reviewed for personal care. The facility census was 77. Findings include:Review of the closed medical record for Resident #78 revealed an admission date of 01/02/26 and a discharge date of 01/14/26. Diagnoses included spinal stenosis, lumbar region with neurogenic claudication, acute cystitis without hematuria, anxiety, and depression.Review of the admission Minimum Data Set (MDS) assessment, dated 01/08/26, revealed this resident had intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Resident #78 needed supervision or touching assistance with activities of daily living (ADLs), which included bathing. Additional review of the MDS revealed hygiene choices were very important to Resident #78.Review of the care plan dated 01/04/26 revealed Resident #78 had an ADL self-care performance related to deconditioning and weakness. Interventions included assisting with personal hygiene.Interview on 01/21/26 at 9:54 A.M. with the Director of Nursing (DON) revealed Resident #78's family called on 01/05/26 regarding concerns with Resident #78 not being washed, as requested, on 01/04/26 due to the facility not having hot water. The DON confirmed staff did not provide care as requested by Resident #78 on 01/04/26 due to not having hot water in Resident #78's room. The DON confirmed hot water was available in the facility.Interview on 01/21/26 at 12:15 P.M. with Resident #78's family revealed that during a visit on 01/04/26, it was noted the facility did not have hot water. When Resident #78's family returned home, the resident called and stated staff would not wash her due to not having hot water. Resident #78's family further stated the staff dressed Resident #78 without completing any hygiene, which upset Resident #78.Review of the facility policy titled, Resident Rights and Facility Responsibilities, undated, revealed residents had the right to adequate and appropriate medical treatment and nursing care, and the right to have all reasonable requests honored.This deficiency represents noncompliance investigated under Master Complaint Number 2709655.

Based on closed medical record review, staff interview and review of facility policy, the facility failed to implement pain management interventions timely to address resident pain. This affected one (#78) of three residents reviewed for pain management. The facility census was 77.Findings include:Review of the closed medical record for Resident #78 revealed an admission date of 01/02/26 and a discharge date of 01/14/26. Diagnoses included spinal stenosis, lumbar region with neurogenic claudication, acute cystitis without hematuria, anxiety, and depression.Review of the hospital progress notes dated 12/26/25 revealed Resident #78 was admitted to the hospital for back and leg pain. On 01/03/26, Resident #78 was discharged to the facility with an order for oxycodone five milligrams (mg) by mouth every eight hours, if needed, for pain for up to three days.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Further review of the MDS revealed Resident #78 was on opioid medication.Review of the care plan dated 01/04/25 revealed Resident #78 was at risk for pain due to lumbago (pain and stiffness in the lower back) with sciatica and neuropathy. Interventions included administering analgesics as ordered by the doctor, offering non-pharmacological pain interventions, and notifying the physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain.Review of the physician orders for Resident #78 revealed orders dated 01/02/26 to assess pain and discomfort every shift and oxycodone five mg, give one tablet by mouth every eight hours as needed for pain.Review of the Medication Administration Record (MAR) for January 2026 revealed oxycodone five mg was not administered from 01/02/26 through 01/05/26. Review of Pain Level Summary revealed Resident #78 had a pain level of two and four on 01/02/26, a pain level of three and four on 01/03/26, a pain level of 4 on 01/04/26, and a pain level of three, four, and six on 01/05/26.Interview on 01/21/26 at 9:54 A.M. with the Director of Nursing (DON) confirmed Resident #78 was admitted to the facility with a prescription for oxycodone. The DON stated Resident #78's prescription was not faxed to the pharmacy upon admission, so the medication was not received by the facility. The DON further stated that Resident #78's daughter was often in the building, or on the phone with Resident #78, and would tell the DON that Resident #78 was in pain. The DON stated on 01/05/26, it was discovered that the oxycodone prescription was never sent to the pharmacy and nursing was made aware and instructed to pull from the contingency box (c-box; on hand supply of medications for immediate use). The DON stated on 01/06/26, Resident #78 was in her room crying from pain. The DON asked Licensed Practical Nurse (LPN) #138 if the medication was available and LPN #138 stated that it did not come in the tote (from the pharmacy) and LPN #138 did not call to pull the medication (authorization needed from the pharmacy to remove narcotic medications from the c-box). The DON confirmed oxycodone was available for administration to Resident #78 to help manage her pain, but nursing staff did not access it from the c-box for administration. Additionally, the DON stated Resident #78 requested an ice pack to help ease her pain and nursing staff told the resident there were no ice packs available, adding there were multiple ice packs available at each nurses' station. The DON verified Resident #78 was not provided neither pain medication or non-pharmacological interventions to manager her pain from 01/02/26 through 01/05/26. Review of the facility policy titled, Pain Management, dated 04/28/25, revealed the facility must ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Non-pharmacological interventions would include, but not limited to, physical modalities such as cold compress.This deficiency represents noncompliance investigated under Master Complaint Number 2709655.

Based on observation, staff interview, review of facility policy, and review of the Certified Nursing Assistant (CNA) procedure regulations, the facility failed to ensure urinary catheter care was completed per approved procedures. This affected one (#26) of three residents reviewed for urinary catheters. The facility identified six residents (#1, #9, #19, #26, #36, and #78) that utilized urinary catheters. The facility census was 78. Findings include:Review of the medical record for Resident #26 revealed an admission date of 11/21/25. Diagnoses included urinary tract infection (UTI), urine retention, and hydronephrosis (blockage in the urinary system that causes back up of urine in the kidney).Review of the admission assessment dated [DATE] revealed Resident #26 was cognitively intact.Review of the October 2025 physician orders revealed Resident #26 had orders for a urinary catheter, 16 French (Fr) (size of the catheter) with a 10 milliliter (ml) balloon (the balloon holds the catheter into position for drainage) and urinary catheter care every shift and as needed.Review of the care plan, initiated 11/25/25, revealed Resident #26 was care planned for a urinary catheter. Interventions included to maintain universal precautions when providing care.Observation on 11/25/25 at 1:26 P.M. of catheter care provided for Resident #26 by Certified Nursing Assistant (CNA) #320 revealed CNA #320 donned Personal Protective Equipment (PPE), placed a barrier under the graduated cylinder, proceeded to empty the contents of the urinary drainage bag into the graduated cylinder, wiped the tip of the spout of the catheter bag with a wet wash cloth, and then placed the tip of the spout back into the holder.Interview on 11/25/25 at 1:33 P.M. with CNA #320 verified the procedure for cleaning the urinary bag spout was to use an alcohol pad. CNA #320 confirmed she did not clean the urinary bag spout with an alcohol pad and used soap and water. Interview on 11/26/25 at 7:42 A.M. with the Director of Nursing (DON) revealed she started education this morning on catheter care with all nursing staff and stated the aides were all aware of the requirement (to clean the spout with an alcohol pad).Review of the facility policy titled, Catheter Care, revised April 2025, revealed staff were to use standard infection control standards when handling or manipulating the drainage system (urinary catheter).Review of a facility resource document titled, Ohio State Tested Nursing Assistant (STNA, also known as CNA) Procedure Regulations, undated, revealed once the urinary bag was empty, clamp the tube and wipe the spout with an alcohol wipe.This deficiency represents non-compliance investigated under Complaint Number 2666853.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff, resident, health insurance provider and waiver service provider interviews, review of an Emergency Medical Services (EMS) run report, review of hospital documents, and review of facility policy, the facility failed to ensure a safe resident discharge to home. This resulted in Actual Harm on 07/24/25 at approximately 10:44 A.M. when Resident #62, who was dependent on others for care and required the use of a mechanical lift for transfers, was discharged to home without the needed equipment and services to meet her care needs. Subsequently, Resident #62 remained in a standard wheelchair for approximately six hours without any care provided, including incontinence care, resulting in the development of a pressure ulcer. This affected one (#62) of three residents reviewed for discharge. The facility census was 82. Findings include:Review of the medical record revealed Resident #62 was admitted on [DATE], left for a therapeutic leave on 07/24/25, and returned to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, muscle weakness, schizophrenia, acute respiratory failure with hypoxia, chronic atrial fibrillation, essential hypertension, Type II diabetes mellitus, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 05/29/25, revealed Resident #62 was cognitively intact and dependent on staff assistance for toileting, lower body dressing, applying footwear, and transfers.Review of the physician orders, dated 05/23/25, revealed Resident #62 had an order for oxygen at two liters per minute (lpm) via nasal cannula, wean as tolerated, every shift. Review of the care plan, dated 07/07/25, revealed Resident #62 was at risk/had an activities of daily living (ADL) self-performance deficit due to deconditioning/weakness and was dependent for transfers. Review of a weekly skin assessment, dated 07/20/25, revealed Resident #62 did not have a pressure ulcer. There was no evidence that Resident #62 had any skin conditions on the coccyx or buttock area. Review of the Discharge summary, dated [DATE], revealed Resident #62 had a planned discharge scheduled for 07/23/25. The summary stated the resident needed physical assistance of two people to complete ADL care, and total care for incontinence of bowel and bladder. Resident #62 made progress in therapy by increasing sitting tolerance when sitting up in a Broda chair (specialized wheelchair to promote proper posture and reduce falls and skin breakdown) to engage in daily activities. A follow-up appointment with the resident's primary care physician (PCP) was scheduled for 08/05/25. Resident #62 required home health services (HHS). Physical therapy (PT) and occupational therapy (OT) were recommended, and a referral was made for HHS. Durable medical equipment (DME) was documented as not required. Review of an EMS run report, dated 07/24/25 at 5:26 P.M., revealed Resident #62's case worker requested a check on the resident after she had been discharged from an extended care facility that day. On arrival, Resident #62 was sitting in a wheelchair. The resident was conscious, alert, and oriented. Vitals were obtained and within normal ranges. The resident stated that she had to go to the hospital because she could not get around her apartment and could not care for herself. EMS services attempted to assist Resident #62 back to bed, but she could not even stand on her own. Resident #62 was transported to the emergency room (ER). Review of the hospital records, dated 07/24/25, revealed the case worker called to report concern for Resident #62's safety after being discharged (from a skilled nursing facility [SNF]) to her home residence earlier today. It was reported that the resident's husband was also ill and unable to care for himself. Resident #62 reported shortness of breath (SOB) and reported improvement after receiving a breathing treatment. The resident reported pain involved bilateral chest pain and pain on her buttocks. An open wound on her coccyx and the anterior, proximal right upper leg were identified and present upon admission [to the ER]. The resident's brief was saturated with urine. Concerns related to home care were identified. Resident #62 discharged from the hospital back to the facility. Review of a weekly skin assessment, dated 07/25/25, revealed Resident #62 had a rash on the chest, groin, and left buttock. The left buttock area measured 0.7 centimeters (cm) by 0.5 cm. Review of the weekly wound assessment, dated 07/29/25, revealed Resident #62 had a stage three left buttock pressure ulcer measuring 0.6 cm by 0.5 cm by 0.2 cm. During an interview on 09/15/25 at 4:25 P.M. with the Director of Nursing (DON) verified Resident #62 was discharged home without oxygen, no working hospital bed, and no Hoyer lift, all of which were needed to provide care for the resident. The DON verified Resident #62's husband was ill and unable to provide needed care for the resident at home. During an interview on 09/16/25 at 8:10 A.M., Resident #62 stated she had discharged home but then went to the hospital because she could not breathe. Resident #62 revealed she did not have anyone at home to provide care for her and she remained in a wheelchair when she arrived home until EMS transported her to the hospital. During an interview on 09/16/25 at 8:20 A.M., Nurse Case Manager (NCM) #301, with the resident's insurance company, stated on 07/24/25, around mid-morning, Resident #62 discharged home from the facility with no oxygen, no working hospital bed, no Hoyer lift, and HHS were not in place. NCM #301 stated Resident #62's spouse contacted the HHS agency and notified them that Resident #62 was home. It was reported Resident #62 did not have her Broda chair and only had a standard wheelchair upon discharge from the facility. NCM #301 encouraged Resident #62 to call EMS due to sounding wheezy and short of breath. NCM #301 revealed she was not notified to assist with a successful discharge home. A follow-up interview on 09/16/25 at 9:50 A.M. with the DON revealed that, according to the census, Resident #62 discharged home on [DATE] at 10:44 A.M. On 07/24/25 at 10:24 P.M., the facility received a call from the hospital inquiring about the resident returning to the facility. The DON stated that former Social Services Designee (SSD) #206 had arranged the discharge for Resident #62; however, had not worked at the facility since the day prior to the discharge. During an interview on 09/16/25 at 10:28 A.M., the DON verified Resident #62 had a planned discharge on [DATE]; however, transportation could not accommodate the resident with her Broda chair. The discharge was rescheduled and occurred on 07/24/25, with Resident #62 only having a standard wheelchair. The DON confirmed that based on the skin assessment completed on 07/22/25, two days prior to discharge, Resident #62 had no skin impairments and the medical record included no evidence of any pressure ulcers prior to discharge. During an interview on 09/16/25 at 10:37 A.M., Licensed Practical Nurse (LPN) #146 verified Resident #62 returned home via a transportation company in a standard wheelchair provided by the family. LPN #146 verified Resident #62 did not have her Broda chair upon discharge. During an interview on 09/17/25 at 2:03 P.M., Wound Nurse Practitioner (WNP) #300 revealed Resident #62's skin was very fragile and could have easily developed a pressure ulcer from sitting in a wheelchair all day. WNP #300 believed the skin assessment on 07/25/25 (the day after the resident's readmission), which identified the left buttock as a rash, was likely misidentified and was a pressure ulcer as determined on 07/29/25 and indicated in the hospital records. During an interview on 09/17/25 at 12:00 P.M., Waiver Service Coordinator (WSC) #302 revealed she was responsible for assisting with arranging care for Resident #62 when she was at home. WSC #302 verified the facility did not contact her to assist with arranging needed services to ensure a safe discharge home for Resident #62. WSC #302 revealed that prior to her initial admission to the facility in May 2025, Resident #62 was nearly bed bound and required extensive care. During an interview on 09/18/25 at 10:16 A.M., Certified Nursing Assistant (CNA) #186 revealed Resident #62 had required a Hoyer lift for all transfers since her initial admission in May 2025, and could not transfer on her own. Review of the facility policy titled, Discharge Policy, reviewed August 2024, revealed appropriate discharge planning would be developed based on the resident's medical, physical, social and emotional condition/needs. Available resources would be recommended and made available to provide for the total well-being of the resident and with the approval of the resident's physician. All available local and community resources would be made available and utilized under the coordination of the social services department to ensure that each resident's specific care needs were met upon discharge to maximize the success of each resident. The deficiency was corrected on 08/10/25 when the facility implemented the following corrective actions: On 07/25/25 at 12:30 A.M., Resident #62 was readmitted to the facility. The physician was notified and Resident #62's orders were resumed. On 07/28/25, the DON implemented a discharge checklist, to be initiated upon admission, to verify required services, family/representative/community resource communication, and equipment needs are arranged prior to discharge. On 07/28/25, the DON reviewed the six resident discharges for the previous two weeks, with no negative findings. Beginning on 07/28/25, the Administrator or designee reviewed scheduled discharges daily, Monday through Friday, during the morning clinical meeting to ensure appropriate discharge planning had occurred. Evidence was received to verify discharges were reviewed. On 07/28/25, the DON educated the Unit Managers (LPN #146 and LPN #204) on the discharge checklist. If SS is not in the facility on the day of discharge, discharge tasks will be assigned to the unit manager or DON to ensure a safe discharge. Evidence was received to verify the education was completed on 07/28/25. On 07/28/25, the DON assumed discharge planning responsibilities until the new SS begins in the position (expected 10/01/25) and is fully oriented. Beginning on 07/28/25, the Administrator or designee will monitor compliance of a safe and orderly discharge weekly for four weeks. Audits will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to ensure the deficient practice has been resolved. Evidence was received verifying audits were completed weekly/after each discharge, with no negative findings. Beginning on 07/28/25, the DON or designee will follow-up contact within 24-hours for any resident discharged from the facility to ensure needs were met. Evidence was received to verify completion and is on-going. Upon the new SSD's start date, anticipated 10/01/25, the DON and Social Service Consultant (SSC) #700 will provide orientation, to include safe discharges and utilization of the discharge checklist to ensure a safe discharge. Review of two (#05 and #06) additional closed medical records, reviewed for safe discharge to home, revealed no additional concerns.This deficiency represents non-compliance investigated under Complaint Numbers 2578313 and 2577168.

Based on observation, staff interview, review of the dishwasher monitoring logs and review of facility policy, the facility failed to practice proper hand hygiene during meal service. Additionally, the facility failed to label and date food items in the resident refrigerators. Lastly, the facility failed to test and monitor proper sanitation of the dishwasher. This had the potential to affect all residents in the facility except one (#137) resident identified by the facility as receiving no nutrition by mouth. The facility census was 71. Findings include: 1. Observation on 02/03/25 at approximately 12:25 P.M. in the dining room revealed Certified Nursing Assistant (CNA) #611 providing assistance to Resident #237 who stood up from his wheelchair at the table. CNA #611 held Resident #237's arm, put an arm around his waist, and guided him back to his wheelchair. CNA #611 touched Resident #237's wheelchair to return him to the dining table. CNA #611 then walked directly to sit with Resident #18 and picked up silverware and began to assist Resident #18 with eating. Interview on 02/03/25 at 12:28 P.M. with CNA #611 confirmed she did not perform hand hygiene between providing hands-on assistance to Resident #237 and before beginning to feed Resident #18. CNA #611 confirmed she should have performed hand hygiene and identified a hand sanitizer dispenser in the dining room. 2. Observations on 02/04/25 beginning at 11:35 A.M. revealed [NAME] #620 preparing peanut butter and jelly sandwiches for meal service. [NAME] #620 put on disposable gloves, opened a cabinet and removed a loaf of bread. [NAME] #620 opened the loaf of bread, pulled out two slices of bread, opened a drawer and pulled out a knife, then opened the peanut butter jar and the jelly jar wearing the same disposable gloves. [NAME] #620 then picked up one slice of bread and used the knife to spread peanut butter on the piece of bread. [NAME] #620 then wore the same gloves to turn on the faucet and rinse the knife under hot water before she turned off the faucet, shook the water off the knife, and put the knife into the jelly jar. [NAME] #620 picked up the other slice of bread and spread jelly on the piece of bread. [NAME] #620 placed the sandwich into a baggy, then reached into the loaf of bread and took out two additional pieces of bread. [NAME] #620, wearing the same pair of gloves, then returned to the sink, turned on the faucet and rinsed the knife under hot water to remove the jelly. [NAME] #620 turned off the faucet, put the knife into the peanut butter and picked up a slice of bread and spread the peanut butter on it. [NAME] #620 returned to the sink, turned on the faucet, rinse the knife under hot water again, turned off the faucet, put the knife into the jelly jar, picked up the other slice of bread, and spread jelly on it. Interview on 02/04/25 at 11:40 A.M. with [NAME] #620 confirmed she did not wash her hands before donning gloves, touched multiple unsanitary surfaces (the cabinet handle, the drawer handle, and the faucet) with the same pair of gloves she used to touch the ready-to-eat peanut butter and jelly sandwiches. [NAME] #620 further confirmed she did not properly clean or sanitize the knife before putting it into the jelly, back into the peanut butter, or back into the jelly. [NAME] #620 was not aware of any residents with a peanut allergy. Additional observation during meal service on 02/04/25 at approximately 12:05 P.M. revealed [NAME] #620, with bare hands, entered the walk-in refrigerator and collected lunch meat and cheese. [NAME] #620 then donned gloves, opened the package of lunch meat, removed the plastic wrap from the cheese, reached into a loaf of bread, pulled out two slices of bread, and began to make a lunch meat and cheese sandwich. Interview with [NAME] #620 confirmed she wore the same pair of gloves while unwrapping the lunch meat and cheese and before touching the bread or preparing the sandwich by picking up individual slices of meat and cheese with the same gloves she used to touch the packaging taken from the walk-in refrigerator. Review of the facility policy titled, Handwashing During Meal Service, reviewed August 2024, revealed nursing and caregiver staff must wash hands before assisting residents with meals, feeding, or helping with personal care during meal times. Additional review revealed hands should be washed after touching potentially contaminated surfaces (for example, door handles and equipment). Further review revealed gloves do not replace handwashing. Hands must be washed before putting on gloves and immediately after removing them and gloves should be changed between tasks. 3. Observation on 02/06/25 at 10:48 A.M. of the North Hall residents' refrigerator revealed food items, which were undated and unlabeled, including an unlabeled leftover container, two bags of unlabeled hard boiled eggs, undated chicken strips on a paper plate, a leftover fast-food bag with no name, undated and unlabeled orange juice, and undated prune juice. Coinciding interview with Medical Records Director (MRD) #666 verified the unlabeled and undated items in the refrigerator. Observation on 02/06/25 at 10:51 A.M. of the South Hall residents' refrigerator revealed unlabeled rice, honey ham dated 01/18/25, an unlabeled grilled cheese sandwich, undated bologna, and an opened jar of undated and unlabeled black eyed peas. Concurrent interview with Licensed Practical Nurse (LPN) #668 confirmed the undated and unlabeled items. Further interview with LPN #668 confirmed items should be labeled and dated and that refrigerators were cleaned out every Monday. Review of the facility policy titled, Food Brought in from Outside Sources and Personal Food Storage, dated 2021, revealed foods and beverages brought in from outside sources that required refrigeration or freezing should be labeled with the patient/resident's name and date. 4. Observation on 02/04/25 at 2:15 P.M. revealed the facility's dishwasher (dish machine) was a low temperature dishwasher (meaning dishes were sanitized with a chlorine solution rather than hot water). Review of the dish machine monitoring logs dated January 2025 and February 2025 revealed staff should document the water temperature and the chlorine concentration in PPM (parts per million). Further review revealed the only documentation on the logs were temperatures. Continued observation, upon request to determine the chlorine concentration, revealed Dietary Manager (DM) #609 retrieved a brand new chlorine test strip container from her desk. DM #609 obtained the chlorine solution concentration three times, after consecutive running of the dish machine. DM #609 confirmed the concentration of the chlorine solution was 10 PPM. DM #609 confirmed the dish machine log indicated the PPM should be at least 50. Further interview at that time with DM #609 revealed she had not yet trained staff on how to use the strips to monitor and document the chlorine concentration of the dish machine and confirmed the dish machine logs for January 2025 and February 2025 only reflected water temperatures, not chlorine concentration, and there was no evidence the chlorine levels were monitored to ensure adequate sanitization. Review of the facility policy titled, Dish Machine Temperature/Sanitizer Records, revised August 2008, revealed all employees shall be trained on the appropriate method of completing the Low Temperature Dish Machine log.

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure open wounds were covered during food preparation and meal service. This had the potential to affect all residents, except one (#137) resident identified by the facility as receiving no food from the kitchen. Additionally, the facility failed to ensure appropriate hand hygiene during wound care. This affected one (#53) of one resident reviewed for wound care. The facility census was 71. Findings include: 1. Observation during meal preparation and service on 02/04/25, beginning at approximately 11:45 A.M., revealed [NAME] #620 was not wearing disposable gloves and prepared to portion cooked broccoli to puree. Continued observation revealed [NAME] #620's right hand was actively bleeding and blood was on the serving utensil being used to portion the broccoli. Concurrent interview with [NAME] #620 revealed she was aware she had cut her hand but did not realize she was bleeding. [NAME] #620 proceeded to wash her hands and applied a bandage. [NAME] #620 then returned to the broccoli and began to pick up the handle of the utensil, which had blood on it, to continue with the preparation of pureed broccoli. At this point, the surveyor intervened and [NAME] #620 removed the utensil from service, washed her hands, donned disposable gloves and used a new utensil to portion the broccoli. Further observation during the lunch meal service on 02/04/25 at 12:11 P.M. revealed [NAME] #620 portioning prepared salad from a large pan onto a dinner plate using tongs in her right hand. [NAME] #620 was not wearing disposable gloves and her right hand had a bandage covering the area previously observed bleeding during preparation of pureed broccoli. Interview with [NAME] #620 confirmed the bandage covering her thumb was not covered by a disposable glove while she plated food. Review of the undated facility policy titled, Personal Hygiene revealed employees with open sores shall wear appropriate personal protective equipment. 47057 2. Review of the medical record for Resident #53 revealed and admitted [DATE]. Diagnoses included Alzheimer's disease and fractured acetabulum (part of the hip joint). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/25, revealed Resident #53 was cognitively impaired and had an unhealed pressure ulcer. Review of the current physician orders for February 2025 for Resident #53 revealed he had an order for wound care to the left heel to cleanse with wound cleaner, pat dry, apply skin prep to peri wound, apply silver alginate, and cover with a border foam. Review of the current care plan revealed Resident #53 had care plan interventions for skin alterations to the left heel, which included heel protective boots. Observation of wound care on 02/05/25 at 9:35 A.M., provided by Licensed Practical Nurse (LPN) #662, revealed LPN #662 donned gloves to remove the old, soiled dressing from Resident #53's left heel and discarded the dressing. Without removing or changing her gloves, LPN #662 obtained wound cleaner and cleansed the resident's left heel wound. LPN #662 then, without removing or changing her gloves, obtained the new treatment supplies, including silver alginate and new, clean border foam and applied the new dressing to Resident #53's left heel wound. Interview on 02/05/25 at 9:51 A.M. with LPN #662 verified she did not change her gloves between removing the old, soiled dressing, cleansing Resident #53's heel wound, and applying the new, clean dressing. Review of the facility policy titled, Wound Care, revised August 2024, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Procedure steps included: don gloves, loosen tape, remove dressing and discard, wash and dry hands thoroughly, put on gloves, cleanse the wound, and apply the treatment as ordered. Review of the facility policy titled, Standard Precautions, revised August 2024, revealed staff must perform hand hygiene before performing an aseptic task, after contact with blood, body fluids, visibly contaminated surfaces, or after contact with objects in the resident's room.

Based on observation, staff interview, medical record review and review of facility policy, the facility to label multiuse insulin pens and vials with the date opened to ensure medication integrity. This affected four (#5, #39, #62, and #137) of four residents reviewed for medication storage. The facility census was 71. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included diabetes mellitus (DM). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/09/25, revealed Resident #5 was cognitively impaired. Review of the current physician orders for February 2025 revealed Resident #5 was ordered insulin glargine (Lantus) 35 units at bedtime. 2. Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included DM. Review of the quarterly MDS assessment, dated 12/26/24, revealed Resident #39 was cognitively intact. Review of the current physician orders for February 2025 revealed Resident #39 was ordered Humalog KwikPen (multiuse insulin pen) to be administered per sliding scale (dependent on blood sugar value): blood sugar zero to 150 equaled no insulin; blood sugar 151-200, give two units of insulin; blood sugar 201-250, give four units of insulin; blood sugar 251-300, give six units of insulin; blood sugar 301-350, give eight units of insulin; blood sugar 351-400 give 10 units of insulin; and blood sugar 401-450 give 12 units of insulin and notify the physician. 3. Review of the medical record for Resident #62 revealed an admitted [DATE]. Diagnoses included DM. Review of the quarterly MDS assessment dated [DATE] revealed Resident #62 was cognitively intact. Review of the current physician orders for February 2025 revealed Resident #62 was ordered insulin glargine 20 units two times daily. 4. Review of the medical record for Resident #137 revealed an admitted [DATE]. Diagnoses included DM. Review of the admission MDS assessment, dated 01/30/25, revealed Resident #137 was cognitively impaired. Review of the current physician orders for February 2025 revealed Resident #137 was ordered Humalog Subcutaneous Solution Cartridge (used with a reusable insulin pen), to be administered based on a sliding scale: for blood sugar zero to 150 equaled no insulin; blood sugar 151-200 give one unit of insulin, for blood sugar 201-250 give two units of insulin, for blood sugar 251-300 give three units of insulin, for blood sugar 301-350 give four units of insulin, for blood sugar 351-400 give five units of insulin and notify the physician. Observation on 02/05/25 at 7:30 A.M. of the medication cart on the back north unit revealed an opened, undated Lantus insulin pen for Resident #62, an opened, undated Humalog insulin pen for Resident #137, and an opened, undated Lantus multiuse vial for Resident #5. Interview at the time of the observation with LPN #634 verified the opened and undated insulin pens and insulin vial. Observation on 02/05/25 at 8:50 A.M. of the medication cart on the back south unit revealed an opened, undated Humalog insulin pen for Resident #39. Concurrent interview with Licensed Practical Nurse (LPN) #668 verified the opened, undated Humalog insulin pen for Resident #39. Review of the undated facility policy titled, Medication Storage, revealed medications would be stored in a manner that maintained the integrity of the product, to ensure the safety of the residents, and is in accordance with Ohio Department of Health guidelines.

Based on observation, review of the menu, review of the menu spreadsheet, staff interview and review of the United States Department of Agriculture (USDA) resources, the facility failed to ensure adequate meal portions were served. Additionally, the facility failed to ensure all components of a meal were provided. This had the potential to affect all residents in the facility except one (#137) resident identified by the facility as receiving no nutrition from the kitchen. The facility census was 71. Findings include: Review of the menu for the lunch meal on 02/04/25 revealed residents would be served pork vegetable stir fry, white rice, and wheat bread. Review of the menu spreadsheet for the pork vegetable stir fry revealed the serving portion was a #6 scoop (approximately five and one-third ounces). Further review revealed mechanical soft and pureed diets would be served a #6 scoop of pork chops, instead of the pork and vegetable stir fry. Observation on 02/04/25 at 10:44 A.M. revealed [NAME] #620 pureed six pork chops for six residents on a pureed diet. Observation during meal service on 02/04/25, beginning at 11:30 A.M., revealed [NAME] #620 plating trays for the lunch meal. [NAME] #620 provided residents on a regular diet with a four-ounce scoop of pork vegetable stir fry and a four-ounce scoop of rice. Additional observation revealed [NAME] #620 provided residents on a mechanical soft diet two, two-ounce scoops of mechanical soft pork chops (four-ounces total), a four-ounce scoop of mashed potatoes, and used a slotted spoon to serve broccoli. Further observation revealed [NAME] #620 provided residents on a pureed diet one two-ounce scoop of pureed pork chops, a four-ounce scoop of mashed potatoes and a slotted spoon was used to serve pureed broccoli. Interview on 02/04/25 at approximately 1:00 P.M. with [NAME] #620 confirmed she used a four-ounce scoop for the pork vegetable stir fry, used two two-ounce scoops for mechanical soft pork chops (for a total of a four-ounce serving), and served one two-ounce scoop of pureed pork chops to the six residents on a pureed diet. Continued interview with [NAME] #620, and coinciding observation, confirmed at least two two-ounce scoops of pureed pork chops remained in the pan at the conclusion of meal service. [NAME] #620 further confirmed the slotted spoons used for the broccoli and pureed broccoli were serving utensils with no measurement lines and, therefore, [NAME] #620 could not measure the portion of broccoli provided to residents. Interview on 02/05/25 at 1:25 P.M. with Dietary Manager (DM) #609 confirmed the facility did not provide wheat bread with the lunch meal served on 02/04/25. DM #609 could provide no explanation why the menu was not followed. A follow-up interview on 02/06/25 at 11:03 A.M. with DM #609 confirmed the spreadsheet for the lunch meal served on 02/04/25 indicated staff should have used a #6 scoop for the pork vegetable stir fry and the mechanical soft and pureed pork chops. DM #609 was unable to determine the number of ounces in a #6 scoop. Further interview with DM #609 verified residents on a regular diet did not receive an adequate portion of pork vegetable stir fry and residents on a mechanical soft and pureed diets did not receive an adequate portion of pork chops. Review of the USDA Food and Nutrition Service documented titled Food Buying Guide, last updated 09/19/24 and located at https://foodbuyingguide.fns.usda.gov/Home/ResourceCenter#:~:text=Scoops%20(sometimes%20called%20dishers%20or,weight%2C%20use%20a%20scale.), revealed a #6 scoop is 2/3 cup (approximately 5 and 1/3 ounces).

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure resident dignity was maintained. This affected two (#42 and #43) of two residents reviewed for dignity. The facility census was 71. Findings include: 1. Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including dementia, traumatic brain injury, and encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had mild cognitive impairment and was continent of bladder. Review of the current care plan revealed Resident #42 was independent with toileting, required one staff supervision with personal hygiene, and required staff set up assistance for eating and meals. Observation on 02/03/25 at 9:11 A.M. revealed Resident #42 was in bed. Sitting on the overbed table was a urinal full of dark colored urine. Continued observation revealed staff delivered Resident #42's breakfast tray and placed it on the overbed table, next to the full urinal. Concurrent interview with Resident #42 revealed it bothered him that the full urinal was on the table where he ate his breakfast. Interview on 02/03/25 at 9:16 A.M. with Certified Nursing Assistant (CNA) #711 verified Resident #42's the full urinal of dark colored urine and the breakfast tray both sitting the overbed table for Resident #42. 2. Review of the medical record for Resident #43 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. Review of the annual MDS assessment dated [DATE] revealed Resident #43 was cognitively impaired and dependent on staff for dressing. Review of the current care plan revealed Resident #43 was dependent on staff for dressing. Observation on 02/03/25 at 9:23 A.M. revealed CNA #654 was sitting at Resident #43's bedside, providing feeding assistance to the resident. Continued observation, which lasted approximately five minutes, revealed Resident #43 was wearing a purple sweatshirt and her left breast was exposed. Further observation revealed Resident #43 was in a semi-private room and her roommate was in bed. The privacy curtain was not pulled between Resident #43 and her roommate and the resident's exposed breast was visible to her roommate. Interview on 02/03/25 at 9:28 A.M. with CNA #654 verified Resident #43's breast was exposed during breakfast and she did not cover her up. Review of the facility policy titled Dignity, revised August 2024, revealed the facility would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. The facility would protect and promote the rights of the resident.

Based on resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure policies and procedures related to reporting and investigating allegations of misappropriation were implemented. This affected one (#16) of three residents reviewed for misappropriation. The facility census was 71. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included: hypertension, hyperlipidemia, chronic kidney disease, gastroesophageal reflux disease (GERD), schizoaffective disorder, psychotic disorder with delusions to own physiological condition, dysphagia, protein calorie malnutrition, muscle wasting, and localized osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/15/24, revealed Resident #16 was cognitively intact. Interview on 02/03/25 at 12:15 P.M. with Resident #16 revealed the resident reported $2.00 was stolen from her room within the past six months. Resident #16 stated she informed Certified Nursing Assistant (CNA) #614 about the stolen $2.00 but stated no resolution was offered and the money was not returned to her. Interview on 02/03/25 at 2:27 P.M. with the Director of Nursing (DON) revealed she was not aware Resident #16 reported $2.00 had been stolen from her room. Further interview confirmed there was no evidence CNA #614, or any other staff, reported the allegation to administration or that the allegation was investigated. A follow-up interview on 02/03/25 at 5:20 P.M. with the DON revealed, after the survey team reported the allegation of misappropriation, an investigation was initiated. The DON confirmed she verified CNA #614 and Licensed Practical Nurse (LPN) #630 were aware of the allegation and did not report it to administration for investigation. Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 07/01/20, revealed upon hire and annually, staff received education regarding misappropriation including the definition, identification, and the reporting process. Further review revealed alleged violations of misappropriation should be reported to the administrator within 24 hours and the administrator should report final investigation results within five business days.

Based on medical record review, resident interview, staff interview, hospital documentation review, review of an incident report, review of witness statements, review of a facility policy, and review of facility corrective action, the facility failed to ensure resident transferring equipment was maintained and utilized in a safe and appropriate manner to ensure proper checks and safety measures were taken when assisting a resident with a mechanical lift transfer resulting in a fall. This resulted in actual harm when Resident #21 was transferred by a Hoyer (mechanical) lift while staff members utilized a lift pad that was known to be defective by previous shift staff members. The defective lift pad was not removed from use, was utilized for Resident #21's transfer, and Resident #21 subsequently fell to the ground when the lift pad strap broke causing a fracture to the right femur which required hospitalization and surgical intervention as well as a bruised scalp and right shoulder pain. This deficient practice affected one (#21) of three residents reviewed for mechanical lift transfers. The census was 72. Findings include: Review of Resident #21's medical record revealed an admitted [DATE]. Diagnoses included morbid obesity, spondylosis with myelopathy, monoplegia of the lower limb, and sickle-cell disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was assessed with a high cognitive function. The resident was assessed to be dependent on two staff members for mechanical lift transfers. Review of the most recent care plan revealed Resident #21 was at risk of falls and fall related injuries related to impaired mobility, impaired vision, anemia, sickle cell disease, and morbid obesity. Interventions included for two staff members to utilize a mechanical lift for all transfers. Staff were provided with education on use of the proper sling size with the mechanical (Hoyer) lift. Review of Resident #21's fall risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Review of an incident report dated 10/30/23 revealed a nurse was called into Resident #21's room after being notified by a nurse aide that the resident had fallen. Three nurse aides indicated that while transferring the resident from his wheelchair to the bed using the Hoyer lift, the lift pad sling ripped, and the resident fell to the ground and hit his head. Resident #21 was seen by the nurse and the resident was noted on the ground on his side. The resident remained alert and oriented. Resident #21 indicated he fell out of the Hoyer lift and was assessed for injury with no visible injury noted. The resident's head and neck were stabilized, and emergency medical services (EMS) were called for hospital evaluation. The nurse practitioner and Resident #21's emergency contact were updated with new orders to send Resident #21 to the emergency room (ER) for evaluation and treatment. The incident report further revealed the predisposing environmental factors were charted as other, and the incident happened during a transfer due to a faulty Hoyer lift pad. Review of Resident #21's hospital documents dated 10/30/23 revealed the resident was being moved by a Hoyer lift which malfunctioned resulting in the resident falling three to four feet backwards on his head. Resident #21 denied a loss of consciousness. Upon arrival, the patient had severe kyphosis (forward rounding of the back) and was complaining of right arm, right hip, neck, and back pain. Review of radiological imaging revealed Resident #21 sustained an angulated fracture of the proximal right femur and distal aspects of the right femur. Resident #21 also sustained a parietal (back area of the skull) scalp hematoma (bruise) and right shoulder pain. Review of Resident #21's hospital progress note dated 11/06/23 revealed the resident presented to the ER after falling from a Hoyer lift at his nursing home. Resident #21 sustained a right proximal and distal femur fracture. On 11/01/23, Resident #21 underwent a surgical procedure of a cephalomedullary nail insertion and open reduction and internal fixation (ORIF) of the distal femur fracture. Review of State tested Nurse Aide (STNA) #410's witness statement dated 10/31/23 revealed at approximately 10:00 A.M. on 10/30/23 she went to assist STNA #400 with transferring Resident #21 out of bed. When she entered the room, the Hoyer lift pad was already under the resident. Resident #21 was transferred into his wheelchair without any difficulty; however, STNA #410 noticed a small area on the lift pad that looked like it was starting to fray. STNA #410 informed STNA #400 to let the second shift STNAs know to remove the lift pad and replace it with another one, and STNA #400 agreed. Review of STNA #400's witness statement dated 10/31/23 revealed on 10/30/23 at approximately 10:00 A.M. she was getting Resident #21 up and put the Hoyer lift pad under him. STNA #410 indicated the lift pad looked too small, and Resident #21 stated it was not too small and they had been using it for the past three days. STNA #410 noted the lift pad did not have any frayed or torn areas at that time. Resident #21 was transferred into his wheelchair without any difficulty; however, once the resident was transferred into his wheelchair, STNA #410 noticed one of the lift pad straps looked like it might pop. STNA #400 indicated she failed to inform any staff members about the damaged lift pad and did not remove the lift pad from under Resident #21 or take it out of service. Review of STNA #430's witness statement dated 10/30/23 revealed at approximately 7:00 P.M. Resident #21 requested to go to bed, and STNA #420 and STNA #440 were asked to assist with the transfer. STNA #430 indicated the lift pad was attached to the Hoyer lift properly, and STNA #420 pulled the Hoyer lift backward while STNA #430 moved Resident #21's legs to the right. The nurse aides moved the Hoyer lift between the resident's wheelchair and bed, then an audible snap or crack was heard, and Resident #21 fell headfirst to the floor. STNA #430 documented the Hoyer lift pad snapped during the transfer. Review of STNA #420's witness statement dated 11/01/23 revealed she was Resident #21's primary caregiver on 10/30/23. When she arrived on her shift the resident was in his chair with the lift pad under him. At 7:02 P.M., STNA #420 went to transfer Resident #21 into his bed with the assistance of STNA #430 and STNA #440. The resident removed his shirt as he always did and put his mechanical wheelchair in reverse to position himself so the nurse aides could get him on the lift. The nurse aides started to connect the pad to the Hoyer lift with STNA #440 at the head of the bed waiting to guide. STNA #420 documented the nurse aides did not notice anything wrong with the lift pad at that time. After connecting the lift pad to the Hoyer lift, the nurse aides began to lift the resident with no issues. STNA #420 then noted the top loop of the Hoyer lift pad near Resident #21's left shoulder snapped, and the resident fell to the floor toward his bed landing on his right side. Resident #21 yelled out for STNA #440 to get him off the floor. STNA #420 called for the nurse, who came to the room and assessed the resident. STNA #420 denied any other employee reported concerns about the lift pad being damaged. Review of STNA #440's witness statement dated 11/02/23 revealed on 10/30/23 he was asked to assist with Resident #21's mechanical lift transfer. STNA #440 noted there were two STNAs in the room and had already attached the lift pad to the Hoyer lift. Once Resident #21 was up to the top of the lift to transfer him, the STNAs started to move him to the bed when the loop on the lift pad snapped abruptly at the resident's shoulder. Resident #21 fell out of the lift pad and landed on his right shoulder followed by his head and torso. STNA #440 had not noticed the lift pad was tattered, frayed, or torn. Interview with Central Supply Coordinator (CSC) #600 on 11/14/23 at 10:21 A.M. stated she was aware that Resident #21 fell from a Hoyer lift during a transfer on 10/30/23 due to a torn lift pad. CSC #600 stated no staff member reported to her on 10/30/23 that Resident #21's lift pad was damaged or needed replaced. CSC #600 stated all mechanical lift pads have since been inspected and a new supply had been ordered. Interview on 11/13/23 at 2:25 P.M. with Resident #21 verified he fell from the mechanical lift when the lift pad tore during a transfer. Resident #21 stated he sustained a fracture which was repaired and required an increase in pain medications as a result. Interview with the Director of Nursing (DON) on 11/13/23 at 2:52 P.M. stated Resident #21 was in the process of being transferred by three STNAs on 10/30/23 when the loop snapped on the mechanical lift pad and he fell to the floor. Resident #21 was immobilized, and EMS was called. The resident received a distal and proximal right femur fracture. The DON stated on the morning of 10/30/23 nurse aides transferred the resident from his bed to the wheelchair and one of the nurse aides informed STNA #400 that the lift pad was frayed and to inform the afternoon shift to take it out of service. Resident #21 was sitting on the pad at that time which was why the pad was not taken out of service. The DON stated STNA #400 failed to inform second shift of the defective pad. Interview with the Administrator on 11/14/23 at 8:34 A.M. verified Resident #21's mechanical lift sling was defective, and she stated the sling was thrown away. Review of the facility policy titled, Mechanical Lift Transferring, reviewed 08/2023, revealed mechanical lift slings need to be appropriate for the mechanical lift and the resident's weight. Prior to placing the mechanical lift complete a visual inspection for tears and frays, and prior to attaching the sling to the mechanical lift, complete a visual inspection for tears and frays. If there are tears or frays get a new sling. If you do not have an appropriate sling to use, get the nurse immediately. The nurse should call the Director of Nursing (DON) or Assistant Director of Nursing (ADON) for further guidance. The facility implemented the following corrective actions to correct the deficient practice by 11/16/23: On 10/30/23 at approximately 7:00 P.M., Resident #21 fell while being transferred with a mechanical lift from his wheelchair to his bed. Resident #21 was taken to the hospital for evaluation and returned to the facility on [DATE]. The Director of Nursing (DON) was notified of the fall on 10/31/23 and reported the incident to the Administrator. On 10/30/23, an investigation was initiated, and written statements were obtained from direct care staff to obtain information regarding Resident #21's fall. A total of 15 staff members' written statements were obtained by 11/02/23. On 10/31/23, CSC #600 and Housekeeping Assistant Supervisor #01 examined all mechanical lift pads for frays, tears, and to ensure all were in good working condition. All lift pads were noted to be free from any issues. On 10/31/23, Maintenance Director (MD) #01 checked all mechanical lifts for proper functioning with no concerns noted. On 10/31/23, all direct care staff were educated on facility guidelines for mechanical lift transfers, mechanical lift slings education, and mechanical lift sling integrity. All nurses and STNAs were educated by the Administrator and the DON by 11/01/23. On 10/31/23, the facility held a Quality Assurance and Performance Improvement (QAPI) meeting to discuss Resident #21's fall. Review of a QAPI plan dated 10/31/23, revealed Resident #21 fell to the floor while being transferred from the wheelchair to bed with a root cause of the wrong size sling was utilized and the mechanical lift sling was frayed. On 11/01/23, South Unit Manager Licensed Practical Nurse (LPN) #300 evaluated all residents who required a mechanical lift for transfers to ensure proper size and lift was utilized and all interventions were in place. On 11/01/23, education was provided to all laundry staff by Environmental Service Director #800 on mechanical lift sling integrity and laundering of slings. On 11/01/23, the DON will audit nursing staff utilizing mechanical lifts to ensure the mechanical lift sling integrity policy is followed three times a week for two weeks and then monthly. The findings will be reviewed by the QAPI committee to ensure compliance was maintained. Audits were completed on 11/01/23, 11/02/23, 11/03/23, 11/06/23, 11/08/23, and 11/10/23 with no concerns observed. On 11/02/23, the facility ordered 19 new mechanical lift slings for residents who required mechanical lifts for transfers. On 11/13/23, observation and interview with three (#400, #495, and #500) STNAs and three (#300, 340, and #360) LPNs confirmed they were educated on mechanical lift policies and procedures, and to check integrity of lift pads prior to transfers. All observations of resident mechanical lift transfers and lift pads noted no concerns. This deficiency represents non-compliance investigated under Master Complaint Number OH00148254.

Based on medical record review, observations, interviews with facility staff, family, and alarm company representatives, review of facility's missing person investigation, review of the incident and accident report, and the "Weather Underground" report, the facility failed to provide adequate supervision for one (Resident #142) of eight residents with exit seeking behaviors of a total of three residents reviewed for elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy for one (#142) cognitively impaired resident with wandering and exit seeking behaviors who successfully eloped from the facility without staff knowledge. On 01/07/15 at 4:12 P.M., the Administrator was notified that Immediate Jeopardy began on 01/01/15 at approximately 12:10 P.M. when Resident #142 walked out of the facility with alarms sounding and staff failed to go outside and check for any residents who may have wandered out of the facility. The facility was not aware that Resident #142 was missing until approximately 3:00 P.M. Resident #142 independently walked approximately two and a half miles away from the facility. The resident was wearing a T- shirt with a fleece jacket, long pants and open-back tennis shoes. The resident was not wearing a winter coat, hat or gloves. According to the history report on "Weather Underground", the local weather forecast, the average temperature in the area on 01/01/15 was 28 degrees Fahrenheit (F), with the wind chill of 15 degrees Fahrenheit. Resident #142 was found by the police department at approximately 3:30 P.M. and taken to her daughter ' s house. The family brought Resident #142 back to the facility at 5:00 P.M. The Immediate Jeopardy was removed on 01/07/15 at 6:00 P.M. when the facility implemented the following corrective actions: ? On 01/01/15 at approximately 5:00 P.M., Resident #142 was returned to the facility and placed on 1:1 observations. Observations were decreased to every fifteen minutes on 01/04/15. Resident #142 was discharged to another facility with a secured unit on 01/05/15 at 6:20 P.M. ? On 01/02/15 at 8:00 A.M., the facility re-assessed all residents in the facility with elopement/wandering behaviors. On 01/02/15, the facility reviewed the Elopement risk binder which included a total of eight residents at risk for elopement with vital information including photos and personal information. ? Between 01/02/15 at 5:00 A.M. and 01/03/15 10:00 P.M., the Director of Nursing (DON) completed an all staff in-service for each shift, including nursing, activities, dietary, housekeeping and maintenance on the "Elopement" policy and procedure. This training included assessments of residents on admission and as needed, implementation of care plans and interventions (i.e. supervision of wandering residents, Secure Care bracelets and redirection by staff), identification of safe areas for wandering and proper procedures in case of an elopement. ? On 01/05/15, Receptionist #40 was given a written warning disciplinary action for the incident on 01/01/15 when the front door alarm was sounding and Receptionist #40 did not go outside to check for residents who may have exited the building. ? On 01/06/15 at 4:00 P.M., the alarm system was repaired and the system was returned to normal and functioning properly to prevent wandering residents from exiting the facility. ? On 01/07/15 between 2:00 P.M. and 4:00 P.M., interviews with State tested Nursing Assistant's (STNA's) #5 and #10, Licensed Practical Nurse (LPN) #20, Registered Nurse (RN) #30 and Receptionist #40, revealed they were able to describe in detail the facility's " Elopement" policy and procedure, location of alarmed doors and new interventions in place to prevent residents from further elopement. ? On 01/07/15, STNA #5 was given a written warning disciplinary action for the incident on 01/01/15 when the front door alarm was sounding and STNA #5 did not go outside to check for residents who may have exited the building. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as not enough time has elapsed to ensure the actions taken by the facility were effective and being monitored for on-going compliance. Findings include: Review of Resident #142's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #142's history and physical from the hospital dated 12/03/14 and physician progress notes [REDACTED]. Review of the resident's admission nursing assessment dated [DATE], revealed Resident #142 was alert, independent in ambulation, and had adequate hearing and vision. The assessment indicated she was pleasant in mood, understands others, was able to be understood, and had no evidence of wandering or elopement. Review of Resident #142's Elopement Risk Evaluation dated 12/09/14, revealed she was not at risk for elopement upon admission. However, an evaluation dated 12/10/14, revealed the resident was only alert to self and had a history of [REDACTED].#142 was at risk for elopement. Review of Resident #142's plan of care (POC) dated 12/18/14, revealed the resident was at risk for elopement, wandering, and exit seeking behaviors related to cognitive impairment. Interventions included a Secure Care bracelet every shift and to check functioning and placement every shift. Review of Resident #142's medication administration record (MAR) dated December 2014 and January 2015, revealed nurses were monitoring the Secure Care bracelet for application and to ensure it was functioning properly. Review of the incident report/nurse's notes dated 01/01/15 at 3:30 P.M., indicated Resident #142 was not able to be found in the facility. The DON, the family, the supervisor, and 911 were all notified. The nurse's note also revealed facility staff completed a door to door search of the neighborhood and were unable to locate Resident #142. Further review of the nurse ' s note dated 01/01/15 at 4:30 P.M., revealed Resident #142 was found by the police, and taken to her daughter's house and then returned to the facility. The nurse's notes documented the residents vital signs were assessed and were within normal limits and no injury was noted to the resident. Resident #142 was taken to the emergency room for evaluation. Upon return to the facility, Resident #142 was placed on one to one (1:1) supervision for safety. Interview with the DON on 01/06/15 at 4:27 P.M., revealed Resident #142 was at risk for elopement and left the facility unnoticed on 01/01/15. She stated the investigation determined STNA #5 and Receptionist #40 were in the lounge at approximately 12:00 P.M., when the front door lobby alarm was sounding. She verified STNA #5 and Receptionist #40 saw another resident sitting by the front door and just assumed it was the resident that set the alarm off and STNA #5 reset the alarm. She further verified neither one of the staff members went outside to look for any residents that may have gone outside the door. She also indicated staff was not aware the resident was not in the building at shift change which was approximately 3:00 P.M. She stated staff searched for Resident #142 in the facility and the surrounding area and were unable to locate her. The facility was notified by Resident #142's daughter the resident was found by the police and taken to the daughter ' s house. The DON stated the daughter brought Resident #142 back to the facility at 5:00 P.M. She stated the resident had no injury but was taken to the emergency room for evaluation because she was out in the cold and did not have on a coat, hat or gloves. Further interview revealed both staff members (STNA #5 and Receptionist #40) had been disciplined for the incident because their policy indicated when staff hears an alarm, they were to go outside and check to see if any residents have exited the building. She stated Resident #142 was on a one to one observation upon return to the facility until the facility felt she was at minimal risk for elopement and decreased observations to fifteen minute checks until she was discharged to a facility with a secured unit. She verified no other elopements occurred with Resident #142 or any other resident for the past three months. Interview with Maintenance Director #50 on 01/07/15 at 9:25 A.M., revealed he tested the door alarms monthly and provided documentation of the door alarm testing. He also stated the front doors in the facility had not been working properly on 01/06/15. He stated the alarm company repaired the system and the system was functioning properly on 01/06/15. He further stated he did not complete weekly testing of the door alarms. Interview with Alarm Company Representative #70 on 01/07/15 at 9:55 A.M., revealed the alarm repair service was out on 01/06/15 to repair the front doors of the facility. He stated it was reported that one side of the double doors was not locking properly with the secure care bracelet. He verified the alarm system was repaired and functioning properly when they left. He also verified both doors should lock when a Secure Care bracelet was near the door. Interview with STNA #7 on 01/07/15 at 10:08 A.M., revealed she worked on 01/01/15 but was not assigned to take care of Resident #142. She stated the last time she observed the resident in the facility on 01/01/15, was approximately 11:45 A.M. She stated the resident was at the nurse's station eating lunch. She further stated it was shift change, at approximately 3:00 P.M., when they noticed Resident #142 was not in the facility. She did verify Resident #142 was at risk for elopement and wore a Secure Care bracelet and also indicated the door alarm was working properly. Interview with Receptionist #40 on 01/07/15 at 10:17 A.M., revealed on 01/01/15 at approximately 12:00 P.M., the front door alarm was sounding. She stated STNA #5 and another resident was in the lobby. She indicated she told STNA #5 to check the alarm and make sure no one went out the door. She stated STNA #5 verified that no one had left the facility. She further verified neither she nor STNA #5 went outside to check and see if any residents had exited the building. Interview with Resident #142's daughter and Power of Attorney (POA) on 01/07/15 at 11:35 A.M., revealed on 01/01/15 between 3:00 and 4:00 P.M., the facility called her house asking if she or any other family members had come and taken Resident #142 out of the facility. She stated the facility said her mother had left the building. She stated she had not taken her mother out of the facility and she hung up to call all relatives and found out that none of them had either. She immediately called 911 and went to the facility. She stated a second sister called her and indicated the resident was taken to yet a third sister ' s house by the police. She stated she was told the resident was found on the corner of Byrne and Copeland Roads and had on a T-shirt, fleece jacket, and open-back tennis shoes but did not have on a winter coat, hat or gloves. She was told by staff upon entrance to the facility that the resident had been missing since approximately 12:00-12:30 P.M. She stated her third sister returned the resident to the facility at 5:00 P.M. The facility gave the resident dinner and the facility then took her to the emergency room per recommendation of the facility. She verified Resident #142 was not injured and was discharged to another facility with a secured unit on 01/05/15. Interview with Alarm Company Representative #71 on 01/07/15 at approximately 2:20 P.M., revealed the alarm repair service was out on 01/06/15 to check the system. He verified both right and left doors should lock when a Secure Care bracelet was near the door. He further stated according to the manufacturer recommendations; the facility alarm system and doors should be monitored and checked once a week. Interview with RN #31 on 01/07/15 at 3:00 P.M. via telephone, revealed she was assigned to Resident #142 the day Resident #142 eloped. She stated the last time she observed Resident #142 was at approximately 11:45 A.M. to 12:00 P.M. when the resident was eating lunch at the nurse's station. She stated during shift change, STNA #6 reported they were not able to locate Resident #142. She further stated an in house search of the facility was conducted two times the resident was not able to be located. She stated she notified the supervisor, DON, family, and police of the aforementioned findings. Interview with STNA #5 on 01/07/15 at 6:10 P.M., revealed she was working the day Resident #142 eloped and was at the front door when the alarm was sounding. She verified she reset the alarm and did not go outside to check and see if any residents had left the building. Observations of the door alarms throughout the facility on 01/07/15 between 10:57 A.M. and 11:05 A.M. and 01/08/15 at 1:20 P.M, revealed the alarm system was functioning properly. The facility had two, 15 second delayed egress locking devices located at the front entrance of the facility and at the exit door near the kitchen. In addition, all the exit doors in the facility were equipped with alarming devices that activated when the doors were opened. Review of the facility's policy and procedure titled, "Elopement Policy", dated October 2012, revealed when a resident was found missing from the facility, staff would immediately call the charge nurse, Administrator, DON, and Social Service Designee. If the resident has been designated as an elopement risk, obtain profile sheet located in the elopement book and distribute sheet to staff and local officials. The DON or designee organizes or institutes an immediate and thorough search of the facility and the surrounding grounds. The entire search process must be completed within thirty minutes. If the search fails to locate the resident within thirty minutes, the Administrator and/or designee contacts the appropriate community agencies, the resident ' s family and physician. The search continued distributing two staff members to search the surrounding streets by car for a two mile radius. When the resident is located, a head to toe assessment will be completed by the nurse, and the social service designee will assess the resident for emotional distress. The findings will be reported to the DON, the physician and family member.