Every finding on record at Highbanks Care Center

Based on resident and staff interview and record review, the facility failed to ensure Resident #35's continuity of care from the hospital to the facility was thoroughly reviewed and implemented. This affected one (Resident #35) of three residents reviewed for infections. The facility census was 53.Findings include:Review of the medical record for Resident #35 revealed an admission date of 06/16/25. Diagnoses included vascular dementia, disorder of kidney and ureter, cyst of kidney, and a history of urinary tract infections (UTIs).Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was moderately cognitively impaired, exhibited no behaviors of refusal of care, required substantial/maximal assistance with toileting and was frequently incontinent of urine and bowel.Review of the hospital after visit summary (AVS) dated 03/19/26 revealed Resident #35 had diagnoses of kidney stone, kidney cyst, and acute UTI. Instructions included to follow up with urologic surgery outpatient and initiate cephalexin (antibiotic) 500 milligrams (mg) by mouth four times a day for seven days. The hospital record noted a left renal calculus with partial obstruction measuring 1.7 centimeters with mild left hydronephrosis. Urinalysis noted small blood, large leukocyte esterase and 30 white blood cells. Resident #35 was given one dose of Rocephin (antibiotic) and instructed to continue Keflex (cephalexin) for one week.The progress note dated 03/19/26 at 10:04 P.M. revealed Resident #35 returned from the hospital. From 03/19/26 to 03/22/26, there was no documentation of refusal of care or the resident's refusal to provide the hospital AVS to staff.Review of the physician order created two days after re-admission on [DATE] at 9:10 P.M. revealed an order for cephalexin 500 mg by mouth four times a day for UTI for seven days with a start date of 03/22/26.Review of Resident #35's medication administration record (MAR) for March 2026 revealed cephalexin 500 mg by mouth four times a day for UTI was initiated on 03/22/26, with the first dose administered upon rising.Interview on 03/26/26 at 8:45 A.M. with Registered Nurse #76 revealed the nurse denied knowledge of Resident #35's UTI and the need for antibiotic therapy upon readmission.Interview on 03/26/26 at 8:55 A.M. with the Director of Nursing (DON) revealed Resident #35 refused to provide staff with the hospital AVS. The DON confirmed the medical record did not contain evidence of this and confirmed no documentation showing staff attempted to obtain the AVS from the hospital or contact the resident's power of attorney, who was present at the time of the hospital admission. The DON further confirmed Resident #35 returned from the hospital on [DATE] with a diagnosis of acute UTI with an order to start cephalexin 500 mg four times a day, which was not initiated until 03/22/26 upon the resident rising. The DON was unsure if the antibiotic was available in the emergency box.Interview on 03/26/26 at 9:08 A.M. with Resident #35 revealed the resident was welcoming and denied refusing to give facility staff the hospital AVS.This deficiency represents non-compliance investigated under Complaint Numbers 2802892 and 2800377.

Based on observations, interviews, and record review, the facility failed to maintain a safe, clean, and homelike environment in the memory care unit and in two resident rooms (Residents #6 and #8). This affected two residents (#6 and #8) and had the potential to affect all 25 residents on the memory care unit. The facility census was 52.Findings include:1.Review of the medical record for Resident #6 revealed an admission date of 10/31/22 with diagnoses to include but not limited to stroke, traumatic brain dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, amputation, and cardiorespiratory conditions.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero, which indicated Resident #6 was rarely or never understood with severely impaired cognition. Furthermore, the MDS revealed Resident #6 was totally dependent on staff for all personal care.Observation on 02/17/26 at 10:20 A.M. of Resident #6 revealed the bed was in lowest position and there was a hole in the wall above the headboard.Observation on 02/18/26 at 2:37 P.M. of Resident #6's room revealed a hole in the wall above Resident #6's bed which was as large as twelve-ounce can. Registered Nurse (RN) #319 confirmed the hole in the wall at the time of the observation.Interview on 02/18/2026 2:50 P.M. with Maintenance Director #506 who stated the hole in the wall above the bed of Resident #6 was from the bed being raised and lowered when the staff were providing personal care for Resident #6. Maintenance Director #506 stated the wall had been repaired multiple times and the dry wall had not been repainted after the wall was repaired. Maintenance Director #506 confirmed there was a hole in the wall above Resident #6's bed which had not been repaired and the dry wall around the hole and the wall to corner of the room behind Resident #6's bed had not been painted and did not reflect a homelike environment.2.Review of the medical record for Resident #8 revealed an admission date of 12/26/24 with diagnoses to include but not limited to cerebrovascular disease, atherosclerotic heart disease, hemiplegia and hemiparesis, vascular dementia, asthma, unspecified mood affective disorder, anxiety disorder, major depressive disorder, hypertension, chronic pain, and gastro-esophageal reflux disease.Review of the quarterly MDS dated [DATE] revealed a BIMS score of eight which indicated moderate cognitive impairment. Furthermore, the MDS revealed Resident #8 was dependent on staff for toileting hygiene, personal care, and was frequently incontinent with bladder and bowel.Observation on 02/17/26 at 10:22 A.M. of Resident #8's room revealed a brown substance that appeared to be bowel movement on the bathroom door handles-front and back.Observation on 02/18/26 at 2:46 P.M. of Resident #8's room revealed a brown substance that appeared to be bowel movement on the handles of the bathroom door. The brown substance was on the front handle of the bathroom door to enter the bathroom and on the back handle to exit the bathroom. RN #319 confirmed the brown substance appeared to be bowel movement and was on both door handles in Resident #8's bathroom at the time of the observation.Interview on 02/18/26 at 7:10 A.M. with Housekeeping Staff #317 stated she worked on the memory care unit. Housekeeping Staff #317 stated she mopped, cleaned the rooms, and cleaned the bathrooms of the residents weekly and as needed. Housekeeping Staff #317 also stated she cleaned the common areas of the memory care unit. Housekeeping Staff #317 stated she sanitized everything on the memory care unit. Review of the facility policy Housekeeping Guidelines undated revealed doorknobs, handrails, bath rails, sink handles, etc. will be cleaned at least once daily and more often as needed.3.Observation on 02/18/26 at 2:47 P.M. of the common area with a television in it on the memory care unit revealed the wall on the right side of the room by the window had multiple holes in the dry wall from straight back chairs rubbing and scratching along the wall. There were multiple brown marks on the dry wall above the electrical outlet. One of the brown marks was as long as a dollar bill and finger width, five brown marks are the size of a quarter and one brown mark was the size of a half dollar, all the brown marks were near the lowest electrical outlet toward the corner. There was no trim for one foot of the wall in the corner and there was no trim from the corner until one foot of the window. Maintenance Director #506 confirmed all the holes in the wall, brown marks on the wall, and the lack of trim at the time of the observation. This deficiency represents non-compliance investigated under Complaint Number 2710656.

Based on record review and staff interview, the facility failed to ensure the advanced directive matched in the electronic medical record and physical hard chart for one (Resident #10) out of 19 reviewed for the sample. The facility census was 53.Review of the medical record for Resident #10 revealed an admission date of 01/29/26. Diagnoses included unspecified mood (affective) disorder, obstructive and reflux uropathy, hyperlipidemia, and dementia of unspecified severity with mood disturbance.Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #10, dated 02/05/26, revealed the resident was rarely/never understood.Review of the advanced directive documentation in the electronic medical record revealed a signed Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) order dated 01/14/26.Review of physician orders for Resident #10 revealed an order for Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) status.Review of the hard chart on 02/19/26 at 10:20 A.M. revealed a code status face sheet indicating Full Code.Interview on 02/17/26 at 3:00 P.M. with Registered Nurse (RN) #307 confirmed the advanced directive documentation inside the hard chart did not match the directive documented in the electronic medical record.Interview on 02/19/26 at 1:30 P.M. with the Director of Nursing (DON) revealed the resident had a signed Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) order dated 01/14/26, however, the electronic medical record and hard chart had not been updated to reflect the resident's current code status. The DON acknowledged the discrepancy and stated the expectation was that code status information remained consistent and accurate across all documentation systems to ensure resident wishes were honored.

Based on observations, interviews, and record review, the facility failed to ensure Resident #8, on the secured memory care unit, was specifically provided activities to meet their interests and meet their psychosocial needs. This affected one Resident #8 of the two residents reviewed for activities. The facility census was 52.Findings include:Review of the medical record for Resident #8 revealed an admission date of 12/26/24 with diagnoses to include but not limited to cerebrovascular disease, atherosclerotic heart disease, hemiplegia and hemiparesis, vascular dementia, asthma, unspecified mood affective disorder, anxiety disorder, major depressive disorder, hypertension, chronic pain, and gastro-esophageal reflux disease.Review of the quarterly MDS dated [DATE] revealed a BIMS score of eight which indicated moderate cognitive impairment. Review of the care plan for Resident #8 dated 05/05/25 revealed Resident #8 was a sociable person, willing to interact with others and participate in activities that relate to her interests and as her condition will allow. The following activities are important to the resident: pet visits, reading, and watching television and movies. The interventions included give the resident the opportunity to express an opinion of the activities attended, give resident verbal reminders of activity before commencement of the activity, introduce resident to other residents with similar interests, disabilities, and or limitations, invite resident to scheduled activities, offer activity program directed towards specific interests/needs of the resident, offer the resident books, newspapers, and magazines to read.Observation on 02/17/26 at 10:22 A.M. revealed Resident #8 lying on her bed in her room.Observations on 02/17/26 from 10:22 A.M. to 3:55 P.M. revealed no activities being offered to Resident #8.Observation on 02/18/26 at 11:31 A.M. revealed Resident #8 sitting in her wheelchair in the hallway outside of her room.Observation on 02/18/26 at 2:22 P.M. revealed Resident #8 sitting in a chair in the common room on the memory care unit.Observation on 02/18/26 at 3:00 P.M. of the dining room and common area of the memory care unit revealed no activities taking place. Interview on 02/18/26 at 2:57 P.M. with Registered Nurse (RN) #319 revealed there were no activities provided today on the memory care unit.Interview on 02/18/26 at 2:58 P.M. with Certified Nursing Assistant (CNA) #230 revealed Resident #8 watches television a lot and listens to music. CNA #230 stated she had never seen Resident #8 participate in any activities other than balloon volley.Interview on 02/18/2026 at 3:30 P.M. with RN #319 revealed the screen on the wall was supposed to show the activities for the week for the residents, but stated the screen was blank and there were no activities listed for this week.Interview on 02/19/26 at 8:10 A.M. with CNA #327 revealed she had not seen Resident #8 participate in any activities since she has worked here. Interview on 02/19/26 at 8:26 A.M. with Activities Director #509 revealed Resident #8 likes music, arts and crafts, and likes to read, but had to be read to now because it is harder for Resident #8 to read. Activities Director #509 verified the Mardi Gras activity scheduled on 02/17/26 did not take place. Activities Director #509 stated Resident #8 participated in activities once a week and sometimes three times a week. Activities Director #509 stated Resident #8 participated in balloon volley on 02/18/26. Activity Director #509 stated Resident #8 had completed a puzzle o 02/18/26.Interview on 02/19/26 at 9:03 A.M. with Activity Assistant #520 revealed Resident #8 came to balloon volley on 02/18/26 but did not stay and participate. Activities Assistant #520 stated Resident #8 did not do a puzzle on 02/18/26.Review of the Activities Calendar for 02/17/26 revealed at 10:00 A.M. Daily Chronicle, 11:00 A.M. Virtual Tour of the Museum of African American History, 3:00 P.M. King Cake for Mardi Gras [NAME] Begins and Mardi Gras. Review of the Activities Calendar for 02/18/26 revealed 10:00 A.M Daily Chronicle, 11:00 A.M. Balloon Volley, 3:00 P.M. Let's Paint Traditional African.Review of the facility policy, Provider Services Activity Department Policy/Procedure Manual, dated 03/2007 revealed the activity department is responsible for planning and scheduling an activities program, consisting of stimulating and therapeutic activities, diverse in focus, and consistent with resident's wishes and needs. The calendar will include a balance of large and small group activities, and one on one programs. The calendar will be implemented as written. When cancellations and changes are avoidable, they will be announced in the morning and afternoon.

Based on observation, resident interview, and staff interview, the facility failed to ensure the call light was within reach for one (Rresident #3) per fall interventions. This affecpted one of one residnet reviewed for fall interventions. The facility census was 53. Review of the medical record for Resident #3 revealed an admission date of 05/28/24. Diagnoses included primary generalized osteoarthritis, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and cerebral infarction unspecified.Review of the Quarterly Minimum Data Set MDS 3.0 assessment for Resident #3, dated 01/05/26, revealed a Brief Interview for Mental Status score of 07, indicating cognitive impairment. The assessment further revealed the resident required extensive assistance with bed mobility and was dependent for transfers and most activities of daily living, including toileting and dressing, and utilized a wheelchair for mobility.Review of the care plan dated 05/30/24 for falls revealed an intervention dated 05/31/24 to ensure the call light was within reach.Observation on 02/17/26 at 10:07 A.M. revealed the call light was out of reach and tucked under the sheets at the end of the bed near the resident's feet. Resident #3 stated she needed help getting out of bed due to the perimeter mattress and stated it made it difficult to get out of bed. The resident stated she did not know why the call light was out of reach. The resident stated she would have to shout if she needed assistance and stated she had done so in the past due to the same issue.Interview on 02/17/26 at 10:16 A.M. with Registered Nurse (RN) #307 confirmed the call light was located at the end of the bed and out of reach. RN #307, confirmed the resident was not able to reach the call light.Interview on 02/17/26 at 01:42 P.M. with Certified Nursing Assistant (CNA) #311 revealed the resident was able to use her call light when it was within reach and was able to understand how and when to use it.

Based on observation, staff interview, and facility policy, the facility failed to ensure Oxygen tubing was maintained in a sanitary manner for one (Resident #3) out of one residents reviewed for respiratory concerns. The facility census was 53. Review of the medical record for Resident #3 revealed an admission date of 05/28/24. Diagnoses included primary generalized osteoarthritis, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and cerebral infarction unspecified.Review of the Quarterly Minimum Data Set MDS 3.0 assessment for Resident #3, dated 01/05/26, revealed a Brief Interview for Mental Status score of 07, indicating cognitive impairment. Further review indicated the resident received oxygen therapy while a resident of the facility.Observation on 02/17/26 at 10:10 A.M. revealed the oxygen tubing was lying on the ground and the nasal cannula was on the floor covered in dust. The oxygen tubing was not dated to indicate when it had been placed or last changed.Interview on 02/17/26 at 10:17 A.M. with Registered Nurse (RN) #307 confirmed the oxygen tubing was not dated and confirmed the nasal cannula was located on the ground in dust.Interview on 02/18/26 at 10:30 A.M. with Regional Nurse #512 revealed it was protocol for the facility to change oxygen tubing weekly. Review of a policy titled, Oxygen Administration, revised 07/30/24, revealed oxygen tubing and mask or cannula were to be changed weekly and as needed if they became soiled or contaminated.

Based on observation, medical record review, resident interview, staff interviews, activity calendar review, facility website review, policy review, and staff job description review, the facility failed to provide activities for residents that were meaningful and of their choice. This affected seven (#3, #6, #16, #31, #33, #41, and #48) of seven residents reviewed for activities. The census was 55. Findings include: Observations on 08/26/24 at 9:15 A.M. and 08/28/24 at 10:00 P.M., revealed residents on the 200 unit, were sitting around the dining tables or in the common area watching the television, with staff sitting and watching them do that as well. 1. Observations on 08/26/24 at 9:15 A.M. and 08/28/24 at 10:00 P.M., revealed Resident #3 sitting in her room, not doing any activities. Review of Resident #3's medical record revealed an admitted [DATE]. Resident #3's diagnoses included: dementia, COPD, nicotine dependence, paranoid schizophrenia, anxiety disorder, major depressive disorder, unspecified intellectual disabilities, and dysphagia. Review of her minimum data set (MDS) assessment, dated 08/08/24, revealed she was cognitively intact. Review of Resident #3's activity assessment, dated 03/12/24, revealed she liked the following activities: card games, playing basketball or football, watching western or love story shows, coloring and painting, reading magazines, going to church/praying, interacting with dogs and cats, and interacting with others/socializing. Review of Resident #3's activity logs, dated 02/03/24 to 02/14/24 and 05/01/24 to 05/31/24, revealed she completed a total of 42 activities during the documented times. The list of activities that she was offered and performed included: bingo, movies, painting, two parties, going outside, and pet visits. Of the 42 documented activities, 36 of them were going outside and pet visits. There was no other documentation of activities offered or performed from 02/01/24 to 08/28/24, other than the ones listed above. 2. Review of Resident #41's medical record revealed an admitted [DATE]. Resident #41's diagnoses included: encephalopathy, chronic obstructive pulmonary disease, type II diabetes, chronic pancreatitis, atherosclerotic heart disease, hypertension, hyperlipidemia, anemia, adult failure to thrive, anorexia, bipolar disorder, alcoholic dependence, dementia, and mood disorder. Review of her MDS assessment, dated 07/17/24, revealed he had a severe cognitive impairment. Review of Resident #41's activity assessment, dated 04/20/24, revealed the following: Resident prefers to participate in activities of his choice at his own leisure. Resident typically enjoys going outside for air and to smoke. Resident's favorite activity is making his own artwork. He draws them out in pencil, sometimes using a ruler, then he colors each area in. Creating really cool and neat designs. He usually works on them in his room, but he'll sometimes work on them in the TV room. Review of Resident #41's activity logs, dated 02/03/34 to 02/05/24 and 05/01/24 to 06/30/24, revealed he was offered and completed a total of 33 activities. The list of activities offered and performed included: bingo, pet visit, adult coloring, cupcakes, resident council, and father's day cookout. Of the 33 documented activities, nine of them were bingo and 20 of them were pet visits; only one was related to adult coloring. 3. Review of Resident #48's medical record revealed an admitted [DATE]. Resident #48's diagnoses included: alcohol dependence with alcohol induced persisting dementia, unspecified focal traumatic brain injury, major depressive disorder, restlessness and agitation, dementia, nicotine dependence, osteoarthritis, hypertension, insomnia, schizophrenia. Review of her MDS assessment, dated 06/12/24, revealed he had a severe cognitive impairment. Review of Resident #48's activity assessment, dated 03/11/24, revealed he prefers one on one activities. His activity preferences were documented as cards, games, watching television, exercise/sports, music/radio, trips/shopping/outings, hobbies, pets, outdoors, and socializing. Review of Resident #48's activity logs, dated 02/03/34 to 02/17/24 and 05/01/24 to 05/31/24, revealed he was offered and completed a total of 51 activities. The list of activities offered and performed included: bingo, popcorn/movie, party, painting, animal documentary (movie), going outside, pet visit, and cupcakes. Of the 51 documented activities, 43 of them were going outside and pet visits. Interview on 08/27/24 10:25 A.M., with State tested Nursing Aide (STNA) #249 revealed there is not an activities calendar in the 200 unit of the facility at this time. STNA #249 stated she doesn't know what activities will be performed daily. STNA #249 stated the activities director will come out of her office and perform an activity with the residents. STNA #249 stated waits until the activities director come out to assist with performing activities. STNA stated most of the time, the residents are in their room, watching television, or going outside to sit. 34298 4. Review of Resident #6's medical record revealed an admitted [DATE]. Resident #6's diagnoses included: type 2 diabetes mellitus, pseudobulbar affect, insomnia, and schizoaffective disorder. Review of Resident #6's Activities assessment dated [DATE] at 10:07 A.M., revealed Resident #6 loves music, especially classical music, and loves to sing. Resident #6 likes karaoke, Bingo, arts and crafts, and snacks. Resident #6 does better with one-on-one activities but does participate in group activities. Review of the plan of care dated 04/11/24 revealed Resident #6 did not engage in group activities. Resident #6 preferred activities in her room. Resident #6 enjoys spa day and getting hair/makeup done. Resident #6 voiced interest in getting nails done. Resident #6 really likes music. Interventions included to invite Resident #6 to music related activities and outside activities. Review of activity log from 02/04/24 through 08/19/24 revealed Resident #6 participated in valentine party, refused movie and popcorn on 02/04/24 and manicure on 08/05/24. Resident #6 had 17 pet visits and one attempt at bingo. Review of the quarterly MDS dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. Observations on 08/25/24, 08/26/24, and 08/27/24 over multiple time frames, revealed Resident #6 was in lying in bed with the door to the room closed. Resident #6 was not observed in any activities. Interview on 08/27/24 at 1:42 P.M., with Activities Director (AD) #223 revealed residents were asked if they wanted to color or do games. AD #223 stated activities were completed in the morning and included art projects. AD #223 stated the popcorn machine was being cleaned and then movies could be done as an activity. AD #223 stated it was difficult to do activities with most of the residents due to short attention span. AD #223 revealed Resident #6 received hospice services and slept a lot and one-on-one activities were completed with Resident #6. Activities Director #223 stated she had a dog name [NAME] that did pet visits. 5. Review of Resident #16's medical record revealed an admitted [DATE], Resident #16's diagnoses included: Alzheimer's disease, palliative care, bipolar disorder, anxiety, and major depressive disorder. Review of Resident #16's Activity assessment dated [DATE] revealed Resident #16 preferred one-on-one, small groups, and large group activities. Resident #16's interest included cards, bingo, movies with [NAME], music, word searches, music, and sitting on the porch. Review of the plan of care dated 04/14/24 revealed Resident #16 did not engage in group activities. Resident #16 loves to walk. Resident #16 loves music and dancing. Resident #16's guardian revealed Resident #16 loved Christianity and may tolerate Bible studies. Interventions include to invite Resident #16 to music related activities, religious services, and offer/provide one-on-one visits twice a week. Resident #16 also enjoys sitting in the courtyard. Review of the significant change MDS dated [DATE] revealed Resident #16 had severe cognitive impairment. Review of activity log from 05/01/24 to 07/19/24 revealed Resident #16 observed bingo three times and the library once. Resident #16 had 18 pet visits. Observations on 08/25/24 at 2:04 P.M., 08/26/24 at 10:01 A.M., 08/26/24 at 3:47 P.M., 08/27/24 at 9:14 A.M., and 08/27/24 at 11:33 A.M., revealed Resident #16 was either in bed or sitting in wheelchair in the common area with the television on. Resident #16 was not observed in any structured activities. Interview on 08/27/24 at 1:42 P.M., with AD #223 stated Resident #16 had a recent decline and had anger issues before but Resident #16 did like to talk to people. 6. Review of Resident #31's medical record revealed an admitted [DATE]. Resident #31's diagnoses included: hemiplegia and hemiparesis, vascular dementia, and contracture of left hand. Review of the activity log from 02/03/24 to 08/19/24 revealed Resident #31 attended bingo three times, participated in watching a movie once, and painted once. Resident #31 refused a manicure that was offered one time and observed the library activity. Resident #31 had 17 pet visits. Review of the Activities assessment note dated 02/06/24 at 10:16 A.M., revealed Resident #31 comes to almost all of the activities. Resident #31 does a really good job, but needs extra help most of the time. Resident #31 particularly likes bingo, doing jigsaw puzzles, reading the paper and eating snacks. Review of the plan of care dated 04/14/24 revealed Resident #31 is a sociable person and comes to majority of the activities. Interventions included to invite Resident #31 to scheduled activities, offer books, newspapers and magazines to read, and provide with leisure supplies for self directed pursuits, Review of the quarterly MDS dated [DATE] revealed Resident #31 had severe cognitive impairment. The MDS also revealed Resident #31 had functional impairment on one side to the upper and lower extremity. Observations on 08/25/24 at 8:23 A.M., 08/25/24 at 2:01 P.M., 08/26/24 at 10:07 A.M., and 08/27/24 at 9:13 A.M., revealed Resident #31 was sitting in a wheelchair in the common area with the television on. Resident #31 was not observed in any structured activities. Interview on 08/27/24 at 1:42 P.M., with AD #223 stated Resident #31 used to like bingo but mainly doing one-on-one visits with Resident #31. 49039 7. Review of Resident #33's medical record revealed an admitted [DATE]. Resident #33's diagnoses included: major depressive disorder, type two diabetes mellitus, tobacco use, schizoaffective disorder, bipolar disorder, anxiety and insomnia. Review of MDS assessment completed 07/17/24, revealed he was cognitively intact, exhibited no behaviors, it was somewhat important to do things with groups of people and participate in his favorite activities. Resident #33 said it was very important to spend time outside. Review of activity assessment completed 07/28/24 revealed Resident #33 enjoys chess, Jenga, bingo, music, arts and crafts, outings, and socializing with residents and staff. Review of Resident #33's undated care plan revealed he is a sociable person who enjoys various activities. Key activities include arts and crafts, bingo, reading, spending time outside, and watching television and movies. Goals were set for him to express satisfaction with self-directed activities and offer suggestions for group activities if he feels dissatisfied. Review of activity log from August 2024 revealed Resident #33 participated in one social/party event for the month of August 2024. Interview on 08/27/24 at 11:15 A.M., with Resident #33 confirmed he participated in a smoke break activity; after smoking his cigarettes, he returned to his room due to lack of activities. Interview on 07/27/24 at 2:08 P.M., with Resident #33 confirmed that the only activities offered are bingo and coloring. He mentioned these activities seemed more suited for a younger age, and as they do not meet his interests and he spends most of his time in his room. Resident #33 suggested increasing outings and social events due to limited time spent in the surrounding areas around the facility. Interview on 08/28/24 at 8:41 A.M., with AD #223 and Activity Personnel #265 confirmed Resident #33 is very sociable, making it challenging to find suitable activities due to the patient population and restrictions. Review of facility activity calendars, dated June 2024 to August 2024, revealed the following activities were scheduled on a daily basis: smoke breaks (five times daily), outside (once daily), snack cart, lunch, and dinner. Other than these activities on a daily basis, there was no more than two other activities scheduled each day. Review of the facility website at https://www.highbanks-care.net revealed under the About Us tab the facility is a 56 bed secured, skilled nursing facility and specializes in mental health services. At Highbanks Care Center we believe in providing a supportive and nurturing environment for adults requiring skilled nursing services and mental health assistance. Our highly trained staff focuses activities related to each individual's life and interests along with a calming environment, which reduces behavioral disturbances. Review of the job description for Activities Director #223 revealed responsibilities and major duties included implementing programs of individual and group activities based on residents needs. Schedule and implement room visits and in room activities for residents not able to leave their rooms. Schedule and implement indoor and outdoor activity programs.

Based on medical record review, financial record review, family interview, and staff interview, the facility failed to ensure residents and/or resident representative was provided assistance in financial matters ensuring resident does not lose eligibility of Supplemental Security Income (SSI) or Medicaid services. This affected four (#27, #30, #31, and #35) of eight resident financial records reviewed. The census was 55. Findings include: 1. Review of Resident #27's medical record revealed an admission on 03/02/22. Resident #27's diagnoses included: Alzheimer's disease, hypertension, dementia, aphasia, mood disorder, anxiety disorder, and psychosis. Review of her minimum data set (MDS) assessment, dated 06/05/24, revealed she had a severe cognitive impairment. Review of Resident #27 's financial records, dated 08/15/23 to 08/06/24, revealed her resident funds account varied between $2,336.04 to $5,693.35. Review of Resident #27's notice for spend down revealed the notices were sent to her representative, dated 08/01/23 to 08/01/24, revealed one was sent each month, indicating that she was over the allowed Medicaid limit of $2,000. Part of the letter stated, due to the fact this balance is over $1,500, please take the necessary steps to spend down the money on anything that the resident may need. Should you have any questions, or concerns, please contact the business office or your Medicaid caseworkers. Further review of the medical record revealed no documented evidence of the facility following up on the notices of spend down to ensure the resident does not lose Medicaid or SSI eligibility. Interview on 08/28/24 at 2:25 P.M., with Resident #27's family/representative revealed he had received one spend down notice letter in the last 12 months. He stated he knew Resident #27 was over the spending limit by receiving that letter, but he didn't know what to do about that from this point forward. He stated he would call the facility to find out what he needed to do. 2. Review of Resident #30's medical record revealed an admission on 11/16/22. Resident #30's diagnoses included: dementia, Parkinsonism, paranoid schizophrenia, adult failure to thrive, dysphagia, depression, and muscle weakness. Review of his minimum data set (MDS) assessment, dated 08/08/24, revealed he had a severe cognitive impairment. Review of Resident #30's financial records, dated 09/21/23 to 08/06/24, revealed his resident funds account varied between $2,591.85 to $15,864.99. Review of Resident #30's notice for spend down revealed the notices were sent to his representative, dated 10/25/23 to 08/01/24, revealed one was sent each month, indicating that he was over the allowed Medicaid limit of $2,000. Part of the letter stated, due to the fact this balance is over $1,500, please take the necessary steps to spend down the money on anything that the resident may need. Should you have any questions, or concerns, please contact the business office or your Medicaid caseworkers. Further review of the medical record revealed no documented evidence of the facility following up on the notices of spend down to ensure the resident does not lose Medicaid or SSI eligibility. 3. Review of Resident #31's medical record revealed an admission on 11/09/20. Resident #31's diagnoses included: hemiplegia and hemiparesis, respiratory disorders, type II diabetes, vascular dementia, hyperlipidemia, anxiety disorder, major depressive disorder, dysphagia, . Review of her minimum data set (MDS) assessment, dated 06/19/24, revealed she had a severe cognitive impairment. Review of Resident #31's financial records, dated 08/02/23 to 08/06/24, revealed her resident funds account varied between $997.97 to $3,929.24. Review of her financial statements revealed she was under the spending limit from 11/17/23 to 01/02/24; but all the other entries were above the spending limit. Review of Resident #31's notice for spend down revealed the notices were sent to her representative, dated 08/01/23 to 08/01/24, revealed one was sent each month, indicating that she was over the allowed Medicaid limit of $2,000. Part of the letter stated, due to the fact this balance is over $1,500, please take the necessary steps to spend down the money on anything that the resident may need. Should you have any questions, or concerns, please contact the business office or your Medicaid caseworkers. Further review of the medical record revealed no documented evidence of the facility following up on the notices of spend down to ensure the resident does not lose Medicaid or SSI eligibility. 4. Review of Resident #35's medical record revealed an admission on 10/29/20. Resident #35's diagnoses included: Huntington's disease, dementia, respiratory disorders, nicotine dependence, psychosis, hyperparathyroidism, vitamin D deficiency, major depressive disorder, anxiety disorder, insomnia, and adult failure to thrive. Review of her minimum data set (MDS) assessment, dated 08/15/24, revealed she had a severe cognitive impairment. Review of Resident #35's financial records, dated 11/08/23 to 08/06/24, revealed her resident funds account varied between $2,492.05 to $9,373.09. Review of Resident #35's notice for spend down revealed the notices were sent to her representative, dated 11/01/23 to 08/01/24, revealed one was sent each month, indicating that she was over the allowed Medicaid limit of $2,000. Part of the letter stated, due to the fact this balance is over $1,500, please take the necessary steps to spend down the money on anything that the resident may need. Should you have any questions, or concerns, please contact the business office or your Medicaid caseworkers. Further review of the medical record revealed no documented evidence of the facility following up on the notices of spend down to ensure the resident does not lose Medicaid or SSI eligibility. Interview on 08/28/24 at 2:15 P.M., with Business Office Manager (BOM), verified the resident has up to nine months to spend down any excessive monies in their account that was the result of money that was owed to them by social security. BOM verified all four residents had more money in their personal accounts than what was permitted for more than nine months. BOM verified the facility has provided spend down notices but has not assisted or followed up with the residents and/ or resident representative in the spending of the extra money so they do not lose benefit eligibility.

Based on observation, record review, family interview, and staff interview, the facility failed to apply a physcian ordered resting hand splint. This affected one (#31) of one resident reviewed for positioning. The facility census was 55. Findings include: Review of Resident #31's medical record revealed an admitted [DATE], with diagnoses including: hemiplegia and hemiparesis, vascular dementia, and contracture of left hand. Review of a physician order dated 11/30/23 revealed Resident #31 was ordered a left resting hand splint per patient tolerance. Review of the plan of care dated 05/02/24 revealed Resident #31 had a left resting hand splint and was worn per Resident #31's tolerance level. Interventions included left resting hand splint as tolerated, with frequent skin checks for redness and monitoring pain or discomfort. A visual reminder was located in Resident #31's room. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had severe cognitive impairment. The MDS also revealed Resident #31 had functional impairment on one side to the upper and lower extremity. Observation on 08/25/24 at 8:07 A.M., revealed Resident #31 had a sign hanging next to the bed that read Nursing: Mrs. (Resident #31) splint schedule least 8 hours daily. Please wrap brace on patient after breakfast and remove after dinner. Observation on 08/25/24 at 8:23 A.M. and 2:01 P.M., and on 08/26/24 at 10:07 A.M., revealed Resident #31 was not wearing a splint to left hand. Interview on 08/26/24 at 3:34 P.M., with Resident #31's son revealed when they visited Resident #31, they have not observed Resident #31 wearing a splint to the left hand. Observation on 08/26/24 at 3:44 P.M. and on 08/27/24 at 9:13 A.M., revealed Resident #31 was not wearing a splint to the left hand. Interview on 08/27/24 at 11:01 A.M., State tested Nursing Assistant (STNA) #244 verified Resident #31 was not wearing a splint to the left hand. STNA #244 stated they did not know Resident #31 was supposed to wear a splint to the left hand. STNA #244 did locate a splint in the second drawer of the nightstand next to Resident #31's bed.

Based on record review and staff interview, the facility failed to ensure a resident was not receiving an unnecessary amount of an antipsychotic medication. This affected one (#6) of five residents reviewed for unnecessary medication. Facility census was 55. Findings include: Review of Resident #6's medical record revealed an admitted [DATE], with diagnoses including: type 2 diabetes mellitus, pseudobulbar affect, insomnia, and schizoaffective disorder. Review of a progress note by psychiatric physician dated 11/08/23 revealed Resident #6's Invega (antipsychotic) was to be increased from 1.5 milligrams (mg) to three (3) mg at bedtime. Review of the medication administration record (MAR) from 11/08/23 through 12/07/23 revealed Resident #6 was administered Invega 1.5 mg and Invega three (3) mg for a total of 4.5 mg at bedtime. Review of a pharmacy recommendation dated 12/01/23 revealed it was difficult to assess the proper dose for Invega. Was the dose to be increased from 1.5 mg for a total of 4.5 mg daily on 11/08/23? Pharmacy requested the total dose be clarified. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. The MDS also revealed Resident #6 received antipsychotic medication and antipsychotic's were received on a routine basis. Review of the plan of care dated 07/11/24 revealed Resident #6 was at risk for adverse effects related to psychoactive medication use. Interventions included to administer medications as ordered, report changes in behavior or mood state, and if continued drug use proves unavoidable use minimum effective dose. Interview on 08/27/24 at 8:59 A.M., with the Director of Nursing (DON) verified Invega was to be increased from 1.5 mg daily to three (3) mg daily instead of 4.5 mg daily. DON verified Resident #6 received the incorrect dose of Invega from 11/08/23 through 12/07/23.

Based on observation and staff interview, the facility failed to provide a homelike environment. This affected two (#31 and #44) of four residents reviewed for a homelike environment. The facility census was 55. Findings include: 1. Review of Resident #31's medical record revealed an admitted [DATE], with diagnoses including: hemiplegia and hemiparesis, vascular dementia, and contracture of left hand. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had severe cognitive impairment. Review of a behavior note dated 08/07/24 at 8:08 P.M. revealed Resident #31 was peeling the wall by the bed. Observation on 08/26/24 at 3:44 P.M., revealed Resident #31 was lying in bed. An area of peeling drywall/paint was observed on the wall next to Resident #31's head. Interview on 08/27/24 at 3:11 P.M., with Maintenance Director #245 verified the wall next to Resident #31's bed needed repaired. Maintenance Director #245 stated the area was going to be fixed the week of 08/25/24. Maintenance Director #245 verified the area had not been repaired at this time. Interview on 08/27/24 at 3:44 P.M., with Licensed Nursing Home Administrator (LNHA) revealed a State tested Nursing Assistant reported on 08/23/24 the wall needed repaired next to Resident #31's bed. LNHA provided a receipt that supplies to fix the wall were purchased on 08/25/24. LNHA verified the wall had not been repaired at this time. 2. Review of Resident #44's medical record revealed an admitted [DATE], with diagnoses including: psychological development disorder, type 2 diabetes mellitus, schizophrenia, and depression. Review of the annual MDS dated [DATE] revealed Resident #44 had a BIMS score of 15, which indicated Resident #44 was cognitively intact. Observation on 08/26/24 at 8:36 A.M., of Resident #44's room revealed multiple filled holes in the wall and the walls needed painted. Interview with Resident #44, at the time of the observation, revealed the holes had been filled a long time ago and Resident #44 had not been provided any updates on when the walls would be painted. Interview on 08/27/24 at 3:11 P.M., with Maintenance Director #245 revealed Resident #44's room was supposed to be painted the week of 08/25/24. Maintenance Director #245 verified the room was not painted to cover the patched areas. Maintenance Director #245 and LNHA were both asked on 08/27/24 and 08/28/24 for information on when the holes where patched in Resident #44's room. No information was provided to indicate how long Resident #44 had been waiting to have the room painted.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to hold routine interdisciplinary team (IDT) care conferences for the residents. This affected four (Residents #1, #15, #16, and #32) of four residents reviewed for care conferences. The facility census was 50. Findings include: 1. Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease, diabetes mellitus type II, depressive disorder, anxiety disorder, insomnia, paranoid personality disorder, atherosclerotic heart disease, adult failure to thrive, convulsions, colostomy status, hemorrhagic condition, hypertension, mild cognitive impairment, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition. Resident #16 required supervision setup help only for bed mobility, transfers, and toilet use. Review of the interdisciplinary team (IDT) Plan of Care Review Summaries from 01/01/22 to 02/15/23 revealed there was only one care conference held on 01/20/23 during the 13 months time period reviewed. There was no documentation if Resident #16 was invited to attend the care conference nor if the resident did or did not attend the care conference that was held on 01/20/23. Interview on 02/15/23 at 10:12 A.M. with Social Services (SS) #136 verified there was only one care conference held in 13 months for Resident #16. SS #136 verified there was no evidence if Resident #16 was invited to attend the care conference held on 01/20/23 and if the resident did or did not attend the care conference. SS #136 stated she had been working at the facility since December 2022 and trying to get everything caught up. She stated the residents were invited to the care conferences unless families requested the resident not be invited. She verified the facility was not able to provide documentation for additional quarterly care conferences for Resident #16. 2. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included atherosclerotic heart disease, heart failure, chronic kidney disease, schizoaffective disorder, bipolar type, borderline personality disorder, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease, low back pain, low back pain, irritable bowel syndrome, conversion disorder, dysphagia, and constipation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 had minimal difficulty hearing. Resident #15 required limited one person bed mobility, transfer, and toileting. Resident #15 required extensive assistance of one person for dressing and personal hygiene. Review of the interdisciplinary team (IDT) Plan of Care Review Summaries from 01/01/22 to 02/15/23 revealed there was only one care conference held on 01/18/22 during the 13 months time period reviewed. Review of the IDT Advance and Care Plan Conference Sheet revealed it was conducted on 01/18/22. Interview on 02/15/23 at 10:12 A.M. with Social Services (SS) #136 verified there was only one care conference held in 13 months for Resident #15. Review of the facility policy titled Resident/Resident Representative Care Conference, revised 05/09/18, revealed the purpose of the care conference was to provide the resident and/or resident representative the opportunity to participate in the resident's plan of care. On admission, the resident and/or resident representative will be informed of the facility's care conference protocols. They will be offered an initial care conference meeting. They may also be informed of a projected schedule for quarterly care conferences for the year, and that they may request a care conference at any time. 44070 3. Medical record review for Resident #1 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, diabetes mellitus, dementia, osteoarthritis, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired and was rarely understood and required extensive assistance of two staff members for mobility and transfers. Review of the IDT Advance Care plan conference sheet dated 01/12/22 revealed a care conference took place on 01/12/22 and the meeting included the resident's emergency contact and social services. No clinical staff or other IDT team members were noted to have attended. Review of the Psychosocial Assessments dated 02/25/22 and 05/25/22 revealed these were not interdisciplinary team (IDT) care conferences. The documents revealed advanced care planning was reviewed but it did not specify which staff were included in the assessment. Review of the IDT Advance Care plan conference sheet dated 06/30/22 revealed a care conference took place on 06/30/22 and the meeting included the resident's emergency contact, social services, and the Assistant Director of Nursing (ADON). There were no other IDT members noted to attend the care conference. Further review of the medical record revealed there was no evidence an IDT care plan meeting was held for Resident #1 from 07/01/22 to 02/15/23. Interview on 02/14/23 at 9:13 A.M. with Resident #1's emergency contact revealed she has only been invited to one care conference meeting since Resident #1 was admitted and would like to participate. Interview on 02/15/23 at 10:20 A.M. with SS #136 confirmed interdisciplinary care conferences were not completed quarterly for Resident #1. 4. Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included chronic ishemic heart disease, malnutrition, mood disorder, dementia, hypertension, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively impaired and required limited assistance of one staff for activities of daily living. Review of the Psychosocial assessment dated [DATE], 05/16/22, 06/03/22 and 09/30/22 revealed these were not interdisciplinary team (IDT) care conferences. The documents revealed advanced care planning was reviewed, but family did not participate in the assessment. The form also does not specify which staff were included in the assessment. Review of the progress note dated 06/23/22 revealed a care conference was held with residents' emergency contact and the Administrator. No clinical or IDT staff were mentioned to have attended the meeting. Further review of the medical record revealed there was no evidence an IDT care plan meeting was held for Resident #32 from 01/17/22 to 02/15/23. Interview on 02/14/23 at 11:33 A.M. with Resident #32's family revealed she gets updates frequently, but denied being invited to care conferences. The family revealed they would like to attend care conferences if offered either in person or by phone. Interview on 02/15/23 at 10:20 A.M. with Social Services (SS) #136 revealed she was hired a few months ago and tried to get in a few care conferences in during the end of the last quarter of 2022. She verified many care conferences had been missed. SS #136 revealed family should be included in the care conference meetings and the IDT Care Conference forms should be completed. SS #136 confirmed IDT care conferences were not completed for Resident #32. SS #136 revealed IDT included several members of the team and should not just include the social service staff and resident or family. Review of the policy titled, Resident and Resident Representative Care Conferences, dated 08/08/16 revealed the resident and or resident representative would be offered and invited to attend an initial and quarterly care conferences. The policy did not include who from the facility was expected to attend the interdisciplinary care conferences.

Based on observation and staff interviews, the facility failed to ensure resident rooms were maintained in good repair. This affected four resident's (#1, #4, #7 and #24) of 24 residents reviewed for environment concerns. The facility census was 50. Findings include: 1. Observation on 02/13/23 at 7:59 P.M. of Resident #1 and Resident #7's room revealed a salad plate size dent in the wall above Resident #7's bed and the window blinds were broken with several pieces sticking out in various directions and several pieces broken off. Interview and observation on 02/13/23 at 7:59 P.M. with State tested Nursing Aide (STNA) #151 confirmed the window blinds were broken and in disrepair and also confirmed the dent in the wall. STNA revealed Resident #7 was aggressive at times and had likely hit the wall herself. Interview and observation on 02/16/23 at 9:31 A.M. with Maintenance Director (MD) #135 confirmed the dent in the drywall above Resident #7's bed. 2. Observation on 02/13/23 at 8:08 P.M. revealed the blinds in Resident #4 and Resident 24's room were broken. Several pieces had broken off and other pieces were bent in various directions. Interview and observation on 02/13/23 at 8:08 P.M. with Licensed Practical Nurse (LPN) #145 confirmed the blinds were not maintained in good repair. Interview and observation on 02/16/23 at 9:31 A.M. with Maintenance Director (MD) #135 confirmed several rooms on the 200 hall had broken blinds and they were working to replace the broken ones. He revealed one of the residents has been wandering into resident rooms and will break the blinds. This deficiency represents non-compliance investigated under Master Complaint Number OH00140325 and Complaint Numbers OH00140308 and OH00140106.

Based on record review, observations, and staff interviews, the facility failed to ensure call lights remained in reach and were easily accessible for the residents. This affected two (Residents #1 and #24) of 24 residents reviewed for call lights. The facility census was 50. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, osteoarthritis and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired and was rarely understood and required extensive assistance of two staff members for mobility and transfers. Review of the care plan dated 02/13/23 revealed Resident #1 was at risk for falls with interventions to encourage and remind the resident to ask for assistance. Observation on 02/13/23 at 7:59 P.M. with Resident #1 revealed the resident was laying in bed. Resident #1's call light was observed to be under the bed and out of reach. Interview and observation on 02/13/23 at 7:59 P.M. with State tested Nursing Aide (STNA) #151 revealed it was wrapped around Resident #1's bed wheels and physically moved the bed to free the call light. 2. Review of the medical record for the Resident #24 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, dementia, schizophrenia and anxiety. Review of the care plan dated 06/16/22 revealed Resident #24 may require assistance with activities of daily living. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively impaired and required extensive assistance of one staff members for mobility and activities of daily living. Observation on 02/13/23 at 8:08 P.M. with Resident #24 revealed the resident was laying in bed. Resident #24's call light was observed to be under the bed tucked next to the wall and out of reach. Interview and observation on 02/13/23 at 8:08 P.M. with Licensed Practical Nurse (LPN) #145 confirmed the call light was on the floor and out of reach of Resident #24. This deficiency represents non-compliance investigated under Complaint Numbers OH00140106 and OH00140308.

Based on record review and staff interview, the facility failed to accurately code Minimum Data Set (MDS) assessments for Resident #39 and #50 for anticoagulation drug use and Resident #52 for hospice services. This affected three (Resident #39, #50, and #52) of 16 residents reviewed for MDS assessments. The facility census was 50. Findings include: 1. Record review for Resident #52 revealed an admitted [DATE]. Diagnoses included dementia and adult failure to thrive. Resident #52 passed away at the facility under hospice services on 12/21/22. Review of the physician order dated 09/23/22 revealed Resident #52 was admitted to hospice for diagnosis of Alzheimer's disease with early onset. Review of the quarterly MDS assessments dated 09/23/22 and 12/06/22 revealed Resident #52 was coded as not receiving hospice services. Interview with Licensed Practical Nurse (LPN) #109 on 02/15/23 at 11:14 A.M. verified she did not code Resident #52 as receiving hospice services on the quarterly MDS assessments dated 09/23/22 and 12/06/22. LPN #109 stated she was new at completing MDS assessments. 47058 2. Record review for Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Huntington's disease and a history of transient ischemic attack. Review of Resident #39's medical record revealed Resident #39 was not receiving anticoagulation therapy since 09/17/22. Review of the quarterly MDS assessment dated [DATE] revealed Resident #39 was marked for receiving anticoagulation therapy for the look-back period Interview on 02/15/23 at 8:57 A.M. with Licensed Practical Nurse (LPN) #109 verified Resident #39 's MDS assessment dated [DATE] was marked incorrectly for anticoagulation. LPN #109 verified Resident #39 was not on anticoagulation therapy at the time of assessment and was last on anticoagulation therapy until 09/17/22. 3. Record review for Resident #50 revealed an admitted [DATE]. Diagnoses included history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of the physician orders from 12/01/23 to 01/01/23, revealed Resident #50 did not receive anticoagulation therapy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/01/23, revealed Resident #50 was marked for receiving anticoagulation therapy for the look-back period Interview on 02/15/23 at 8:57 A.M. with Licensed Practical Nurse (LPN) #109 verified Resident #50's MDS assessment dated [DATE] was marked incorrectly for anticoagulation. LPN #109 verified Resident #50 was not on anticoagulation therapy at the time of assessment. Review of the MDS guidance revealed N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the seven-day look-back period (or since admission/entry or reentry if less than seven days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here.

Based on staff interview and record review, the facility failed to ensure the surety bond was sufficient to cover the balance of resident accounts. This had the potential to affect all 30 residents who had active fund accounts. The facility census was 50. Findings include Review of the Surety bond revealed a signature date of 05/26/21 and effective date of 06/01/21. The surety bond revealed a bond amount of $20,000. Review of the resident's fund account balances revealed a balance of $26,668.97 on 01/2022; a balance of $25,473.92 on 02/2022; a balance of $22,689.62 on 03/2022; a balance of $23,982.36 on 04/2022; a balance of $22,321.30 on 05/2022; a balance of $24,058.89 on 06/2022; a balance of $38,843.03 on 09/2022; a balance of $40,496.27 on 10/2022; a balance of $41,290.44 on 11/2022; a balance of $50,421.78 on 12/022; and a balance of $82,962.98 on 02/14/22. Review of the surety bond increase penalty rider with a signature date of 02/15/23 and effective date of 09/29/22. The surety bond revealed a bond increase to $100,000. Interview on 02/14/23 at 5:50 P.M. with Business Office Manager (BOM) #133 revealed she was not aware the surety bond was that low and the overall facility balance was that high. Interviews from 02/15/23 at 9:00 A.M. to 02/16/23 at 6:30 P.M. with the Administrator revealed the facility had requested a surety bond increase to $100,000. The Administrator revealed it was dated for coverage to start on 09/29/22. The Administrated acknowledged the form was not signed and dated until 02/15/23 after a copy was requested by the state survey agency. Review of the facility's undated policy titled Resident Trust Fund Deposit Procedure revealed the policy does not include any language related to the surety bond amount.

Based on medical record review, staff interview, law enforcement interview, and facility policy review, the facility failed to ensure proper monitoring was in place to minimize the risk of potential sexual abuse. This affected one (Resident #36) of three residents reviewed for sexual abuse and monitoring. The census was 52. Findings Include: Record review revealed Resident #36 was admitted to the facility on [DATE]. Her diagnoses were Parkinson's disease, dementia, disorganized schizophrenia, schizophrenia, major depressive disorder, anxiety disorder, hyperlipidemia, and insomnia. Review of her Minimum Data Set (MDS) assessment, dated 12/03/22, revealed she had a significant cognitive impairment. Resident #36's progress notes, dated 12/11/22 to 12/12/22, revealed that a male resident (Resident #7) was found to be in her room on 12/11/22. After contacting Resident #36's guardian, it was decided that she would be sent to the emergency room for further evaluation. She returned from the hospital on 12/12/22; no acute distress was noted. There was no documentation to support this alleged incident had any negative effect to her physical/mental health. Review of Resident #36's Minimum Data Set (MDS) assessment Section G, dated 12/03/22, revealed she needed extensive physical assistance with her activities of daily living. Review of Resident #36's care plan, undated, revealed she had an altered cognitive functioning. Record review revealed Resident #7 was admitted to the facility on [DATE]. His diagnoses were schizoaffective disorder, hemiplegia and hemiparesis, chronic obstructive pulmonary disease, type II diabetes, seizures, bipolar disorder, hypertension, traumatic compartment syndrome of unspecified upper extremity, anxiety disorder, major depressive disorder, hyperlipidemia, dysarthria and anarthria, and obesity. Review of his MDS assessment, dated 11/17/22, revealed he had a significant cognitive impairment. Review of Resident #7's progress notes, dated 12/11/22 to 12/13/22, revealed documentation to support he had been up all night from 12/10/22 to 12/11/22. On 12/11/22 at approximately 1:32 P.M., progress note stated Resident #7 was wandering into other resident rooms, exposed his genitalia while in the common areas of the facility, used profane and inappropriate language toward staff, and was exhibiting aggressive behaviors. He was documented as being on 1:1 staffing at that time. On 12/11/22 at 4:50 P.M., the facility received a call from the facility psychiatrist, and agreed to prescribe Haldol five milligrams (mg) every six hours as needed for Resident #7's agitation and stated the psychiatrist would be in the facility the next day (12/12/22) to evaluate Resident #7. Resident #7 was given one dose of Haldol five mg shortly after it was ordered. On 12/11/22 at approximately 8:29 P.M., a nurse heard yelling down the hall, walked into Resident #36's room and found Resident #7 beside Resident #36's bed with his hand on her knees; they were separated. Review of Resident #7 skin assessments revealed no evidence on his hands/fingers that he had any pieces of depends/incontinence brief (from Resident #36) on them. Review of Resident #7 care plans, undated, revealed he had an alteration in mood and behavior, which included manipulative behaviors. Also, his care plan revealed he required secured unit placement as the resident displays physically aggressive behaviors, resident is an elopement risk, resident wanders and has no safety awareness. Review of Resident #7's medical records revealed no documentation or assessment completed to support the reduction from 1:1 staff to 15-minute checks on 12/11/22 at approximately 5:00 P.M. There was no evidence to support Resident #7's behaviors had decreased or what was assessed to support the facility to decrease Resident #7's supervision levels when staff left at 5:00 P.M. and they began 15-minute checks instead of maintaining 1:1 staffing. Interview with the Director of Nursing (DON) on 12/15/22 at 10:45 A.M. confirmed Resident #7 was in 1:1 staffing protocol due to behaviors that were being exhibited earlier in the day (12/11/22). She stated they had an extra staff person who could provide 1:1 for him. That staff person left around 5:00 P.M. on 12/11/22, which then Resident #7 was switched to 15-minute checks. The DON stated she was contacted about Resident #7 behaviors earlier in the day (12/11/22), and told the facility staff to contact the physician. She was also contacted around 5:00 P.M. about staff having to leave her shift early, so they decided to do 15-minute checks with Resident #7. The DON was called around 7:30 P.M. to be informed about the sexual abuse allegation. All notifications were made, the facility sent Resident #36 to the hospital for evaluation, and kept her there until they could find a place to emergency discharge Resident #7. Resident #7 had not exhibited sexual behaviors like this before that day. The DON confirmed that since they did not have an extra staff member after 5:00 P.M. on 12/11/22, they felt his behaviors had subsided enough to keep him on 15-minute checks for everyone's safety. Interview with State tested Nurse Aide (STNA) #103 on 12/15/22 at 11:10 A.M. revealed she was on the opposite side of the building as a float aide the morning of 12/11/22. A nurse came over and stated they needed her to be 1:1 with Resident #7 due to increased behaviors. She had to leave the facility shortly after 5:00 P.M., and she is not sure what happened after that. She had worked with Resident #7 before; no sexual behaviors were noticed. She had not seen him attempting to sexually abuse anyone. He would curse often and be aggressive with his communication, but never anything sexual. Interview with Licensed Practical Nurse (LPN) #101 on 12/15/22 at 11:17 A.M. stated she was working with Resident #7 and Resident #36 on 12/11/22. She confirmed he was acting different all day, which is why they called the psychiatrist and DON. The behaviors Resident #7 was exhibiting included showing his genitalia in common areas, cursing, going in/out of resident rooms, and overall agitation. They decided to use 1:1 staffing due to his behaviors. Unfortunately, the float staff had to leave for a family emergency, so she contacted DON and was told to start 15-minute checks. During shift change, at about 7:20 P.M., that is when Resident #7 took advantage of the situation and went in Resident #36 room. She heard the yell from Resident #36 room as she was getting ready to leave the facility. When she walked in, Resident #7 was in his wheelchair, his hand on Resident #36's knee. Her depends was shredded, she was incontinent, her nightgown was lifted to her waist, and her knees were lifted toward her chest. She removed Resident #7 from Resident #36's room to do an assessment on him. There was no allegation made to her at that time. She confirmed it would have been beneficial for 1:1 staffing to continue, but felt they had enough staff for 15-minute checks. She feels that Resident #7 took advantage of the time after the checked on him, and when the staff were completing shift change duties. Interview with LPN #102 on 12/15/22 at 12:58 P.M. revealed he came to work on 12/11/22 at about 7:00 P.M. He was told they were performing 15-minute checks on Resident #7 due to on-going behaviors. He confirmed he heard a noise from Resident #36 room, saw Resident #7 sitting in his wheelchair beside Resident #36, who was lying in her bed. Resident #7 hand was on her knee. Resident #36 depends was shredded and her nightgown was up to her waist. After Resident #7 was removed from her room, he asked Resident #36 what happened; she stated, he touched my vagina hairs. Shortly after making that allegation, he performed an initial/visual observation of Resident #36's body and could not find trauma but did not go in depth and waited for that evaluation to occur at the hospital. Interview with Law Enforcement #104 on 12/15/22 at 4:06 P.M. revealed he was contacted about the incident on 12/11/22. He stated he went to the hospital first to speak with Resident #36; she was not able to give much information. He confirmed the nurse that examined her, stated Resident #36 stated Resident #7 stuck his fingers inside her. He confirmed a rape kit was completed and the results could confirm if she was digitally penetrated. After going to the hospital, he went to the facility and spoke with Resident #7. He stated when he arrived, Resident #7 was lying in bed, dried spit in the corner of his mouth, and he was slightly out of it. When he interviewed him, he confirmed Resident #7 stated he had stuck his hand down Resident #36's pants earlier that day. Review of facility Self Reported Incident (SRI) number 230015, revealed Resident #7 was found in Resident #36 room with his hand on her knee, and her nightgown up to her waist. The facility had not fully completed their investigation, but it was not required to be completed until 12/19/22. The facility documented appropriate steps to keep all residents safe after the incident was discovered. The outcome of the investigation had not been determined yet. Review of facility Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy, dated 11/21/16, revealed it is the facility's policy to investigate all alleged violations involving abuse. Additionally, the facility should immediately report all such allegations to the administrator and state department of health. In cases where a crime is suspected, staff should also report the same to local law enforcement. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. If the resident is injured as a result of the alleged or suspected incident, immediate action should be taken to treat the resident. Staff should not leave a resident unattended, unless it is necessary to summon assistance. A nurse should perform an initial assessment of the resident. The resident's attending physician should be notified if an incident has occurred requiring physician involvement. If appropriation, the facility should send the resident to the hospital for an examination. If a person not on staff is accused of abuse, the facility will take action to protect the resident including, but not limited to, contacting the third party and addressing the issue directly with him/her, preventing access to resident during the investigation, and/or referring the matter to the appropriate authorities. In the case of resident to resident suspected abuse, the parties are separated from one another until the investigation has been completed. The resident representative, and the resident's attending physician, if appropriate, should be notified of the incident. All incident and allegations of abuse must be reported immediately to the administrator. Ensure that all alleged violations involving abuse are reported immediately, but no later that two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Have evidence that all alleged violations are thoroughly investigated. Prevent further abuse while the investigation is in process. If the allegation is verified, appropriate corrective action must be taken. Review of facility monitoring form, dated 12/11/22, revealed Resident #7 was visually seen every 15 minutes from 5:00 P.M. to 7:15 P.M. This deficiency represents non-compliance investigated under Self Reported Incident Investigation Control Number 138348 and Complaint Number OH00138319.

Based on review of medical record, review of policy and staff interview, the facility failed to ensure an advanced directive was accurately reflected in the electronic medical record. This affected one (#12) of one residents reviewed for advanced directives. The facility identified 22 residents who had advanced directives. The census was 49. Findings include: Review of Resident #12's medical record revealed she admitted to the facility 11/05/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a form titled, Do-not-resuscitate-comfort-care-arrest (DNRCCA), dated 04/10/21 revealed Resident #12 elected to be a DNRCCA. The physician signed on the same date. Review of Resident #12's care plan dated 10/07/20, last revised 04/15/21 stated Resident #12 was a full code. Interview on 04/28/21 at 7:33 A.M., with Administrator and Director of Nursing (DON) revealed a resident's advanced directives should be accurately reflected in both the hard chart and electronic medical record. Interview on 04/28/21 at 11:15 A.M., with DON confirmed Resident #12 elected the DNRCCA on 04/10/21. DON confirmed Resident #12's care plan and electronic medical record were never updated to accurately reflect her advanced directives. Review of a facility policy titled, Residents' Rights: Treatment and Advance Directives, dated 11/22/16, revealed residents' advanced directives would be placed on the chart and communicated to the staff.

Based on review of medical record, staff interviews and review of policy, the facility failed to ensure a resident representative was notified of a significant weight loss for a resident. This affected one (#19) of one resident reviewed for notification of change. The census was 49. Findings include: Review of Resident #19's medical record revealed she admitted to the facility 09/15/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A dietary note dated 03/24/21 revealed Resident #19 lost 16 pounds since February 2021. Her supplement was increased and the physician was notified. There was no evidence her resident representative being notified of her weight loss. Interview on 04/27/21 at 12:42 P.M., Dietician #307 stated nursing staff were responsible for notifying resident representatives of dietary/nutritional changes. Interview on 04/27/21 at 12:43 P.M., Director of Nursing stated Dietician #307 was responsible for notifying resident representatives of dietary and nutritional changes. He confirmed Resident #19's resident representative was not notified of her weight loss identified 03/24/21. Review of a facility policy titled, Change of Condition, dated 10/18/01, revealed the unit manager or charge nurse was responsible for notifying the resident representative of any change in condition, including weight loss.

Based on medical record review, observations, staff interviews, review of facility policy and facility checklist, the facility failed to ensure a resident was free from the use of a physical restraining device utilized by staff and preventing the resident freedom of mobility. This affected one (#20) of one resident reviewed for physical restraints. The facility identified no residents who used physical restraints. The census was 49. Findings include: Review of Resident #20's medical record revealed he admitted to the facility 10/15/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE], revealed he had a severe cognitive impairment. He required a one person extensive assist with bed mobility and a two person physical assist with transfers. A bed alarm was used daily. There was no assessment of a restraint being used. Review of Resident #20's care plan initiated on 10/16/20 and revised on 11/03/20, revealed Resident #20's wife stated he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions did not include use of a wedge pillow. Review of Resident #20's [CONDITION(S)] care plan last revised 11/03/20, did not include the use of a wedge pillow. His activity of daily living care plan dated 10/20/20 revealed he required a two person assist with repositioning and bed mobility. Interventions did not include the use of a wedge pillow below his mattress. Review of Resident #20's skin integrity care plan dated 10/16/20 revealed an intervention of a pressure reducing mattress. The care plan did not include the use of a wedge pillow below the mattress. Further review of Resident #20's care plan created 10/16/20 and last revised 10/30/20 revealed he was at risk of falls secondary to Lewy Body Dementia and restless legs. He was observed crawling out of bed onto the floor mat. Interventions included non skid socks as tolerated (11/08/20); rest in recliner before lunch (12/18/20); encourage activities after breakfast (12/20/20); offer to lay down after dinner (12/21/20); medication review (12/26/20); stirrup over non-skid socks as tolerate (03/08/21) and sounding alarm on bed as tolerated (02/04/21). Interventions dated 10/16/20 also included floor mat next to bed at all times, geriatric hip protectors on as tolerated, and low bed. Observations on 04/28/21 at 7:30 A.M. and 8:26 A.M., revealed Resident #20 lying flat on his back in his bed. His bed was in the lowest position and Resident #20 faced the door to the hallway. The left side of Resident #20's bed was against the wall. A standard wedge pillow (measuring 32 inches by 20 inches, by 12 inches at a 20 degree angle) was placed under the center of Resident #20's mattress. Either side of the wedge pillow was raised 12 inches from the base of the bed at a twenty degree angle. Resident #20 was flat on his back, his right arm against the wall and his left arm secured him to the position due to the angle the mattress laid due to the wedge pillow beneath it. Observation and interview on 04/28/21 at 8:32 A.M., with Director of Nursing (DON) confirmed the above description of the position of Resident #20 in his bed. DON stated it was something the facility night-shift staff had done to help reposition Resident #20 to prevent skin breakdown. DON confirmed Resident #20 did not have any current skin conditions and the wedge limited his freedom of movement. Further interview on 04/28/21 at 10:43 A.M., with DON confirmed Resident #20 was on hospice but hospice staff did not place the wedge cushion. DON stated he interviewed night shift staff from the previous night and they placed the wedge to assist Resident #20 with positioning as he could not tolerate laying flat on his back. A restraint-enabler decision tree was completed. Staff were re-educated to utilize pillows for positioning above the mattress as opposed to a wedge pillow below the mattress. DON confirmed Resident #20 was observed lying on his back during the mutual observation, not positioned on his side as night shift stated. DON confirmed Resident #20 required two person physical extensive assist to get out of bed and one person extensive physical assist with bed mobility. DON stated during the Restraint-Enabler Decision Tree assessment, revealed the wedge pillow use did not prevent Resident #20 from exiting the bed. DON stated the intervention of the wedge pillow had never been discussed between himself and night shift staff. He stated there was no documentation of when the intervention was implemented or who was notified the intervention was implemented. DON stated Resident #20 was unable to remove the wedge pillow from underneath his mattress. DON stated staff were never educated to use a wedge pillow under the mattress for repositioning and it was not facility policy. He stated interventions were typically developed by nursing management, not State tested Nurse Aides. He stated the facility night shift staff were educated to not use the wedge pillow under resident mattresses. Review of a facility policy titled, Restraint Use, dated 06/20/15, revealed a physical restraints were defined as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual could not remove easily which restricted freedom of movement or normal access to one's body. Review of an undated checklist titled, Turing and Repositioning while in Bed, did not include placing a wedge pillow under the mattress.

Based on observations, resident and staff interviews, review of the medical record, review of the facilities investigation and the local police department report and review of the facility's elopement policy and procedure, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at high risk for elopement from the facility and with exit seeking behaviors, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #15 was placed at potential risk for serious harm and injury when the resident eloped from the facility without staff knowledge and exited through her window she broke. The resident was missing for six hours and 15 minutes and was found two miles away from the facility in a busy construction area. This affected one (Resident #15) of three residents (#09, #15 and #31) reviewed for elopement. The facility identified six current residents (#09, #12, #15, #21, #31 and #42) to be at risk for elopement. The facility census was 42. On [DATE] at 12:15 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 2:20 A.M. when Resident #15 had barricaded herself in the room and broke her window by throwing her television threw it. Licensed Practical Nurse (LPN) #301 heard the sound of breaking glass and she had to push hard on the door to get it open because it was blocked by a dresser. The facility began 15-minute checks. At 9:00 A.M., Maintenance Director #500 cleaned up the broken glass around the window and put two dressers and a bed in front of the window to avoid the resident climbing out of the window. At 2:25 P.M., Resident #15 exited the secured memory care/behavioral unit through the broken window of her room to the outside. Facility staff found the resident's furniture was moved from the window. Resident #15 was found approximately six hours and 15 minutes later about two miles away from the facility in a busy construction zone. The resident was placed at potential risk of falling due to the rough terrain, numerous construction holes and a lack of sidewalk in the construction area. At the time of discovery, Resident #15 was found to have a minor physical injury to her left hand's first digit measuring 1.2 centimeters (cm) in length by 0.1 cm in width. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 2:25 P.M., the resident was noted to not be in her room. Facility and surrounding grounds were searched, and police were notified at 2:45 P.M. of the missing resident. Community search was immediately implemented with the assistance of law enforcement until the resident was located by facility staff at 8:30 P.M. · On [DATE] at 2:30 P.M., the DON, Nursing Supervisor #50, and State tested Nursing Aide (STNA) #201 checked on and accounted for all other residents in the facility. No negative findings were noted. · On [DATE] at 3:30 P.M., the broken window in Resident #15 ' s room was repaired by Maintenance Director #500. All other windows and exit doors were checked to ensure all were secure and functioning properly. · On [DATE] at 9:15 P.M., Resident #15 was returned to the facility by the Administrator. Upon return, a physical assessment was conducted, and found the resident had a new abrasion to her first digit on her left hand. Resident #15 was placed on continuous one-to-one staff supervision and a wander guard (an alarming device for staff to respond to the alarm when a resident attempts to leave a safe area) was placed. A new elopement assessment was completed, and her care plan was updated with the new interventions. · On [DATE], the DON and/or designees audited all the residents ' elopement risk assessments, applicable care plans, and physician orders [REDACTED]. The DON and/or designees reviewed and updated all elopement books. · On [DATE], the DON and designees began all staff education on accurate completion of Elopement assessments, Elopement Policy and Best Practice and notification of Administrator when there is a safety risk in the environment to ensure adequate mitigation of risk. On [DATE], all 52 staff had been provided the in-service content. · On [DATE], the Administrator and Maintenance Director #500 conducted an environmental safety risk assessment to ensure all potential egress points were properly secured. · On [DATE] and [DATE], the Administrator and/or DON interviewed all staff who were present on the unit or provided care to Resident #15 at the time of incident on [DATE]. · On [DATE], a Quality Assurance (QA) Committee meeting was held to review the incident investigation, internal action plan and audit plan. The QA committee meetings will continue weekly for four weeks to review the effectiveness of the action plan and audits. · Beginning on [DATE], Maintenance Director #500 or designee will audit windows, door alarms and locks five times weekly for four weeks, or until otherwise directed by the QA committee. · Beginning on [DATE], Elopement Drill and Audits will be completed by the DON, Administrator or designee weekly for four weeks, or until otherwise directed by the QA committee. · Beginning on [DATE], the DON or designee will conduct weekly audits of all elopement assessments completed during the previous seven days, for four weeks, or until otherwise directed by the QA committee, to ensure accuracy and appropriate interventions. · Beginning on [DATE], the DON, Administrator or designees will conduct interviews of staff to validate their understanding of the in-service content (e.g., completion of elopement assessments, elopement policy and best practice and notification of Administrator when there is a safety risk in the environment to ensure adequate supervision is implemented). Random interviews will continue three to five times weekly for four weeks, until otherwise directed by the QA committee. · On [DATE], the medical records for Residents #05, #11, #27, #32, #37, #39 and #42, identified at risk for elopement, were reviewed with appropriate assessments and plans of care in place. There were no other identified elopement events. · Observation on [DATE] from 12:45 P.M. to 1:30 P.M. revealed the windows were all secured and functioning. Resident #15 remained on one-to-one supervision. · Interviews on [DATE] at 12:45 P.M. with State tested Nursing Aide (STNA) #201, STNA #202, Registered Nurse (RN) #101, Dietary Manager #800, and Maintenance Director #500 revealed they have been trained and could accurately verbalize the elopement policy and procedure. They verbalized they were interviewed by the DON and took a quiz on their knowledge of the elopement policy and procedure. · Review of the facility audit records for window and door alarms from [DATE] to [DATE] verified the facility completed them five times weekly. The elopement drills and audits were completed the last two weeks during the period reviewed. The elopement assessments were audited weekly by the DON or designee during the period reviewed. · Review of the facility QA committee meeting sign-in sheets revealed the committee met weekly during the period from [DATE] to [DATE]. · Review of the audits completed by the DON, Administrator or designee revealed the staff interviews were completed three to five times weekly, validating the in-service content provided on [DATE] and [DATE], during the time period from [DATE] to [DATE]. Findings include: Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission paperwork, dated [DATE], revealed the resident was to be monitored for exit seeking behaviors every 30 minutes every shift. Review of the care conference note, dated [DATE], revealed the resident's niece attended the care conference. The niece revealed the resident had previously attempted to break a window at her previous place of residency to elope. Review of the Elopement Risk Assessment, dated [DATE], revealed Resident #15 was at a high risk because she was physically capable of leaving the facility. The resident was confused to time and place and wanders, roams and paces. Review of the plan of care, dated [DATE], revealed the resident was at risk for elopement, had exit seeking behaviors, history of elopement, expresses grandiose thoughts of renting a car and seeing her deceased brother who lives in their deceased parents' home. The resident was unaware of safety needs. The resident required secure unit placement, the resident was an elopement risk, the resident wanders and has no safety awareness. Resident has cognitive function altered dementia. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had severe cognitive deficits and had exit seeking behaviors. The resident required supervision for locomotion on and off the unit. Review of the History and Physical, dated [DATE], revealed the resident continued with exit seeking behaviors. Review of the progress notes, dated [DATE] at 2:20 A.M., documented by LPN #301 revealed the resident stated she used the flat screen television to break the window. The resident was placed on 15-minute checks. The progress notes, dated [DATE] at 2:25 P.M., documented RN #101 checked on the resident, but she was not in her room. On [DATE] at 2:30 P.M., the DON was notified the resident was unable to be located at this time. The resident was last seen approximately 15 minutes prior by the resident's charge nurse. The charge nurse reported the resident was requesting to speak with her niece via telephone, and the nurse assisted the resident in placing the phone call. The resident's room and immediate surroundings were searched with no findings. A code alert for an elopement (Code E) was announced to the staff and the interior/exterior of the facility was immediately searched by all staff. Nearby residents and staff were interviewed with no relevant findings. On [DATE] at 2:45 P.M., the DON documented the law enforcement was notified of the resident being unable to be located at this time. Relevant health information and description was shared with the law enforcement. A secondary interior check was completed with no relevant findings. On [DATE] at 8:30 P.M., the DON documented the resident was located by two staff members. Law enforcement was notified and stated they will send the Emergency Medical Technician (EMT) for an initial assessment as a precaution prior to returning to the facility. On [DATE] at 9:15 P.M., the DON documented the resident was assisted back into the facility at this time. A head-to-toe assessment was completed, and a small laceration was noted to the left hand on the first digit. The laceration measured 1.2 cm in length by 0.1 cm in width. The area was cleansed with normal saline and was left open to air. The progress notes, dated [DATE] at 11:15 P.M., revealed the resident had a new order for a wander guard and increased supervision and heavy/unsecured items remain moved from the resident's room. Review of the 15-minute checks, dated [DATE], revealed the resident was in the hallway from 1:00 P.M. to 1:45 P.M. From 2:00 P.M. to 2:15 P.M., it was noted the resident went to her room after the phone call to her niece. Review of the facility's investigation revealed Resident #15 was on 15-minute checks since [DATE] at 2:20 A.M. due to breaking her bedroom window. On [DATE] at 2:45 P.M., the local police were called. On [DATE] at 3:30 P.M., a bystander reported seeing the resident on U.S. Route 23. On [DATE] at 5:00 P.M., another bystander reported seeing the resident on the road about a half mile away. At 5:50 P.M., a news broadcast went out of the missing resident. On [DATE] at 6:15 P.M., the K-9 Unit/Search & Rescue arrive to assist with search. On [DATE] at 7:25 P.M., the local transit agency was notified of the missing resident. Ohio State Highway Patrol (OSHP) drones were initiated and Metro Rangers searched nearby parks with no success. At 8:30 P.M., the resident was found. On [DATE] at 8:45 P.M., the resident was assessed by the EMT and was cleared to return to the facility. Review of a witness statement, dated [DATE], revealed LPN #301 heard the sound of breaking glass and when she went to enter the room, the resident had the room door blocked with a dresser. She had to push hard on the door to get it open because it was blocked. The resident was observed to be standing near her window with window glass shattered over the floor. Review of the witness statement, dated [DATE], revealed when STNA #201 went to look for the resident in her old room after the elopement code was called, she observed two dressers turned sideways in front of the window with the glass removed. Review of the facility's Search and Rescue Questionnaire, dated [DATE], revealed the resident was found at a location two miles from the facility by the Administrator and Staff #900. Review of the police report, dated [DATE], revealed they were made aware Resident #15 was missing on [DATE] at 2:55 P.M. It was reported the resident was discovered missing from the facility and the screen was out of her window. The window was broken, and the two dressers were moved away from the window. The police arrived at the facility and launched a drone to circulate the area. A construction site stated they observed her at an intersection approximately a half a mile away from the facility. The local Missing Detectives unit were called to the scene to assist. The report did not state the resident was found. Interview on [DATE] at 11:05 A.M. with RN #101 revealed she has worked for the facility for one year and stated she mainly works on the dementia and behavioral unit where Resident #15 resided. She reported she was working on [DATE] when Resident #15 eloped. She stated the resident tends to wander on the unit daily. She stated some days she was in a good mood and other days she was not in a good mood. She stated on [DATE], she was agitated and wanted to leave the facility. She stated when this behavior starts, they notify the family and the resident speaks to the family which tends to deescalate the situation. RN #101 reported she spoke with the resident's family member around 11:00 A.M. and the resident seemed fine. The resident seemed agitated around 2:00 P.M. to 2:15 P.M., and she called the resident's family and she spoke with them. RN #101 stated she thought this calmed the resident down, but it did not. She went to check on her around 2:25 P.M. and she was not in her room. RN #101 stated she was not sure how she got out of her room but knew maintenance was in her room earlier that day. She reported no alarms sounded when she left. She stated she believed she went out the window. Observation on [DATE] at 11:15 A.M. with RN #101 revealed the secured behavior unit had two doors that exited to the outdoors and one door which lead to a dining room. When Door #1, Door #2 and Door #3 were pushed for an extended amount of time, the doors would not open. RN #101 stated the doors would not open unless a code was used on the keypad. During this observation on [DATE] at 11:15 A.M., Resident #15 was in her room along with a staff member sitting in her room. Resident #15 appeared agitated and did not want to be spoken to. Interview on [DATE] at 11:25 A.M. with LPN #300 revealed she was working on [DATE] when the resident went missing. She reported the alert went out around 2:20 P.M. of a Code E. She reported she was found down the road past the roundabout by the overhead train crossing. She stated there was a subdivision and she was found in front of a tree by the Administrator. She reported the behavior unit's doors were connected to the fire alarm and would not open unless the fire alarms were going off or the nurse pulls the emergency exit button at the nurse's station. She reported the resident always talks about leaving. She reported the resident has been here for a couple of months and had this behavior at her other facility she was at. Interview on [DATE] at 11:55 A.M. with Maintenance Director #500 revealed he has worked for the facility for four months and was working the day the resident eloped on [DATE]. He reported he completed his morning checks of windows and screens. He stated he noticed the window was broken around 8:15 A.M. on [DATE]. He stated he did not receive a call from the facility of the broken window. He stated he told the Administrator in morning meeting on [DATE], he would fix the broken window, but would have to call someone at corporate for a window manufacturer. He said nothing was ever mentioned to staff regarding how to keep Resident #15 safe and out of her room. He stated after speaking with corporate on the window, he was notified around 1:00 P.M. to replace the window with plexiglass from the local hardware store. He stated he left around 1:00 P.M. after measuring the window and placing two dressers and a bed in front of the window while he was gone to the hardware store. He stated he received a call from a staff member on [DATE] around 3:00 P.M. notifying him that Resident #15 had eloped. Interview on [DATE] at 1:42 P.M. with the DON revealed he has worked for the facility for seven years. He stated Resident #15 had increased aggression and threw the television at the window and broke it. He stated this happened around 2:20 A.M. on [DATE]. He stated they removed the resident from the room and placed her into a room located on the same secured unit, down the hallway and around the corner from her previous room. She was also placed on 15-minute checks. Subsequent interview on [DATE] at 2:45 P.M. with the DON stated the window was completely taken out by Maintenance Director #500. He stated she got out of the window. He reported in her previous facility she had elopement behaviors. He further stated they found this out yesterday when they called the previous facility. Interview on [DATE] at 2:50 P.M. with the Administrator revealed the resident was wearing a black and white sweater, black pants, black shoes and had a short-sleeved shirt on underneath. She reported she was aware Resident #15 had broken windows at a previous facility. She stated when she first came here, they believed she pulled the fire alarms which then unlocks the doors. They have since placed plastic covers over the pull handles that when lifted, alarms to alert staff to know if someone was going to pull the alarms. She stated they have not had any further issues with anyone pulling the alarms. She reported she did not know how the resident got out of the facility. She reports there were no cameras on the inside or the outside of the building. Observation and interview on [DATE] at 4:40 P.M. with Maintenance Director #500 revealed at 9:00 A.M. he removed the glass out of the window and cleaned up the broken glass in Resident #15's room. He stated he placed two dressers, and a bed in front of her window. At 9:00 A.M. on [DATE], the resident was still in her old room. He stated he usually assisted with physically moving the resident's items and then the aides move the resident. However, in an emergency, just the resident was moved to another room. He stated the last time he saw the resident was at 1:00 P.M. and she was in the common area. He stated when you leave the unit and you see a resident there you know you are to use another door, so they do not follow you out. During the tour of the facilities grounds, there were several busy roads observed surrounding the facility. There were two roads you could use to get to the facility and one of those roads was closed to traffic because of construction. The other road has a heavy amount of traffic. He stated he heard there was a tip she was on U.S. Route 23, which was another high traffic area. Interview on [DATE] at 5:30 P.M. with Resident #15 revealed she does not know if she climbed out the window the day before. She reported she was not missing yesterday. Observation at this time revealed she was in her room eating dinner with a staff member in the room. Review of the facility's policy titled Elopement and Wandering Residents, dated [DATE], revealed it stated door locks/alarms may be in place to aid in deterring elopements. Staff are vigilant in responding to alarms in a timely manner. The facility shall utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents will be assessed for risk of elopement and unsafe wandering following admission and through their stay by the interdisciplinary care plan team (IDT). The IDT will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accident or elopements. This deficiency substantiates Complaint Number OH 299.

Based on clinical record review, observations, review of hospital records, review of hospice notes, facility staff and resident interviews the facility failed to provide adequate supervision and prevent avoidable accidents which resulted in harm. This affected three residents ( #46, #17, #8) of 12 sampled residents. Resident #46 was left unsupervised and fell fracturing his left wrist and required sutures to a laceration to his scalp. Resident #17 suffered an injury to her face when she was improperly turned in bed and fell on the floor, face first. Resident #8 fell out of a shower chair after being left unsupervised and suffered a hematoma to the left side of the forehead. Findings include: 1. Clinical record review revealed Resident #46 was admitted to the facility on [DATE]. Review of Resident #46's accumulative [DIAGNOSES REDACTED]. Review of the significant change minimum data set (MDS) assessment completed on 09/29/10 revealed Resident #46 had short term memory problems and was moderately impaired for daily decision making and required supervision. The MDS further revealed Resident #46 was an extensive assist with a one person physical assist for bed mobility and eating. Review of progress note (nurse's) dated 09/09/10 revealed Resident #46 was found sitting on his bottom, on the floor, in his room next to his television. Resident #46 was noted to state he lost his balance trying to reach a movie on his entertainment center. Resident #46 was noted with a red raised bump area to the back of his head. Resident #46 was assisted to his bed with his call light in reach and encouraged to use it for assistance with items out of reach. On 09/15/10 it was noted Resident #46 was found lying on his floor beside his recliner. The recliner was noted to be lying on it's side. Resident #46 stated he was attempting to sit in his recliner, however sat on the arm of the recliner and the recliner tipped over. He denied any injury. On 09/19/10 at 7:25 A.M., it was noted Resident #46 was found lying on the floor, on his back. The resident stated he was going to take a walk. At 7:15 P. M., the note revealed Resident #46's daughter was concerned over his recent past three falls and increased confusion. Resident #46's physician was notified and an order was received to send the resident to the local emergency room for an evaluation due to mental status changes. On 09/21/10 Resident #46 returned to the facility with a [DIAGNOSES REDACTED]. Review of hospice nursing assessment and visit note dated 11/01/10 revealed Resident #46's functional limitations included being non-ambulatory, he could not sit up without assistance and required a maximum assistance of two persons for a transfer. Review of progress note (nurse's) dated 11/07/10 revealed a crash was heard and Resident #46 was yelling for help. Resident #46 was found face first on the floor in a puddle of red blood around his face. Resident #46 was noted to state, "get my arm out from under me". Resident #46 was noted with a two centimeter by one and half centimeter gash to his forehead with active bleeding. Emergency Medical Service (EMS/911) was notified. Resident #46 stated he was sitting on the edge of the bed while he was feeding himself and slid off the edge of the bed. The note further revealed the involved staff received both verbal and written counseling/education regarding the incident. Review of the hospital's history and physical report dated 11/08/10 revealed Resident #46 was admitted to the hospital with [REDACTED]. Interview with the Director of Nursing (DON) on 01/20/11 at 9:00 A.M. confirmed Resident #46 was left on the side of the bed to feed himself on 11/07/10 by state tested nursing assistant (STNA #99). The DON stated Resident #46 should not have been left alone, sitting on the edge of the bed to feed himself. She further stated STNA #99 had been given a verbal warning on 11/06/10 regarding the issue. Review of STNA #99's personnel file revealed the STNA received a verbal warning on 11/06/10 not to leave Resident #46 alone sitting on the edge of the bed during meals, stating he needed assistance and it was dangerous to leave him sit on the side of a high bed unassisted. Then again on 11/07/10 STNA #99 received a written warning for failure to use good judgement when Resident #46 fell after being left alone on the side of his bed. STNA #99 was educated and counseled if she did not understand what was asked of her to ask for clarification from her supervisor. 2. Clinical record review revealed Resident #17 was admitted to the facility on [DATE]. Review of Resident #17's accumulative [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) completed on 12/03/10 revealed Resident #17's cognition was in tact. Further review of the MDS revealed Resident #17 required extensive assistance with a two person assist for bed mobility, transfers, toilet use and personal hygiene. Review of the falls risk assessment completed on admission revealed Resident #17 was assessed as a high risk for falls. Review of Resident #17's plan of care related to safety, dated 11/22/10 revealed a low bed was in place. Review of progress note (nurse's note) dated 11/30/10 revealed STNA #99 called a nurse into the room. The note revealed Resident #17 was noted to be on the floor, face down, bleeding from the facial area. The bed was noted to be in a high position. The STNA stated she was providing incontinence care when Resident #17 was rolled out of bed. Resident #17 was noted to have bleeding from the left nares and upper lip. STNA #99 was noted to receive education/counseling regarding the incident. Review of STNA #99's personnel file revealed the STNA was discharged from employment on 12/01/10 for practicing unsafe turning to Resident #17. The personnel file further revealed STNA #99 had been verbally warned on 11/06/10 about unsafe practices and received a written warning on 11/08/10 for continued unsafe practice. On 12/01/10 it was noted STNA #99 was terminated for unsafe practice when she improperly rolled Resident #17 away from her, with her bed in high position, causing the Resident to fall off the bed onto the floor, causing facial injury. Interview with Resident #17 on 01/19/11 at 3:20 P.M. revealed she was in a low bed with mats to both sides of her bed. Resident #17 was noted to have a red, swollen lip with a laceration. Resident #17 stated she was rolled out of bed a few weeks ago, when STNA #99 was providing care to her. Resident #17 further stated her lip was cut and her knee was hurt due to the fall. Observation by surveyor on 01/20/11 at 9:30 A.M. revealed Resident #17 was in her room alone. Resident #17's bed was noted to be in a high position (approximately three and a half feet high) with no side rails and no mat on the floor. Resident #17's bedside table was noted at the side of the bed with her breakfast tray on it. Resident #17 requested her bed to be lowered. Surveyor requested licensed practical nurse (LPN #10) who was in charge of the unit, to come and assist Resident #17. Interview with LPN #10 at 9:35 A.M. confirmed Resident #17's bed was in a high position and without a mat to the floor. Resident #17's bed was then lowered and a mat was placed on the floor beside her bed. 3. Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurses' notes in the medical record revealed on 10/20/10 at 8:48 A.M., a nursing assistant alerted a nurse to "come quick", stating the patient fell on the floor out of the shower chair. The nurse immediately went to the resident's room and found him lying on his left side on the uncarpeted floor without clothing. The shower chair was setting behind him. It was noted that the resident had a hematoma to the left forehead. The nurses' notes stated the nursing assistant stated the resident's fall occurred due to the resident leaning forward during his shower earlier. The nursing assistant stated she had to hold the resident back to prevent him from leaning forward and when she "freed her hands briefly, pt (patient) fell forward". The nurses' notes stated the nurse then provided "staff education" to the nursing assistant. Review of the staff education provided to the nursing assistant by the nurse revealed the nursing assistant was advised that she needed to use better judgment of situation if a pt. (patient) is expressing behaviors or postures that appear "like you may not be able to handle on your own, than (then) you must get help from another staff personal (personnel) to avoid injury to pt (patient)". Review of the resident's MDS (Minimum Data Set) that was completed on 08/08/10 (most recent prior to the fall of 10/20/10) revealed the resident was totally dependent on staff for transferring and bathing and required the assistance of two for transferring. An interview with the Director of Nursing on 01/19/11 at 1:30 P.M. confirmed the resident should have had two staff with him at the time of the fall and confirmed the nursing assistant had been "educated" regarding providing safe, adequate care to residents during personal care.